Councillor Richardson provided a recap setting out the Committee’s consideration of the issue. This was the third time that members had considered the in-patient unit at Pembridge House in the context of local palliative care provision which was currently suspended due to the lack of a lead palliative care consultant.
Janet Cree referred members to the CCG paper which provided update on specialist palliative care review and accompanied. A letter dated 17 January 2020 was sent collectively from all the CCGs commissioners and providers (included in the pack). The letter set out public engagement undertaken so far, and a summary of the work planned for the future model of care. Feedback had identified that there was an inequity of access to services across the four boroughs with 48% of residents accessing specialist in-patient palliative care services. The Committee was informed that the CCG would be planning a programme of engagement and discussion once potential solutions had been published to develop a future model of care. The information would be collated and analysed to indicate whether a full consultation was required. The local overview and scrutiny committees would have an opportunity to provide feedback. The Committee was informed that the CCG was aware of what the in-patient unit at Pembridge meant to residents, but it had not been advisable to recruit during a period of transition, as set out in the letter. It was confirmed that the day patient service would remain open.
James Benson assured the Committee that providers understood importance of the in-patient unit to residents but reinforced the CCG’s view that it was not advisable to recruit during a period of transition and reiterated Janet Cree’s earlier reference to the 17th January letter.
Co-optee Victoria Brignell asked if health colleagues acknowledged that there was a need for in-patient services at Pembridge. Janet Cree responded that this would be identified as part of the review of in-patient services and that critical to this was to achieve the right balance of services. Responding to a follow up point that the unit had been shut because the provider had been unable to recruit to the post, Janet Cree clarified that the recruitment process could not continue while the service was in transition. A potential candidate would have to take on a position in a service that was undergoing transition.
Councillor Lloyd-Harris queried the 48% statistic and asked why it was as low as it was. The figure implied that people were not aware of the provision. Janet Cree acknowledged that the anomaly was part of the issue that needed to be addressed. The current service was inaccessible or unavailable and one of the outcomes that was hoped for was to ensure that uptake of the service was increased. Councillor Lloyd-Harris commented that residents needed to be informed because it appeared that the service was intentionally being run down with many obstacles that prevented progress toward a suitable resolution. Janet Cree countered that the main priority was to achieve the right service specification. It was explained that the CCG had tried to consider sharing a lead consultant but that even if a suitable person had been found the unit could not have been re-opened. James Benson added that the providers were unanimous that this was not feasible. The acute trusts had indicated that they did not have the resources available to support a 13-bed unit. They had explored alternative options for a lead consultant and in conjunction with the acute trusts a prospective appointee had been trialled, but this had been unsuccessful. It had been unsafe to continue and therefore he had agreed with the CCG to suspend recruitment. Co-optee Jen Nightingale suggested that there would still be a need for a lead clinician regardless of what the future service specification looked like. James Benson responded that there existed potential leadership within the community specialist palliative care service. The question was whether there was a need for separate leads for both this and the in-patient service, with a new model of care.
Councillor Richardson probed this point further and queried why there had been such sustained difficulties over an extended period. Janet Cree felt that it was not possible to explain the difficulties in recruitment, but the review had led to a shared position agreed by commissioners and providers which would be sustained until it was possible to recruit to the correct resource.
Co-optee Jim Grealy sought clarification that the CCG did not want to recruit during the review process but was aware that there were two phases during this process. He reported that he had recently attended an event at RBKC and had read the Penny Hansford independent review (also included in the papers). It appeared that in-patient beds of any kind had been ruled out as if the decision had already been made and he suggested that there must be a way in which the provider and the acute trusts could work together.
Jen Nightingale enquired what arrangements were in place to ensure that there was an out of hours service in place. James Benson explained that there was an on-call system in place cover for which was shared between nurse leadership team, provider and acute leads.
Co-optee Keith Mallinson queried the recruitment issue and asked what the difficulties in recruitment existed in London and within the home counties (Hertfordshire) given that they did not appear to have similar problems. James Benson replied that colleagues in acute trusts did have the same issues. He was aware the St John’s Hospice had struggled but had managed to maintain their position. Many palliative care workers were employed part-time which was a positive given the operational requirements, but this was more than just a local issue and there were wider national concerns in parallel.
Councillor Quigley recounted her personal experience of Pembridge where her mother had been looked after in 2012. The care and support that her family had received had been much valued. She asked the CCG to explain what might have changed to such an extent since this time that had led to the current recruitment problem. James Benson welcomed Councillor Quigley’s positive comments and stated that the CLCH had always been proud of the service offered by the palliative care team. This was a difficult situation however a decision was needed, and he could not offer any further insight as why it was so difficult at this time. In response to Cllr Quigley’s further query as to whether this was because of the lack of qualified clinicians or if CLCH was refusing to recruit James Benson clarified that a key factor had been the sequence of events and the timing of when the vacancy had arisen. He reiterated the current position was to not recruit while the review was underway.
Councillor Bora Kwon questioned why there had not been a contingency plan in place and that it appeared precarious to run the unit without taking account of workforce changes. The issue had been discussed first in December 2018 by the Committee and Councillor Kwon was unclear what efforts had been undertaken during this period and queried if there was an issue with the post that had prevented movement. Councillor Kwon suggested that lessons should be learned from this experience.
Councillor Freeman informed the Committee that RBKC had written to Central and West London CCGs to say that they while they recognised the challenges every effort should be made to keep Pembridge open. There was an expectation that the CCGs would work together to address the challenges around recruitment. Imperial College Healthcare NHS Trust and Chelsea and Westminster Hospital NHS Foundation Trust had confirmed that they were unable to stretch resources to provide the level of cover required however he hoped that a further meeting was planned with Chelsea and Westminster and which might be helpful. Referring to the RBKC event it was clear that the overwhelming response of residents was that the Pembridge was a service that was enormously valued, and it was important that it remained open. Pembridge was also one of the very few palliative care providers funded by the NHS in contrast to those which were funded by charities.
Councillor Jonathan Caleb-Landy referred to an earlier point regarding the recruitment in the home counties. This was one example and he queried why this was being viewed as a national crisis. He asked to what extent the CCG and CLCH had been working with others to resolve this. Councillor Caleb-Landy also sought further details about any contingency plans formulated given the lack of a replacement and enquired what allowances had been put in place to allow people to travel to hospices in other areas such as St Johns or Trinity. He pointed out that each time this issue had been discussed the Committee had received incredibly powerful, personal testimonies about Pembridge. James Benson explained that two palliative care consultants were not needed to run a unit like Pembridge. Historically, when the in-patient unit had been closed, the contingency plan had been to share the lead clinician with St Johns. There were junior doctors and community consultants that could step in and he acknowledged the lack of foresight in not having a contingency plan in place. Initially they had felt that it might be possible to recruit, had offered accommodation and explored a wide variety of options. They had also approached hospices that were closing but this was also unsuccessful. It was confirmed that given that they were not recruiting they had not therefore taken steps to speak with other providers. They had tried to work with multiple providers to recruit which the acute trusts had been aware of.
Councillor Richardson pointed out that it would have been helpful to have shared this information so that the Committee could understand the challenges. Janet Cree responded that Dr Joanne Medhurst had articulated this point at the previous meeting of the Committee. Councillor Lloyd-Harris added that it would have been helpful to have had this clarified to facilitate shared working but that it did not appear that this was intended.
Councillor Coleman thanked Councillor Freeman for the event organised at RBKC and for all his efforts. He referred to an earlier point that a potential solution might be identified by the beginning of February and asked if this would include in-patient services. Merril Hammer (H&F Save our NHS) commented that there was a need to find more radical and innovative solutions to address the shortage of clinicians without letting services disappear. Querying the statistic of 48% referred to earlier in the discussion, it was reported that a clinician from Imperial at the RBKC event had stated that not everyone who was dying needed specialist palliative care support. However, the CCG had inferred that this was an issue attributable to the lack of patient outreach work. These were two distinct arguments to explain the low take up of services: was this due to the lack residents requiring specialist care or because they were not aware of the service being available. It was pointed out that the Penny Hansford review had set up the foundation for potential conflict between care in the community and establishing an in-patient unit. This was not the case and those who had attended engagement events had made it clear that both were required. In a final point, the Penny Hansford report did not take into consideration local democracy or social factors. Pembridge was in one of the most deprived areas of the borough populated by large numbers of, single person households, vulnerable and elderly residents. A further question was why an NHS funded facility such as Pembridge had been targeted.
Janet Cree responded that their aim was to ensure that patients who received palliative care were ensured a smooth end of life. Much of end of life care took place within the community or in a nursing home and they did not all have access to specialist palliative care. The CCG wanted to ensure that the service was more widely provided. They sought to achieve a balanced provision that met the needs of in-patient care and community-based care services and to get this balance right. It was never intended to preclude in-patient beds from the review. Patients receiving palliative care in the community also had access to the in-patient service. There was good palliative care provision within the community but there was not always access to the specialist provision that would enhance that experience for family and friends. This is what the CCG hoped to address, and nothing had been predetermined within the review.
Councillor Coleman sought clarification about what the review entailed and if this meant that the CCG would work through the views already received, or would they undertake a consultation. Councillor Coleman also asked if the potential solution paper currently being drafted would form the basis of further consultation. Janet Cree responded that there was an on-going engagement process and referred to the ‘What Next’ section of the 17 September letter which was read out. Councillor Coleman probed further and suggested that the Committee might be able to consider some real ideas at its next meeting. He asked when the document would be available and if it would touch on the future of the in-patient’s unit. Janet Cree replied that she had not indicated that it would “touch” on in-patients but would address in-patient access to specialist palliative care. The expectation was that the service would be offered as part of the whole range of provision for the local population. It was confirmed that the Committee would be included in the engagement process and that members would be able to scrutinise concrete proposals and solutions. Following further discussion, it was clarified that this document might be available at the beginning of February or at the latest, within two to three weeks.
James Benson picked up the earlier point that had been made regarding the statistic of 48% take up and acknowledged that this was low however, not everyone required specialist palliative care and further work was required to understand figure. Janet Cree added that this point could be made more clearly during the next stage of the review process and that this would be rectified in future briefings.
A member of the public reported that they had participated in the engagement workshops and a member of the Tri-borough Residents End of Life Care Group. Pembridge Hospice was distinguished by the fact that it was wholly NHS funded and that creating a broad service that would meet the need of an increasing local population would have to be achieved within a limited budget.
Lisa Redfern observed that it was hard to understood what different skills were required by a lead palliative care consultant, supervising both community care teams and hospice staff. Whilst it was acknowledged that there were concerns about recruitment it was accepted that this was a difficult process to manage. The need for a lead consultant was queried. Janet Cree confirmed that a lead consultant was the only option and that a junior specialist clinician would not be appropriate. In reviewing the Hospice UK Workforce report Lisa Redfern was of the view that there did not appear to be recruitment difficulties. In a final point, concern was expressed regarding capacity within the existing configuration given the potential closure of Garside and the part closure of Pembridge which indicated that this would be an issue across the four boroughs in terms of nursing capacity.
Julia Gregory, a journalist from West London News, asked about and an aspiration to have 75% of patients receiving access to specialist palliative care services, a point that had been made at the RBKC event.
James Benson responded to the points raised in reverse order. Regarding the point made at the RBKC event, it was clarified that this point had been made by Professor Ursch that probably, 75% of residents should be able to access the service and that in his view, it was unlikely to be 100%. It was explained that there was a fundamental difference between nurses in the community and the in-patient unit which required specific leadership. An additional complexity was that if the unit was opened with a shortage of clinicians. This would require cover to be provided by either St Johns or St Elizabeth’s which they would not be happy to do. Having inconsistent cover would not work operationally and would present significant challenges in running the unit. An in-patient unit like Pembridge would expect to see more complex cases and would need an experienced lead.
Addressing the point raised by Lisa Redfern on capacity, Janet Cree commented that Garside care home currently had suspended admissions due to quality issues but had recourse to alternative provisions elsewhere with the system. In the interests of transparency James Benson commented that additional support was being provided to assist residents while they remained at Garside.
A member of the public queried the suspension of the service at Pembridge, given that the CQC had in 2018 rated it as “good”, outlined events to date and reported that they had been informed that the unit could no longer accept patients who had previously been sent to Pembridge to undertake control of their pain management. Pembridge had been providing a service across the wider community. James Benson acknowledged that Pembridge and the quality of leadership had been regarded as “good” and repeated his previously articulated response about the need for a full-time lead specialist palliative care consultant in order to deliver good quality care. Janet Cree added that they were closely monitoring patient take up of the current services available from other providers.
ACTION: The CCG and provider to provide further updates and for the PAC to continue to monitor developments closely. Further engagement work was planned by the CCG and CCG was to report back potential solutions within two to four weeks.
ACTION: For the issue to be considered at a further meeting of the PAC, planned for February 2020.
That the Committee note the report and that issue continues to be closely monitored.