§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Peter Lloyd.]
9.27 pm§ Sir Philip Goodhart (Beckenham)I am privileged to have St. Christopher's hospice in my constituency. For the last 20 years St. Christopher's has given comfort and care to many thousands of patients who have been terminally ill with cancer. It has also provided support for the families of those terminally ill patients. Last year the hospice staff and the home care team, which is an important part of St. Christopher's, provided help for about 1,400 terminally ill patients. That is about 1 per cent. of those who die from cancer in the whole country.
St. Christopher's has been a blessing to many of my constituents and to many who live in the neighbourhood, but it has also been an inspiration and example to the rest of the hospice movement in this country and the rest of the world.
When I went to St. Christopher's last week it was holding a three-day conference for 70 people, doctors, nurses, priests and pharmacists, from Scandinavia, on the care of the terminally ill. Last year there were 24 study conferences at St. Christopher's, mainly, of course, for doctors and nurses from this country.
The inspiration for all this is Dame Cicely Saunders, the chairman and principal founder of St. Chistopher's. She has been described by one of my constituents as a jolly saint. Certainly this remarkable woman has a warm and vigorous personality, and many people can testify to the power of her faith. It she is a saint, she is probably the first old girl of Roedean and the first holder of the DBE to qualify for this unusual distinction. On a slightly less high-flown level, it would be fair to say that she provides the same charismatic inspiration for the hospice movement as Florence Nightingale did for the whole nursing profession 100 years ago.
St. Christopher's is not just a one-woman movement. It has a caring staff of 127, of whom 105 are nurses. They are supported by an administrative and domestic staff of 100. They, in their turn, rely upon the assistance of 200 volunteers, many of whom come from my constituency.
The nurses tend to serve 18 months to two years and then take their experience back into the National Health Service. All this costs money. In 1986 St. Christopher's spent about £2.5 million and received just under £1 million from the NHS. The NHS has done rather well out of St. Christopher's. The estimated current cost of an in-patient at a London teaching hospital is £150 per night. The comparable cost at St. Christopher's is £110 per night, of which the cost to public funds is £46 per in-patient night.
The way in which the NHS contribution to St. Christopher's is calculated has grown in a haphazard way. Support levels for the hospice, for training and home care were set at different times by different people and authorities, being kept more or less in line with inflation. I suggest that the level of governmental support for St. Christopher's, which now stands at rather more than 35 per cent., should be recalculated and that the NHS should aim to meet 50 per cent. of St. Christopher's costs.
It would be reasonable if the National Health Service were to meet the ascertained cost of 30 of the 60 hospice beds, or £950,000 at current costs. It would be reasonable if the Government had met half of the home care team 1151 costs, amounting to a further £100,000. Finally, I believe that the National Health Service should meet the whole cost of the study centre, which would be a contribution of £200,000 a year.
In other words, I am asking that the NHS contribution, which now stands at almost £1 million, should be raised to £1.25 million. I think that this is reasonable, and I am astonished by my own moderation. Many people in the hospice movement would accept that a 50:50 partnership between the National Health Service and the voluntary sector in this extremely difficult field was appropriate.
It is right that St. Christopher's should be supported by the local community, but it should not have to devote excessive energies and thought to fund raising. It should not have to worry about cutting the work of the home care team because there is a shortage of vehicles. That seemed likely only a few weeks ago. I am glad to say that the generosity of a local firm, Ancaster Garages, has recently solved this mini-problem, but such a problem should not be allowed to arise in future.
The role of the hospice movement in the care of the dying has been brought to the attention of the public forcefully in recent months because of the AIDS problem in general and because of the recent trip of the Secretary of State for Social Services, to the United States, where he looked at the care of AIDS patients. After my right hon. Friend returned from America, Dame Cicely Saunders wrote to him:
At St. Christopher's, we have for some time been debating the ways in which we could properly contribute towards the care of patients suffering from AIDS … We believe that our home care services could be developed to provide symptom control, counselling and support, possibly throughout our catchment area of south east London, providing close liaison could be arranged with local hospitals or specialist units. Such a service would lend itself particularly well to evaluation of the medical and social needs of patients and their families in the community, study of the appropriateness of community care, and definition of the type of in-patient support that is required. I should explain that we have strong reservations about the use of our existing inpatient facilities for AIDS patients. We have difficulty in meeting the present demand of those suffering from terminal malignant disease and motor neurone disease in our wards".In a separate memorandum to the Select Committee on Social Services, Dame Cicely said:
Another concern is the fact that we have little expertise in handling young demented patients who are still active and likely to wander. Moreover, a hospice ward is a very personal place, welcoming families, with their children, to be with the dying family member. Among them, I believe, there would be many who would be extremely fearful of doing this if they knew AIDS patients were being admitted. However irrational, this fear is a very real matter, and would be an added burden on those facing the loss of loved ones.I agree with Dame Cicely's views and I am sure that the Government will provide the people and the money to take up Dame Cicely's offer of help with the training of home care teams who would in their turn look after AIDS patients and those who were terminally ill with cancer.So far, I believe that the National Health Service decision to set up special AIDS wards in certain hospitals is correct. Clearly a few special wards will not be adequate if pessimistic projections of the spread of AIDS are proved right. No one, whatever his medical expertise, can say for certain what will happen. Some predict that 600,000 people will die of AIDS in this country before the end of the century. We must all hope that this turns out to be a 1152 huge over-estimate, but it could be an under-estimate. After all, the words "mutating virus", the description of the AIDS virus, can provoke a flicker of apprehension within the most celibate bosom.
As there is so much uncertainty, it would clearly be sensible for the Government to start making contingency plans for the establishment of AIDS hospices in the Greater London area, where the incidence of AIDS is likely to continue to be higher than elsewhere in the country. Here I note that the Bromley health authority, for example, has just handed over to the South-East Thames region the Lennard hospital site, which was a centre for geriatric care, and it is proposed that the South East Thames region should dispose of this site in the near future. But it has been estimated that if £1 million were spent on refurbishing the existing buildings the site could support 80 hospice beds. The Lennard site is accessible, but it was once an isolation hospital. I note that it is also reasonably close to the Wellcome research laboratory, which is also in my constituency. Wellcome has, of course, played a leading role in the development of drugs that have some impact on the control of AIDS symptoms.
Meanwhile, I note that AIDS is a disease that has come to this country from abroad, and we should clearly be wise to try to limit any increase in the pool of infection in this country. My hon. Friend who will be replying to this debate has recently reminded us in characteristically colourful terms that Britons travelling overseas can become infected and bring the virus back to to this country, and she has suggested a pleasantly acceptable way of limiting that risk.
Following recent reports in the newspapers, I am uncertain about the Government's attitude to potential foreign carriers who want to enter the country. Clearly, it would be wholly impractical to try to screen every visitor from overseas, as many foreign visitors pay only fleeting visits to this country. I note, however, that foreign students are necessarily going to stay in this country for some time and that many of them come from Africa, America and the middle east, where there is a high level of AIDS infection.
I know that there is a powerful body of opinion within and outside the Government which believes that all foreign students, except perhaps those coming from EC countries, should be screened before they come or as soon as they arrive in this country. It ought not to be too difficult to ensure that foreign students do not start their courses here until they produce a valid AIDS clearance certificate. The British Council — hardly an illiberal body — has supported the idea of an AIDS test for foreign students and I hope that the Government will make up their mind well before the next academic year begins.
Finally, having made a number of suggestions that would inevitably lead to increased expenditure on behalf of the taxpayer, I suggest that the Government should make some economies in the AIDS publicity programme.
Of course, any information campaign on the subject faces the twin dangers that it will be meaninglessly bland or offensively explicit. I have seen lots of posters and I have seen the AIDS cinema advertisement, all of which seem to me to be wastefully bland. On the other hand, some of my constituents think it offensive and ridiculous that taxpayers' money should be used to warn their 89-year-old grandmothers of the dangers of anal sex.
The Health Education Council, in a new form, is to take over responsibility for the AIDS information campaign. I do not know what budget has been earmarked for general 1153 propaganda about AIDS. However, if money is tight, and if future campaigns are not better based, I suggest that that budget is squeezed and the money diverted to fund the sensible projects to which I have referred.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)I am very pleased that my hon. Friend the Member for Beckenham (Sir P. Goodhart) has taken up the question of the way in which we are to care for AIDS victims, especially in the context of the excellent work carried out by the hospice movement in his constituency and by his constituents.
I want to place on record how much I value this opportunity to pay tribute to all those who give selflessly to the care of others throughout our services in the Health Service and elsewhere. However, the hospices are rather special. They bring not only a skill in controlling pain and other symptoms and a deep understanding of the sense of impending loss among patients and their relatives, but a compassion and friendship. They enable people to feel in control of their lives once again and to die with dignity. I am certain that we all hope that when our end comes, we have that opportunity.
The hospice movement has been developing that approach to terminal care since the 1960s. There are now about 100 hospices, 38 of which are run by the Health Service. I am patron of the Nightingale hospice run by the Macmillan Continuing Care appeal in Derby on behalf of the health authority. I also had a small part to play when St. Mary's hospice was established in Selly Oak in Birmingham. Many of the other hospices, like St. Christopher's, are entirely run by voluntary bodies. Altogether, they provide about 2,000 beds, 90 per cent. of which are currently used by cancer patients.
St. Christopher's hospice was opened in 1967 on a capital cost of £500,000 which, 20 years ago, was a far larger sum than it is now. That money was raised entirely by voluntary subscription. During the past 14 years, St. Christopher's hospice has achieved a worldwide reputation as a centre of excellence in the care of the dying. I am not entirely sure why my brief states 14 years. I suspect that the hospice has been a centre of excellence since it was opened.
Under the medical directorship of Dame Cicely Saunders, who is now recognised as an international authority on the subject, the hospice has pioneered methods of care based on a comprehensive approach to the needs of each patient as a total individual and, where appropriate, as a member of a family. Treatment has been directed towards the effective relief of pain without the destruction of personality in the terminally ill.
St. Christopher's is an independent hospital and a Christian foundation. Its catchment area is restricted to a 10-mile radius from Sydenham for in-patients, to facilitate visiting by friends and relatives, and a six-mile radius for home care. Most of the catchment area therefore falls within the boundaries of the South East Thames regional health authority and the remainder within the South West Thames regional health authority.
My hon. Friend the Member for Beckenham referred to the cost per patient day. 1 agree that the service at St. Christopher's, in that respect as well as in many others, is worthy of considerable attention. I understand that there are about 200 full-time and a number of part-time staff at St. Christopher's. The full-time staff include two 1154 consultants, a senior registrar and two junior registrars, nursing staff, social workers, ward orderlies, domestics, clerks, catering assistants and a full-time chaplain. The running of the hospice is assisted by 200 volunteers who offer their services in a variety of capacities under the supervision of a voluntary health organiser. They all do excellent work. However, I suspect that in the Health Service, where our costs are somewhat higher per patient day, we could not expect to run such a service on the basis of half paid staff and half volunteers as occurs at St. Christopher's. I am not saying whether or not I wish it were so: I merely point out that the Health Service substantially relies on our excellent paid staff.
St. Christopher's hospice is independent of the Health Service and is administered by a council of management chaired by Dame Albertine Winner. The council members include Dame Cicely Saunders, Dr. West and Dr. Gillian Ford. All the capital costs of the hospice come from private sources. I mentioned earlier the £500,000 raised by voluntary subscription. Revenue costs are borne mainly by contractual arrangements, chiefly with the regional health authorities that I mentioned. Some patients contribute to the cost of their own care, either from their own money or through one of the provident associations.
It is the firm policy of the hospice not to exclude patients on financial grounds. Apart from the National Health Service, which my hon. Friend mentioned as a source of direct funding, there are several other public sources of funding, which assist or might assist the hospice and the hospice movement. For example, Drapers wing is funded by the local authority social services department, from which the residents are drawn, in combination with personal payments by some of those patients.
The out-patients' department is funded by grants from the DHSS through the South East Thames regional health authority. Supplementary benefit of up to £230 a week is available for terminal care patients who qualify and is paid for many such patients in nursing homes which make a charge. That benefit is payable only if a charge is regularly made.
§ Sir Philip GoodhartMany people in the hospice movement think that this form of financing is not entirely appropriate. There are problems in trying to get hold of that money. The nearly £1 million about which I spoke covered the generality of Government support.
§ Mrs. CurrieI understand the point that my hon. Friend makes. I merely make the point that the additional needs of terminally ill patients in such establishments as nursing homes are already being recognised by the payment of £230—should the nursing home be set up in such a way that a claim can be made. I also take my hon. Friend's point about how the system functions.
I understand that the hospice needs to find about £55,000 each month in order to pay its running costs. This amount comes chiefly from bequests, open days and appeals. The hospice is supported to an extraordinary extent by local people. I am sure that they derive great satisfaction from the opportunity to show their gratitude for the work of this marvellous place. Despite the tightness of the running costs, I understand that the hospice is planning a modest expansion, which will include a patient day centre. I am sure that that will be most welcome in the area.
In general we do not make central finance available to voluntary hospices as such, but the local health authorities 1155 can assist them and the level of support around the country varies from nought to 80 per cent. of revenue costs. We estimate that the average is about 35 per cent. and that is about the level of funding which St. Christopher's attracts at the moment from that source.
Where a hospice plays an essential part in a health authority's overall plan, we expect that authority to make an appropriate financial contribution. We take rather a firm view on that. As well as making a grant, a health authority can contract for beds and can donate or let surplus land or buildings. I understand that in Birmingham in the very early days we were also able to assist in one or two quiet ways with secretarial assistance, office accommodation and the like. There are various ways in which such help can be given.
The precise level of spending on specific services and support for individual local hospices should be left for health authorities to determine. Health authorities will have a lot more money to spend in the coming year. Our plans for the year starting in April provide for an increase in overall allocation to health authorities in England alone of £626 million. That is 2.2 per cent. above forecast inflation. We shall, in addition, allow them to retain benefits of cash released through cost improvement programmes that are planned to achieve £150 million in the current year. We have made an allocation of £4.4 million for 1987–88 to the three Thames regions that together care for 75 per cent. of the AIDS cases that my hon. Friend the Member for Beckenham has mentioned.
My hon. Friend the Member for Beckenham has rightly drawn attention to the tragic and growing need for terminal care for this new group of patients suffering from AIDS, many of whom are young people who would otherwise have had the greatest part of their lives to which to look forward. By 31 January 1987 AIDS had already claimed the lives of 355 people in the United Kingdom. This year we expect 1,300 cases and next year 3,000 new cases. We expect that the cumulative total of deaths by the end of next year will be nearly 10 times the present number.
Most of us prefer to be treated in our own homes among family and friends and in familiar surroundings, whatever our illness. A hospice may be the choice for some and it may be the solution in their circumstances. Inpatient care may be appropriate for active treatment of certain phases of illness, but towards the end a different approach may be needed. I hope that my hon. Friend will agree that we need a full and varied spectrum of care facilities.
We are about to ask all health authorities to examine their current services for the terminally ill, including AIDS patients, and to plan to fill any gaps, if possible by collaboration with the voluntary sector. On 3 March a circular on terminal illness will be sent to all regional general managers, district general managers, special health authorities, family practitioner committees and community health services — in other words, to all the appropriate bodies. I shall arrange for a copy to be placed in the Library of the House of Commons and for another to be sent to my hon. Friend, who has shown such a caring interest in this subject.
In addition, my right hon. Friend the Secretary of State for Social Services intends to hold a conference before Easter on the provision of care for AIDS sufferers outside 1156 hospital. It will bring together the experience of those in the relevant professions, the statutory and voluntary services and the churches. The intention is to indentify more clearly the priorities and responses for the years ahead. As my hon. Friend knows, the Secretary of State recently visited the United States of America and was impressed by the innovative approach to community care there, especially in San Francisco, where the average length of in-patient stay during the progress of the disease is 12 days, compared with 31 in the United States of America as a whole, and at least 50 in England. My right hon. Friend will report to the conference on what he learned on his American visit.
There is clearly scope in this country for the community-based patient care of AIDS sufferers. In the United States, care is provided at the patient's home to supplement or replace hospital care, according to individual circumstances. That can include the administration of medicines with nursing supervision and the use of infusion fluids and antibiotics. In other words, there are possibly no limits to what can be done outside hospital.
My right hon. Friend told me that in San Francisco the volunteer community agency, SHANTI, works with the city to provide small-group housing for patients with AIDS who would otherwise be unable to be independent. Patients may share an apartment and be regularly monitored by volunteers, who alter the services as the condition of the residents changes. Residents also help to care for each other. Obviously, there is a great deal to learn from all those developments. I have no doubt that those who are experienced at caring for the terminally ill, for example those working at St. Christopher's, will have much to offer us in their contributions on this subject.
The hospice movement in the United Kingdom has traditionally offered care to cancer patients. There has been some concern about whether it can offer an appropriate service to people who suffer from AIDS. I know that in the past the council of management at St. Christopher's has found that the hospice was not the right place to care for those patients. There are 130,000 deaths from cancer each year, 20,000 of whom are patients who will spend some time in a hospital bed, and the hospices have therefore felt unable to admit patients from other specialties. However, I am glad to know that Dame Cicely Saunders and others from St. Christopher's will shortly visit the chief medical officer, Professor Sir Donald Acheson, to discuss how the hospice might become involved in the care of AIDS patients. I understand that some other hospices will admit AIDS patients by agreement with the local health authority. One hospice specifically for AIDS patients, known as the London Lighthouse, is being planned. We are presently considering what financial assistance we can offer.
As well as 100 United Kingdom hospices ranging from two beds upwards, there are about 125 home care teams involving over 300 nurses. Much of this is funded through the Health Service direct. We also have about 25 hospital support teams in NHS hospitals, providing help and advice to dying patients in the hospital—
§ It being Ten o'clock, the motion for the Adjournment of the House lapsed, without Question put.
§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Peter Lloyd.]
§ Mrs. CurrieMany hospices are developing day care units which patients living at home can attend. There is 1157 clearly scope for a hospice-in-the-home approach, rather similar to the San Fransico movement, involving widespread support from volunteers in the community. Perhaps as much as anything, the experience of St. Christopher's in motivating and organising volunteers to help and work with people in the direst straits at the end of their lives might be one on which we can draw. To put the matter in context, about 35 per cent. of cancer patients die at home, 60 per cent. die in hospital and 5 per cent. die in hospices.
If the existing hospices choose to take AIDS patients—the choice is theirs—they will need help and support on education and training for staff. In the coming financial year, we have allocated £200,000 to our two AIDS counselling training units at Paddington and Bolton so that they can double the present training capacity and offer courses to community health staff, personal social services staff, hospice staff, and anybody else who requires it. As well as counselling training, the units offer valuable advice and support to care staff on the many issues that arise in the care of AIDS patients. We hope, too, that the educational resources of hospices will be available to staff who undertake the care of AIDS patients. In other words, we see that as a two-way process. We look forward to close co-operation on education and training.
I heard what my hon. Friend said about the advertisements. We have come a long way in six months. Last year, most people did not even know what AIDS was. This year, in our recent independent survey of people's reactions to the current campaign, we have established that about 95 per cent. of people have seen one of the advertisements. That is a remarkable achievement already. Around the same number of people — 95 per cent. —think that we are right to have this campaign. Around 80 per cent. now feel confident that they know enough to avoid catching AIDS. I remind my hon. Friend that that was one of the objectives of the campaign. There is clearly still some hestitation about what does not cause AIDS and what processes in normal life are perfectly acceptable and will not cause the passing of AIDS, but at the moment public education is our only vaccine.
I take my hon. Friend's point about the good lady aged 89. I merely suggest that, to have read about any kind of sex, she must have picked up a sealed envelope that clearly had a message printed on it in large type about what was inside. She must have read the message. She must then, nevertheless, have opened the envelope and, no doubt, sat down somewhere to read it.
1158 We have thought long arid hard about what should be in the leaflets. We needed to get them out as quickly as possible. I am sure that my hon. Friend will agree that, to try accurately to extract the names of, say, elderly people from what might have been out-of-date censuses or electoral registers would have been an almost impossible task and widely open to error. Indeed, there might have been some older people who would have been offended at being left out. We should recognise that there is a risk to the whole population and that the whole population needs to be included in a campaign of this kind.
The most serious counter-argument that I offer my hon. Friend was made by the Secretary of State in the debate on AIDS late last year, which is that we may have to risk offending some people in order to promote the greater good of the country as a whole. I hope that my hon. Friend can accept that.
Suggestions about the screening of students and visitors are due to be considered by the Cabinet Committee that is now so ably chaired by my right hon. Friend the Lord President of the Council, to whom I am sure my hon. Friend would like to add his words of thanks for the excellent work that the Committee is doing. I share my hon. Friend's misgivings about the practicality and the expense of screening everybody who comes to the United Kingdom, or who may be returning to the United Kingdom after a visit abroad. Whether it is practical and in the interests of the British people to screen particular groups will be for the committee to decide.
I began by paying tribute to the hospice movement in general and I shall close by saying a few words in particular about St. Christopher's. The sympathetic and honest relationships that have developed at St. Christopher's between patients, relatives, nursing and medical staff are a shining example in a dark world. Death has been recognised as a part of life and as a family affair. The bereaved are not only counselled, advised and assisted; they are uplifted and helped towards a better understanding of our lives and souls as human beings.
AIDS is a growing problem. This year we expect a further 1,300 cases. If St. Christopher's can help — by advice, training, counselling and support — it will help AIDS patients and their families and, in the end, perhaps it will help all of us to come to terms with this terrible scourge.