Agenda item

The Committee will scrutinise the suspension of residential palliative

care services at The Pembridge Hospice and in addition consider the

engagement work undertaken by the CCGs to date on the provision of

local palliative care services.

The Chair welcomed Janet Cree, James Benson and colleagues to the meeting. Councillor Richardson briefly explained the background and that the issue had been considered by members at previous meetings.  The Committee had provided the CCG with questions in advance of the meeting with aim of achieving critical insight and Councillor Richardson thanked CCG colleagues for written responses submitted prior to the meeting (questions and answers attached as Appendix 1).

Janet Cree explained that CCGs commissioners had agreed to undertake further engagement work. Consideration of the Involvement Document by the Committee was regarded by the CCG as part of that process. The engagement period was expected to last six weeks until 13 March 2020 and subsequent to this the CCG governing body was expected to receive a report on the outcome of the engagement indicating next steps. It was confirmed that any recommended substantive service changes would generate the appropriate level of engagement and / or consultation. Any proposed timeframes for consultation was to be shared with the Committee for comment.

Mark Jarvis outlined the engagement process undertaken to date which had utilised existing networks.  Approximately 160 local people and groups had participated in workshops and further events were planned before the end of the consultation period outlining the scenarios set out in the Involvement Document. The intention had been to undertake focused engagement with smaller, local groups and to engage hard to reach groups with protected characteristics.  Details of the engagement work had been circulated across the affected boroughs, members of parliament and councillors utilising multiple media channels.

The questions were divided into four key areas of discussion (attached as Appendix 1). Each section was reviewed, and the following points were raised in response by the Committee:

1.  Operational / management

Q1a - James Benson confirmed that the current staffing arrangements for the community service was in line with the Trust’s safer staffing requirements with a level of consultant leadership provided as appropriate.

Q1c - Keith Mallinson sought clarification about the NHS intention to purchase ‘bed days’ from providers and how did the CCG ensure that a palliative care consultant was able to supervise staff in other locations. Janet Cree responded that services had always been commissioned from several hospices in addition to Pembridge (Trinity and St Johns) predominantly used for Hammersmith & Fulham residents and so this already formed part of the routine contract arrangement.  Palliative care consultants were in post at these sites. James Benson added that at the point the inpatient unit was suspended other providers were allocated junior doctors for further support to maintain a level of stability across the area.

Q1b – Councillor Richardson commented that the response to Q1b implied that the facilities at the Pembridge inpatient unit were under-utilised.  Janet Cree responded that this was not the case and that point she had made was that the increasing number of units means that a full complement of staff was required per unit.  Given that there was capacity across the service being commissioned from the providers, including Pembridge. James Benson clarified that an inpatient hospice required three registered professionals on site in order to be able to operate at any time. This was to ensure that registered medications such as controlled drugs could be administered to a patient with the requisite authorisation.  Magnifying this staffing model across numerous sites was necessary regardless of the available capacity.

Q1f - Councillor Lloyd-Harris referred to the 48% take up of service mentioned at previous meetings.  She enquired if this had been a consideration in the formation of the four scenarios or was there any expectation of additional services being required in response to greater need.  Janet Cree confirmed that the aspiration was to increase the access from 48% to a higher percentage.

Janet Cree outlined the need for care provision to be consistently offered and planned.  The CCG was aware that a small number of patients who might benefit were using the ‘My Care My Way’ service access model in West London.  However, the interoperability of this an issue and the London Ambulance Service did not have access.  While this was improving as the CCG worked on a London wide programme, they wanted to ensure that pathways correctly and contemporaneously recorded patient statistics and treatment.  It was confirmed that the 48% statistic was based on a survey carried out by Marie Curie (cancer care charity).  Feedback from residents had been that it was not enough to aspire to have 75% of people accessing the service and that 100% would be a better goal. Janet Cree reiterated that the current engagement process reflected the design phase.  A solution to the issue was being developed and this would then be brought back to the local authorities as one of the stakeholders that the CCG was engaging with.

In response to a query from Jen Nightingale regarding the awareness of patient pathways, James Benson clarified that pathways were easier to navigate if the patient was already known to the hospice.  The process was co-ordinated by palliative care nurses and it was not possible to envisage how this might be improved in future.  Dr Cavanagh added that a lot of palliative care provision was made that would not be regarded as specialist.  As a clinician, he favoured a co-ordinated hub model which would ensure speedy access and bolster existing teams.  One of the key aims of the referral process recognised that it was possible to facilitate greater choice allowing people remain in their own homes for as long as possible.

Merril Hammer (HAFSON) queried what specialist palliative care provision was commissioned by H&F CCG, noting that H&F commissions three beds but it was clear that there were services that were not commissioned.  Janet Cree responded that this not included the engagement document but was covered in the evidence document. Commissioned services included inpatient beds and day services demand led in varying proportions from different providers.  The hospice at home model was not commissioned but an outreach services were commissioned from St Johns or Trinity.  Janet Cree acknowledged that members of the public might struggle to understand the provisions, but different contracting arrangements were in place such as the block contract for Pembridge which allowed providers to forward plan.  There was a balance to achieve between consistent utilisation and building in flexibility to meet demand using spot purchases where needed.

Q1g – Janet Cree clarified that further conversations with providers would be needed but the largest resource increase would be in capacity and specialist nurses and care staff in the home but that this would be envisaged in any new model.

2.  Local socio-economic factors and patient pathways

Q2a - Jim Grealy asked about travel concerns which he felt had been raised at the workshops but not fully addressed to date.  Vulnerable people in deprived areas would struggle to visit family and loved ones in some hospices which were difficult to access by public transport.  The time, distance and cost of travel was an issue for many and there was concern that the involvement document lacked information about how these concerns would be addressed.  Janet Cree acknowledged the point and explained that they were examining all of the possible scenarios and that this would be considered if a definitive consultation was undertaken. 

Jim Grealy referred to Sir Michael Marmot’s review (Fair Society Healthy Lives,2010) which looked at health inequalities, public health facilities, mental health and the decline in life expectancy in deprived communities. The social demographic profile of affected communities was not included in the prospective scenarios.  In response, Janet Cree explained that there was no intention at this stage to close the Pembridge Hospice and that the day unit remained open.  It was reiterated that the current plans were proposals. James Benson clarified that CLCH was required to collect data about patients and recognised the need to understand local diversity and need, and to engage and support people with protected characteristics.

3.  Financial Transparency / Business Case / Contingency Planning

Q3a – Roy Margolis asked if there was a figure that could be provided for the percentage of those requiring hospice day care, and, whether scenario 4 nurse led care could be incorporated in scenario 3.  Janet Cree reiterated that this was not a formal consultation and that more detail would be provided in the next phase.  Scenario 3 reflected the fact that there was a recognised need for specialist palliative care but that there were different levels of care within this and scenario 4 had been developed in response to this.  James Benson clarified that the hospice movement was borne out of nurse led services and specialist services had developed over time.  Some nurses were more experienced and knowledgeable than junior doctors but although a consultant was required to be on call, they did not need to be on site. 

A member of the public sought clarification about the level of expertise and competency provided in nurse led care.  Janet Cree said that this had been noted in the feedback received but that the details required further discussion.

Councillor Coleman observed that two of the scenarios sought to close Pembridge hospice and he asked if it was possible to do so under scenarios 3 and 4. Janet Cree explained that a full business case had not been prepared but would be considered in the next phase and that there were currently  no planned savings against the budget for palliative care. 

4.  Consultation and Engagement

Clarity was sought regarding engagement with residents and the local authorities and how the decision to close Pembridge will be undertaken.  Janet Cree responded that where there was a substantial variation in service then a formal consultation was required.  During the discussion that followed the need to co-produce formal consultation was highlighted by Linda Jackson.  A good example of this was the co-designed work undertaken with Healthwatch on urgent treatment centres.

Merril Hammer outlined concerns about difficulties in accessing information about the engagement on the CCG website, whether the period of the consultation would be extended given this, and the cancellation of a patient reference group event.  Mark Jarvis gave assurances that the issue about website access would be checked. He clarified that they had taken an approach to deploy limited resources that focused on small scale, localised events and engage with individuals or groups that would not normally engage.

RESOLVED

That the Panel noted the report.