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Lord Avebury: My Lords, I believe the noble Lord must have made a slip of the tongue when he said that in any one year we detain about 900 asylum seekers. Will he confirm that at the moment there are over 950 asylum seekers in detention and, as they are not there for the whole of the year, the actual figure for the 12 months must be many times that amount?
I mentioned earlier that other European countries had experienced substantial increases in asylum seekers. The traffic in clandestine entrants is almost entirely via other European countries. We must therefore see our asylum policies within a European context. We were wisely encouraged by the noble Lord, Lord Wright, to do exactly that. Our aim is primarily to harmonise asylum procedures within the EU and within the remit of the Amsterdam Treaty. The Amsterdam Treaty commits the EU to adopting minimum standards in the following areas: criteria and mechanisms for determining which member state is responsible for considering an application for asylum; the reception of asylum seekers; the qualification of nationals of third countries as refugees; procedures for granting or withdrawing refugee status; and the granting of both temporary and subsidiary protection.
There is a need to address all our international obligations, not just those arising from the 1951 convention. Subsidiary protection covers those individuals not meeting the requirements of the 1951 convention who remain in need of international protection. Temporary protection refers specifically to the protection granted to individuals at times of a mass influx of humanitarian evacuation--for example, from Kosovo or Bosnia. This is what member states have signed up to for the next few years. It is likely to lead to greater, beneficial harmonisation but much depends on what standards can be agreed.
The Dublin Convention is a treaty to which all the EU member states are parties. It governs arrangements for determining which member state should be responsible for examining asylum claims made within the EU by non-EU nationals. The basic principle behind Dublin is that the member state responsible for the presence of an asylum seeker in the EU should be responsible for examining the claim, wherever it is made. The Immigration and Asylum Act 1999 will strengthen our ability to return asylum seekers to other member states under the Dublin Convention.
Nevertheless the hijacking of an aircraft is a criminal offence and no one should consider that any benefit is to be obtained by hijacking. Those responsible are being held in police custody and will be subject to due legal process. Four members of the cockpit crew have been assisting the police with their inquiries and remain in the UK. They have not claimed asylum and are expected to leave shortly with the aircraft when flight clearance is received.
The remaining flight crew and 58 passengers have returned to Afghanistan. Seventy-nine passengers have either claimed asylum in Britain or are dependants of applicants. These claims will be judged in strict accordance with the law. The applicants are being held at Tinsley House, Gatwick, a purpose built immigration detention centre. They have access to support and free legal advice. I advise the noble Lord, Lord Avebury, that that support and free legal advice have been available to them from the outset. We are satisfied that everyone who wants representation is receiving it. My right honourable friend the Home Secretary is shortly to make an announcement about the future of all the other applicants for asylum status.
I am mindful of the time. Many questions have been raised which I have not been able to cover. I shall gladly write to noble Lords on those points. I hope that I have been able to reassure the House that government asylum policies are effective and humane. We have a comprehensive strategy in place for which the foundations have already been carefully laid, but there is still much to do. We need to speed up the asylum process. We need to implement major legislative reforms. But it is essential that we do so in order to create a system which is genuinely fairer, faster and firmer and one which I think is both effective and humane, in all of our interests not least those of the genuine asylum seekers.
Lord Elton: My Lords, it remains for me to thank, first of all, the large number of organisations outside this Chamber which have made my contribution and those of others possible. They are far too many to mention or indeed to weave a lot of what they have said into words. Their work is deeply valuable and deeply appreciated.
Secondly, I thank your Lordships for a most remarkable series of contributions which leave me with the clear impression that the intention of the Government is that we should have policies towards asylum seekers that are both effective and humane, but that that intention will not be achieved until the enormous queue has been reduced and a swift turnaround of fraudulent applicants discourages further fraudulent applicants from abroad. This will enable us to be more humane with greater resources for those who remain here.
I must not make a speech at this stage. However, in withdrawing the Motion that stands in my name, I wish to say how daunted and yet how encouraged I have been to see the Bishops' Bench full until the very last minute. I wish that the noble Earl, Lord Longford, had chosen some other evening to draw attention to my precative activities upstairs! The presence of the Bishops reminds me also that no country is an island any more. We may look like an island but in this world we are very much part of a world community. I return to my closing remarks and say that, if we ignore the conditions which produce the refugee pressures upon our shores, we are not only making a rod for our own backs but we are also in breach of our Christian duty. I beg leave to withdraw the Motion.
Lord Walker of Worcester: My Lords, I welcome the opportunity that the Motion on the Order Paper gives us to discuss and to look at the remarkable achievements of the hospice movement over the years since it was founded.
I was provoked to seek this debate by two occurrences in my own life in recent times--one, alas, when a few weeks ago my brother died in a hospice in Berkhampstead. He, like others, had gone to hospital and had been diagnosed as having cancer of the lung. It was in its later stages, incapable of operation and unlikely to respond to any known treatment. In that situation, the hospital could do very little more for him and he wanted, in any case, to spend the remaining weeks of his life with his wife and his children.
But when someone with such an illness is at home, being nursed with loving care by his family, there is the terrible problem of a rapid deterioration in the health of that person. He finds difficulty in eating and in drinking; he has pain; he cannot sleep at night; and he becomes more and more immobile. That creates a need for professional nursing and professional care. It is normally at that stage that the local doctor or the district nurse recommends not that the patient should go back to a hospital--there are no beds at the hospital to go back to--but that he should, if possible, go to the local hospice.
In my brother's case, he went to the local hospice, where he received the medical assistance and enormous compassion and loving care for which the hospice movement is noted. It was given not only to him, as the patient, but also to his wife and to his children, who received a great deal of comfort from the manner in which the hospice helped and guided them. Since my brother died, that same hospice has continued to be in close contact with my brother's widow and has given her and her family every possible help and assistance.
It is only a few weeks ago that I, having been its patron over many years, visited that hospice and spoke to the chairman and the chief executive to discover how they were progressing and what was happening. Perhaps I may give your Lordships a little information about that hospice because I think it is an illustration of what is happening throughout the country.
As I said, the hospice was started in 1984. Progress was such that by 1993 it was tending to 280 patients. Last year it tended to 700 patients. In fact, it is dealing with approximately 60 per cent of all those in the area who are suffering from cancer--a remarkable contribution to the health service.
During that period it has recruited a full-time and part-time staff of 38 people, all of them professional and well trained. But it also has 450 volunteers, who provide more than 1,500 hours of work per week for no payment. Those, too, are people who have gone through training in order to provide proper assistance to those in need.
In 1993, with 280 patients, the hospice had an expenditure of £418,000. This coming year it will have an expenditure of £1 million and will deal probably with 800 patients and more than 500 referrals from the National Health Service. There has been an increase in expenditure this year of £264,000, but during that same period the increase in its funding from the National Health Service has been a meagre £13,000. In 1993, the National Health Service provided 30 per cent of its expenditure; by 1996, that had been reduced to 25 per cent; and last year to 20 per cent.
This creates a problem for the future of that hospice. In the county of Worcestershire there are only four beds available for patients who, like my brother, have passed beyond the possibility of treatment and are in the dying phases of their lives. I repeat: only four beds in the whole of Worcestershire. Aware of this problem, Sir Richard's Hospice discussed with the hospital authority the need for more beds and came up with a scheme to create 12 to 15 more beds in the county. The capital cost of doing that is £4 million. The local health authority said that it had no capital expenditure of that kind to put into it.
So those at Sir Richard's Hospice said, "Right. We will go out and raise the £4 million of capital expenditure to create the beds that the people of Worcestershire require". But they obtained no funding at all from the local health authority--not only in terms of capital expenditure but also for the running costs, having completed the project. The running costs will be £500,000 a year, and they cannot get a penny in funding from the local health authority towards that expenditure; nor can they obtain any kind of long-term guarantee about funding.
So what are the trustees of the hospice to do? If they decide to proceed with the capital expenditure--where they will raise all the money--they will be unable to service the capital expenditure and the facilities provided. They cannot recruit new staff and they cannot enter into contracts when the degree of funding available is perhaps nil and when no guarantee can be given. One might consider that that is a local case and that it is not repeated all over the country; but if one looks at the national scene, one finds that it is repeated all over the country.
I want to say a few words about the national development of the hospice movement over the years. It is a very remarkable achievement. We now have 185 hospices for adults, which spend £250 million a year. Of that, less than one-third is contributed from the National Health Service. Hospices deal with the majority of cancer patients in need of care.
The Government--quite understandably and to everyone's applause--have said that they have a great campaign as far as concerns cancer. They also have a campaign to seek better facilities for the elderly. If there was ever any part of the National Health Service which has contributed to both of those areas, it is the hospice movement--and yet year after year the proportion of its expenditure funded from the National Health Service has steadily declined. In the past two years, it has gone down from 35 per cent to just over 32 per cent, and that decline is continuing.
The Government have said that it is the duty of the health authorities to give hospices long-term contracts. Of 13 hospices in the Midlands, only two have obtained any kind of long-term contract--and those two long-term contracts exclude any contribution to costs. So they are not particularly valuable long-term contracts.
In announcing their policy that this should be dealt with by the local authorities, the Government have a valid argument: local authorities know the local needs. I have nothing against that. But if in relying on the local authorities to do this the Government find that they are not doing so, they have a duty to take speedy action to ensure that the proper funding is provided.
The hospice movement has contributed not only to the elderly and the dying; it has also dealt with the problems of other incurable diseases. It has offered considerable help to people with the problem of AIDS. It discovered very quickly that, although there was a great need to give counselling and help to the elderly in their final days, there was an even more horrific problem of children with incurable diseases. There are now 17 children's hospices in this country, which spent £20 million last year. The total contribution from the National Health Service to these children's hospices is a meagre 4 per cent of all of their expenditure.
As somebody who spent most of the time between 1970 and 1990 in Cabinet, I am well aware of the problems faced by governments in regard to expenditure on the health service. I have sat through Cabinet meetings and Cabinet committees with a desperate desire to achieve--in fact, we always
I was always in favour of extra expenditure, being described as the leading "wet" in previous governments and in John Major's autobiography as the "Dick Turpin of the Cabinet". I recognise the problems. In the totality of expenditure on the health service, here is one area where for every £1 given, one receives more than £1 by voluntary effort and voluntary contribution. One has injected into this service a compassion, an understanding and a sympathy that is quite unique. Anyone who visits hospices and meets the volunteers--the people running them and guiding them-- will recognise their unique spiritual and compassionate contribution to the health service.
I urge the Government to examine the drift in contributions from the National Health Service to see whether, by perhaps administrative methods if not direct financial methods, this can be changed and the movement encouraged to expand in the future. If one does not do that, one will quickly face a crisis.
In 1998 Professor David Clark examined the hospice movement and said that one in five hospices was worried about its financial viability. The position has deteriorated since then. Instead of an expanding movement in the coming decades, we shall have a contracted movement, to the immense detriment of the National Health Service. My Lords, I beg to move for Papers.
Lord Blease: My Lords, I thank the noble Lord, Lord Walker, for the very moving and practical way in which he introduced this informative, challenging and timely debate. It enables me to mention some of the constructive, caring and civilised community work that the hospice movement provides in Northern Ireland, work and services which bind strongly all classes and creeds in caring and the relief of suffering which, sadly, in due course, will affect some one in three people in Northern Ireland.
For me the debate is something more. It is a much more worthy change than trying to analyse, explain and cope with the evils, distrust, the terrible human suffering and deaths that cruelly and sadly arise from rampant sectarianism generated political evils.
I wish to mention especially the provision of a new Northern Ireland Hospice Children's Service. This was launched two years ago with a £5 million appeal to provide an essential children's service for some 700 life-limited ill children, a number recorded annually in Northern Ireland. The appeal fund was launched two years ago in February 1998. It provides for a purpose-built hospital with suitable bed accommodation for 12 children up to 18 years of age. It will also have suitable living accommodation for family members of the very ill children in the hospice.
The estimated cost of building and suitably equipping the children's hospice is £5 million. Some £4 million has already been donated voluntarily by hospice friends and supporters. It is scheduled to open officially on 1st April 2001. It will require some £1 million per year to provide the essential nursing, bereavement counselling and support personnel.
I know from debates and reports in this House over some 22 years that there is earnest, studied support for 50 per cent funding by government of approved hospice annual revenue expenditure. For some years the Northern Ireland Hospice annual revenue costs have had a "grant in aid" from Northern Ireland health boards in the region of 13 per cent for approved revenue account expenditure only. There is almost entire dependence on the generosity of local citizens and special fund-raising events for both capital and approved revenue expenditure.
A number of noble Lords have held ministerial office in Northern Ireland. I know that they are well acquainted with the priority needs in the Province for special cancer-related illnesses and hospital treatment. There have also been a number of special debates in this House expressing concern about the hospice movement's unique nursing services and related financial needs.
Noble Lords will be well acquainted with the financial needs of the hospice movement about which the noble Lord, Lord Walker, spoke ably today. The Chief Whip, the noble Lord, Lord Carter, and the Leader of the House, the noble Baroness, Lady Jay, are on record as having drawn attention to the important role of the hospice movement within the National Health Service. The noble Baroness, Lady Jay, stated in 1998:
Baroness McFarlane of Llandaff: My Lords, I, too, would like to express my thanks to the noble Lord, Lord Walker, for his contribution and authoritative start to this debate. It is, I believe, a timely debate on the hospice movement.
Perhaps at the start I ought to declare my interest or the perspective from which I approach the subject. As a student nurse I spent many months on night duty going from ward to ward acting as a special nurse to dying patients. That had a lasting impact on my professional outlook. From that time I have always regarded the care of the dying as one of the most skilled and worthwhile areas of nursing care. Later in my career I became a council member of St Anne's Hospice, Manchester, with a particular brief to look at the educational needs of the hospice nurses. I am still a vice-president of St Anne's but with far less active involvement. Later I became a trustee of the Malcolm Sargent Cancer Fund for Children and the council of Macmillan Cancer Relief. I am aware that there are many other voluntary agencies, all contributing to this field and representing a tremendous public commitment to care.
I have been privileged to visit many hospices in this country and in other countries. Without exception, it seems to me that the hospices that I have visited in other countries pay tribute to the model set in this country. The hospice movement has inspired the imagination of the public since its beginnings with the work of Dame Cicely Saunders, who has already been mentioned. She started at St Joseph's Hospice before she founded her own hospice. When speaking she often reminded audiences that a hospice was originally a place of rest for travellers kept by a religious order. It was the devoted care given by the nuns at St Joseph's which was a powerful inspiration to Dame Cicely in her own experience of bereavement and became a model for her future work.
That model included expert physical care, bedded in the kind of hospitality which was the hallmark of the ancient hospice, and the recognition that the process of dying is as much a spiritual journey as a physical process. There has been a close association between the hospices and the various Churches and representatives of different faiths in acknowledgement of that. To this Dame Cicely added her expert knowledge of pharmacology with which she was able to pioneer new approaches to pain management. Those have transformed the experience of dying for many.
The hospice movement has profoundly influenced the way in which we care for the dying. In what can be a traumatic experience for patients, relatives and friends, the kind of care which allows people to die in peace and with dignity is highly prized and the public have always been willing to give generously to providing that quality of care.
I have talked to different people who are now intimately involved in the hospice movement and they have raised several issues with me. I have talked to nurses who belong to the RCN forum for palliative
In the early days, which I can still remember, of hospice provision, funding was almost entirely from the voluntary sector. Gradually, hospices pressed the fact that they were supplying healthcare that would normally fall to the National Health Service and they were able to negotiate funding for a proportion of beds based on the estimated local need. It was quite a fight to establish that principle. But the contribution of health authorities has always come under pressure, reflecting the pressure on resources in the National Health Service itself. The previous government at one time made a commitment to work towards a 50/50 funding. However, as Peter Tebbit pointed out, NHS contributions measured as a percentage of annual running costs have declined on average by about 3 per cent over the past three years despite the cash contribution rising year on year.
The contribution to individual hospices varies from 9 per cent of the total cost to 61 per cent of the total cost. There is a tremendous variation. At St Anne's Hospice, Manchester, the contribution from the National Health Service has fallen from 51.2 per cent to 33.4 per cent over five years. Even in National Health Service-managed units, there is an increasing call on non-NHS funding. There is thus an increased reliance on non-NHS funding and there is a competition for fund raising between hospice and hospice and other charities, particularly the cancer charities.
Dr Maher of Macmillan Cancer Relief pointed out to me that a high percentage of posts in palliative care--lecturers, researchers, doctors and nurses--are funded by the voluntary sector. She said that they at Macmillan are able to pump prime appointments, but then no one seems willing to take on a more permanent funding of the post. In addition, effective palliative care needs to be organised across a number of organisational boundaries in a range of units. A worker may have to work in palliative care, general practice, a hospice, in a DGH or in a cancer centre. There is a reluctance to share in funding for such posts across boundaries.
In summary, there needs to be a more equitable and dependable process for palliative care funding, a longer term and more stable health authority contract base and a clear funding policy based on tangible criteria for cash distribution. A great debate is going on between the voluntary and statutory sectors about what criteria should be adopted for funding. Peter Tebbit suggests that the Government's own healthcare policies should be used as a basis for determining funding criteria.
Lord Varley: My Lords, I join my noble friend Lord Blease and the noble Baroness, Lady McFarlane, in thanking the noble Lord, Lord Walker of Worcester, for initiating this important debate. The noble Lord, Lord Walker, referred to his time in the House of Commons. When he was Secretary of State for Trade and Industry and I was his shadow, we often crossed swords over the Dispatch Box. Similarly, when I became Secretary of State for Industry, the same thing happened again. However, I am very pleased today to be able to walk side by side with him and to thank him very much for initiating this important debate.
I start by declaring an interest. I was a founder trustee of the Ashgate Hospice in Chesterfield, which serves the whole of north Derbyshire. I am now one of its vice presidents. The Ashgate Hospice was opened in 1988 after a very successful fundraising campaign which was massively and generously supported by the local people. By some standards within the UK the hospice is quite small. It has 14 beds, a day centre, a home care team, specialist palliative care nurses and a bereavement support service. Its administration and nursing arrangements are organised by a dedicated hospice manager and a medical director. They lead brilliantly teams of nurses and carers as well as dozens of local volunteers. I honestly do not know how the people of north Derbyshire could cope without the hospice and the contribution it makes to the National Health Service. It is a very special place.
The Ashgate Hospice has established a very good working relationship with the National Health Service locally and with charitable organisations. I expect that the excellent relationship that I find in north Derbyshire is repeated throughout Britain where hospices and National Health Service trusts work closely together. The partnership between the statutory services and the voluntary services is the only way to maximise or optimise the care that is so essential for people with terminal illnesses.
All the indications show that the need for palliative care is set to rise. As people live longer, and as the older age groups are at greater risk of contracting the disease, cancer incidence will increase. As the treatment for cancer improves, people will be surviving for longer; in other words, living longer with their cancer. The need for more and more palliative drugs and care will increase. That trend will put even greater pressure on the resources of hospices and on the voluntary services.
The new optimism that existed as regards the benefit of good palliative care is now becoming more widely understood. But it is tempered by uncertainties about the funding of hospices. That was the essential point
I understand that the aim of 50/50 funding for hospices advocated by the Conservative government in the early 1990s has now been abandoned. Will my noble friend the Minister say whether it was in fact advocated by the previous government, why it has been abandoned, and whether the matter can be re-examined? Also, is it the case that the palliative care moneys given by the Government in the early 1990s, which were ring-fenced, have also been scrapped? If it is the case, why was that decision taken?
In the early 1990s, the Government made available special additional money for the provision of drugs to hospice patients. As palliative medicine has developed as a speciality, money for drugs has not been increased, except, I understand, to cover the cost of inflation; therefore hospices are now expected to meet from voluntary sources the additional cost of drugs. If that is the case, I cannot see that it is right. I should like my noble friend the Minister to comment. He will know that hospices are expected to find some costs for drugs as palliative medicine develops. However, to place a great burden on the voluntary sector is not the best way to go about it.
There is another matter on which I should welcome my noble friend's comments. The higher pay awards for trained nurses are greatly to be welcomed, and nurses deserve every penny. But is it true that the cost of those pay awards will have a disproportionate effect on hospices because they employ larger percentages of trained nurses than average? Coupled with the pay awards is the 1 per cent increase in employers' contributions to the National Health Service pension--because hospices try to match, and in most cases do match, National Health Service pay and conditions.
Will my noble friend say something about the £23 million New Opportunities Fund for hospices, which I understand was launched in October 1998? Is it correct that the fund will not be fully distributed until the end of this year? Why will it have taken two years to administer it?
I am told that the question of whether hospices are to receive adequate finance is a burning issue at present. The split between the statutory and voluntary funding of the hospice movement, and the question whether the proportions are correct, is casting a cloud over those who do so much to make them a success. I had intended to talk about St Christopher's Hospice, but the noble Baroness has already done so and I shall not repeat her comments.
I have no doubt that my noble friend the Minister will readily accept that the hospice movement has made, and will continue to make, a massive and valuable contribution to the National Health Service. But I hope he will acknowledge that there are worries and concerns about the rising costs of running hospices.
In north Derbyshire, the population is not well off. Great swathes of industry have gone over the past two decades. All the coal mines have been closed and most of the heavy industry has been shut down. The male unemployment rate is above the national average. So the task of raising money year on year to fund the hospice is a matter of immense concern. It is necessary to raise some £600,000 a year to maintain it--and that takes some doing. I hope that, in replying, my noble friend will be able to reassure all those who have helped--I have done very little, but I refer to the thousands of volunteers who have pioneered the hospice movement--that not only is their work valued and worth while, but that the Government stand ready not only to encourage but to help financially as well.
The Lord Bishop of Bristol: My Lords, I join with noble Lords who have spoken in thanking the noble Lord, Lord Walker of Worcester, for introducing this issue. It is nearly 30 years since I had the privilege of meeting Dame Cicely Saunders and ensuring that clergy in training received the opportunity to experience ministry to the dying at St Christopher's Hospice. I was caught, and since then I have been involved in the hospice movement, as Bishop of Wolverhampton in raising sufficient funds to build Compton Hall, and, when I came to Bristol, undertaking a role with St Peter's Hospice.
Local hospices are registered charities--and perhaps we need to remember that, and that they are delighted that they are; otherwise, funding would be even more difficult. But they are also significant community organisations, as I hope to demonstrate, as well as healthcare institutions. Perhaps I may use the example of St Peter's Hospice in Bristol, as it illustrates some of the issues which have been alluded to but which need to be underlined.
There are some 1,400 volunteers in the local hospice movement. That is a significant number of people. They are financially supported with great generosity by men and women across the Greater Bristol area, which St Peter's Hospice now serves. That is what the community contributes to the hospice movement. In return, it receives an immense amount. There are presently 350 patients, who are seen in their own homes by specialist community nurses. That has been one of the great developments over the past 20 years since the hospice movement started at St Christopher's. Keeping patients at home supports the family and allows people to die with dignity among those whom they know and love. We should be very proud that, as a nation, we have been able to pioneer that approach.
In addition to home care, there are 100 places in day hospices--another creative development. It must be seen alongside the original concept of providing beds in a particular hospice. St Peter's now has two hospice buildings, one in the south and one in the north of the city. Thirty beds in all have been provided, but funds are presently available for the use of only 20. That is a significant factor. We cannot quantify the
As we have heard, hospices have spawned a speciality called specialist palliative care, involving consultants and highly qualified nurses who deal with some of the most complex cases. St Peter's Hospice was the first palliative care provider in Avon. Since then, St Peter's has encouraged the development of hospital teams and presently pays towards consultants' salaries at two local hospitals. It is not just about receiving, but about giving to Frenchay and Southmead Hospitals in the Bristol area, so extending palliative care and pain control to patients in those hospitals. Many of the staff of the trust care teams were trained by St Peter's Hospice and at the hospice itself.
There are also continuing new initiatives, not merely a movement from the provision of beds to domiciliary care and day centres. There is now a lymphodema service. I did not know what that meant, so I rang up to ask. I am told that it seeks to ameliorate the distressing, painful and often debilitating swelling of the limbs and body arising from certain cancerous conditions. That initiative, which is provided by St Peter's Hospice and has a very high reputation among the medical and nursing professions, improves the quality of life of patients, which is important. It also brings about a reduction in hospital admissions, which allows beds to be used for other people.
I was told that, with grateful thanks to the National Lottery Charity Board and the New Opportunities Fund, it would fund such an initiative--it was not required--but that no one would continue to contribute to the annual cost of £86,000 to keep the service going. That is one of the problems that we face. By and large, capital costs can be met by the generosity and understanding of English people, but to maintain the ongoing revenue costs is much more difficult. We are in danger of losing some of the greatest initiatives because that has not been taken care of.
Clearly, the hospice movement has engaged the hearts and minds of Englishmen and women, and that has been exported abroad. Two years ago I spent some time in Norway. From the middle of the previous century that country has had a very great tradition of caring for people through institutions. Norway did not provide a great deal of care for those with terminal conditions but it learnt from us and is grateful for it.
The hospice movement provides to those with terminal conditions dignity and a quality of life. Perhaps it courts something which is an important part of human nature: the need to care. The hospice movement provides us with an opportunity to exercise the care and generosity which all of us need. The movement is about dying with dignity and, if we are honest, it is to talk about ourselves, because we too may need to be ministered to there.
I should like to raise two issues both of which have been alluded to. First, I refer to continuing costs. The lymphodema service will continue in its present way only if we can begin to address the issue of revenue
We are really talking about a partnership between the hospice movement and the National Health Service. One of the problems in the NHS is understanding how it might organise itself into partnership with voluntary organisations. I believe that it requires a change of mind and ethos, but I also suspect that it needs confidence that it has the necessary funding over a significant period of time. Therefore, I echo the questions that have been asked of the Minister and look forward to hearing his answers.
Dame Cicely taught us that the hospice movement is about hands on the bedclothes which need to be taken by somebody else so that the patient does not die totally alone. Hands are also about partnership and being moved out from the hospice movement to be held by the National Health Service so that it underpins the healthcare of a whole community, not just part of it.
Lord Hayhoe: My Lords, like all who have spoken, I begin by thanking my noble friend Lord Walker of Worcester for initiating the debate. I add my congratulations to him on his distinguished speech. I too must declare an interest as a former president of Help the Hospices. How fortunate we are to have such a thriving and flourishing hospice movement in this country. One must never forget that as soon as the hospice movement is mentioned the mind automatically switches to Dame Cicely Saunders who initiated the movement and who has animated so much of it over the years.
The whole concept of palliative care has moved up the medical agenda in recent years. In 1987 it was formally recognised as a sub-specialty in the medical world. Major teaching hospitals have professors of palliative care who did not exist 20 years ago. More and more doctors now concentrate on this branch of medicine. I should like to hear the latest total from the Minister. I understand that in the middle of last year the figure was about 100. Those developments have knock-on effects on hospices. Changes in the hospice movement must take account of developments in palliative care. In this country we used to take pride in the fact, rightly, that in the NHS we had the best medical service in the world. Alas, those days have long since gone. However, we can and do claim to have one of the best hospice movements--if not the best--in the world, and long may it remain so. The acknowledged dedication of all concerned, both professionals and volunteers--Macmillan Cancer Relief, Marie Curie Cancer Care, the Sue Ryder Foundation and many other local groups and interests--contribute to the success of the hospice
People often think of the hospice movement only in terms of the buildings themselves and those who occupy them without appreciating that the majority of patients are now looked after in their own homes. Outreach and respite care are vital elements which are highly regarded by patients and their families and friends. All aspects of hospice care must be cherished, but one cannot avoid the financial implications. However, the hospice movement is probably, in aggregate, the most successful charity fundraiser in the country with its diverse and locally focused enthusiasm. One of its secrets is that people are more likely to give to their local hospice than to a national charity because they have ownership of that local hospice.
It is the combination of enthusiasm and ownership which contributes so much to the success of fundraising. But the Government, through the NHS, should not take advantage of that by reducing the element of state funding which would otherwise be required to do the work of hospices. We need a greater contribution from the state--the NHS--to core funding which is essential to maintain the hospice movement. An answer by a health Minister in another place last December revealed that approximately one third of hospice running costs is met through the NHS. If that is in a reply to a parliamentary Question, one can rest assured that it will not be over one-third. That contribution has gone down to 32 per cent, and it would be helpful to hear the Minister's comment. Although that figure applies generally, one of my greatest worries is that children's hospices account for less than one-twentieth. If that fact were widely known in the country--I hope that the Minister will tell us that the figure is indeed 4 per cent--people would rise up and say that more should be done.
It seems to me from comments already made about the 50-50 split that that is about the right proportion. I should own up to the noble Lord, Lord Varley. Although it was a Conservative government who made the 50-50 split objective in the early 1990s, it was another Conservative government in the mid-1990s who abandoned the target. Today's debate has shown that there is no party point to be made on the issue. I hope that all of us are united in urging greater support from the Government. It would be better if we had a Treasury Minister sitting on the Government Front Bench because it is not the health Ministers who are being difficult or reducing funding, as I know from my experience as Minister for Health many years ago.
As I understand the position, government support for the running costs in England has declined from about 35 per cent in 1996-97 to under 32 per cent in 1998-99. Therefore, I welcome very much the establishment of the Independent Hospices Representative Committee (IHRC). This new body will be working with Help the Hospices as a powerful,
Putting on a political hat, and not a party political one, if one thinks of a co-ordinated approach by all the local hospices in the country to their local Members of Parliament, and pressure from all party sources locally on those Members of Parliament, urging that more should be done, a pretty powerful lobby would be built up of which I hope the Government would take proper account. I have mentioned the wonderful organisation Help the Hospices. I again pay tribute to the Duchess of Norfolk for her fabulous fundraising and long term leadership of that organisation. Her contribution to the hospice movement has been, and is, superb.
I conclude by saying that I hope that the representations that come from the Independent Hospices Representative Committee later this year will give the Government an opportunity to review the whole area. I hope that the effect will be an increase in the support given to hospices and a more rewarding partnership, as the right reverend Prelate said, between the voluntary and statutory sectors for the benefit of the hospice movement in all its varied and fulfilling aspects as it grows and develops to meet future needs and public expectations.
Lord Clement-Jones: My Lords, perhaps I, too, may congratulate the noble Lord, Lord Walker of Worcester, not only on initiating the debate but also on the very passionate and persuasive way in which he introduced the subject today. I also thank other noble Lords for their particularly knowledgeable contributions to the debate, all speaking from their own personal experience.
Hospices are a cause very close to my own heart. My late wife, Vicky, died of ovarian cancer in 1987. She did not actually die in a hospice because she had an unexpected remission for a short period due to steroid treatment. In 1986 we went through the process of identifying where she wanted to die and, above all, reconciling ourselves to her imminent death. The place we chose was located in Clapham. We were very lucky indeed to have it so close at hand. The Trinity Hospice is our nearest. It has huge local and London-wide loyalty from all who know about it.
It felt strange to her at the time to be doing all these things because as part of her early research in setting up Cancer BACUP she visited St Joseph's in Hackney and St Christopher's in Sydenham, where she met Dame Cicely Saunders. It seemed to be odd to be looking at hospices from a different angle. Fifteen years ago she was also fortunate in some ways in that she was able to take advantage of pioneering home-based palliative care techniques, many of which we now take for granted. Bart's itself was a pioneer at the time, but it had learned almost all of those techniques from the hospice movement.
As the result of the work by pioneers like Dame Cicely, we now have a total of 236 hospices caring for 60,000 patients a year, as we heard from the noble Lord, Lord Walker, and other noble Lords. They involve a huge number of volunteers, as mentioned by the right reverend Prelate the Bishop of Bristol.
I welcome the resources, such as they are, that are made available by the Government. As we have heard, just under one-third of hospice resources are derived from the NHS. There is about £20 million for palliative care coming from the New Opportunities Fund, with 88 lottery awards made to 75 hospices. However, I believe that the noble Lord, Lord Varley, asked some extremely cogent questions about the funding and when it will be made available.
I also welcome the much stronger role that palliative care now plays within our hospitals as well as in our hospices, which led the way in the first place. I particularly welcome the way in which the department is spreading best practice. But as we have heard from every single noble Lord in this debate, there is a great deal more that should be done.
As we have heard, Government funding has been declining over the past three years and hospices are having to rely more and more on, and compete for, private donations. If that has been the case under the existing commissioning system, what effect will the commissioning by the new primary care groups have? What guidance is being given to the primary care groups? Will the agreements be sufficiently long-term, as noble Lords have asked, or is the picture painted by the noble Lord, Lord Walker, and others correct as regards individual hospices? Is there a major problem, with hospices that can raise the capital being unable to guarantee that revenue funding will be available in future years?
There are also parts of the country where there is less hospice or palliative care than in others. How will that imbalance be assessed and dealt with? Is there any evidence that the health improvement plan system is up to the task? Will the relevant national service frameworks, such as that coming down the track for older people, make sure of that? Also, is it NHS policy to have palliative care and pain control clinics attached to each district general hospital? What is the pattern of care anticipated by the Government? Clearly, there are also insufficient doctors who have the necessary skills to deliver palliative care. What plans do the Government have to improve that situation?
A number of your Lordships have mentioned the very wide role that hospices play, quite apart from the care for those in residential care. They are not solely concerned with palliative care for the terminally ill. They are also a valuable community resource. They are as much concerned with maintaining a good
The vast majority of patients in hospices are there as a result of cancer. Ultimately, however, we need to ask why we have this number of terminally ill cancer patients. Recent reports from the hospices themselves show that carers and managers say that an increasingly large number of their patients are reporting a history of medical errors or delays in treatment. Some hospices claim that one in three of their patients have been victims of delays or misdiagnosis. There is little sign that delays are improving. If anything, they are getting worse.
There are deep concerns, despite the priority attributed to cancer by this Government--I welcome the appointment of Professor Mike Richards as National Cancer Care Director and his making supportive care one of his highest priorities--and a huge amount of additional resource is needed. An additional 500 cancer specialists are needed. We need to spend £1.2 billion on equipment and £170 million on drugs, as Professor Karol Sikora recently stated, if we are to catch up with the rest of Europe.
I wish to raise another matter with the Minister which is relevant to hospices and those who are terminally ill. It concerns the joint statement from the BMA, the Resuscitation Council, and the Royal College of Nursing on decisions relating to cardiopulmonary resuscitation. The matter was raised not only by the noble Baroness, Lady Miller of Hendon, in a recent Question for Written Answer, but also by the noble Baroness, Lady Seccombe, at Starred Questions. The statement requires doctors effectively to obtain consent from a patient who is dying of terminal cancer if he has not indicated his wishes, even when resuscitation might be futile and unethical. Under the statement doctors are required "to sensitively explore" the wishes of patients regarding resuscitation in those who are dying of cancer. A very experienced and senior consultant medical oncologist at St Bartholomew's and the Royal London Hospital has written to me in the following terms:
This important debate has highlighted the work and value of hospices. I have an enormous admiration for them and believe that we should aim for all those who are terminally ill either to have residential or at home support from a hospice. The ethos of hospices as an institution is one of the most impressive I have ever come across. The right reverend Prelate the Bishop of Bristol said that they had engaged the hearts and minds of men and women. I do not think that that statement can be improved upon. Dame Cicely was quoted in The Times last June. As so often she had it right when she said:
Earl Howe: My Lords, every so often the House has the good fortune to debate a subject that carries with it a deep resonance for all of us; and this is one such example. I join other noble Lords in thanking my noble friend Lord Walker for giving us that opportunity and for the superb and moving way in which he introduced his Motion. After a debate of this quality, there is little left for me to say other than to draw together some of the more important themes, and this I shall try to do.
Perhaps the best description of what the hospice movement seeks to achieve was one given to me recently by the charity that my noble friend Lord Hayhoe has supported so closely, Help the Hospices. A hospice is a place that seeks to add life to days, even when days cannot be added to lives; and to offer the best quality of care to every patient according to his or her needs or wishes. Hospice care is based on the simple idea that a dying patient is a living person; someone who deserves peace, respect and calm until the very end of his life.
I do not think that there can be any better guiding principle than this for the care of the terminally ill; but it is a principle that surely casts its net even more widely because it gives rise to a mode and style of palliative care that should, and does, inform every branch of clinical practice and every type of nursing discipline. Indeed, the idea that it rests on is the same one that makes the National Health Service itself speak as powerfully to us as it does: and that is the idea of human dignity. If there is any guiding belief that marks a civilised society--I refrain from saying too much about a Christian society, although I could--it is surely the belief that individual human lives and human dignity are worthy of the highest recognition in all that society does.
I am struck, as many noble Lords have been, by the predominance of the voluntary sector in the provision of hospice care. The hospice movement has its origins in the work of religious orders during the last century,
I mentioned ability to pay. Patients do not, of course, pay for care provided by voluntary hospices. The greater part of the running costs of such hospices is funded from charitable sources. But, as my noble friend Lord Walker was right to emphasise, the NHS is also a contributor to, just as it is an important user of, hospice services. It is perhaps worth recounting some recent history. In the early 1990s specific funding for voluntary hospices was ring-fenced by the Department of Health, so that a certain budget was assured. Then from 1995-96, the funding was absorbed into the ordinary departmental allocations which had the benefit of enabling health authorities and hospices to agree contracts over a longer term and thus provided a firmer basis for planning ahead.
Before that, in 1993 Ministers had set a target. The target was that, overall and over time, public funding for hospices should match voluntary giving, pound for pound. There was a recognition then that the voluntary sector and the NHS needed to work together and develop hospice services in a structured and co-ordinated way and to plan services flexibly over the long term. But that equal division of financial responsibility, as my noble friend has revealed, has not materialised. Indeed, it is apparent that the proportion of hospice funding provided by the NHS is falling, not rising. That is a matter for concern. I follow the noble Lord, Lord Varley, and the noble Baroness, Lady McFarlane, in asking for the Minister's comments.
We have heard the point made by my noble friend and many noble Lords that across England the average percentage contribution from the NHS towards running costs for voluntary hospices fell from over 35 per cent in 1996-97 to 32 per cent in 1998-99. That fall coincided with an increase in the use of hospice services by the NHS. In other words, the NHS is leaning more and more heavily on the voluntary hospices and providing proportionately less and less means of sustaining that burden. Currently the voluntary hospices are raising well over £150 million a year from non-NHS sources, with hospice running costs rising at a rate of 8 per cent a year. There are real fears that with increasing competition from other charities, the National Lottery and even fund-raising by NHS trusts, the hill for hospice fundraisers will become too steep a hill to climb.
Let me follow my noble friend's example of St Richard's Hospice and the right reverend Prelate's example of St Peter's Hospice with the example of the Hospice in the Weald, situated in Tunbridge Wells. At any one time, this hospice is looking after 200 patients, whether in the community, in nursing homes or in the hospice itself. Last year, a total of 545 patients were referred to the hospice by GPs and hospital doctors. The team provides counselling and family support as well as training in palliative care to health professionals. There are service agreements with two health authorities and an active partnership with the local NHS at every level. Yet, of the annual running costs of £1.5 million, only £262,000, or 16 per cent, is covered by statutory income. The remainder of the running costs have to be met from charitable fundraising.
That is a tall order for any voluntary organisation, but it means also that any ideas for expansion of the hospice's services--additional beds, treatment for lymphoedema, or physiotherapy--simply cannot be countenanced without the support of partner health authorities. Discussions are, I understand, under way, but even now the Hospice in the Weald is receiving only half the rate of funding from the West Kent Health Authority (on a per capita basis) compared to that given to hospices nearby. Such a gap seems anomalous.
The picture is even less satisfactory when we look at support for children's hospices. The Association of Children's Hospices has stated that while some children's hospices receive anything between 8 and 15 per cent of their funding from health authorities, many others receive nothing at all. The average amount is less than 5 per cent. Compared to adult hospices, this is almost derisory. Although no doubt the reasons for the discrepancy are partly historic in that children's hospices are a comparatively new phenomena, there is more than a feeling here that health authorities are placing undue reliance on the ability of such hospices to attract charitable income. To echo my noble friends Lord Walker and Lord Hayhoe, I ask whether this is right and whether it is not something that Ministers should review carefully. There could be no better recognition of the valuable community service provided by children's hospices than a firm commitment by government to increase the level of statutory funding.
As other noble Lords have pointed out, it is impressive and extraordinary to look at the growth of the hospice movement over the past 20 years. Since 1980, the number of hospice units in the UK has grown from 38 to 223; the number of beds from 1,000 to more than 3,000. Of those units and beds, the independent sector accounts for about two-thirds; and this of course excludes the development of community support teams, hospices at home, day centres and bereavement counselling, all of which are an integral part of modern-day palliative care.
What is equally striking is the regional disparity of service provision. In the north-west, there are 66 hospice beds per million of population; in Trent, only 36. Why should that be? I should be glad to hear
The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath): My Lords, I join the noble Earl, Lord Howe, in congratulating the noble Lord, Lord Walker of Worcester, on being successful in securing a debate on the hospice movement. I found his remarks most moving. His patronage of St Richard's Hospice in Worcester has given him tremendous insight into the achievements and challenges of hospices in this country.
Like other noble Lords, I want to pay tribute to three important figures in the hospice and palliative care world. I refer, first, to Dame Cicely Saunders, who has rightly been mentioned by many noble Lords tonight; and, secondly, to Professor Eric Wilkes who in 1980 chaired a working group which considered the organisation of primary, continuing and terminal care services for cancer. He set the scene for the changes that we have seen in palliative care during the past 20 years. It is also appropriate to join the noble Lord, Lord Hayhoe, in admiring the enormous fundraising gifts of the Duchess of Norfolk.
Like other noble Lords, I am a great admirer of the modern hospice movement. Every noble Lord has mentioned at least one hospice he knows well and I cannot resist the temptation to pay tribute to my local hospice in Birmingham, St Mary's Hospice, which does extraordinary work for the city of Birmingham and its people.
From the foundation of caring for the whole person, the hospice movement has established the development of effective symptom control, openness, respect for the patient's own wishes and needs, and care for the patient's family as the cornerstones and founding principles of palliative care. It is this approach which sets this country among the world leaders in palliative care, as the noble Baroness, Lady McFarlane, pointed out.
My noble friend Lord Blease spoke vividly of the achievements of the hospice movement in Northern Ireland and it is the same throughout the United Kingdom. The care provided by hospices, the great majority of which are voluntary organisations, is
However, I believe that excellent examples are to be found where the NHS is doing well. In the Bloomsbury area of London, a rapid response palliative care crisis support team, spanning hospital and community settings, is run and managed by nurses. The primary care team and the specialist palliative care team work well together. Both the health and social care needs of patients are met, including personal care. There are many other examples.
The principles and practice of palliative care, which are all about partnership and quality of care, must be available to all healthcare professionals, to people facing life-threatening illness and to their carers. The field of hospice and palliative care is setting gold standards in partnership working, as the right reverend Prelate said. That is why in June 1998 we distributed to the NHS three excellent guidance documents, as the noble Lord, Lord Clement-Jones, pointed out. These covered cancer pain, the last years of life, and the provision of palliative care in hospitals. The documents, produced by the National Council for Hospices and Specialist Palliative Care Services, and written by hospice experts, are available to help all NHS trusts. Taken together, they identify how all concerned can improve the quality and care they provide for the dying.
That is a good example of hospices and the NHS working together. I was particularly interested in the reflections of the noble Baroness, Lady McFarlane, on her experience in the NHS. There can be no doubt that the lessons learnt in the hospice movement have also had a profound effect on NHS practice--it is not yet sufficient, but they have appreciably improved the quality of what the NHS does.
Another area which I have mentioned in relation to partnership working concerns joint appointments for consultants, crossing health and voluntary sector boundaries. I know from a recent visit to my local hospice that shortage of medical directors in particular is an issue for many hospices. We certainly support the joint appointments approach, with a medical director also holding a consultant's post within a local NHS trust. In answer to the question raised about the number of palliative care consultants in post at present, my understanding is that there are 245. That figure is growing year by year, and I am very pleased about that.
A number of questions have been raised about standards and performance indicators and the consistency of service availability throughout the country. As the noble Earl, Lord Howe, pointed out, there is no doubt that there are striking differences in the provision available in different parts of the
That work is being taken forward with the National Council for Hospices and Specialist Palliative Care Services as the voluntary organisations with specific expertise in that area. The work is an integral element of the Supportive Care Strategy and will play a significant role in ensuring equitable access to, and quality of, palliative care services. The standards and performance indicators are part of the generic national core standards which will be developed for cancer generally. They will be used as a tool by service providers, health authorities and, in answer to the noble Lord, Lord Clement-Jones, primary care groups to deliver and measure continuous quality improvement in services in a consistent manner across the country. They will have the potential for making significant differences to patient outcomes.
A number of questions were asked about the New Opportunities Fund and, in particular, about its palliative care initiative. My noble friend Lord Varley raised a number of points about that. As noble Lords will know, the New Opportunities Fund is a major distributor of lottery money and is responsible for distributing grants to education, health and environment projects determined by the Government. The New Opportunities Fund is allocating £23 million as part of the Living with Cancer programme to fund projects based on a palliative approach to care. In answer to my noble friend Lord Varley, I understand that the second phase of the overall NOF cancer funding programme, which embraces the £23 million, was launched in February this year. Applications must be submitted by May and announcements will be made in September. I very much hope that hospices will make bids and, obviously, I hope that they will be successful.
That brings me to what I imagine to be the crux of this debate: the issue of funding of hospices. I know from the comments made by every noble Lord in this debate and, indeed, by the enthusiasm and vigour with which my own local hospice has lobbied me in this area that the issue of funding is a matter of great concern to the hospice movement. I have certainly taken careful note of those comments and of the particular points raised by the noble Lord, Lord Walker, in his opening remarks.
In responding to those matters, I turn first to the point raised by my noble friend Lord Blease and the noble Earl, Lord Howe. They spoke of the intent of the previous government in the early 1990s to move to what is known as "50:50 funding". As the noble Lord, Lord Hayhoe, also remarked, that concept was withdrawn in 1994-95. My understanding is that it was withdrawn on the basis that it was not sensible to specify centrally what the proportion of NHS funding in each area should be, given the extent of local diversity, both of services provided and of alternative sources of support. I give an example of that. While noble Lords have been absolutely right to point out
I was also asked about the move from central funding, which, I understand, occurred after the financial year 1995-96. Between 1990 and 1994, funding was allocated to the health authorities in England specifically to support hospices and similar organisations. However, since 1994 those resources have been built into the general NHS allocations. It is also true that guidance was issued to health authorities which made it clear that each health authority should agree a local strategy for the provision of specialist palliative care provision based on an assessment of the health needs of the local population and taking account of local priorities, available resources and patterns of services. I am well aware that there is a general view within the hospice movement that that has not worked through sufficiently. It is felt that it has left hospices with problems in relation to funding and with a lack of certainty about future funding from the NHS.
I also accept the point raised by my noble friend Lord Varley in relation to pay awards made by the NHS which the hospices will follow. I accept that if we make awards above the rate of inflation, if we accept the pay review body awards in full, and if we make provisions to upgrade certain nursing grades for good reasons, that will have a knock-on effect on the hospice movement. It seems to me that that issue falls to local discussion and, clearly, it should be taken into account by the NHS when it considers its resource allocation decisions with regard to hospices.
I have listened very carefully to the serious points made about funding. I believe that the way forward is through local discussion. The health improvement programme is the mechanism by which a serious discussion can take place, embracing health authorities, trusts, the voluntary sector and primary care groups, and where decisions can be made about the appropriate level of future support. Of course, the whole purpose of health improvement programmes is to enable longer-term decisions to be made, rather than the "short-termitis" from which, I believe, we have suffered in the past.
It is important to recognise that ultimately this is a matter for local decision, based on the local healthcare needs of the population, and that there will always be different priorities for different local health systems. I believe that that is inevitable. However, in reflecting on the points raised by noble Lords, I accept the need to examine how the profile of palliative care can be raised overall within the health authority decision-making process. I can assure noble Lords that over the coming months we shall consider how that can be achieved.
In addition, I very much share the concern of both the noble Lord, Lord Walker, and the noble Baroness, Lady McFarlane, with regard to what I believe they described as the need for long-term stability in funding decisions made by the health service. That point has
I am also aware that currently approximately only 50 per cent of health authorities have in place palliative care strategies. Again, I accept the need to explore the reasons why some health authorities are able to develop strategies and others are not.
I want to make a couple of points before concluding. I fully accept the points raised by the right reverend Prelate and the noble Lord, Lord Hayhoe, about the changes in hospice work and the move towards more home-based care. We should all applaud that. I am confident that hospices will always look for new challenges in the future.
Of course, I applaud and accept all the support that noble Lords have expressed for the hospice movement this evening. I understand the points that have been raised about funding. The noble Lord, Lord Walker, will understand that as a humble health Minister, I cannot give any commitment tonight; but I shall reflect on the debate. I have affirmed our commitment to developing a set of performance indicators and standards in relation to palliative care; to use the health improvement programme as a key feature for bringing about change; and to consider how we can encourage long-term stability in financial allocations. Again, I thank the noble Lord, Lord Walker, for introducing this debate.
Lord Walker of Worcester: My Lords, I am very grateful to the Minister for his summing-up and for his assurance that he will carefully examine the points that have been made--
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