HL Deb 15 November 1990 vol 523 cc545-64

9.50 p.m.

The Earl of Longford rose to ask Her Majesty's Government when their commitment to pound for pound funding for the hospices will be honoured.

The noble Earl said: My Lords, the purpose of this Unstarred Question should be plain to all, including the Minister. I have given her full information about what I propose to say. I hope that by this time she realises the high regard I have for her and perhaps she will convey to the new Minister with responsibility for health how happy I am that he is taking over from his colleague. The new Minister has a brilliant academic record. In some eyes that is perhaps a disadvantage as people at once suspect someone who is immensely clever. However, I believe that it is a plus mark; we need intelligence in this difficult area in which so large a proportion of the public is interested. Let us look forward with hope to the new Minister proving even more successful than his predecessor.

My purpose is plain: to press the Government—having been given notice I do not know how many times—to tell us clearly how and when they propose to honour their commitment to make sure that the hospices receive 50 per cent. of their total spending, pound for pound—that is, £1 from public money for every £1 raised by voluntary subscriptions. There is nothing extraordinary about this commitment; the 50 per cent. arrangement is already operating in Scotland and again and again the Government have indicated their desire to honour it.

As regards this matter there is no party political issue; no party is remotely concerned here. However, before coming to the crucial, practical issue, I wish to say one word about the hospices. I dwelt on the subject at greater length on 31st October last year and I shall not repeat what I said then. I venture the opinion quite confidently that among all the excellent developments of the National Health Service in recent years none has been quite so noble as the development of the hospice service. I say that irrespective of anything done or not done by governments. It has been a wonderful human initiative.

If one asks, "What can hospices offer that is not offered elsewhere?", the answer is a quality of life for those suffering incurable illness or dying. I understand that hospices today are not referred to as places to die but as places to live. There has been a remarkable harmony between what we might call the spiritual and medical initiatives, exemplified perhaps by Dame Cicely Saunders, OBE, more than anybody else, but also by many others. We find in hospices a coming together of the spiritual and medical, which in my experience is something unique. There have been big developments in hospice care but I do not wish to imply that one can only die with dignity when under hospice care. On Sunday I said goodbye to Malcolm Muggeridge, who was then unconscious. His devoted wife and brother were sitting at his bedside. Nothing could have been more inspiring than the serenity and beauty of the whole situation. I do not think one can say there is anything tragic about such a situation, unless one thinks that death is tragic. However, I do not.

I believe a good quality of life can be provided in all kinds of situations. I can say with absolutely no fear of contradiction that in the hospices a great many people are helped to die with dignity. They are also helped to live for quite a long time in a way that makes their lives worth living. Some people achieve that in the hospices who could not achieve it in other places.

There is no doubt that this is, mercifully, a subject where party politics do not come in. The hospices have been strongly supported in all parts of the House. In this area humanity reigns supreme. I must offer a few quotations to the House. They will be familiar to the noble Baroness as I have already supplied her with a copy of them. The House will also remember the quotations as they concern a Starred Question of 31st October. The noble Baroness, Lady Cox, asked a Question on the hospices. The noble Baroness speaks with first-hand authority on hospices. I always listen to her with particular respect for two reasons: first, because she is such a good Christian and, secondly, because she is a nurse. A Christian nurse is the tops, in my opinion.

The noble Baroness asked the Government on 31st October, at col. 1840 of the Official Report, how they intended, to fulfil their commitment to achieve matched giving to voluntary hospices". The noble Baroness stated: hospices were encouraged by the Government Statement in December 1989 to plan their strategies on the basis of 50 per cent. funding". I seldom quote anyone speaking on the other side of the House to this extent, but one has to make a start somewhere.

The noble Baroness further stated: There is a real urgency for the situation to be addressed, otherwise hospices already face problems of redundancies and bed closures. That is a great tragedy given the enormously important services that hospices provide and the great dedication of staff who work in them". I certainly could not express those sentiments better myself.

In reply the noble Baroness, Lady Hooper, who is to reply to the debate tonight, said: I can assure my noble friend that the Government are still working towards that aim". Those words need to be carefully studied. On the face of it, that is rather like saying that the Government are working towards the reduction of inflation. That may happen at any time but it does not actually happen. However, the Minister made that point more positively in reply to a question that I put later on in that Question Time. The noble Baroness, Lady Hooper, said at col. 1841 of the Official Report:

We are still working towards that commitment".

I stress the word "commitment". A commitment is not just a good intention; it is a promise and an undertaking. I am bound to ask the Government how they are working towards fulfilling their promise. That is the issue before us and it is worth raising it even at this rather late hour.

At the same Question Time the noble Duke, the Duke of Norfolk, asked: is the Minister aware that originally the hospice movement asked for £23 million this year and received £8 million? She spoke of £11 million for next year. Is the Minister aware that to match giving pound for pound £30 million is now required?". That is reported at col. 1842 of Hansard.

I should explain to anyone who is befuddled by those figures that the £8 million goes up to £11 million if one includes Scotland, where the Government are already matching pound for pound. Therefore, whether one calls it £8 million for England and Wales or £11 million including Scotland the sum in no way approaches the government commitment.

We are all aware of the immense variety in the circumstances of the hospices and in the extent of their public funding. I pointed out last year that some hospices receive no public funds. One example is St. Luke's in Plymouth, where, as some noble Lords know, the medical director is Dr. Sheila Cassidy—and if they do not know they are impoverished. Anyone who wants to hear her preaching on prayer should go to Westminster Abbey in the near future. She is a remarkable woman. Now the hospice will receive a share—although it cannot be a very large share—of the £8 million which has been conferred by the Government. A year ago it received nothing and now it will receive a little.

It is difficult not to take an example if one wants to make a point, but any example in a sense cannot be typical because there are such variations. However, perhaps 1 may take an example from the area where I live, East Sussex. St. Michael's Hospice, Hastings, will spend £600,000 this year. Just under £100,000 will be received from the district health authority. As a result of the provision by the Government of new funds last year St. Michael's will receive more than £50,000 from that source. That is called the Bottomley money after Mrs. Virginia Bottomley, who is the Minister concerned.

As a result, a quarter of the hospice's funding will be provided from public money as compared with half of the funding, to which the Government are committed. I hope that they will not run away from that commitment and that the word "commitment" will not be elided into some phrase about an aim or an objective. I ask what is to be done in that one case about raising the public funding from one-quarter to one-half in accordance with the Government's commitment.

I have tried to pursue the matter locally. Naturally I approached the regional health authority. It says that it has no more money and that if more money were given to the hospices some other vital service would be deprived of the funds. I shall not accept that in detail. It may be possible to squeeze out more money by greater efficiency. However, without going into the question of whether that is 100 per cent. true, it is broadly true that if the Government's commitment is to be fulfilled it cannot be achieved by calling upon the local authorities, the district authorities or the regional authorities to find the money. The money must come from central government or the Government will be betraying their trust. That is the simple issue.

We should like to know whether the Minister agrees—be the proportion a quarter or perhaps a third over the country as a whole—that it should be raised to a half of the funding. I must ask the Minister whether she accepts the commitment for the central government to find the money. That is the simple issue before us tonight.

I shall touch on other topics in a moment but that is the issue in question and we must not run away from it. If the Government are committed to it they should go to the regional authorities and tell them that they should find the means. In fact they know perfectly well that they cannot do so. It is a very simple issue that faces us tonight.

There are one or two other issues which I might mention. In the Minister's statement of 13th July there is a reference to contracts. I shall not discuss that matter tonight. It fills me with disquiet and it has also filled with disquiet a good many people in the office world. There was a reference in the reply that the Minister gave to some system of contracts in the future. However, I shall leave that matter for tonight.

There is also the question, which will always arise in a matter of this kind, of how far this government money is to be distributed. How will it be worked out? Many questions could be raised on that issue. There are other points too. It could be asked whether any authorities will lose under the new arrangements about income support. There are issues of considerable importance. On the face of it, it may be that an authority obtains more money and then the hospice loses it through income support.

Those matters may be raised but I do not want to distract attention from the central issue. Are the Government ready tonight, through the Minister, upon whose word we rely absolutely, to stand firm by their commitment and how soon will it be honoured? If they give an evasive answer I shall view their reply with contempt. That is the last word that I would ever wish to apply to the noble Baroness and so I hope for good news when she comes to speak.

10.7 p.m.

Baroness Cox

My Lords, I should like to thank my noble friend the Duke of Norfolk for allowing me to change places with him in the batting order so that I may the sooner relieve my noble colleague on the Woolsack from his responsibilities there.

I should like to begin by congratulating the noble Earl, Lord Longford, for initiating this very timely and important debate on this crucial subject and for introducing it with his customary eloquence, charm, wit and sensitivity. I must declare an interest. I have the great privilege of being a member of the Council of Management of St. Christopher's Hospice. I therefore have in mind the particular concerns of that hospice. But they reflect the wider concerns of the whole hospice movement in this country at the present time. Therefore I trust that what I have to say will have relevance beyond the immediate experience of St. Christopher's.

At the outset I want to join the noble Earl, Lord Longford, in paying tribute to the hospice movement, the ideals on which it is founded and all who work in it. Those ideals have transformed the care of the dying and those who love them. In traditional hospital care the inevitable tendency has been to define those for whom no cure is available and who have entered terminal illness as those for whom "there is nothing more to do" other than to try to control pain and provide as much tender loving care as possible.

But in the inevitable busyness and hurly-burly of a hospital ward, with the best will in the world it is often impossible to provide the most beneficial conditions for the care of the dying and their families. By contrast hospices have been able to specialise in the care of the terminally ill. In so doing they have developed great expertise in palliative care with the control of pain and other unpleasant symptoms. They have also developed a comprehensive service for the support of the families or other loved ones, helping them through the difficult days of seeing the person whom they love, dying and then continuing with the bereavement service, as in due course they have to come to terms with their grief and loss.

That approach to the care of the dying has revolutionised the experience of death itself for countless people. The realistic reassurance of pain and symptom control, combined with the embracing of the family in their distress, means that it is often possible to conceive of a good death, of death as a part of life, and to achieve a well ordered, peaceful farewell to life and loved ones.

The achievement of the ideals and practices of the hospice work entails high personal costs for those who work in the hospice movement either in the hospices themselves, or in outreach work in the community —caring for people dying in their own homes. The personal and emotional demands on staff are very great indeed. For example, St. Christopher's staff recently gave a presentation illustrating not only the experiences of what they described in their presentation as "A family in pain" with the loss of a loved one, but also of "A team in pain" with the pressures and sorrows of working continually with human suffering, grief and death.

Therefore I believe that it is very unfortunate that staff who may already be under great stress, perhaps at the limit of their endurance because of the nature of their work, should also be subjected to acute anxieties about the availability of funding necessary for them to continue to provide their unique ministry.

That brings me to the general question of resources and to the specific question which is the subject of the debate. The extra support that has been given by the Government for 1990 and 1991 of £8 million has been most welcome. However, that does not meet anything like the level of matched giving. Moreover, in some cases the existing district health authority support for voluntary hospices has been reduced in the expectation that that loss would be made up from that £8 million. In the original announcement made on 15th December last year in another place, when stating the Government's commitment to provide matched funding, my honourable friend indicated that it would create a closer partnership between the NHS and the hospice movement. She also stressed that the arrangement would provide a clear basis on which hospices could plan ahead. However, committing hard-pressed health authorities to provide 50 per cent. of hospice funding without giving them the means to do so is not conducive to a closer partnership. Instead it has been in many places divisive and a cause of friction.

Moreover, health authorities are saying that they do not have the means to provide that matched funding and that they are not in a position to do so without more central funding. That means that although hospices were encouraged to plan their services on the basis of matched giving, they now find that they have no idea when that will be available and, as the noble Earl, Lord Longford, indicated, many long awaited developments are seriously under threat.

Many hospices are also fearful of the negotiations which have to take place with health authorities over contracts. In the case of St. Christopher's Hospice, contracts will have to be made with nine different health authorities. That will generate a considerable burden of extra work with no guarantee of a reasonable financial outcome. Those responsible for hospice finances therefore consider that it is vital for matched funding to take effect before contracts are entered into and they are very fearful of the consequences if that is not achieved.

In the short debate following the Starred Question that I asked recently, the Minister assured your Lordships that the Government would stand by their commitment to match funding. That was indeed reassuring. However, "standing by" is not the same as fulfilling. While the Government are standing by, the hospice movement is suffering. Some hospices have closed beds. Developments are under threat. The staff too are suffering from the additional burden of financial stress on top of the stress inherent in their professional work.

That really is unacceptable. The hospice movement is highly cost-effective, operating with so much charitable support and voluntary contributions of all kinds. It is also highly care-effective, relieving NHS hospitals of some of the most demanding and difficult cases of palliative and terminal care with their distinctive and ultimately worthwhile ministry.

I wish to ask my noble friend two questions. First, will the Government now give a commitment to achieve matched funding within a clearly specified timescale, say by April 1992? That would enable those working in the hospice movement to plan realistically. They could think ahead and it would give them the much-needed encouragement to continue their valuable work. Secondly, will the Government provide health authorities with the specific additional funding necessary to fulfil the obligations to ensure matched funding so that the money is not lost or dissipated en route?

I conclude with a brief quotation from the book edited by Dame Cicely Saunders called St. Christopher's In Celebration, 21 Years at Britain's First Modern Hospice. She concludes her introduction with these words: We celebrate a place where 'the new life rising within us' has had an opportunity to grow". It would be tragic if the Government's failure to honour their commitment to matched funding resulted in the stifling of that new life which has been growing so magnificently in the hospice movement. I hope that the Minister will be able to reassure the House, and more importantly all those who work with such dedication in the hospice movement, that the new life it embodies will be able to continue to grow.

10.16 p.m.

The Duke of Norfolk

My Lords, I too declare an interest. Some years ago my wife and I visited St. Joseph's Hospice in Hackney. It is the second oldest hospice in the country and was working in the 19th century. We were so impressed that we founded an appeal and my wife founded a movement called Help the Hospices of which she is chairman. It is of great importance at the present time.

It was in the name of Help the Hospices that my wife met Virginia Bottomley and talked about funding. In December 1989 it was agreed that they would work towards 50–50 funding, as is the case in Scotland. Incidentally, the other day I learnt that Northern Ireland receives two-thirds funding. I ask only for 50–50 funding as was promised by Virginia Bottomley during the meeting last December.

When announcing the extra £8 million funding for England Ministers stated that it would bring the level of NHS support to £20 million. In fact, during the past year only £6 million was allocated to voluntary hospices by regional and district health authorities. That allocation has been very uneven. Charitable funding to meet the running costs of voluntary hospices, excluding Scotland, amounts to more than £50 million a year. It would therefore be necessary for the Government, in allowing for 50–50 funding, to allocate more than £30 million now. That is very different from the £6 million that they have given. Even then health authorities would have to accept that the extra money should be allocated solely to cover the running costs of each voluntary hospice. We are talking only about the running costs. That point is every bit as crucial as the availability of the money required.

In my view, it is unreasonable to expect the Government to predict when the problem can be satisfactorily resolved. It is more realistic to ask how and by what process Ministers will ensure that their intentions and their policy will, through the regional and district health authorities, be fulfilled. Then we might know whether "working towards" means something other than a progressive allocation of more and more money. It should mean working towards a goal which regional health authorities, under some form of direction, earmarking or obligation are actually going to implement.

I believe that there is a second and even more important point that should be made. Health Ministers are presumably looking forward to the time when the provisions of the new health Act will apply —I see the noble Lord, Lord Carter, nodding in agreement—and when health services are provided through contracts with health authorities. Will the Government explain how they see this 50–50 funding applying, or even being worked towards, which is the phrase being used, for the voluntary sector in, say, 1993? Can we look that far ahead? Can they explain how they are going to reach that 50–50, pound for pound, in 1993?

If no such system is planned I have to agree that the Government's intentions in this matter are hollow. The two speakers who spoke before me, the noble Earl, Lord Longford, and the noble Baroness, Lady Cox, said the same. I have supported the Government and I do still in every way—let me say unequivocally that I support the present Prime Minister—but I say without wanting to needle the Government that we have been let down. Will the Minister please bear that in mind when she replies?

10.22 p.m.

Baroness Ryder of Warsaw

My Lords, it would be impossible for me to overstress the urgency of the point that has been raised by the noble Earl, Lord Longford. The drain on the funds of those charities involved in the care of the sick and the dying is now running at a truly alarming rate. The charity of which I am a founder had to find over £1.5 million last year from central funds to help its homes. This year the sum is expected to rise to over £3 million, and the forecast is that next year it may be in the region of £4 million. That is over and above all the local fund-raising that the homes themselves are able to achieve and takes no account of capital expenditure, which all homes need to make from time to time.

These demands, if not reduced, could bring to a standstill the foundation's plans to expand its badly needed services and could seriously damage the services being provided. I would therefore wholeheartedly agree with the point made by the noble Earl, Lord Longford. Bearing in mind the thousands of sick and handicapped with whom we have the privilege of working it seems most unfortunate that the foundation I represent, and also the Marie Curie Foundation and the hospices, are obliged to make such hugh efforts to raise funds themselves.

I could quote dozens of examples from the past 40 years among the sick and the dying and those whose families, if they have one, are so distressed because they cannot cope with nursing them, especially at night, if they are not admitted to a hospice, a Marie Curie or Sue Ryder home. For board and lodging we receive an allowance from the Department of Social Security of £260 per week for patients in receipt of, or eligible for, income support. Later, a long claim form has to be completed and signed by a patient when he is so ill and often is dying. Later still, when he has died, the form is normally posted to the next of kin, who may well not post it back to the Sue Ryder home. To be frank, that leaves my foundation the poorer.

If patients are in receipt of an attendance allowance of between £25 and £27 a week on admission, that is normally paid over to the Sue Ryder home. However, a claim made after the patient enters the home is often not allowed due to some contributions made annually by the health authorities. A great improvement could and would be made if board and lodging which dated from the day of admission were payable to the Sue Ryder home. Treatment by DSS offices varies considerably throughout the country, and there is a perpetual struggle to obtain allowances. Meanwhile, the patient is dying, has died or is being discharged.

I appreciate that the government commitment to which the noble Lord referred relates only to hospice care. I shall therefore confine myself to the help received so far from government sources by my foundation's cancer care homes. For every £1 provided for them from charitable sources this year, we received only 45p from health authorities; that included our share of the £8 million. Were the Government's commitments to be honoured this year we could expect health authority grants, including a share of the £8 million, to increase from £775,000 to £1,245,000. That would not resolve the financial problems to which I referred, but it would go a long way towards helping them.

I urge the Government to take steps to ensure that the commitment that they clearly gave that funds which come from government sources will match those from charity sources is honoured without delay. If the present method of distributing the £8 million made available to 1990–91 cannot ensure that all of it reaches the voluntary organisations entitled to it, perhaps some other arrangements can please be made.

There are generous funds made by central government for many other charities. When I inquired and had the opportunity recently to meet the Minister, the right honourable Mrs. Virginia Bottomley, I was told that there were no funds for our charity. How can that be said when such blatant evidence is there for all to see? I refer to a long list in your Lordships' Library.

There has been little or no mention of the necessity of providing funds directly to the charity; that is, the hospice movement, the Marie Curie homes or the Sue Ryder homes, rather than sending funds to the health authorities which can then decide to whom they want the funds distributed. That is quite paradoxical as direct funding works well in Scotland. The Scottish Office gives one-quarter of running costs and health boards give another quarter, which equals 50 per cent.

I can give an illustration of one Sue Ryder home which receives £8,500 per year from two area health authorities towards the £700,000 which must be raised every year to cover the full nursing and caring costs. From 1st January to 30th June 115 patients in that particular home attended a daycare centre; staff made regular bereavement visits; 180 visits were made by domiciliary nurses, and 297 patients were cared for of whom 120 died in peace and without pain.

No other facilities are offered in an area with a population of over 800,000 except for 10 beds in a small hospice. So pressed are the local consultants and doctors who worked with us in the Sue Ryder Foundation that the cobalt unit in the local hospital —again paid for by local funds—has only 30 beds. It admits patients on Mondays for radio therapy. They are discharged on Friday and at the weekend patients are admitted for chemotherapy. As I have already said, there is also a shortage of nurses in that radio therapy centre.

This foundation which I represent tries to absorb some of the patients who are discharged from National Health Service hospitals as well as people from society in general, but it is faced with a vast and appalling increase in VAT and a continuing increase in nurses' salaries. No one knows how the foundation will cope, year in year out, and it is not the practice of the foundation to turn away sick people. I ask the Minister and noble Lords how they think the foundation can cope, now and in the future.

We are always hearing that needy people depend upon the voluntary sector, but this is a blatant example of a situation where little or no help that we can absolutely count upon is given by the government for the very people the government suggest the voluntary sector should care for. This work does not come cheap, either in terms of money or human effort.

10.31 p.m.

Lord Dunleath

My Lords, I thank the noble Earl, Lord Longford, for having once again raised the matter of hospices. We have both spoken on this subject on previous occasions. I think that what the noble Earl has said in the past, and perhaps something of what I have said in the past, has helped to bring about a situation in Northern Ireland with which he would be satisfied. I am not aware whether the noble Earl is familiar with the way things are at present, but we have had very good treatment compared with Great Britain. I believe that what the noble Earl, and other noble Lords, have said has contributed to that end.

In Northern Ireland direct rule comes in for a certain amount of flak from time to time, but credit where credit is due. The noble Lord, Lord Skelmersdale, has taken a very personal interest in the Northern Ireland hospice and in the hospice movement. When a tight ship is run in the Northern Ireland Office and Ministers are personally interested in such matters, it is possible to get things done. I am extremely grateful for that. I am also grateful to the noble Earl, Lord Longford, for his support of the hospice movement.

The only reservation we have in Northern Ireland is that with the way things are at the moment it is not possible to plan for more than two years ahead. However, with a hospice or a similar institution clearly one must plan more than two years ahead. While the noble Lord, Lord Skelmersdale, is in office I have complete confidence that Northern Ireland will continue to receive sympathetic treatment, but time, like an ever-rolling stream, bears all its sons away and on occasions, unfortunately, bears some of its daughters away, too. Therefore, we cannot be entirely confident as to the future. Nevertheless, I express gratitude to Her Majesty's Government, and particularly to the Minister, for the way in which he has supported the hospice. I hope that it is a foundation which, having been laid, will result in continuing support in future. I thank the noble Lord for his assistance in this matter.

The Earl of Longford

My Lords, I must respond by saying that that is the first time anyone has said that I did any good in Northern Ireland.

Lord Dunleath

My Lords, I beg to differ with the noble Earl. I have paid tribute to him on many previous occasions.

10.35 p.m.

Baroness Masham of Ilton

My Lords, I too should like to thank the noble Earl, Lord Longford, for bringing to your Lordships' notice the need for funding for hospices. At present we all know that many great changes are taking place in the running of the National Health Service. Recently I attended a seminar of regional, district and family health service authority members. Two members of the King's Fund centre had travelled to Yorkshire to be the main speakers at the seminar which was about the new National Health Service.

At question time at the seminar I asked about the future funding of hospices. It seemed to me that this very important subject had not been included in the brief. That is why I am pleased that the noble Earl has brought up this matter tonight. I look forward to hearing the Answer of the noble Baroness. I hope that she will be able to clear up some of the problems of uncertainty. A long time ago I served on a community health council before going on to serve with the Yorkshire Regional Health Authority. I now serve with the FHSA for North Yorkshire.

I know that hospice support is very patchy. The CHC received a letter from a young man who was dying of cancer and who was a patient in a general hospital ward at the local district hospital. He wrote a most heartrending account of why a general ward was not the best place in which to die. I have visited several hospices. What struck me most was the gratitude of the patients for being in a relaxed atmosphere with people around them who understood their condition, and for the fact that they were able to have their pain controlled.

The other great advantage is the home care support service which treats patients in their own homes but has the hospice as a base. It is wonderful thing and something that we fully appreciate; namely, that everyone who is terminally ill should be able to have the choice of hospice care if he so wishes. One of the hospices that I visited was in Sunderland. I think that I am right in saying that it was, and still is, most likely run entirely by the National Health Service. In that hospice there was some special equipment, such as low air loss beds, to prevent pressure sores. This equipment was of immense benefit to some of the patients.

The nursing staff understood and were trained in the use of these technical aids which can save much suffering. What worries me slightly about the noble Earl's Question concerning pound for pound funding is that some areas may not be as affluent as others —here I speak of the North East—and there might have to be total funding. If a hospice which had been part of the National Health Service suddenly found that it had to find half of the running costs, it might not survive. That would be a serious matter for the community at large.

However, when the money starts to follow the patient, would that not also apply to a patient going into a hospice? Perhaps the Minister can answer these questions. There is no doubt that hospices need security, especially as fund-raising may become more difficult. My hope—which applies to any patient who is ill and who needs good medical care and treatment —is that the patient will get it without having to worry about the money. I hope that all terminally ill patients will have the opportunity to die with dignity if they possibly can.

The first hospice for AIDS patients will shortly be opening in Scotland. I am sure that this is not before time. I should like to ask the Minister what plans the Government have for prisoners who become ill with AIDS and need the correct care when they are dying. Today a Question was asked about a ward for AIDS patients at Hammersmith Hospital not being used for its originally planned purpose. There is also an extra ward at Westminster Hospital unable to open to AIDS patients because of lack of money.

What will happen in a few years' time when many more people will be dying due to infection from contaminated needles used for injecting drugs? I think it is important that there should be some forward planning, with the Home Office and the Department of Health working together and not hiding behind the prison wall saying that prisons have adequate facilities. To have seriously ill patients with AIDS in prison must be very bad for the morale of everyone involved.

The hospice movement has expanded over recent years to include care for children. I feel it should also expand so that all people, including prisoners, who need a hospice place to die with dignity will have it. As your Lordships will, I am sure, agree, it is much easier to raise money for children than it would be for prisoners. Therefore we should have some flexibility.

10.42 p.m.

Lord Carter

My Lords, the House will be grateful to my noble friend Lord Longford for giving us a chance to debate this important topic. It is a topic which he has brought to the attention of the House before and on which I know he will continue to harry the Government until he receives a satisfactory answer. Your Lordships will know that once my noble friend takes an interest in something he does not easily give up.

Other speakers in the debate have covered the ground most expertly and adequately, so I will not need to detain the House for very long. It is clear that a good deal of clarification is required concerning the amount of direct government funding for hospices, the amount which health authorities are supplying both in cash and in kind, and the shortfall in the Government's own commitment to pound for pound funding. There is also concern about the reforms in the health service which are due to take effect next April.

To put it simply, how do the Government propose to operate an internal market in terminal care? Will standards of palliative care be written into NHS contracts; and if standards are written in, how will they be monitored? How is the purchase of provider relationships supposed to work for hospice care? How is it expected—this point has been made by other noble Lords—that pound for pound funding will work when the internal market is introduced? Will the funding for hospices be in effect ring fenced so that the funds cannot be raided for other purposes?

The point has also been made that the postponement of the introduction of community care plans until 1993 may have created a major problem for hospices as regards their funding from the Department of Social Security. I should like to know whether the DSS is interpreting the allocation of Department of Health funds to voluntary hospices as a reason for reducing or removing the allocation of the DSS funds for income support and board and lodging. A number of cases have been quoted where hospices are experiencing a net reduction in their total funding from the DSS and the Department of Health together. It would be helpful if the Minister could comment on that point.

I hope that she will not mind if I say that her answer to the Starred Question of the noble Baroness, Lady Cox, on 31st October was somewhat less than clear on these matters, although I appreciate that her reply was constrained by the need to await the Chancellor's Autumn Statement. However, the Statement has now been made and therefore the noble Baroness can be much more forthcoming in her reply. We are confident that she will be.

There is no need for me to repeat the questions which have already been put to the Minister. She will be aware of the very real anxiety which now exists in the hospice movement. We all hope that she can allay those fears. It is right for us to press the Minister regarding resources, but it would be wrong to concentrate purely on money and not say something about the marvellous work carried out by the hospice movement. There is an American aphorism which says: The rest of your life begins today". In a curious way that maxim seems to be particularly relevant to the work of the hospice movement. Those who work in it are much more concerned with living than with dying. The rest of the life of those for whom they care begins on the day that they come into care. Those of us who have cared for loved ones during their last days, or in some cases their last years, know that every day of that care is a blessing. Those who work in hospices express love for their neighbour in the most selfless terms.

I know that governments have to make harsh choices when allocating scarce resources, but I very much hope that the Minister will be able to tell us that they have been able to find the resources to fund the hospice movement properly.

10.45 p.m.

Baroness Hooper

My Lords, I, too, am grateful to the noble Earl, Lord Longford, and to all those who have spoken so warmly about the achievements and the worries of the hospice movement. I know that this is a topic of abiding interest and I welcome the opportunity to reaffirm the Government's attitude and intentions. I shall certainly convey the noble Earl's remarks to my right honourable friend the new Secretary of State for Health.

As has been said, we debated this question fully last year. Since that time, I have had the opportunity to add to my first-hand knowledge on the subject by visiting the Princess Alice Hospice in Surrey, the Mildmay Mission Hospital and the Hospice Care Trust in North Devon. Even after acquiring this increased first-hand knowledge, I find that it is easier to recognise what the hospice movement is than to describe it.

Hospice care is not about a disease or a building; it is first of all about people. It is a concept of care founded on high technical standards of pain and symptom control and —just as important—on social, emotional and spiritual support for patients and their families, so as to maximise quality of life right up to the end and through into bereavement. Hospice care is essentially a multidisciplinary approach but it is also more than that; it has helped to broaden the concept of teamwork, beyond harnessing the strengths of a range of professionals and voluntary helpers, into the active involvement of the patient himself and his family in the planning and provision of care. As has been said in this debate and in previous debates on the subject, one of the major benefits this concept has brought is a greater openness all round on the subject of death—a more positive emphasis on living fully with disease rather than on dying from it.

Among the important developments of the past 20 years is the relatively recent emergence of specialised training for doctors in palliative medicine. A network of training posts has been established in the National Health Service and in voluntary units which will have a significant impact on maintaining and raising standards as the doctors develop their careers. They can expect to work closely with the national networks that have already been established of Macmillan and Marie Curie nurses, who provide direct care in people's homes and in day centres or highly-valued advice and support to other carers. They may be based in one of the specialist in-patient units in the voluntary sector or in the National Health Service which have brought so much peace and comfort to dying people and their families and which often also fulfil a vital educational role in spreading their principles and practice beyond the physical confines of the hospice unit. They may become part of one of the symptom control teams giving expert back-up wherever it is needed in a hospital setting. They will also need to tap in to the experience of bereavement counsellors and into the rich network of less formal voluntary, pastoral and self-help organisations whose roots strike deep into the community.

The pattern of services 20 years ago, or even 10, was nothing like it is today. It is doubtful whether the raising of standards and expectations on the scale that we have seen in that time could have been achieved without the unstinting efforts of a few pioneers in the voluntary hospice movement and of the public who supported them. We have every reason to be grateful to them today.

The Government for their part are deeply appreciative of what has been achieved. They recognise that the hospice movement has attracted widespread public support. Its hallmark is generosity in the time it gives to patients—time which would not always be available on a normal busy general ward. That means higher ratios of staff, notably nurses, to patients; and that means that hospice care does not come cheap, as we all recognise.

So our policy must, and does, amount to more than one of mere appreciation. We welcome the growing partnership between the NHS and the voluntary sector in this field, and we want to strengthen it. Our clear expectation—for England this was set out just over three years ago in a circular—is that the NHS should take the lead in planning and co-ordinating a comprehensive range of services for people with a terminal illness and their families, in collaboration wherever possible with voluntary organisations. We also expect that where such organisations provide services that form an essential part of its strategy the NHS will make a realistic contribution to the costs.

In 1988–89, the Government contributed £1.3 million towards the cost of pay awards for hospice nurses in England. They also distributed £400,000 via the charitable trust, Help the Hospices, to support voluntary projects in short-term financial difficulty. This year we have moved away from ad hoc interventions of that kind and fortified our commitment to the hospice movement in two ways. First the Government have earmarked substantial resources amounting to over £11 million for health authorities. I remind the noble Earl that health authorities receive all their money from central government, but that £11 million is earmarked additionally to encourage them to increase their contributions to the voluntary hospice movement where that is necessary.

The allocation for 1990–91, the current year, as has been said, comprises £8 million for England. My noble friend the Duke of Norfolk mentioned the figure of £6 million. I hope that that was a slip of the tongue. There is £8 million for England, £2.5 million for Scotland and over £500,000 for Northern Ireland. Funding arrangements for Wales remain under consideration; I understand that an announcement is due soon.

The Duke of Norfolk

My Lords, I said that of the £8 million only £6 million reached the hospice movement because it was hijacked by the regions. I know that that is a small point, but the money is not getting through.

Baroness Hooper

My Lords, I am grateful to my noble friend for explaining what he meant. I shall ensure that his suggestion that part of the £8 million did not arrive where it should have done is investigated thoroughly.

That was the first of the Government's responses. Secondly, we have asked health authorities and boards in England and Northern Ireland to work towards a position in which their contribution to the cost of agreed services matches that raised from voluntary giving. This has been the tenor of most of the contributions to our debate this evening. It is already happening in Scotland where hospices have been eligible since 1st April this year for public funding of at least 50 per cent. of their running costs. As for future funding, for the time being authorities in England have been advised to plan on the assumption that funding will continue in 1991–92 at a similar level to that in 1990–91. In Northern Ireland, as the noble Lord, Lord Dunleath, said, a further £200,000 will be set aside next year to support hospices. The Scottish scheme is being monitored and will run until at least 1992–93 when a review will be carried out.

The Government are monitoring both the expenditure of the additional sums I have mentioned and health authorities' overall plans in the field of palliative care. We will consider carefully the need for any further action in the light of the information we receive.

Lord Carter

My Lords, will the noble Baroness permit me to intervene? Did she say that the amount for England in 1991–92 would be the same as for 1990–91? That means £8 million.

Baroness Hooper

My Lords, I did not say that. I said that for the time being we are asking health authorities to plan on that assumption. I understand the wish of many noble Lords, not least my noble friend Lady Cox, to pin me down to a timetable for achieving matching funding, particularly in England. I believe it is worth emphasising that the steps we have already taken have gone a considerable way towards providing a firm basis for future planning and partnership, and to alleviating the financial uncertainty experienced by some voluntary projects, to which reference has been made.

There are wide variations in the distribution of hospices and in the level of support that health authorities have been able to give. Last year we started with a very wide range of between 0 and 80 per cent. contribution to running costs. The noble Baroness, Lady Masham, referred to an example. I think she said that in Sunderland a hospice was fully financially supported by the National Health Service. But whatever the average may turn out to be, it must also he remembered that it will not reflect the fact that a number of hospice units which started life as voluntary projects have since become fully integrated into the National Health Service. Exactly the same is true of hundreds of specialist posts within the hospital and community health services which were initially pump-primed from charitable funds.

The arrangements I have mentioned are by no means the only reflection of the attention that we pay to the hospice movement. The Government have also decided this year to support the total cost of the development by the Open University of an open learning package on the care of the dying and their families. This is specifically designed to disseminate the principles and good practice accumulated by the hospice movement to a wide audience of professionals and lay people.

Another of this year's changes, for which the hospice movement campaigned very effectively, is the Government's decision to modify the rules on attendance allowance to enable people with a terminal illness to receive this benefit earlier. As from last month, the people affected will be able to receive attendance allowance at the higher rate of £37.50 a week, increasing to £41.65 from next April, without first having to satisfy the normal six months' qualifying period. These provisions will help, we understand an estimated 58,000 people a year, at a cost of £20 million in 1990–91.

Another social security benefit of interest to the hospice movement is income support. The Government are certainly aware of hospices' concerns about their potential loss of income once income support for residents of nursing homes is abolished. Changes in income support arrangements will not now be implemented before 1993–94. The noble Lord, Lord Carter, mentioned that. In the meantime, the Government are gathering information on the extent to which hospices benefit from this source of income, and we will consider the position carefully in the light of that information.

The noble Baroness, Lady Ryder of Warsaw, referred to difficulties and delays with current arrangements for income support. I should explain that income support is paid to individuals to help them to meet the costs of residential care, and not to the institutions which provide it. Residents of hospices which do not wish to raise charges for board and care are not eligible. Where a hospice has no contractual arrangements with a health authority and does wish to raise such charges, the individual may claim income support up to a maximum of £260 a week—£283 in Greater London—plus a personal expenses allowance of £10.55. I understand that managers of local social security offices are always pleased to discuss general procedural requirements with organisations which advise claimants. The noble Baroness, Lady Ryder, suggested direct Department of Health funding for hospices. However, it would be wholly against the Government's determination to devolve responsibility for all aspects of local services to local districts to make an exception in respect of hospices.

The noble Lord, Lord Carter, asked whether Department of Social Security funding was being withdrawn because of Department of Health funding. I can assure him that there has been no change in the eligibility for income support of claimants in independent hospices. If an adjudication officer is satisfied that a claimant is not to be regarded as a National Health Service patient, income support will be the amount of the charge subject to the national limit and the personal allowance. However, if the noble Lord can provide details of specific instances where benefit is being withheld as a result of the allocations made by health departments, I shall be most happy to have them investigated.

The hospice movement has also represented that it finds the current arrangements for getting the drugs it needs to be insufficiently flexible. Proposals for a revised scheme have been the subject of wide consultation this year, and, subject to the resolution of some technical queries raised during the process of consultation, an announcement will be made in due course.

I was delighted to hear the appreciation of the noble Lord, Lord Dunleath, of the input of my noble friend Lord Skelmersdale in Northern Ireland. I shall ensure that those remarks are brought to the attention of my noble friend. I was not so delighted to hear the noble Baroness, Lady Masham, refer to the Starred Question raised earlier today about the use of the special AIDS unit at Hammersmith Hospital as she omitted to mention my reply, which was that the unit is to be used for the purpose for which it was built; namely, the care of people suffering from AIDS. The noble Baroness also asked about prisoners. I understand that a Home Office inquiry is currently under way. I shall investigate that matter and write to the noble Baroness in due course.

In summary, I believe the Government have acknowledged both the achievements and the concerns of the hospice movement. However, that is not to say that there are not many challenges ahead. The movement has seen a very rapid and often haphazard growth over the past decade; in some cases projects have expanded faster than their ability to generate resources. That is why it is of crucial importance for services to be planned in partnership with the National Health Service. That goes some way to answer the anxiety of the noble Lord, Lord Carter.

When districts move into the new area of contracting the intention is that they will have to assess the needs of their districts' populations and enter into contracts to meet those needs. In the National Health Service as a whole that process starts, as we all now know, next April. Although it will not apply to hospices in all districts at that stage, there will inevitably be a move in that direction. If there are more hospice facilities in a particular area than are required as a result of assessment or need by the authorities concerned, I do not believe that those authorities can reasonably be expected to pay even 50 per cent. of the cost. It is therefore time for fundraisers to reflect on whether it is reasonable now, as it may once have been, to hurry into putting up a new building and then expect the health authority to commit itself to the long-term running costs. Everyone concerned to spread the concept of hospice care to all those who can benefit from it—and I reaffirm the commitment of myself and my colleagues in the Department of Health to that aim—must work together to ensure that the total envelope of service, in hospital, hospice and community, is coherent, comprehensive and genuinely matches local needs and priorities.

I believe and hope that I have responded to most of the specific points raised in the course of the debate. I must ask those who were anxious to hear a fixed timetable or a large and fixed figure at the end of it to consider carefully what the Government have done and are continuing to do in this important area of health care, in which so many people give so much of themselves.

The Earl of Longford

My Lords, before the noble Baroness sits down, I ask whether she will be surprised to know that all those who care for the hospice movement will feel that she has evaded the main issue raised tonight. They will feel profound disappointment and will continue to press her until they receive a much more satisfactory answer.

House adjourned at seven minutes past eleven o'clock.