Hospice Care

HL Deb 31 October 1989 vol 512 cc205-32

7.37 p.m.

The Earl of Longford rose to ask Her Majesty's Government what steps they have in mind to strengthen the hospice movement and hospice care in the community.

The noble Earl said: My Lords, I rise to ask the Government about their attitude and intentions towards the hospice movement. A debate in this House on hospices is long overdue. There are those speaking after me whose knowledge of the movement and whose association with it is much greater than mine. I note that the noble Duke, the Duke of Norfolk, is to follow me. He speaks with much authority of his own and suitable authority derived from one very near and dear to him who has done so much for the movement. I shall contribute not only my own thoughts. I shall hope also to distil the wisdom of those very much better qualified. I assure the House that if I follow my notes more closely than usual, it is only because I would take much longer otherwise and might ramble over a much wider field.

I am told that out of 140,000 patients who die each year of cancer, some 40,000, or their families, have contact with a hospice or the hospice care service. We are aware that many patients who do not suffer from cancer are ministered to by hospices. We must not only think of hospices in this country, although the initiative in modern times has come from this country. We must look upon it as a worldwide development.

The major developments have occurred in the last 20 years in this country. It was in 1967 that Dame Cicely Saunders inaugurated St. Christopher's Hospice which has had so much influence on the creation of hospices here and abroad. Dame Cicely has rightly been described as the founder of the modern hospice movement. That is a perfectly correct description. However, she would be the first to say that the spiritual foundations of the hospice movement were laid before her time. She worked as a doctor in St. Joseph's Hospice for seven years from 1958. St. Joseph's had been founded by Irish nuns in 1905. Dame Cicely was already qualified as a medical specialist in terminal care. She learnt a tremendous amount and gained a great deal from St. Joseph's. She helped St. Joseph's enormously and then made full use of her knowledge in establishing St. Christopher's with far-reaching results.

During the Summer Recess I visited four hospices. I have already referred to St. Christopher's and St. Joseph's. I look upon St. Michael's Hospice, which is in Hastings, as my local hospice. I suppose that the time may be drawing near when I shall be a candidate for hospice membership and it may well be that I shall seek admission there. I also visited St. Luke's Hospice in Plymouth, which these days is presided over by Dr. Sheila Cassidy. She is a remarkable woman—and still young, but then, by my standards, so is everybody. She was tortured in Chile and is well known also for some remarkable books, among which her book on prayer is my favourite. Although we are talking tonight about hospices, I hope that no one will neglect to read her book on prayer. However, that is not in fact our topic this evening.

I believe that there are about 140 hospices in the United Kingdom at the present time. Each of them has its own way of working and its own financial relationships with the public authorities. So variegated are those relationships that it is impossible to generalise. Nevertheless, I must speak in general terms.

Hospices are often spoken of as homes for the dying. In fact I had always thought of them in that way. Today the hospices themselves lay more stress on living than on dying. The message that comes from all of them speaks of their determination to provide a quality to life while life remains. In many cases they provide a vital service to those who are not dying but who seem to be beyond cure. They also cater in non-residential ways for many of the terminally ill: in out-patient services and care for those who prefer to die at home. The House may hear something on that subject from another noble Lord this evening.

The hospices maintain friendship with the relatives when the terminally ill patients have died. Nevertheless originally, and in a sense it is still true, the special achievement of the hospices lay in their residential care for the dying.

What are the distinctive features of a hospice? I must be careful to say nothing to disparage the care provided in hospitals or by the medical profession generally. Thousands of health service staff show very great care for the dying. They cope with dying patients almost every day and with the grief of relatives and friends. I should point out that many of the staff in the hospitals today have been much influenced by the initiative, training and teaching inspired by Dame Cicely Saunders and others in the hospices. So even in the hospitals care for the dying is not by any means in the state that it was when the work of the hospices began.

There are particular characteristics of hospices which provide the foundation of the care that they give and which are incorporated in their educational programmes. One is the control of symptoms. Dame Cicely specialised in that from the very beginning and others have carried on and developed her work. It sounds obvious but it is true that if the root cause of an illness cannot be eradicated, a patient who has pain, nausea or breathlessness may be overlooked or their symptoms be regarded as untreatable. I have been told time and again—and I am sure it is true—that one will never hear a member of staff in a hospice or a community based team giving hospice care say, "I'm sorry but there's nothing more that can be done". In their eyes that is a sin against the Holy Ghost when faced with a patient in pain or discomfort in his last illness.

Another feature of hospice care is that the staff listen as well as talk. I have seen that in the hospices and many more examples are known to other noble Lords. The staff encourage patients and families to talk about their grief and fear both with them and with each other. They offer bereaved relatives the opportunity to share their sadness and encourage them not to bottle it up. That openness—the word was said to me very often—in the face of death and dying does not give rise to miserable staff or gloomy places in which the patients are looked after. It may be misunderstood when I say that I found the atmosphere of the hospice was cheerful but I cannot help myself using the word.

Hospices are places where staff, through their training and experience, tackle issues which all of us may face at some time—the physical and mental distress of an incurable illness, the financial and social problems of the death of the breadwinner, the devastating loss of their mother to small children and the spiritual pain of those who in their illness experience isolation or lose control of their surroundings; these are all desolating. The staff show an awareness. They live with such issues and yet refuse to be discouraged.

In one of the hospices I asked a doctor, "How do you bear it? How can you stand looking after people in that condition day after day, month after month, year after year?" She replied, "There are three answers. In the first place I am part of a team. In the second place I have regular breaks, and I could not do without them. Thirdly, at the end of the day I lay it all before God. I say, 'That is all I have been able to do and I now leave it up to you' ". So said one doctor, but in a sense I believe that she speaks for them all.

It is still true that, if one talks to patients in a hospice who are dying, they will tell you—indeed a number of them have told me—that they are happy in a way that they never could have been happy in a hospital. They feel the difference. I do not think that anybody who has visited a number of hospices will question my statement.

I come back therefore to the question of the distinctive virtues of a hospice. Yet again I must pause because in the cases that I have examined and probably in most or all of the other cases the hospices enjoy an all-important advantage in one vital respect: by and large the ratio of nurses to patients is much higher than elsewhere. One must take note of that as a fact.

I said just now that the staff in a hospice listen. Or they will just sit in silence for a long time possibly holding the hand of a dying patient. I have been told that again and again. That is obviously beyond the capacity of an ordinary hospital. It is something that we have to bear in mind when we begin to try to work out the cost. The essence of the hospice approach is loving care. The patients are enabled to feel that they are not only accepted but valued as they are. Again that phrase kept cropping up during my visits to hospices: we value the patients as they are, not as we think they ought to be. Within the inevitable limits they are given freedom of choice.

I should not be believed if I were to say that everyone who dies in a hospice dies happily and comfortably. But I do believe that that is true in the great majority of cases. Those who work in hospices appear to have very strong motivation for the work. It is not just the doctors and nurses but also the social workers, chaplains, therapists and others. For some staff the origin of their inspiration is the love of God; for others it is more their feeling for their fellow men. Of course there is no contradiction between the two.

Some of the hospices that I visited have developed from religious communities; others have a Christian as well as a medical foundation. In none is there any kind of requirement which would act as a ban on the admission of patients or the employment of staff who belong to a different faith or who do not profess any faith. Again and again I was told that no religious doctrine is pushed down anybody's throat. Nevertheless it is inconceivable that the hospice movement would have developed as it has done in this country and ultimately abroad if it had not been for the Christian inspiration of such people as Dame Cicely Saunders and others. The spiritual foundations of the hospice movement were already laid down when she appeared on the scene. She was a doctor who already specialised in pain control. One cannot think therefore of the hospice movement without its Christian inspiration. One cannot think of it today without its unyielding insistence on the highest medical standards of training, care and research.

The hospices are splendid places with splendid teams. They have proved their worth and their staying power. But how are they managing to keep going as more demands are made on them, such as the need for the treatment and care of patients with diagnoses other than cancer, the addition of day centre facilities and out-patient care, the teaching of staff with many different specialities and other factors which keep raising their heads? The fact that they have managed until now is a great credit to their fund-raising efforts and to the public who have supported them. But some are not the recipients of any funding from the NHS and some have seen their original funding whittled away by recent developments. There is an extraordinary variety of financial situations. But one way or another all hospices are in need of funds. It may arise because of their success. The fact that there are more hospices in an area means that each hospice is having to work harder to find a source of funds.

We now come to a crucial point that is bound to be in the minds of all who take part in this debate. The Scottish Office has recently announced that it will match pound for pound the support being given by the public to Scottish hospices. This is indeed welcome news for Scotland. We are waiting anxiously to know whether this country will do equally well. The Minister—whose personal sympathy on such a matter I take for granted— had the opportunity in reply to a Question by the noble Baroness, Lady Cox, last Thursday to announce that similar support would be forthcoming in England. That opportunity was not taken. I cannot help fearing that it will not be taken this evening.

However, on Thursday the Minister raised our hopes. I know that she would not do so unless she thought that there was something good in the pipeline. It was indicated that an important announcement would be made before very long. We had to conclude that it would be an announcement favourable to the hospices. I am sure that everyone speaking in this debate will urge the Government to announce as soon as possible that they are following at least the Scottish example. Even if such an announcement were made, I would not like to imply that the hospices will feel that they are now being satisfactorily looked after. The 50–50 level of support would by no means take away all the anxieties carried by relatives with patients at home or hospital staff responsible for in-patient units.

I am glad that one grievance often referred to by the noble Lord, Lord Ennals, and others in this House is now being apparently rectified. It is most obviously unfair in the case of hospices, and it has been grossly unfair in general, that patients being cared for at home for the last few weeks of life should fail to qualify for the attendance allowance because they do not live long enough. But better late than never, my Lords. It is indeed good news that the situation is at last being rectified.

I have time to give only two other examples of the anxieties that would remain, although a number of examples could be provided. Even if the 50–50 grant were accorded—and we have not reached that position yet—it is very unfair that supplementary benefit, which should cover board and lodging costs, is often delayed or not paid by local offices. It is very unfair that hospice staff often have much difficulty in obtaining drugs for their patients under NHS arrangements. No doubt as noble Lords speak they will deal with other matters.

I have stressed the way in which the Government can help, primarily by funding, but in other ways upon which I have touched. They will be touched on by other speakers. Looking to the future, the health authorities should ensure that NHS staff who would benefit are indeed able to take advantage of the training opportunities that are provided in the hospices where there is so much knowledge and experience of these matters. Insurance agencies such as BUPA should recognise that patients in hospices are receiving care for which payment should be made and that it is distinguishable from long-term nursing care which is excluded from most policies.

Those are two issues. Other noble Lords will speak of other matters. So much remains to be done to help the hospice movement to take its proper place in care for people nearing death. I need hardly say that this does not mean that I believe that everyone should die in a hospice or that general practitioners cannot look after any patients at home. We have an overwhelming need for the services provided by hospices and the domiciliary teams working with patients in their own homes. There is also the need to be sure that the staff looking after patients within the NHS have a full knowledge of what can be achieved through the philosophy of the hospice. There is a great deal to be learned.

Even if I had longer in which to speak I am not capable of doing full justice—I hope that others will do more justice—to the inspiration provided by the hospice movement. To me it is a supreme example of spiritual endeavour and professional efficiency working hand in hand. I realise that the Minister will not be in a position today to make concrete promises. But I hope that she will share with us our conviction, as I believe she will, that every support should be given to such a demonstration of practical wisdom, indomitable courage and tender love.

7.58 p.m.

The Duke of Norfolk

My Lords, I should like to thank the noble Earl, Lord Longford, for introducing the debate on this very vital subject which has come to light only in the past 20 or 30 years. Until recently hospices were hardly known. They were departments of hospitals. Now they are thriving parts of our medical care. It is true to say that not only do we lead Europe with the hospice movement but the world.

I last spoke in this Chamber on the hospice movement when we were talking about the attendance allowance. It had been pointed out that the Government were not willing to give the attendance allowance to a patient who needed it until after six months had elapsed. When the Government knew of this situation they gave the allowance at once. I am very grateful to them for agreeing that a hospice patient can have an attendance allowance paid to dependants at once. He does not have to wait six months.

I became acquainted with the great movement when my wife and I visited St. Joseph's Hospice in Hackney where we knew a patient. We found an amazing convent where the nuns had been caring for the dying since 1905. They were one of the first groups to do so. We were so impressed by what was happening that my wife founded a charitable movement called Help the Hospices. It does everything that it can to further the progress of the hospice movement and to raise funds and beaver away on its behalf.

I realise that the night is moving on, so I shall not speak for too long. The main problem is that more government funding is required. Of the 100-odd voluntary hospices, approximately one-third receive no government funding. I hope that in his reply the Minister will give the House some information about that.

Roughly speaking, the cost of running a 10-bed or 15-bed hospice is £600,000 a year. That is a large sum of money for a local community to raise by charitable applications. I am confident that the Government see the need to match that figure from their resources. My wife and I have visited Richmond Terrace. I believe that things are going well and that the Government will help towards its funding. I hope that perhaps not tonight but eventually we shall hear that the Government have taken the matter on board and they will tell us that they will help the charities of the kingdom to receive money towards their efforts for the hospice movement.

8.2 p.m.

Lord Dunleath

My Lords, we are grateful to the noble Earl for introducing this topic. It is gaining greater currency as time passes and it is appropriate that he should have raised it tonight. He has fully covered the subject of hospices and I hesitate to repeat his comments. The main point arising from his comments and from the research that has been carried out is that our hospitals are already overstretched as a result of attempting to deal with all the patients who have a reasonable chance of recovery. Hospital beds are at a premium and ideally they should not be occupied by those who are terminally ill. Hospital beds are for one purpose; hospice places are for another. Apart from that, a hospital is not the best place in which to die.

I am fairly new to the subject. When I visited the Northern Ireland Hospice in Somerton Road, Belfast, I was astonished to discover such a congenial atmosphere compared with that in a hospital. Indeed, when the time comes—and I am sure that it will be in advance of that for the noble Earl, Lord Longford—and I am admitted to a hospice I shall look forward to the thought that reveille will not be at 0600 hours; that visiting times will be flexible and that there will be no clanking trollies going up and down the passage during the night to keep me awake. Indeed, the atmosphere in a hospice is a great deal more congenial than that in a hospital because the mood and the purpose are different.

Inevitably, our population is ageing. As a result of modern medical science people are living longer and therefore there will be a greater need for this type of terminal care. Not only must we look to the future, but when we look at the present we see that the need already exists for more places in hospices. At the Northern Ireland Hospice there is an urgent need for an extension providing 10 extra beds, but owing to lack of finance that has been postponed. Finance is the crux of the matter. The running costs are the crippling factor. The noble Duke mentioned a figure of £600,000 per year needed to run a hospice. The Northern Ireland Hospice costs £950,000 per year. Therefore, reserves cannot be accumulated to provide for extensions which are urgently needed.

The health and social services boards are doing their best within their limited budgets. Between them the Eastern Health and Social Services Board and the Northern Health and Social Services Board are granting £80,000 per year. The Department of Health and Social Services has set a most helpful attitude. However, the regular grant is only £52,000 per year, leaving a great deal to be found from voluntary fund raising sources.

I am pleased to see the noble Lord, Lord Skelmersdale, in his place tonight because he has taken a most constructive attitude towards the subject. Recently we were delighted to welcome him at the hospice and I know that he assimilated the information he was given. I hope that I am not too presumptuous in saying that he must realise that the department's contribution does not make a significant impact on the shortfall considering the total cost of £950,000 per year.

Admittedly, one-off payments have been made. For example, £100,000 was given to help the hospice in an emergency and £150,000 in capital grant was given towards the extension. Even so, the trouble is that the general running costs are such that instead of the hospice being able to indulge in orderly budgeting it is a matter of crisis management. When one is trying to market something to the public, crisis management is not the best profile that one can project. When staggering from one emergency to another one tends to lose credibility and confidence.

The noble Lord, Lord Blease, will speak later in the debate. He will be able to throw more light on the subject than I can. We have been involved in a number of fund-raising activities of one kind or another. I am sure he will agree that if one puts a definite project before the people of Northern Ireland they are astonishingly generous. In just under two years over £1 million was raised for the children's cancer unit. That was a defined project and people knew that when that amount of money was raised that was the end and they would be able to see the result. However, continuing to go back to people again and again asking them to help with running costs is much more difficult. That is why I appeal this evening to the noble Lord and to Her Majesty's Government to try to work out some way in which the running costs of the hospice could be put on a firm financial basis.

We were much encouraged recently to learn that Mr. Michael Forsyth, the Minister responsible for health at the Scottish Office, had arrived at a pound for pound arrangement for the 10 hospices in Scotland amounting to some £4 million per year. I respectfully ask that Her Majesty's Government should consider doing something similar for the hospices in Northern Ireland, because that is cost effective. The Eastern Health and Social Services Board said that last year or the year before—and I cannot remember which—the hospice was actually saving it £200,000 per year because the terminally ill did not have to be accommodated in geriatric wards in hospitals, taking up the time of medical staff and district nurses. Therefore, that is cost effective and is something which I respectfully suggest Her Majesty's Government should address as a matter of urgency.

Another point on the periphery of the matter is that the Northern Ireland hospice is planning to carry out an extension of a further 10 beds. However, value added tax will be a considerable adverse factor to those plans. Once again, it is rather a question of the Lord has given and the Lord has taken away. Would it not be possible to zero-rate the conversion of buildings like that? Otherwise, whatever capital grants are given by Her Majesty's Government will be very substantially eroded by VAT.

Therefore, in thanking the noble Lord for his interest and his constructive attitude towards the hospice in Northern Ireland— and we were very glad to see him there recently—with every respect, I ask him to take note of the requests which we have put before him this evening.

8.11 p.m.

Baroness Blackstone

My Lords, I make a short contribution to this debate this evening not as a social scientist, not as someone who has expertise in the area of social policy nor even as someone with a long-standing interest in health care but as someone who has personally benefited and whose family has personally benefited from the hospice movement.

Almost exactly five years ago I received the devastating news that my former husband had terminal cancer. He was 43 years old. A week earlier cancer of the stomach had been diagnosed but we all hoped that surgery would solve the problem. We were living on our optimism and of course we were clutching at straws. A major operation, a partial gastrectomy and extensive exploration revealed that cancer had invaded his lymph system and he was doomed.

All the same, he made an amazing recovery from that surgery and eventually returned to work. However, six months later he was back in hospital for major surgery. He was then sent home and died less than eight weeks later. Throughout his last six months he made it clear that he wanted to die at home when the end eventually came, and it was possible for him to do that because of the support of the home care branch of the hospice movement. Without that, we could not have coped.

I submit that many of us would prefer to die at home surrounded by our family and visited by close friends in a familiar environment where a favourite poem can be read from a much-loved volume or where music which we particularly enjoy can be played. That is as true, in my experience, for those who are struck down in the prime of life as it is true of those who are old and especially attached to their homes.

However, the care of the dying—and again I speak from personal experience—is an enormous physical and emotional drain, especially where the patient is young and dying before his time. There are physical demands of lifting the patient, laundry, medication and turning the patient during the night. Above all, there is the awful fear of failing to relieve the suffering and pain and the anguish of watching someone one loves dying.

In our case, the North London Hospice Group, which helps some 300 terminally ill patients each year, provided the support which we needed, the quality of which I do not believe could have been provided by anyone else. Without that, my former husband would have had to go back to hospital and we should all have felt everlastingly sad that we had failed to respond to his last wish to die at home and that we had let him down.

It is the great expertise based on depth of experience in caring for the dying which is the special and unique characteristic of the hospice movement. However caring a hospital ward or a GP may be, they are dedicated to curing people and to the care of the living, of those who will get better. Success is largely measured by the speed and completeness of the cure. A death is a failure. The care of the dying in that sense requires the suspension of many normal medical objectives; for example, the use of drugs in the control of pain must be geared to the fact that the patient will not get better. Therefore the relief of pain, rather than anything else, is paramount.

The care of the dying also involves the support of those close to the patient to make it easier for them to cope. Again, the hospice movement has established a justified reputation for great skill and humanity in helping people to cope with bereavement. Again, I can testify to that personally.

I hope that I have said enough to convince your Lordships' House about the enormously positive nature of hospice treatment, especially home care, which has the added advantage of being cheaper, although I recognise that some will need institutional care and others a combination of home and institutional care. Indeed home care must have back-up beds so that, when families need respite or cannot cope, there is provision available, which involves staff skilled in the care of the terminally ill. There is nothing more demoralising for a home care team than to see a patient admitted to a hospital where the necessary skills are lacking and where all the good work which they have done is undone. Of course, that is also terribly traumatic for the patient.

So far, unfortunately, it looks as though the Government have not recognised the need to support the hospice movement and expand it. There are a small number of NHS hospices, as has already been mentioned. The rest receive varying degrees of support from regional and district health authorities. However, on average, it amounts to only about 30 per cent. of their costs and, as the noble Duke said, some receive absolutely nothing. That leaves many scrabbling for funds and leading a scrimping and saving existence. Each hospice on its own must try to make ends meet and I think that doing so often diverts energy from service provision to fund raising. That is not a satisfactory state of affairs. I ask the noble Baroness to give an assurance that that will be changed.

One solution would be to provide central funding for all bona fide hospices established through some kind of registration scheme. I think that that funding should cover at least two-thirds of their costs, perhaps leaving them to raise the remaining one-third.

A condition of central funding which I believe many hospices would be pleased to meet is the provision of training for medical students in the care of the terminally ill. At present students have little training in what ought to be an extremely important part of their job. If it were provided, the principles of hospice care could then begin to be disseminated into the medical profession more generally. Pursuing the same theme a little further, will the Minister consider establishing a number of hospices around the country attached to teaching hospitals which could extend knowledge about appropriate care for the dying to an even higher proportion of our future doctors?

While the provision of funds from health authorities is so uncertain it seems that there is little alternative to a central allocation direct to the voluntary sector, but perhaps the Minister can say something about the results of her department's request, made I believe some time ago to health authorities, to submit plans for terminal care and to fund hospices providing support services. After all, they are providing a substantial back-up for the NHS.

Many hospices want to retain their voluntary status and some independence. However, they do not wish to be so short of funds that they have to turn away many people, as happens at present. It is vitally important that the Government take action, and take action soon, to provide resources by whatever mechanism to allow this great, inspiring and humane movement to do its work and, above all, to expand so that others can benefit from it as my family and I did.

8.21 p.m.

Baroness Cox

My Lords, I join other noble Lords in thanking the noble Earl, Lord Longford, for initiating this debate on a subject of such importance and timeliness. As has become clear, the hospice movement represents one of the most significant developments in health care in recent years, radically transforming attitudes and practices in the care of the terminally ill and their families.

I must at the outset declare an interest as a member of the council of management of St. Christopher's, Britain's first modern hospice. It opened its doors just 22 years ago, in July 1967. Since then many other hospices have been established in Britain and throughout the world, extending their care from within the hospices themselves to people in their own homes, enabling them to spend as much as possible of their last weeks and days in familiar surroundings with those closest to them—a development of hospice care which was so movingly described by the noble Baroness, Lady Blackstone.

Before I address some of the problems faced by hospices and the ways in which they might be helped to develop their distinctive ministry, it might be helpful to highlight some of those key aspects of their work in order to identify ways in which it can be facilitated and why they deserve support. Research, endorsed by the experience of those who work with people who know they are going to die, has shown that among those things which they fear most are pain, other symptoms such as nausea or breathlessness and loneliness. They are also often deeply distressed about the impact of their impending death on their families. Some express concern about spiritual values and others experience an existential crisis of faith and worry whether it will sustain them throughout the experience of dying.

Of course, as the noble Earl, Lord Longford, and others indicated, many hospitals and community care services provide high quality terminal care; but it is often extremely difficult for them to focus on and ensure time for the problems of the dying and the needs of their families. Hospitals are inevitably committed primarily to trying to cure the ill, to heal the injured and to improve the quality of life for those who are not dying but who cannot be cured or healed. As a nurse I know how hard it is—indeed, sometimes impossible—in busy wards to give to those who are dying the intimate and sustained attention which they and their families need. That is nobody's fault. It is a problem of competing and conflicting priorities and pressures, but it highlights the need for the distinctive kind of care which hospices provide.

Hospices are committed to the concept of trying to make death as positive an experience as possible. If we recognise that the one sure fact of life is death, there is a commitment to try to ensure that each person has as good a death as possible in their own terms and that their family receives the support needed both during the death of their loved one and during the subsequent bereavement.

Therefore, with all their experience hospices have been in the forefront of research and development in palliative care and have made major contributions to methods of pain control and symptom relief to the extent that they can now offer genuine reassurance to the great majority of their patients on this aspect of their fear of dying. Their opportunity to specialise in palliative care means that they can also perform a valuable and a valued teaching function for colleagues working in hospitals and in the community, helping them to benefit from the hospice experience.

Hospices are committed to what is called "whole person" or "whole medicine" care. They are therefore committed to offering patients and their families the assurance of psychological support, with great attention being paid to emotional needs both in the preparation for death and for families with follow-up care. For those who express a wish for spiritual support there is an assurance of help for those of Christian and other faiths, and there is always a readiness to listen to any non-religious approach and seekings. As I have already indicated and as has been emphasised by other speakers, there is this important and rapidly growing development of hospice care in people's homes with the provision of medical, nursing, psychological, social and spiritual resources to enable those who choose to do so to stay in their own homes for as long as possible, often to the end of their lives.

In a book celebrating the 21st birthday of St. Christopher's Hospice, Dame Cicely Saunders, its founder and, as the noble Earl, Lord Longford, said, to a great extent the founder of the modern hospice movement, presents the stories of 21 of the many thousands of patients cared for at St. Christopher's. In introducing their stories she writes: Their needs and achievements have been the centre and the stimulus for all the developments of these years. But they would not have been free to find and express their true selves and to remain close to their families for the last part of their lives had it not been for the awareness and skills of the various members of staff; so we celebrate them also". It is appropriate in this debate to celebrate all who have made the hospice movement possible and enabled it to develop its unique ministry of compassionate, sensitive, appropriate and effective care. It is also appropriate to consider ways in which that work can be supported so that it can go from strength to strength to meet an ever increasing demand.

I should therefore like to ask my noble friend the Minister to consider the following issues and questions. First, while hospices value their voluntary status and greatly appreciate the support they receive from many different sources, it would be very beneficial if their staffs could be relieved of some of the burdens of fund raising. I am sure my noble friend realises that the work undertaken by staff in hospices and by the home care teams is immensely demanding physically, emotionally and spiritually. I ask my noble friend please to note how heartened so many people were by the recent announcement of pound for pound financial assistance in Scotland and to convey the urgent request expressed last week, repeated here again this evening, that similar initiatives be taken for the rest of the United Kingdom.

Secondly, while hospices appreciated the speed of the response by the Government to the financial implications of the 1988 nurses' pay awards (which were warmly welcomed) there is a real problem for many hospices. Is my noble friend aware that many hospices have had to shoulder two-thirds of the costs of those awards, adding a further burden to their funding? It does not seem that that was the government's intention. Therefore could my noble friend take steps to remedy this unintended consequence of the increase in nurses' salaries?

Thirdly, as I have indicated, many hospices regard teaching as a vital part of their work and particularly the dissemination of their knowledge and experience to others working with the terminally ill in the National Health Service and in other places, especially abroad. In addition to providing courses for external staff, many hospices also take on a strong commitment to training their own staff. For example, St. Christopher's employs three registrars in training posts, all of whom intend to remain in the specialty of terminal care. Over a three-year period 54 St. Christopher's nurses have returned to the NHS after completing the hospice's staff development programme. Could my noble friend bear this time-consuming aspect of the work of hospices in mind when considering their funding?

Fourthly, could my noble friend take note of the financial implications of the importance of the care of the families of the terminally ill, many of whom are young and in need of support from hospice staff in rebuilding their lives after their tragic loss?

Fifthly, and finally—at least for this debate—will my noble friend give an undertaking that, in the formulation of policies concerning hospices, there will be consultation with all who have direct experience of their work? For example, I refer to senior staff in established hospices, the Association for Palliative Medicine, the Royal College of Nursing Symptom Control and Care of the Dying Forum, the Association of Hospice Social Workers, the Association of Hospice Administrators and the Association of Hospice Chaplains. These and other professional associations clearly have much of great value to offer. I believe it is a matter of some concern that their views should be taken into account in discussing the criteria for designation as a hospice and professional standards of care, training and education.

In conclusion, perhaps I may pay a final tribute to all who work in hospices, for their vision, dedication and commitment, which alleviates so much suffering and brings hope to so many in the face of fear and despair. As Dame Cicely Saunders concludes the introduction to her book from which I quoted earlier: We celebrate a place where 'the new life rising within us' has had an opportunity to grow". I hope that as a Government and as a nation we will help all hospices to continue to foster the new life rising within them.

8.33 p.m.

Lord Stallard

My Lords, I too wish to add my thanks and congratulations to my noble friend Lord Longford for putting down this Question and giving us this opportunity this evening. I almost feel that enough has been said and that nearly all that can be said has been put forward by people who are much more experienced than I. However, I should feel guilty if I did not continue if only to repeat what has already been said. It is important that those of us who have feelings and views on this subject should state them whatever the circumstances.

My own involvement was as chairman of a local authority health committee for many years. I was privileged to visit some hospices and some units for long stay and terminally ill elderly people. I was able to view at first hand the treatment that was given to those people and what it meant to their relatives. I consider that there is a growing need for these facilities, as mentioned by the noble Lord, Lord Dunleath, if for no other reason than that they are much more efficient in the management of this particular traumatic event.

It has been generally accepted— I accept it too—that in this country we have been loth to talk about terminal illness or death. It is something we fight shy of. We have never faced up to it until now. I believe that is due to the growth of the hospice movement and the knowledge of the work that it has done as regards pain control, the treatment of patients and the bereavement counselling for relatives which is an essential part of the process. These factors have broadened the discussion to a much wider population.

Training courses are run for nurses and other staff who work in hospices. The home care service that has been referred to involves more and more people in the work of hospices and other special units. So we are slowly coming to terms with the problems surrounding terminal illness and death. It has to be said also that the publicity surrounding the tragic onset of new diseases such as AIDS and motor neurone disease, besides the broader spread of age groups affected by cancer, have played a part in raising our awareness of the issues, the problems and the necessity for the services provided by hospices.

Television and radio have also made a very valuable contribution in recent programmes in raising the awareness of people as to the benefits that these services can bring. It is true, as my noble friend said, that most people have always looked on hospices as somewhere to go to die. I believe it was a patient at the Strathcarron Hospice near Stirling who said in one of the programmes that I heard that he had always thought a hospice was just a place to go and die. He explained: But it is a place for peace and dignity and caring. If you have to go, you go without pain; it makes you less fearful of death". I believe that that is quite a tribute to the management of pain control and the counselling to which I and others have referred.

The noble Duke and others have given some very impressive statistics and I do not intend to repeat all of them. However, I believe that some need underlining. The noble Duke said that, since 1967 when the modern hospice movement was founded, there has been a steady increase in its development which has occurred even more rapidly in the past 10 years. Now I understand that there are 2,432 beds in about 133 units. Together with care teams, they care for 40,000 patients a year. Of these 133 units, 100 are in the voluntary sector and are registered as nursing homes. The remaining 33 are run by the National Health Service.

I understand that one-third of the money to run these hospices comes from the NHS and the rest comes from grants and donations together with fundraising. Other speakers have mentioned the need to try to reduce that commitment. The tremendous burden is now much larger and will continue to increase as the demand grows for these kinds of services. The Government should recognise that it is a more efficient way of dealing with these cases. It will be money well spent.

I am the first to admit that the Government have made some positive responses in recent months in reply to the demands for extra funding. For example, I refer to the extra funding for the nurses' pay award. The Government responded constructively, as they did in response to the setting up of the London Lighthouse and Mildmay Mission Hospices. Both are in the London area and I know them. They are both urgently needed and benefited very much from the assistance that the Government were able to give.

However, the service needs much more than that. It has to be extended even further. In a Written Answer in another place on 10th February 1988, the then Minister listed 103 district health authority areas where there was no in-patient hospice unit within their boundaries. That gap will have to be filled. And, as more people become aware of the benefits of the service, there will be demands for the gap to be filled. More resources are needed to develop what is now a necessary service.

Age Concern, with which I am closely connected, has made a number of suggestions. It believes that we should encourage the introduction of the hospice concept in all care settings; in hospices, long-stay hospital care, nursing homes and in the home. Previous speakers in this short debate have pointed out that this is not a question of hospice versus hospital. It is a recognition of the problems faced by hospitals at the moment. The need for this specialised service is becoming more and more apparent as demand grows. We need both services, but we need the hospice concept for the chronically ill and the terminally ill.

There should be national guidelines for the care of the terminally ill, with sufficient resources made available for this highly intensive system of care to be put into practice. Many elderly people who are not terminally ill require and receive in long-stay hospitals, in nursing homes, in residential homes and in their own homes long-term care for chronic conditions. That is where we should try to improve the standard of care (where it needs improving) and that is where the hospice concept could be introduced.

We also believe that different levels of care are necessary to give older people a greater choice. There should be a choice at that stage and in those circumstances. Long-stay hospital care should be provided in local hospitals which serve the needs of the whole community. The quality of life for all chronically ill elderly people must be improved with a greater respect for their individual needs and choices. As old mental and geriatric hospitals are closed all over the country, we must replace them with smaller, more localised units. The move from institutional care to care in the community must consider their needs and the needs of future generations. There must also be recognition of the continuing need for some long-stay hospitals. We have talked about domiciliary care where possible. My noble friend Lady Blackstone gave an emotional description of how domiciliary care is absolutely necessary. However, we need long-stay hospitals as well for a number of reasons.

The Government have expressed their commitment through Ministers both here and in another place to the voluntary hospice movement. I should like to ask the Minister one or two questions. Those of us who scan the papers and the agendas for anything that is helpful have noticed the not unexpected initiative in Scotland, from where so many initiatives come. The Scottish Office has offered pound for pound for the financing of hospices. Is the noble Baroness able to give a timetable for when that can be introduced in the rest of the United Kingdom. The Government have committed themselves to the principle, or something similar. I should like to know the timetable. One or two other points have troubled me in my recent reading. I understand that in 1987 the Department of Health issued a circular, HC(87)4, requiring health authorities to consider their plans for terminal care and to make an appropriate financial contribution to hospices providing support services. Is the noble Baroness able to tell us what progress has been made since that circular was issued? Has there been any response from the health authorities involved?

Earlier this year the department wrote to the Royal College of Nursing's hospice care forum stating that there seemed to be considerable variance between the resources the DHAs said they allocated to hospices and the amount the hospices said they received from the DHAs. If there is a discrepancy, has it been investigated? How far have the investigations gone? Can the noble Baroness give us any information about the present position?

I should be grateful for replies to those questions. In the meantime I hope that the Government will underpin their commitment by ensuring that adequate financial resources are made available to plan and build the hopices that must be opened if we are to meet the new demands that will be made on them.

8.46 p.m.

Lord Blease

My Lords, I join other noble Lords in thanking my noble friend Lord Longford for initiating this timely, informative and challenging debate. I consider the debate timely because of widespread public concern about the Government's reforms of the National Health Service and the current political controversy over the future of patient care. The timing is particularly important because of the concern about the major financial crisis in the hospice movement.

The typically sensitive and frank speech of the noble Earl and the succeeding practical and emotional points made by other noble Lords should help to heighten public awareness of, and stimulate government action in response to, the urgency for reasoned expansion and development of the hospice movement. This debate challenges us all earnestly to seek to promote reasoned co-operation and partnership between the statutory health authorities and the independent voluntary hospice organisations, a partnership encouraged by government which will fulfil the need for wider availability of hospice type care for the terminally ill.

The historical development of the hospice movement can be traced to the fourth century. We know that most of the medieval hospices in Britain were founded by religious orders. Even today some of the existing hospice and palliative care services are staffed and managed by religious foundations and trusts. I understand that the modern hospice movement has been developed in its present charitable, registered form during the past 40 years.

I have received today an excellent paper prepared by the Royal College of Nursing's hospice care unit which sets out approximate figures for the number of hospices in the United Kingdom. There exist about 136 independent hospitals having in-patient units. These units are widely dispersed throughout England and Wales, with 13 in Scotland and four in Northern Ireland. In addition, there are in England 26 hospices under the direct control of the National Health Service. I state those figures because they are approximations and we find different aspects of the service being promoted as hospice services. Some of the care is in-bed hospital care, while a lot of the work is done at home or by out-patient activities which have already been mentioned. These have to be related to the total costs of the central organising hospice unit.

Notwithstanding the growth of the hospice movement, there are deplorable gaps in the range of in-bed unit facilities. My noble friend Lord Stallard mentioned some of these. If we are a really genuine caring society, surely these hospice services should be readily available to all terminally ill patients and their families in both urban and rural areas. I believe that this is a great challenge to both the Government and the hospice movement. There are many areas which are totally neglected in this connection. After all, it is not large buildings which are requested in connection with hospice services. Smaller units, such as cottage hospital care, would meet the need in much more effective terms than the large buildings which are being planned.

My views are mainly conditioned by my experiences in Northern Ireland and my contacts with individual personnel working directly in hospices in Scotland and in England. I have been privileged to be associated with the provision of hospice facilities in Northern Ireland for over 30 years. I was a member of the working party appointed in 1979 by the then Lord Mayor of Belfast, Alderman David Cooke, which founded the Northern Ireland Hospice, and I had the honour to be its first president for a period of five years. I state that because I feel that I have some detached knowledge of the general work that is required and the general needs of the present situation.

There are four hospice-type facilities in Northern Ireland. There is the Northern Ireland Hospice. There is the Foyle Hospice, which is only a room where three nurses meet, take telephone calls and go out to provide a service, but it is an excellent organisation which has been set up pending the acquisition of an in-bed unit. Then there is the St. John of God Hospice which has been established for a long time and is now proposing to set up an eight-bed unit. Then the Beaconfield-Marie Curie Home was established in, I think, 1963 in Belfast. These four hospice units have had very generous community financial aid and voluntary support. All fund-raising and voluntary work is given wholeheartedly by all sections of a divided community.

It is important that I should say that the people at all levels who work at and are involved in the four hospices in Northern Ireland are of differing religious faiths and of no faith. They all join in sharing the work and in caring for patients, who are admitted and treated with the same respect and dignity, irespective of their religious outlook. My noble friend Lord Longford spoke in this connection and I felt that it would be useful in the Northern Ireland context to say that these four hospices are oases of human compassion, light and hope in a bleak wilderness, where often the sense of human dignity and values seems to be lost. They are indeed an inspiration to us all. However, the problems of these Northern Ireland hospice units are largely the same as elsewhere in the United Kingdom. The problems are of increased demands for their services and the increasing difficulty of obtaining funds for revenue costs.

It might be helpful if I quote from a briefing I had from the Beaconfield Hospice in Northern Ireland. It states: There is a great deficit between the cost of Beaconfield and the income … This has to be met by voluntary contributions, fund-raising events and legacies. Relatives of patients will send donations in lieu of flowers following a death and staff and friends of the Home are constantly pursuing ideas for fund-raising. The work of Beaconfield complements the National Health Service in the following ways:

1. 1. By providing care for patients when treatment is no longer appropriate—beds in the NHS wards are not blocked by terminally ill or convalescent patients.
2. 2. By providing care for patients admitted from home who would otherwise be needing hospitalisation.
3. 3. The cost of nursing a patient at Beaconfield costs much less than in any area of NHS care. The cost of care for a patient for one week in Beaconfield was £344.55 last year. Figures for NHS are not available but previous years were very much in excess of this amount".

That puts the matter in perspective in relation to what was said earlier. They render a service to the community and they ought to be compensated in some way. While the quality of care and the treatment differ little, quoted bed unit costs vary by as much as £300 per week between the lowest and the highest currently stated figures.

Another aspect of the overall general development of the hospice movement is the absence of any apparent effective central voice for the movement. Except for the Royal College of Nursing Hospice Nurse Managers' Forum and the recently formed "Help the Hospices" group, there appears to be little attempt to present hospices in a professional and effective way and as a movement with all its ideals, objectives, functions, problems and financial difficulties.

If I may cite a problem that I foresee, some hospices are pleading for and supporting the pound for pound scheme. They are asking for it to be extended to them and are supporting it in general terms. The pound for pound scheme was announced by Mr. Michael Forsyth, the Health Minister at the Scottish Office. After giving the scheme due consideration, I think that it would be financially disastrous for many hospices. Voluntary fund-raising is now more difficult than ever and is not returning anything like the amounts required to balance the books. Indeed, many hospices are running a two or three-year deficit and certainly the books have not been balanced.

When voluntary appeals fail, what does the pound for pound scheme yield for any hospice? The answer is nothing. This is an issue which should be examined very carefully by those putting it forward. Even if hospices are not in deficit this year, there are difficulties about expanding the service and obtaining funds for capital development, as well as not having the revenue to meet the ordinary administrative and running costs. My belief is that a partnership with the health authorities should be established and there should be sound contractual arrangements made for hospice services.

I should like to quote from the excellent paper which I have mentioned. It shows the concern of the Royal College of Nursing Hospice Nurse Managers' Forum and should be read by many who are giving their services to the hospice movement. It states that it would like to see: 1. That hospice service be regarded as a core service. 2. That GP budgets be realistic enough to allow for the proper subscribing of terminally ill patients so that they can have all the medication they require, regardless of cost. 3. That drugs for hospice in-patients be provided free and prescriptions for out-patients and for day-care patients also be free". They are practical things which should be quantified in some way and met out of existing health service funds.

All those interested in the hospice movement should seek to have appointed an independent working party urgently to undertake a study and to issue a report on the present internal structure and needs of hospices in the United Kingdom with a view to meeting the future developments in the best interests of the terminally ill.

I realise that it might be some time before such a study could be accomplished. Perhaps it could be set up independently by some of the trusts that have done such valuable work in that connection. In the meantime I urge the Government to try to meet the running costs of existing hospices.

9 p.m.

Lord Hylton

My Lords, I apologise for speaking without having put down my name. I do so only because I have listened to the whole debate and have a number of friends currently working in the hospice movement. I should like to make just one financial point. In doing so, I support strongly what the noble Lord, Lord Blease, has just said. Pound for pound is no doubt a big step forward in Scotland. I am sure that the Scottish hospices are grateful for the scheme, but something a little better and a little more thought through is called for for England and Wales.

We should note that the population of England and Wales is much larger and the problems are rather more complicated than those in Scotland. We need a definite co-ordination of approach among a number of government departments; there is the Department of Education and Science in which the noble Baroness, Lady Hooper, has served for a number of years. That department could perhaps take on 100 per cent. of the costs of education and training within hospices. After all, it is entirely an educational and training service for adults. Secondly, there is the Department of Social Services. Is it not possible for that department to look after the counselling requirements and bereavement care of families? One would imagine that that would fall within its terms of reference.

Finally, one comes to the Department of Health. My noble friend Lord Dunleath rightly made the point that the higher the proportion of support that can be given to the running costs of hospices, the easier it will be to raise additional capital from the general public, which is, I am glad to say, extremely generously minded on this theme and subject. With that, at this last moment perhaps I may beg the noble Baroness to respond generously to my plea for a co-ordinated across-the-board government approach.

9.3 p.m.

Lord Ennals

My Lords, the whole House will be grateful to my noble friend Lord Longford for opening, in a moving way, a debate which, as he said, is long overdue and which has been of great value. The debate has been well informed because so many of those in your Lordships' House—I am thinking of the noble Baroness, Lady Cox, the noble Lord, Lord Dunleath, and my noble friend Lord Blease—have worked in the hospice movement in their own parts of the country.

I have visited several of the hospices referred to—St. Joseph's and St. Christopher's—and many others during the past 20 years, and I agree with all that has been said about the remarkable atmosphere which exists among those who know that they are dying. I should like to echo the tributes which have been movingly paid by my noble friend Lady Blackstone and all who have spoken to all the people who work in the hospice movement. I include those who work in home care for the terminally ill, because increasingly we see that as a broad spectrum of services to the terminally ill.

It must be, as the noble Baroness, Lady Cox, said, tremendously challenging work. I do not believe that I could maintain it. It requires great qualities to cope with the physical, emotional and spiritual needs of the terminally ill and their families. Some of us may be more aware of what has been done for families than for the patients themselves. I should like to echo the plea made by my noble friend Lord Stallard and Age Concern that the lessons which have been learnt in the past 25 to 30 years, since the remarkable work done by Dame Cicely Saunders, should be extended to all parts of the care setting: to hospitals, hospices, long-stay hospitals, care nursing homes and home care. We are not today talking about a luxury; we are talking about an essential core part of our National Health Service. We must look at the service as an essential one which more and more people will look to and hope for in their terminal years.

I wish to emphasise the importance, which was touched upon by my noble friend Lord Stallard, of preparing national guidelines for the care of the terminally ill, because we must plan for expansion. Inevitably of course expansion, as always, will need more money.

There has been no reference to the needs of children. Perhaps the Minister can say something about that and, if not, perhaps she will write to me. A recent National Association of Health Authorities report said that there were about 5,000 children at any one time with terminal illness, and yet there are only three hospices for children. I do not suggest that people would want children to die in hospices, although it may be the best thing for some in view of their home circumstances. There is a call for something to be done for children as well as adults.

Several noble Lords referred to the legal status of hospices. Hospices outside the National Health Service are registered nursing homes. They are registered and inspected by district health authorities under the Registered Homes Act 1984 and the equivalent legislation for Scotland, Wales and Northern Ireland. They are registered charities and as such their management is governed by articles of association. The voluntary hospice movement, as I understand it, would like a simple registration system for hospices to be established in order to ensure that a distinction is clearly made between the services offered by nursing homes and those offered by hospices. This again may be something on which the noble Baroness will be able to comment.

My noble friend Lady Blackstone referred to the circular HC(87)4 issued in February 1987. I hope that the Minister will say something about what has been the result of the circular. It called upon health authorities, to examine their current provision of services for all terminally ill patients … to plan …to rectify any deficiencies, where possible in collaboration with the voluntary sector". Paragraph 5 of the circular states: Where a voluntary group provides a service that represents an essential element in a health authority's overall plans for terminal care, the health authority should agree with them a contribution to the costs of that service". Health authorities were due to submit their plans to the Department of Health by summer 1988. I wish to know how many health authorities have done so and how many have not. The health authority support has remained static in many cases. As I understand it, in one or two cases the provision of hospice care has been reduced. The health authorities argue that, in the tight financial climate in which they operate, it is very difficult for them to increase funding for voluntary hospices. As I said, in some cases there has been a reduction.

Perhaps I may repeat my request for a comment by the Minister on the Scottish situation. I agree strongly with the view of the noble Lord, Lord Hylton, that it may not be the best way forward. But for those who desperately need money it is a way forward. I think that in Scotland there has been an enormous welcome for this initiative of the Scottish Office. Perhaps it can be improved, maybe there are better ways of doing it. I am certain that when the Minister comes to reply she will tell us what the situation would be likely to be in England, Wales and Northern Ireland. It would be very unsatisfactory if we were to have one system operating generously in Scotland and no equivalent in other parts of the United Kingdom.

As has been shown, there is clear and widespread concern about the funding problem. I am certain that the noble Baroness will bring some clarity to bear on the matter. I have asked her to do so. As I understand it, in 1988 it was estimated that an extra £6 million would be required to enable hospice nurses—most of them employed by voluntary organisations—to be brought up to NHS pay levels. Essentially, if the best nurses are to be attracted, they should get the rate for the job. It would be quite wrong if there were a lower standard of pay for those working in the voluntary hospices than for those working in the NHS.

At the Conservative Party Conference in October 1988, the figures seemed to come down to £4.5 million. As I understand it, that was promised. There then seemed to be a cut to £1.3 million, and in March this year Mr. Mellor referred to £400,000, for distribution to local projects in short-term financial difficulty". I am quoting what was said. That was a very welcome payment, but was it enough? Perhaps it was in addition to another sum that had been paid. I hope that the Minister can clarify the situation when she comes to reply.

I am sure that she would agree that, as was mentioned by my noble friend Lady Blackstone, it is unsatisfactory that some hospices receive nothing at all; some receive as little as 1.5 per cent. of their total costs; and others receive upwards of 50 per cent. I am certain that all their needs are equally great. As my noble friend Lord Blease stated, what is needed is that these should be brought together. There has been a tremendous improvement in the situation which is very welcome but it lands us in some confusion. The Royal College of Nursing referred in their description to "arbitrary and variable" situations. That seems to be a fair criticism. The same view is held by Help the Hospices, to which reference has already been made.

We need to see a national picture. The Minister told us last week, in answer to a Question from the noble Baroness, Lady Cox: arrangements for … independent hospices have been under careful consideration for some time".—[Official Report, 26/10.89; col. 1549.] She said that she hoped to bring forward plans, "in due course". With great respect, that sounds a rather leisurely timetable for those hospices that are desperately in need of help. I have spoken to several hospices since then and there is a great need not only for funds but for clarity about where the department stands on this. I know, of course, that health authorities are now under great financial pressure and in many cases are once again planning cuts in their own services. I am certainly not asking that health authorities should be required to cut their services in order to give the assistance that is needed for the hospices. Some extra money must be made available, but, when one looks at that as extra money, one must realise that the hospice provision means a saving for the National Health Service as a whole. I hope that the Minister can give us, or give to the voluntary hospice movement, a hope that it will be brought in in a rather more co-ordinated way, that there will be rather more effective assistance from the department, and that the movement will be able to plan for its future.

It would be quite wrong for me to sit down without positively welcoming the decision of the department as regards attendance allowance. Many of us had raised this issue in your Lordships' House on a number of occasions. It was very good news to hear that the little battering that had come from all sides of the House had produced a response from the Minister. I hope that some of the pressures that have come from today's debate will also make an impact on the department, and that the Minister can give us some encouraging news.

9.14 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper)

My Lords, I too am grateful to the noble Earl, Lord Longford, for introducing this short debate, and to all those who have contributed their views, which were nearly all based on personal experience, and who have raised questions on this important aspect of health care.

The Government are deeply appreciative of the high standard of continuing care that has been developed and provided by the independent hospice movement, and welcome its growing partnership with the National Health Service in caring for people who are terminally ill and for their families. We expect health authorities to take the lead in planning and co-ordinating a full range of facilities for the terminally ill, covering home, day and in-patient care.

In Circular No. HC(87)4, to which the noble Lords, Lord Stallard and Lord Ennals, referred, we have asked health authorities to do this, to work closely with voluntary bodies in carrying out this task, and to agree contributions towards the cost of any essential services that they provide. I am pleased to be able to say that regional health authorities in England have already appointed, or are in the process of appointing, co-ordinators to advise on the implementation of strategies for this important service.

Some statistics have been quoted and I should perhaps try to set the record straight. In the United Kingdom there are already, within the NHS, 28 specialist in-patient units, over 140 home care teams and 38 hospital support teams, working alongside front line staff. The latter include general practitioners and community nurses who come into contact with a wide range of patients in their own homes. They are supported by a cadre of 600 specialist Macmillan nurses and some 4,600 Marie Curie nurses who are jointly funded by health authorities and charities.

The number of independent hospices providing specialist in-patient care for people with a terminal illness is considerably larger—113 in the United Kingdom, providing some 2,600 beds. Information from the hospice movement indicates that there are plans for a further 37 units, providing 277 additional beds. Three-quarters of those projects have been started in the past 10 years, and there is a wide variation in the geographical distribution of hospice beds and in the level of financial support that health authorities have been able to provide.

The running costs of independent hospices in England last year are estimated to have been just under £54 million, to which health authorities contributed just over £11 million or, on average, 21 per cent. In the same year, the Government also contributed £1.3 million towards the cost of pay increases for hospice nurses and distributed £400,000 via the charity Help the Hospices specifically to voluntary projects in short-term financial difficulty.

As has been said, the average NHS contribution conceals wide variations in support, from, I am sorry to have to say, in some cases nil, up to 80 per cent. of running costs. The bulk of the remaining costs is found from charitable giving, and some hospices welcome the independence of operation that such public support allows them. Nevertheless, the Government accept in principle the desirability of a more balanced, stable and equitable pattern of NHS support.

As I have already said, that matter is under careful consideration at the moment. Therefore at this stage I cannot give noble Lords a timetable. However, I am grateful to those who pointed out that although the pound for pound concept sounds simple it is a complicated principle to put into practice. In saying that, I realise that in Scotland the Minister responsible for health has announced his intention to introduce from 1st April next year a scheme which would provide financial assistance for hospices up to a level of 50 per cent. of their running costs. It remains to be seen what we shall be able to do in England once our consideration has been completed. However, I can assure your Lordships that the points that have been raised in the debate will not be lost in that process and will certainly not delay it.

The same applies to arrangements for Wales and Northern Ireland. In that respect I noted what the noble Lords, Lord Dunleath and Lord Blease, said about Northern Ireland, as indeed—as they will recognise—did my noble friend Lord Skelmersdale.

Whatever the outcome of those deliberations, it is worth emphasising that the hospice movement is already strong. As my noble friend the Duke of Norfolk reminded us, the United Kingdom has developed a leading international role in the field and much of its strength has been built on substantial voluntary efforts. We have no wish to supplant that activity, rather to complement it by encouraging the growing partnership between the National Health Service and the voluntary sector.

Many of your Lordships have referred to individual hospices and to the outstanding work that they do. It would be invidious of me to refer to any particular hospice. Suffice it to say that I have visited a hospice and recognise fully the devotion of the people who work there and the amazing cheerfulness, as the noble Earl mentioned, of the patients.

The hospice movement is not primarily about buildings or beds but about quality of care regardless of the physical setting. It means a team approach, involving specialist and generalist staff in a range of disciplines, often supported by volunteers, aimed at ensuring that the dying person achieves the best possible quality of life. Meeting that aim depends on the availability of a high standard of pain relief and symptom control and also of sufficient time to provide emotional and social support for patients and their families. That sort of time is not always available on a busy hospital ward where the emphasis will be on active treatment and cure.

It is at the same time thanks to improvements in active treatment that many diseases which were formerly fatal, particularly cancers, can now be cured. Where complete cure is not possible, patients can still survive and remain active for longer periods than in the past.

The hospice movement is adapting to that. In-patient admissions need to be more carefully planned. Patients are not necessarily admitted in a crisis or in their last few days of life. They may increasingly attend as day patients or receive at home treatment that was previously available only in hospital or in a hospice. They may be admitted to a hospice for a brief respite—to give them or their families a break or to have symptoms brought under control—before returning home. There is a developing and changing pattern.

As has been said, many people want to die in their own homes and it is in any event unlikely that more than a minority will die in a specialised in-patient hospice. About 62 per cent. of deaths occur in hospital and 26 per cent. at home. Of the remainder it is estimated that up to 10 per cent. may occur in hospices (although hospices providing home and day care will naturally be in contact with a wider population).

The noble Lord, Lord Ennals, asked me specifically about children. I am afraid that I must take up his suggestion that I should write to him on that subject because I do not have the information with me.

There has been and still is an enormous fund of enthusiasm for local in-patient hospices. But it is clearly important for all concerned at that level to plan and work together to determine how existing and proposed units can best meet local needs and how they fit in with other services for the terminally ill. A co-ordinated approach at local as well as government level is necessary. It also underlines the value of disseminating the best practice that has been developed in such units far beyond their walls to the staff in the community and hospital services who come into contact with a wide range of patients and their families, through training, staff exchanges and the deployment of the specialist advisory teams that I have mentioned alongside frontline staff throughout the health service. In our view these are the key factors which underpin the partnership between the National Health Service and the independent hospice movement which we so very much value.

Turning to other specific points that have been raised, I am pleased at the welcome that has been given to the Government's intention to make attendance allowances available to people with a terminal illness without the normal six months' qualifying period. I know that this is an improvement to which the hospice movement attaches great importance and I hope that it will particularly help to ease the burdens of people caring for a very sick relative at home.

As for delays in the payment of income support for people with a terminal illness, that benefit is of course payable to individuals to help them to meet the charges that they incur for residential care and not to the institutions providing it. Many independent hospices do not wish to raise charges for admission. However, where a hospice has no contractual arrangements with the health authority and wishes to raise charges for an in-patient's board and care, the individual may claim income support up to a maximum of £235 a week or £258 in Greater London, plus a personal expenses allowance of £10.05 a week. Managers of local social security offices will always be pleased to discuss general procedural requirements with organisations which advise claimants. While those claims may take a little longer to process, I understand that income support claims nationally are now being dealt with on average in just five days.

As for drugs, the majority of hospices already receive the supplies that they need at National Health Service expense. GPs are entitled to prescribe drugs for their patients who have been admitted to hospices. That entitlement applies equally to hospice medical staff who are also general medical practitioners. In addition, health authorities have discretion to supply drugs to hospices without charge, at reduced rates or to make contributions to the cost of the services that they provide. The Government are aware that some hospices find current arrangements insufficiently flexible and we are in the process of considering the scope for simplifying them.

We are in no doubt about the importance of training. We have already asked health authorities to assess their training needs in this field and to consider how local facilities, including hospices, can be used to best advantage in meeting them. Both NHS units and voluntary organisations are active in providing specialist nurse training courses and some less formal facilities such as study days, conferences and publications for professionals and the public. The Royal Marsden Hospital and St. Christopher's Hospice have built up international reputations in that field.

Furthermore, palliative medicine has now achieved recognition as a medical specialty in its own right and a number of training schemes have been or are in the process of being established involving the NHS, the universities and independent hospices. The Cancer Relief Macmillan Fund has been instrumental in launching, in partnership with the universities and health authorities, a series of medical and nursing posts both for teachers and trainees. Cancer Relief and Marie Curie Cancer Care have also launched a number of educational initiatives to coincide with the European Year of Information on Cancer 1989, including video packs for general practitioners on the care of patients with advanced disease. The Department of Health has for its part contributed £100,000 to support charities' efforts to disseminate information on care and prevention for the public and for professionals in connection with the European initiative against cancer.

On the question of nurses' pay, hospices provide a local service and their funding is therefore essentially a local matter. The impact of pay awards for nurses is a factor that we should expect health authorities to take into account in determining the support that they can give.

With regard to the question of consultation which was raised, we do our best to keep in touch with the relevant professional bodies and associations for consultation purposes. However, I must say that it would be helpful in this respect if there were a single national co-ordinating body which represented all groups within the hospice movement.

Finally, I have been asked why there is no mention of services for the terminally ill in the White PaperWorking for Patients. The White Paper is essentially a strategic document about changes in the management of services. It emphasises the important task that health authorities will have of ensuring that all the health needs of the population for which they are responsible are met and that people have access to a comprehensive range of high quality and value for money services. The specific form that those services take and the way in which they are provided will be for local management to determine in order to meet local needs and circumstances.

As I said at the outset, so far as concerns services for people with a terminal illness, we have already asked health authorities to take the lead in planning and co-ordinating a full range of facilities. They are doing so. That policy remains unchanged but I think that it may well have been reinforced by this debate.