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I agree with the noble Baroness, Lady Neuberger, about certainty of funding. I well understand that if a hospice does not know from the beginning of the financial year or, indeed, within the financial year what its allocation from the health service will be, that is a pretty poor position to be in. I also agree with her that it is very desirable that hospices have long-term certainty of funding. That is not in my gift. As the noble Baroness rightly said, these are matters for primary care trusts. However, every time I can, I take the opportunity to make it clear to PCTs that, when they deal with voluntary organisations, they must recognise issues about the raising of money and the fact that those organisations cannot depend on

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funding in the way that statutory agencies can. I will talk about the end-of-life care strategy in a moment, but I hope that it will address some of those points.

The noble Lord, Lord Alton, referred to the challenges for those providing children’s palliative care. The end-of-life care strategy does not cover provision of palliative care services for children, but an independent review of the long-term sustainability of children’s palliative care is being undertaken by Professor Sir Alan Craft and Miss Sue Killen. My understanding is that the review findings will be reported to Ministers shortly.

I say to the noble Baroness, Lady Masham, that I and other noble Lords were very moved by what she said about her experience and that of her late husband. I was very sorry to hear of the shortcomings in the service and I shall refer her comments to officials working in this area, as well as to the primary care trust covering North Yorkshire. She is right to mention the Quality and Outcomes Framework for general practitioners, which I assure her contains some points relating to palliative care. The framework certainly recognises the need for GPs to provide their support in palliative care. Obviously, we will look at that to see whether more needs to be done. On C. difficile, of course we have mandatory guidance, but we look to update it from time to time. There is a rapid revaluation panel which looks at ideas and products for dealing with C. difficile and MRSA. I am happy to refer the product that the noble Baroness mentioned to the panel.

The noble Baroness, Lady Emerton, and the noble Lord, Lord McColl, made important and heartening contributions on the potential of pain relief. However, we heard from the noble Baroness, Lady O’Neill, in another very moving account, about the experience of her brother and the problem of pain relief in nursing homes, particularly at a holiday time. The availability of drugs within the community will be considered as part of the end-of-life care strategy. I am also aware of the problem that professionals post-Shipman have concerns and may be deterred from using effective painkillers. Of course, that is the last thing that we would wish to see happen. I understand that the department is working closely with healthcare professions on this issue in order to get the right messages across. The noble Lord, Lord Cavendish, talked about rurality. Perhaps I may write to him with details of the NHS approach to that.

On the end-of-life care strategy, perhaps I may say to the noble Lords, Lord Colwyn and Lord Alton, and the noble Baroness, Lady Emerton, that I was particularly struck by the demographics. They are quite right that the strategy will need to reflect the demographic challenge that we all face. This strategy is the way in which the Government will address many of the issues raised by noble Lords. The noble Lord, Lord Patten, said that the report is expected to be made to Ministers in the autumn of 2007 and asked me to define the Department of Health’s definition of autumn. I am tempted to say that it has its ordinary and regular meaning; I am afraid that I cannot go further than that. However, of course we treat this with great importance. I am sure that my

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ministerial colleagues who are concerned with this area of policy will wish to study it with the greatest of care and be able to report to Parliament and the public on the outcome of that work. Several working groups have been set up, which will cover primary care, as referred to by the noble Baroness, Lady Neuberger, and the care home sector. They will also cover the very important issue of the training of staff—not just specialist staff, but general staff in particular.

I understand the importance of the questions raised about the membership of Professor Richards’s group and the working groups. The advisory board has representation from the chief executive officer of the National Council for Palliative Care, which is the umbrella body for the NHS and hospices. I understand that Marie Curie is also represented on the board.

I would like to take back the issue of spiritual care to consider whether we can strengthen the ways in which the churches, religions and faiths in general can make a contribution to the group. There are a number of working groups on which, I understand, both spiritual care providers and hospices are strongly represented, as are, I should say to the noble Baroness, Lady Emerton, nurse consultants. The working groups have a broad representation, which is very important because we want the ownership of this work to be from as wide a spectrum of stakeholders as possible. As I have said, I will consider the position of the churches, particularly in relation to the advisory group, to see whether we can at least establish some kind of liaison between the churches and the faiths and the work of the group. I understand the importance of that.

The noble Lord, Lord Cavendish, is right about the recruitment of consultants, doctors and other staff in general. We believe that the recruitment of consultants in palliative care will increase significantly in the next few years. One of the working groups that have been established is looking into that issue.

I very much appreciate the quality of the debate. It has been very helpful and will inform the end-of-life care strategy. I again congratulate the noble Baroness on her Bill and I look forward to debating it in Committee in due course.

2.31 pm

Baroness Finlay of Llandaff: My Lords, I thank all noble Lords who have spoken today. It has been an outstanding Second Reading debate and every contribution has been riveting. The courage and dignity of the noble Baroness, Lady Gardner of Parkes, in coming here today to share her recent experience has raised an acute awareness of the importance of the debate. My noble friend Lady Masham illustrated what can happen when care is not available and, even more poignantly, my noble friend Lady O’Neill of Bengarve illustrated what happens when there is no care. She also referred to what has happened in the wake of Shipman. I shall return to that point as it is crucial in the care of patients.

I appreciate the Minister’s generosity in welcoming the intent of my Bill. I recognise that he finds himself between a rock and a hard place in the tension

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between rationing and the allocation of resources. Perhaps the time has come when we are beginning to have an open debate about the country’s priorities. The end-of-life care strategy is welcome and I am delighted that Professor Mike Richards has invited me to participate in the process. I hope to be able to carry the mantle and that responsibility forward into the work of the board and working groups.

The noble Baroness, Lady Neuberger, brought to the debate her wide experience and knowledge of palliative care services going back over many years. Her speech complemented mine completely. I feel that they should be read in conjunction in order to flesh out the importance of the issues that we have tried to address today.

Palliative care must become a basic part of the healthcare training of every professional. I am sad that some nursing courses have decreased their palliative care training in recent times, but glad that all medical schools in the UK now teach palliative care and that, in many of them, it is a subject of the final examination.

On the tension between rationing and the allocation of resources, it is an issue of choices. We have to be very careful that choices are not placed in a hierarchy in which those that save the NHS money are accorded a higher ranking, and more time, than those that cost more. After all, good care is not cheap care. I would also like to build on the issue of choices at the end of life, as alluded to by the noble Lord, Lord Lester, and my noble friend Lady Greengross. Choices are difficult, as are informed choices. The autonomy of one person cannot override the autonomy of another. There has to be an equipoise in the management of autonomy. Choices are acutely difficult when people are vulnerable.

During the summer I went to Belgium, which has recently introduced a euthanasia law, and saw the hospital services in Antwerp. I was struck by the fact that the palliative care team there, in conjunction with the hospital authorities, has introduced a palliative care filter. Every week, two or three patients who are expressing a wish to die—who are desperate to end their lives—are referred to the team. Since the Belgians introduced their law, only four patients have gone on to euthanasia, with three in the first year. The team felt that it had been a bit too rapid with at least two.

So there is a problem. Patients often express very clearly a wish to die because the situation in which they find themselves is overwhelming. It is gratifying for those of us who work in palliative care to find that we can lift the veil of black despair for patients. We can help them live again and get their symptoms under control. But as the noble Lord, Lord Alton, pointed out, despair is fuelled by misinformation; for example, misinformation to motor neurone disease patients on issues of suffocation and choking to death. That does not happen, particularly when they have good care. A very good international study which included post mortems showed that these patients do not choke to death. As was so eloquently pointed out by the noble Lord, Lord MacKenzie of Culkein, patients with motor neurone disease have

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complex needs. Good care allows them to fulfil their lives; bad care is a disaster. As my noble friend Lady Howe of Idlicote said, the effect of bad care on the bereaved lives on. That trauma never goes away.

The noble Lord, Lord Patten, pointed out the problems of bad or appalling care when decisions are not made properly over withholding or withdrawing food and fluids, or when patients and families are not involved. I am glad that the Minister has today given us an assurance that he is taking this very seriously. I must declare an interest here. I was part of the BMA ethics committee group which is shortly to publish guidance on withdrawing and withholding. I hope that it will set the profession right on what to do and what not to do to avoid bad care. The Liverpool Care Pathway which was alluded to by the noble Baroness, Lady Neuberger, and the advanced care planning tools are helping to make decision-making better at the end of life.

The noble Lord, Lord Colwyn, highlighted the complexities of end-of-life decisions. I was interested that so many noble Lords spoke about the present cost problems. The noble Lords, Lord Alton and Lord Cavendish, the noble Viscount, Lord Bridgeman, and the noble Baroness, Lady Neuberger, all spoke about the tension in establishing a partnership with the NHS and in obtaining funds. The noble Lord, Lord Carlile, alluded to the problems of the lotteries and the unforeseen consequences of actions taken on the Floor of this House.

I was, however, glad that the noble Lord, Lord Carlile, spoke about the need to celebrate life, because nearing the end of life is not necessarily depressing at all. Many people in hospices are cheerful, and many volunteers come back time and again because they say the hospice is such a happy place. The noble Lord’s story reminded me of a paraplegic patient of mine who, against all the odds, managed to get home, where his wife amazingly coped with him for some weeks. When he died, his children decided that he should be buried in his Welsh rugby shirt and that the time of his burial should be exactly at the kick-off for the Wales-England match. We all laughed about it quite a lot. The importance of bereavement care shone through. I was glad that that was alluded to by the noble Lord, Lord Cavendish. Bereavement care, not only of adults but of children, is crucial. I hope it is not forgotten as we look at services.

The noble Lord, Lord Brennan, touched on a fundamental principle of the founding of the NHS—that of human dignity and equitable access for those in need, as well as the profound moral principle and serious political objectives which have to come together. Those words will ring in the ears of all who have participated today. He also spoke of the value to our society of the individual who is facing the end of life, and I hope that my Bill will be able to enhance that and ensure that they can contribute maximally for as long as they want.

Let me return to the vexed questions of Shipman, morphine and decision-making. In his study of decisions at the end of life, Professor Seel noted that a culture of sharing decisions with patients and

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relatives was evident. There is a slight problem with one of the questions in his survey, however. He asked, “In your estimation, how much was the patient’s life shortened by the last mentioned act or omission?”. That is a leading question; one could flippantly say it is a little like, “When did you stop hitting your wife?”. It makes an assumption that the giving of the drug shortened life.

How has this happened? Over the years, the early physiology in animal studies showed that morphine given to animals which were not in pain depressed respiration. From that grew the assumption that morphine was a dangerous drug and was associated with addiction. The logical fallacies ran as follows: “Morphine is a good analgesic but it is an addictive killer. I must not harm my patients so I do not give it too often, but then I am pushed into doing so because pain in the dying is so severe. I give morphine only to the dying, but if my dying patients are given morphine and then die, perhaps it was my morphine that killed them”. But there will always have been a last dose of a drug, as there will have been a last cup of tea and a last breakfast. That logical fallacy has carried on through.

Double effect occurs in some branches of medicine, including oncology. Potent drugs are given with the intention of treating a malignancy, killing off malignant cells. Sometimes they overshoot the mark; the patient has a bone marrow suppression, develops sepsis and dies. But we do not wring our hands and say, “You killed the patient with your oncological treatments”. We say, “What did we get wrong with that dose and how could we have done it differently?”. That is double effect—the intent was to treat the disease, but the outcome, unintended but foreseeable, was that the patient died.

What about morphine? The evidence that morphine is remarkably safe is increasing. I will not run through all the references, but an increasing number of studies show that morphine given properly to patients in pain does not depress their respiration, even patients with restrictive lung disease whom we would expect to be the most vulnerable. There have been some very good studies internationally; it is worth noting that the Dutch abandoned using opioids as a method for euthanasia because they found they did not work. Excellent studies have been done all around the world and more are coming forward. They are worth looking at. The principle of double effect is not good palliative care in its being invoked. You do not need it but you do need to treat patients properly.

I appreciate all the contributions that have been made. We shall all die one day, and many of us will need good palliative care when we do. That sobering thought should guide us to channel healthcare resources towards the needs of such patients, as well as towards those whose conditions can be successfully treated. Such action is indeed the mark of a civilised society, and I hope that the House will afford my Bill a Second Reading.

On Question, Bill read a second time, and committed to a Committee of the Whole House.

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Energy Efficiency and Microgeneration Bill [HL]

2.45 pm

Lord Redesdale: My Lords, I beg to move that this Bill be now read a second time. It is traditional at this point for everybody to do a runner out of the Chamber. I do not have the voice to speak over them. I apologise to the Minister because it will be quite difficult to hear what I say. I apologise to Hansard, because it will be difficult to record what I say. However, I thank all those noble Lords who, on a Friday afternoon, are taking part in this debate.

I had prepared a long speech, but I shall cut it rather short in case my voice disappears entirely. I shall just run through the pertinent parts of this small Bill. The purpose of the Bill is to deal with the great threat of climate change. It is a practical attempt to solve some of the issues which are stopping people reducing the high level of carbon which is pumped into the atmosphere from domestic use.

It is interesting to note that a study carried out by Carbon Neutral North East questioned people about how they were affecting climate change themselves. A staggering proportion, more than 70 per cent, thought that their actions had nothing to do with climate change. They just got up in the morning, had a shower, came home again and turned on the heating. The fact that between 25 per cent and 28 per cent of our emissions, depending on which figures one reads, come from the home is a real concern. If we are to meet our Kyoto targets, and our further targets of reducing emissions by quite significant amounts in the coming decades, we have to look at changing the issue within the home. That is why the Bill picks out two areas where it is important that people are given help. The first is behaviour. A lot of carbon is wasted because we live in a society which wastes a great deal anyway, and it is done without thought. The second is cost.

It is amazing how much energy can be saved in the home through just the most basic of measures. This is why the Bill concentrates on what are seen as the uninteresting measures, loft insulation being the most important. When people talk to me about how they are going to save the planet, they often ask whether they should buy a wind turbine for their roof. One tells them, “Well, no, loft insulation will save a great deal more”. They often reply, “Well, that’s not very exciting”. It can be done, on a DIY basis, in an afternoon, and it would save an enormous amount of energy. It is important to note that 75 per cent of the energy used in the house is not from electricity consumption, where most people invest all their effort in saving energy, but from water and space heating, which people are loath to do anything about.

The second area which the Bill addresses is people’s apparent need to feel that they are saving money. There is a group of people who will do the work without worrying about the cost, but it is strange that, whenever one mentions microgeneration or any form of energy efficiency, people talk about the payback period. It is galling that, having installed a very fine

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new kitchen, I tried to raise the subject of the payback period with my wife, but it cut no ice whatever. However, if I were to think about installing a solar thermal panel on the roof, the cost and how long it would take to pay back would be very much an issue. It is a very fine kitchen. If my wife reads Hansard, which I hope she does not, I would say that it is worth every single penny.

This Bill is one of the first steps to ensure that many of these issues have real influence. I have been involved in discussions with many in the industry, especially B&Q. Many of the Bill’s measures concern the DIY industry. When I considered the Bill’s home efficiency measures I was surprised to note that we are talking only about a cost of £1,000. Considering that the average gas bill is £1,000 a year and rising, the payback on incurring that cost is not inconsiderable but has to be borne. However, I understand the vicious circle of fuel poverty for the poorest people. They cannot afford to insulate their homes, which means that they have to pay more for heating and have less money to spend on these measures. However, the Bill is aimed mostly at owner-occupiers. It is distressing that owner-occupiers will happily pay higher gas bills rather than go to the effort of insulating their roofs. This comes back to behaviour. We need regulation and inducements to make people change their attitude.

I shall consider each clause in detail. Clauses 1 and 2 deal with home information packs and seek to change people’s attitude to energy efficiency. Home information packs will include an energy performance certificate. The home information packs were badly gutted by their opponents. That is a great shame. Even some noble Lords on my Benches are against home information packs but I think that they are an excellent initiative on the Government’s part. I very much hope that they will be taken up by a vast number of people, as I am sure they will, as they quicken the buying process. Once people realise how logical they are, I believe that home information packs will be taken up and will be effective.

I have a question for the Minister. This is a Private Member’s Bill but I very much hope she can confirm that the late and rather aggressive response by the Council of Mortgage Lenders to the consultation will not cause delay in the implementation of the home information packs in June.

These two clauses take the energy performance certificate out of the small print, where many people will not read it, and put it in the main body of the pack. That is important as people will then take notice of it. Clause 2 requires a property’s energy rating to be included in all estate agents’ particulars. Therefore, this information will be prominent when you are trying to sell your house. It is well known that when you buy a house you negotiate the price on the basis of the state of the carpets and curtains. Given that a property’s energy rating will be so prominent, including all the recommendations on upgrading a house in that respect, it will become standard to start haggling over who should implement those measures.

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Clause 3 concerns council tax. This is a real concern to those who are looking at the higher end of energy efficiency. Somebody might install a wind turbine at a cost of £25,000 or a solar panel on the roof to reduce their energy bills. This might have a disproportionate impact on the price of the house as it is then seen as more desirable. Those valuing the property might increase its value. There may be a disincentive to implement energy-saving measures if they result in an increase in the property’s council tax rating. The Government are considering this matter but I emphasise its significance as energy efficiency becomes more important.

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