This report aims to outline circumstances that led to a decision to suspend all admissions into the in-patient beds of Pembridge Hospice, describe the service that is currently provided and to provide an update on the current situation.
The Chair welcomed Andrew Ridley, and Dr Joanne Medhurst, from CLCH, supported by Janet Cree. Mr Ridley briefly explained the circumstances that had led to a decision to suspend all admissions into the in-patient beds of The Pembridge Hospice. Staffing levels at the Hospice had been maintained and provision for day patients had continued, so it remained open in all other respects.
Co-optee Victoria Brignell asked about the wider context and whether other hospices had experienced similar difficulties. Dr Medhurst reported that she had spoken to several other hospices in the London area, all of which had reported difficulties in recruitment. It was confirmed that this was also a national experience. CLCH had tried to offer improved remuneration and had made informal enquiries through medical and professional networks. One application had been received but this had been unsuitable, and a review commissioned by the CCG. Dr Medhurst commented that the model of care outside of London was nursing led, by contrast to the model operated at Pembridge, which was consultant led, which indicated a need for more creative solutions. In response to a follow up question, Dr Medhurst confirmed that the issue had been escalated to the Department of Health and that she had been unaware of the recent private members bill to improve palliative care.
Co-optee Jim Grealy commented that a member of his family had received palliative care and that this was an issue that would not be resolved quickly or easily. It was a strain on family members to have loved ones placed in hospices located outside their boroughs. Janet Cree confirmed that the CCG had no intention to reduce the provision of palliative care from a commissioning perspective but needed to ensure that the provision remained clinically safe. Dr Medhurst added that the Pembridge was not just a hospice but also included day and community units. The community service aspect of the whole provision was very important. Many people hope to end their lives peacefully, in their own homes. The Trust had redeployed hospice staff and reconfigured services around community focused provision.
Dr Medhurst expressed her concern about the possible loss of highly valued and skilled nursing staff, who may choose to leave the service, because of the temporary closure. They would have to consider the clinical strategy and look at staff models. The impact on the wider system was that patients had been transferred to St Johns and that The Pembridge was closed to new admissions. Patients had been diverted elsewhere to minimise the number of transfers, and this was currently being managed. Ms Cree reported that she was not aware of patients experiencing delays in care, but recognised that there had been increased flow. It was acknowledged that the demand for palliative care could be variable, which had been included in the forecast of projected need.
Co-optee Bryan Naylor enquired about the anticipated length of the temporary closure. Dr Medhurst replied that the Trust will re-advertise the New year and were working with provider commissioning boards to find a solution. The CCG had appointed a chief nurse as a clinical expert to help with the modelling. It was accepted that given the difficulties, a suitable appointment might not be made until the end of February, given the lack of suitable candidates.
Lisa Redfern queried the shift in the model of care from being nurse to consultant led. It was observed that the Trust may have had early awareness of the difficulties and asked why the CCG received late notice of the situation. Ms Redfern expressed further concern regarding the mixed messages about the refurbishment of Pembridge, and the implication that the hospice was closing due to the need for redesign. Given the added pressure on acute beds, Ms Redfern was unconvinced that there would be no corresponding impact, although the lack of a suitable appointment was noted.
Dr Medhurst responded that they had spoken to all the professional, medical leads in the palliative care network, with no result. They had considered appointing a doctor in training, however, this was a position for a lone, lead consultant. It was important to recruit a person with the appropriate level of expertise. Dr Medhurst admitted that they were in a tenuous position and had not fully appreciated the issue of the notice period being so critical. Patients had complex care needs and the opportunity to refurbish the facility and restructure the service was timely. As they went through the redesign, the Trust would consider how to mitigate and make provision for wider end of life care cohort.
Councillor Richardson commented that this was an end of life pathway and that to consider closing the unit, while simultaneously considering changes to it sounded ambitious. Councillor Richardson added that she had also received reports about the poor fabric of the building and asked whether an impact assessment had been conducted, before the closure had been determined. Dr Medhurst reiterated that the unit had been closed on safety grounds. Mr Ridley added that it was not possible to change the model and move it away from being medical. This was a complex provision and he stated categorically that there was no plan to close the unit permanently. The assumption that the closure was because of the refurbishment was incorrect.
Councillor Richardson invited members of the public to provide details of their personal experiences of using the palliative care provision provided by Pembridge.
Members of the public recounted shared, collective experiences. They presented overwhelming support for the service, recognising that The Pembridge offered a unique form of care that extended beyond clinical treatment. It was about having a safe, peaceful, and caring environment, that provided support to not just the person who was reaching the end of their life, but their family and loved ones, who wanted to support them throughout the process. The expertise and knowledge offered by units such as The Pembridge was essential for ensuring this. It was also clear that the stress of travel (including distance) was an important factor in keeping The Pembridge. Palliative care needed to be provided locally, and it was important to have a qualified consultant in post, so that the service could be re-opened as soon as possible. There was significant concern that the loss of beds would continue, leading to additional pressure on local hospitals such as Charing Cross.
The comments were based on real life experiences and were particularly evocative, advocating strong support for the service to be reinstated.
In identifying some of the points raised, Dr Medhurst clarified that it was not possible to have a visiting consultant. They had tried to appoint one candidate, who worked for two weeks before it had become apparent that they did not have sufficient experience or expertise and could not prescribe the specialised drugs. The Pembridge Hospice was a facility to be extremely proud of, but safety assurances were necessary for the protection of both staff and patients.
Ms Clymer highlighted the quality of the communication undertaken by CLCH. The lack of communication had caused distress and serious concern. She explained that Healthwatch, was part of the regulatory care framework and Healthwatch was able to help address this and form part of a working group, that would work with the CCG.
Ms Cree recognised that communication was a concern and as part of a review going forward, the CCG wanted to ensure that engagement with the right stakeholders was undertaken. A steering group would offer an opportunity to do so.
Councillor Sue Fennimore asked at which point the CLCH and the CCG had recognised that it would be difficult to recruit. Given the chain of events, she questioned whether the residents of Hammersmith & Fulham were being best served. Councillor Fennimore understood that there were service pressures, but having relatives end their lives in noisy hospitals, in an undignified fashion was unacceptable. Councillor Fennimore challenged the quality of the Trusts communications and queried if the potential impact on Charing Cross hospital had been considered. It appeared extraordinary that the Trust should find itself in such a position, with little urgency in its actions and no information provided about who would be represented on the steering group.
Councillor Lloyd-Harris observed that in addition to the lack of communication, it was fundamentally wrong to not have an appropriate forum in which the issue could be discussed, in advance of the Committee’s meeting. Councillor Coleman confirmed that the Council members and officers met regularly with NHS colleagues but the key point to note was that this was a public meeting of the Committee and therefore played an important part in safeguarding the democratic process.
Councillor Caleb-Landy enquired about how the CLCH would mitigate against the risk of impact on other services. This would be particularly unacceptable as the difficult winter pressure period commenced. Dr Medhurst replied that most staff at CLCH were recruited through multiple ways but that the current situation at The Pembridge was unusual. Hospices had hugely fragile systems and Dr Medhurst gave an assurance that they would try to resolve this as quickly as possible.
Councillor Coleman enquired about the land that The Pembridge was situated on, given that the NHS was nationally trying to sell off land. He asked if anyone had considered what the Trust would do with the land, should The Pembridge unit be closed, what the possible value of the land would be and how much would the CLCH save if the unit was closed.
Mr Ridley confirmed that NHS estates owned the land on which The Pembridge was situated and that he did not know of its value. CLCH had paid rent on the unit, which had now been closed for two months. In addition, the Trust had also met the cost of recruitment. The Trust was currently losing money but if the unit closed, this would be cost neutral. Mr Ridley’s primary concern however, was the loss of experienced, committed staff, and the loss of the service contract commissioned by the CCG.
Ms Brignell asked about whether consultant training was an issue that the Trust could address, possibly through overseas recruitment. Dr Medhurst explained that the Trust was considering how to address the shortfall in consultant training. In early 2019, the Trust will be trying to encourage signposting of The Pembridge overseas and registering this with recruitment agencies. Applicants will still need to meet regulatory requirements.
In summarising the key points of the discussion, Councillor Richardson welcomed the Trusts intention to not reduce or reconfigure the service during its hiatus and noted that the day patient provision would continue unimpeded, for the time being. Councillor Richardson looked forward to hearing more about how the recruitment process was progressing after Christmas, following re-advertisement; and about Healthwatch’ s involvement in the work of the steering group. Councillor Richardson thanked members of the public, who had shared their personal stories, recognising that these collective experiences indicated whole-hearted support for maintaining local, palliative care provision for the residents of Hammersmith & Fulham.
ACTION: CLCH and the CCG to keep the PAC informed as to the future provision of palliative care services from The Pembridge Hospice and provide an update on the recruitment following re-advertisement
That the report be noted.