Agenda item

James Benson provided a brief overview which set out the background details. The service had been suspended temporarily and was now permanently closed and that a decision to cease recruitment had been taken.  They had continued to support staff and residents and were proud to report that no staff had been lost although some had retired. Paragraph 3.7 of the report outlined planned next steps.

Janet Cree added that the CCG independent review had been published in June 2019. Engagement had been undertaken with patients and the palliative care working group.  The aim was for the engagement to progress, to be followed by an agreed service specification which was currently being outlined.  Formal consultation would commence once the service specification was completed. It was confirmed that information and papers would be circulated to the Council and to all stakeholders as part of the engagement process.

Councillor Richardson invited Dr Paul Thomas to provide the Committee with his personal experience of palliative care services, balanced with his professional expertise and understanding as a clinician.  Dr Thomas extensive background of over thirty years included the development of what was now regarded as Primary Care Networks for collaborative working in Liverpool (1989 and 1995) and again in Ealing (2010, where he was the Clinical Director for Ealing PCT).  He was presently a full-time carer for his wife who was being looked after by the Pembridge Unit. 

Dr Thomas explained that his work in Liverpool’s PCT was similar to what was being currently replicated with the LTP, with interlinked and multiple services delivered from surgeries.  It was vital that palliative care remained on the LTP agenda, it was not possible to disentangle this from integrated care as one led to the other.  Dr Thomas referred to “community orientated integrated care” and how it was important to understand how multiple systems connected and fitted together. Dr Thomas supported the view that palliative care services be continued at Pembridge and opposed any bed closures at the unit. 

In thinking about what constituted a “healthy” death it was helpful to also consider what was disease.  A successful system must integrate primary care and personal care which should work in tandem.  The question to ask was how this work could and what were the different approaches to health care, and, how could primary care teams work to improve patient care hand overs.  Dr Thomas was of the view that a healthy death was as important as a healthy death.  A support network of friends and family was essential, as were the components of achieving a healthy life.  Dr Thomas offered three points for the Committee and CCG colleagues to consider:

1.   There will be a need for more palliative care beds in future.  There will be an increased number of isolated elderly people and fewer cancer patients and part of the integrated care system approach is to keep people out of hospital.  The role of the Pembridge unit was not just to offer beds, but it could have the potential to be a centre for learning.

2.   It was important to really understand the need to manage deficits and a whole systems approach to learning was invaluable. He acknowledged that there was a need for future planning within NWL but there was a need for more palliative care units, not less, given the geographical locations of other units at St Johns (WCC) and St Lukes’ (Harrow).  In his view, Pembridge could be developed into a hub where people understood integrated care.

3.   Skilled end of life care practitioners offered an understanding of death.  If the aim was to have successful community integrated care that worked, then the skills of palliative care practitioners were essential.  Dr Thomas suggested that the unit could form an alliance with other units such as St Marys and St Lukes’ and work collectively.

Councillor Richardson thanked Dr Thomas from his enlightening approach and invited further comments and views from members of the public in attendance. 

A member of the public recounted her personal experiences with friends and family and the end of life care that they had received.  As a resident of H&F for thirty years who had worked in palliative care, she explained that the experience had been transformative. In her view, there was a substantial lack of palliative care beds within NWL and a paucity of palliative care provision. It was important to maintain and pass on palliative care expertise.

Another member of the public shared similar experiences about the different end of life experiences that her friends and family members had received. Two neighbours had gone through very different experiences, one of whom had received little support and had unfortunately died without palliative care support that was unfortunately offered too late. 

Dr Joanne Medhurst explained that she had worked for thirty years as a GP and was responsible for co-chairing the design group.  52% of residents did not get access to palliative care services. There was an aging population and the causes of death were different to what they were when the hospice movement was set up.  Hospices were set up to deal with disease and it was important to understand this.  Dr Medhurst gave a clear assurance that financial factors had not influenced the permanent closure of palliative care beds at the Pembridge. The aim was to manage end of life care provision for all. 

Councillor Richardson thanked everyone for sharing moving and personal accounts of palliative care.

Jim Grealy agreed that it was important that people had a support network, particularly given that many who lived in the area did not have family members who lived locally.  Pembridge was in one of the poorer areas between Brent, RBKC and H&F.  There were many on low incomes who would find it difficult to travel to other boroughs to visit family and friends who needed end of life care. He encouraged the CCG to consider a more creative solution for Pembridge rather than the permanent loss of palliative care beds and that the consultation should be wide ranging. 

James Benson said that the decision to close the palliative care beds had not been an easy one.  The vast majority of people were supported by end of life care at home.  He continued that they would be considering different models of care, leadership and accommodation.  The prime aim of suspending the service was to maintain community beds. 

Lisa Redfern sought clarification about the way in which the decision to first suspend temporarily and then permanently close the provision had been progressed.  Initial discussions had centred around the difficulties in appointing a suitably qualified palliative care consultant.  It was advocated that if bed closures were being considered, a full and vigorous consultation would be required.  Facilitating good, end of life care required a great deal of skill and huge network of support and care and it.  It was important to understand what was being proposed by the review so that residents properly understood what they were being consulted upon.

Lisa Redfern referred to a recent CQC rating for Pembridge which had been “good” but information was later offered to indicate that there were problems about standards of care.  She continued that she found it difficult to identify the direction of travel for the service and queried why support could not be sourced from Imperial College Healthcare NHS Trust.  She explained that her understanding was that supervisory support from a hospital would be possible if there was a palliative care doctor in post at Pembridge.

RESOLVED

That at 8.55pm, the meeting be guillotined until 9.30pm

Janet Cree responded that the direction of travel was based on the events that had occurred and following the independent review.  An assessment of H&F services had identified some gaps in provision and that the next step was to identify a service specification.  This was an opportunity to check and reflect to ensure that the services being commissioned are meeting the required need.  There was a difficulty in recruitment and the current model was not sustainable. The decision to suspend the service was because they had been unable to make a suitable appointment.  The CCG was committed to ensuring that the service was fit for purpose and this work was currently underway.  Lisa Redfern responded that to move from a suspended service because of a recruitment issue to one which had resulted in a permanent closure and a wide-ranging review was a challenging position that was difficult to sustain. 

As a registered practitioner Dr Medhurst assured the Committee that the recruitment issue meant that there was not the right staffing structure in place and that there was not a doctor in post with palliative care experience.  There was a specialist palliative care lead consultant, but this individual lacked sufficient experience and did not have capacity to supervise Pembridge staff.  In response to Councillor Colemans suggestion that the Council offer to assist in recruiting a suitable clinician, Janet Cree explained that the purpose of the review was to identify what the future service would look like and that is was not possible to accept or decline the offer of assistance while the review process was on-going.

In response to a query from Victoria Brignell regarding the percentage of those dying at home, Dr Medhurst explained that this would be considered by the working group, to develop a high-level service specification, followed by a month-long period of consultation. The working group would consider what the outcomes should be and how carers could be supported during bereavement.  Janet Cree categorically stated that there was no financial incentive driving the process and that it was about ensuring that palliative care services were provided to residents and their families. Vanessa Andreae added that H&F CCG will be making the same level of investment, but it was not possible to specify at this stage what the outcome of the consultation would be.

Councillor Richardson invited Councillor Robert Freeman, RBKC to contribute his views to the discussion given that most patients came from RBKC.  Councillor Freeman recognised the complexity of the current commissioning arrangements and encouraged the CCG and CLCH colleagues to find a suitable solution at the earliest opportunity.  There was good relationship with CLCH but there had been little progress on this issue and there was an urgent need to address the problem. 

Councillor Coleman commented on the need to consult as set out in NHS guidance and reiterated his view that there was much the Council could offer in terms of expertise about engagement and consultation.  He sought further clarification about the aims and objectives of the consultation. Janet Cree responded that the aim was to develop the service specification and the outline of this would be informed by the outcomes of the consultation.  She indicated that the CCG would welcome input from the Council on this.

RESOLVED

That the report was noted.