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Palliative Care

My Lords, the noble Baroness, Lady   Finlay, should be congratulated on choosing a subject that will become increasingly important over the years. Not only are more of us surviving into old age because the diseases that used to polish us off before we reached three score years and ten are now better prevented and treated, but there will be a bulge of ageing people when the post-war baby boomers reach 80 or so around 2020 to 2030. Terminal care, as many noble Lords have said, is appropriate not only for patients with cancer, but for many medium to long-term illnesses that lead inevitably to death, such as organ failure and some forms of dementia. Motor neurone disease is a distressing condition, as my noble friend Lord MacKenzie pointed out, which often needs palliative care towards the end. Some 60 per cent of patients say that they would prefer to die at home, and another 20 per cent would prefer a hospice. Sadly, only 18 per cent of deaths happen at home and 4 per cent in hospices. A higher proportion of cancer patients die in hospices—20 per cent, as the noble Baroness, Lady Greengross, has just said. As a doctor working in the community in north London, I was privileged to have the help of outreach teams from two hospitals—University College and the Royal Free—caring for dying patients at home. They were staffed round the clock by Macmillan-trained nurses, backed by a consultant in palliative care, with links to a famous hospice, Eden Hall. It was a Rolls-Royce service that was greatly appreciated by patients, families and GPs alike. But for some time to come, it is not a model that can be replicated all over the country. There are not enough specialists or palliative care nurses. However, several projects are running, which make use of existing National Health Service staff by training and helping to provide effective and satisfying palliative care, about which I shall speak more later if time permits. In a completely different setting, last year in rural west Kenya on the shores of Lake Victoria I was able to see a community-based terminal care scheme in operation. It was operated by the NGO, ICROSS, which is run by a dynamic Anglo-Irishman called Mike Meegan. Care workers were recruited from literate, intelligent, but otherwise untrained, members of the local population. They were given several weeks’ training for the specific task of caring for AIDS victims dying in their own homes. They had links with the local district hospital, which admitted patients to initiate treatment for opportunistic infections, but, once they were stabilised, continuing care took place in the community. The benefits of the scheme were remarkable. First and foremost, the patients were hugely relieved to have a carer. A load of anxiety was shed and they became spiritually calmer. If further opportunistic infection occurred, they had ready access to the local hospital. One result of the scheme was that only 50 per cent of the hospital’s beds were occupied by AIDS patients, instead of 90 per cent before the community-based care scheme started. In the much more sophisticated context of the UK, the same principles can be, and in many cases are being, applied to end-of-life care in the community. It is very good news that the Department of Health has recognised that demographic and healthcare trends, quite apart from patients’ wishes, require expanded palliative care services. I am afraid that time does not allow me to give a list of all the projects and guidelines on good end-of-life care that have been initiated and supported by the Department of Health, which often contributes to or collaborates with the voluntary sector. Some of these schemes have been mentioned by noble Lords in their speeches. I could recite a list of them, but there is no time, so I shall refrain. However, I am particularly impressed by the Gold Standard Framework, which was mentioned by the noble Baroness. It is based in east Birmingham and is led by a general practitioner, Dr Keri Thomas, who has drawn up, and enthusiastically promotes, a detailed scheme that could be applied to most GP practices to improve the quality of their end-of-life care. An initial evaluation of the scheme is very positive. I think that I echo the noble Baroness, Lady Finlay, when I say that home-based care is not appropriate for everyone in the end stages of their illness, however much they would like it. Sometimes symptoms are so severe that they need institution-based care, for example, severe respiratory difficulties, double incontinence, or intractable nausea and vomiting. Such problems may arise in patients having home-based care and for them there should still be a speedy pre-arranged route into nearby institutional care. That need not be an acute hospital. Hospices can cope with most severe symptoms, but there are simply not enough of them and they are unequally distributed, as the noble Baroness showed. A temporary solution is for certain wards or parts of a hospital complex to be dedicated to providing palliative care—as the noble Baroness described happening in Cardiff—if hospital staff can be persuaded to switch from a radical curative treatment-based outlook to a more gentle, caring outlook. It is sometimes hard for clinicians to stop treatment and to accept that the aim is to assist dying, rather than to prolong life. I hope very much that my noble friend will be able to say that there will always be funds available to make Sir Nigel Crisp’s aspiration a success. Two years ago, he said:"““Better care for the dying should become a touchstone for success in modernising the National Health Service””." It is a very good investment as, as other noble Lords have said, it will relive pressure on acute hospitals, and everyone agrees that palliative care ensures a dignified and peaceful end to people’s lives.