Pither is one of up to 45 patients who attend the unit each week. “I thoroughly enjoy coming here, the staff are so helpful,” he says.
Since 1 April, the hospice has been run by Sue Ryder, after NHS Berkshire West primary care trust outsourced its entire specialist palliative care services to the charity. The move mirrors a similar development in Rotherham where earlier this year the NHS transferred specialist palliative services to the local hospice.
Although the voluntary sector provides much end-of-life care locally across the UK, this is the first time that it has been given responsibility for an area’s entire palliative services.
As such, end-of-life care is at the vanguard of the government’s “any qualified provider” policy. Last week, the health secretary, Andrew Lansley, announced that up to £1bn of NHS services would be opened to competition from voluntary organisations and the private sector.
For both Berkshire West and Rotherham, the drive to outsource palliative care comes from the Department of Health’s transforming community services programme, which in 2009 instructed primary care trusts to stop directly providing services. While some PCTs opted to transfer responsibility for palliative care to foundation trusts or community foundation trusts, Rotherham and Berkshire West outsourced to the voluntary sector.
“The idea predated the [open public services] white paper,” explains Charles Waddicor, chief executive of NHS Berkshire West. “It came out of an analysis of what was happening in palliative care. Too many people were dying in hospital.
“We didn’t want to base services in the acute hospital. Instead, we wanted to come up with a model that helped us move from bed-based services to one more in tune with people’s desires.”
With 70% of people saying they would like to die at home, that meant more care provided in the community.
On referral in West Berkshire, patients are either admitted as an inpatient to the hospice or they are visited in their own homes by one of Sue Ryder’s nine clinical nurse specialists, or a consultant, who will assess their needs and work out a treatment plan in conjunction with their GP. While some will become inpatients at the hospice, others will receive a combination of care at home, in outpatient clinics and at three day-therapy units in the region.
“We are trying to keep people in their homes as long as possible by giving them good quality care,” explains Storm Cooper, the Sue Ryder day therapy sister at the Duchess of Kent hospice. “We aim to get on top of their symptoms before they become an issue.” In addition to blood transfusions and lymphoedema clinics, the day care centre offers counselling, complementary therapies and access to a dietitian and physiotherapy. “We also ensure patients get all the benefits they are entitled to,” she says.
Inevitably, there is a lot of advance care planning and discussion with patients about how they wish to die, says Cooper.
Leslie Dean, 83, who has been attending the Duchess of Kent daycare unit since June, says he enjoys the company and finds the help provided by staff invaluable. “If you have a problem, they sort it out.”
Some 96 staff transferred from the NHS to Sue Ryder in April. In addition, it is recruiting a new clinical nurse specialist and hopes to be able to hire two additional clinical nurse specialists to better support seven day a week working, which it introduced as part of its new role. Next month, the 15-bed Duchess of Kent hospice intends to expand with a further three inpatient beds.
Although it is early days, the PCT says so far the results look promising. “Since 1 April, nobody [who’s known to palliative services] has gone into hospital to die,” says Waddicor. “Previously, three or four a week were dying on acute wards.”
In Rotherham, the emphasis is on supporting patients and families at home, where many say they prefer to receive care. Although palliative care services have always been supported in the community by GPs and district nursing teams, Paula Hill, clinical services lead at Rotherham hospice, says that one of the biggest changes following the transfer is “how the hospice supports people in the community”. Many hospice treatments and services are now also available at home, including complementary therapies, physiotherapy and counselling support. “This helps to prevent unnecessary outpatient visits and hospital admissions,” says Hill.
Staff work across inpatient, day unit, and community services, which the hospice says gives patients more continuity of care. In addition, palliative care consultants, funded by the hospice, work across all areas including hospital care. Around 80 members of staff transferred from the NHS to Rotherham hospice. Another 25 staff, primarily in clinical roles, have been appointed since then.
While palliative care services have traditionally been geared towards cancer patients, both Rotherham hospice and Sue Ryder are keen to make their services more readily accessible, whatever patients’ conditions. Sue Ryder chief executive Paul Woodward explains: “Conditions such as cardiac, renal and liver wouldn’t come under a traditional hospice service but only 25% of people die from cancer.”
Charities have always supplemented what the state provides, and Simon Chapman, director of policy and parliamentary affairs at the National Council for Palliative Care, points out that the voluntary sector, not the NHS, has been the main trailblazer for end-of-life care.
He welcomes these new initiatives. “It will be interesting to see how successful these projects are in working with other agencies in the communities they serve to develop innovative and integrated services that enable people to be cared for and die in the place that they want to be,” he says. “Ensuring round-the-clock access to symptom control, nursing care and specialist advice will be vital; this is currently very patchy and needs to improve. People approaching the end of life don’t just need care nine to five, Monday to Friday.”
Any suggestion that cost-cutting could lie behind the decision for the wholesale transfer of palliative services is denied by Waddicor at NHS Berkshire West. “We didn’t do it to save money,” he insists. “As a PCT, we are not in financial difficulties and Sue Ryder are receiving broadly the same envelope of funding as we spent on palliative services before the transfer.”
Roughly speaking, that is around £2m, he says, with around half spent running the Duchess of Kent hospice.
Yet the funding won’t cover all the services Sue Ryder wants to provide. There is a shortfall of around £250,000, which Sue Ryder and four local charities in the hospice and local hospitals and clinics will have to fundraise to plug.
“We are not being funded 100% for taking over the service,” Sue Ryder’s Woodward confirms. The funding gap is much bigger in Rotherham where the hospice will have to raise £2m a year in addition to the £2m it gets from Rotherham NHS.
There are concerns that outsourcing services even to national charities will create a two-tier workforce. Although staff transferred from the NHS to Sue Ryder under NHS terms and conditions, new employees will be employed on the charity’s terms and conditions. Sue Ryder says it is working very hard to minimise contractual differences.
“We are what the NHS calls a ‘directional employer’,” says Heather Aldridge, Sue Ryder’s palliative care area manager for Berkshire West, which means someone who leaves the NHS and joins Sue Ryder will still be able to continue their NHS pension. “We also try to keep salaries on a par with the NHS as much as possible,” she adds.
Ultimately, Rotherham and Berkshire West NHS believe the move will empower patients. As Gail Palmer, who leads on end-of-life care at Rotherham NHS, says: “We want people to realise the hospice isn’t just a place to go to die – they can go there for treatment and then go back home and that people are able to die where they want and not in hospital.”
http://www.guardian.co.uk/society/2011/jul/26/palliative-care-outsourced-voluntary-sector?CMP=twt_fd
