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Health: Palliative Care

Volume 689: debated on Wednesday 31 January 2007

asked Her Majesty’s Government how they assess the effectiveness of palliative care services; and on what basis decisions to fund additional services are taken.

The noble Baroness said: My Lords, I am very grateful to my noble friend. I had intended in my opening sentence to say what a good thing it was that this very important debate was now the last business and that therefore all the distinguished speakers would have a little more time for their contributions. I also thank everyone in advance for taking part in the debate. As this is my first opportunity to do so, I congratulate the Minister on returning to the Department of Health and on his promotion.

I congratulate the Government as a whole on their recent decision to develop an overall strategy on palliative care under the distinguished leadership of Professor Mike Richards. As the House will be aware, Professor Richards is the so-called cancer tsar for the NHS, but I understand that this project will extend well beyond cancer services to develop a much more general programme on how we look after people who are reaching the end of their lives.

I was surprised to discover that this is the first time that the health service has taken a systematic look at services for the dying. The founding father of the NHS, Aneurin Bevan, famously promised that care for us would go from the cradle to the grave and, in the 60 years since, the cradle has been properly looked after. Developments in obstetrics, maternity services and neonatal care have all ensured that at the beginning of life most people are well cared for, but there has been much less attention to the end. Perhaps it is a combination of social taboos and medical disinterest, which has far too often resulted in poor provision for the more than 600,000 people who die in Britain every year.

Personally, as a member of various local health authorities and, later, as a Minister for Health, I have always encouraged more and better palliative care for those at the end of their lives. I am a particular supporter of the hospice movement, which, as many noble Lords will know, has struggled for NHS resources over many years.

Nevertheless, I think that the Government's current review gives us an opportunity to take an overview of how we as a society want to develop those end-of-life services so that they are fit for the 2lst century. For example, can we assume that palliative medicine, if it is well resourced and expertly practised, can provide all the answers? On what basis should we judge its effectiveness? In this short debate, I can only express my questions and concerns in headline form, and they really fall under three broad headings.

To start with, I am concerned about the exact remit and scope of palliative care. When I first became interested in this area, the explicit aim of palliation was, as I understood it, to control the pain and other physical symptoms of those suffering from terminal illness—specifically cancer. No one, of course, could possibly question those compassionate aims. In many cases, palliation involves very sophisticated drug therapy and medical treatment, and I pay a warm tribute to those specialists who have made so much progress in this field in the past few years.

However, when I look at some of the contemporary definitions of palliative care and listen to some contemporary practitioners, I sense what in other policy areas might be called mission creep. For example, the noble Baroness, Lady Finlay, who I am delighted is to speak in the debate and who is of course recognised as a leading specialist in this field, has introduced a Private Member’s Bill, which is to be heard by your Lordships very shortly, to create a duty on the NHS to provide universal palliative care. In the Bill, her definition of this care goes much further than the relief of physical symptoms to include,

“psychological, social and spiritual help and support”.

I wonder what exactly is intended by that, what it should include and, very importantly, how such provision would be evaluated. How and on what basis, for example, would NHS performance managers measure the efficacy of spiritual interventions?

I raise that not least because, as a member of the Select Committee on the Bill on assisted dying introduced by the noble Lord, Lord Joffe—I am delighted that he, too, is in his place tonight—I heard some palliative care practitioners make what I thought were extravagant claims for their services. Several witnesses asserted that appropriate palliative care could alleviate all the possible suffering of all patients at the end of life. They were certain that that could include psychological problems, emotional difficulties and what one could call the more existential issues of loss of dignity and personal control. One consultant physician claimed that if patients would, in his words, co-operate and “let go”—in a particular religious context, I understood—then they would always, again in his words,

“die with great ease and comfort”.

I deliberately use the verbs “assert” and “claim” to describe those witness statements because, although we heard individual examples from practical experience to support their remarks, the witnesses were unable to give the kind of research references which I think would be considered essential by most clinical specialities in a similar situation.

That is, indeed, my second concern about palliative care. There seem to be few randomised control trials and few peer-reviewed experiments to support the view that palliative care, in its broadest sense, is always effective. I believe that the noble Baroness, Lady Murphy, will speak later in the debate from her professional viewpoint about the difficulties of using outcome measurements and other conventional tools of evaluation in the palliative care field.

As a lay person, I simply note that the health service now places great reliance—in my view, quite rightly—on evidence-based therapies and payment by results to determine both policy priorities and resource decisions. I very much hope that these principles can, and will, be rigorously applied to palliative care.

A further important strand of this Government's health reforms has been to introduce the concept of patient choice. Personally, I have some difficulty in recognising patient choice in some palliative care practice that I have observed, and this is my third area of concern.

I was disturbed when the previous chairman of the Ethics Committee at the Royal College of Physicians told your Lordships’ Select Committee that palliative care could become,

“the last bastion of unreconstructed paternalism in UK medicine”.

As your Lordships will be aware, the Commission for Patient and Public Involvement in Health has existed since 2003 precisely to give proper expression to patients’ views in developing services; in the commission’s words,

“to help place patients at the centre of everything the NHS does”.

I hope that, as Professor Richards develops his end-of-life strategy, he will work closely with the commission and other representational bodies. We already have some relevant research results, and obviously need more in greater depth. I was interested in the report this month from the Journal of Medical Ethics of interviews with 41 terminally ill patients. The majority of those interviewed wanted a change in the law to allow people like themselves to choose when to die. I obviously appreciate that the Department of Health’s current work can consider end-of-life strategies only within the present legal framework, but I am also aware of growing public pressure to widen the debate about how we die. The Minister will not need reminding that the 2007 British Social Attitudes Survey published last week showed that 80 per cent of the public now support voluntary euthanasia for the terminally ill.

I conclude with one person’s story which illustrates some of the present difficulties of palliative medicine, emphasising the need to think carefully, widely and probably laterally about how the health service should look after those at the end of their life. The NHS is caring for a terminally ill young woman whose suffering has not responded to the various combinations of therapies prescribed by her palliative care specialist. In December, last month, she asked three doctors who were looking after her, including a palliative care consultant, to increase her pain-relieving drugs to a level which would produce deep sedation. All the doctors refused her request on the basis that it would be tantamount to euthanasia. The patient then consulted lawyers, who took expert advice from a leading professor of intensive care medicine. He disagreed with his professional colleagues and argued the principle of double effect applied to this patient, a principle about which I know that the noble Lord, Lord McColl of Dulwich, who is also speaking tonight, has given much thought.

I remind your Lordships that the principle of double effect has established that it is lawful for a doctor to provide a patient with treatment that may shorten his or her life if its primary purpose is to relieve pain and suffering. This case shows the difference in current professional views and in practice regarding end-of-life care. It highlights the need for a better grasp of what can and cannot lawfully be done, and what the boundaries and limitations of palliative care may be.

I hope that my questions and concerns are not seen as a critical challenge to palliative medicine as a whole, which I know is practised with great skill and is of great value to many patients. My concern is that palliative care should not unthinkingly be accepted as a universal panacea for the dying, but should be rigorously assessed and evaluated on the same basis as other health service therapies. Most importantly, I want the views of NHS users, particularly those imminently facing death, to weigh heavily with those charged with developing the health service’s new end-of-life strategy. I look forward to the debate and the Minister’s reply.

My Lords, I thank the noble Baroness, Lady Jay of Paddington, for the opportunity to debate palliative care services, whether for three or six minutes. I also congratulate her on her timing, coming before the debate of the noble Baroness, Lady Finlay of Llandaff, at the end of February.

It is now nearly 13 years since the noble Baroness and I sat on the Science and Technology Select Committee on Medical Ethics chaired by the noble Lord, Lord Walton of Detchant. It became obvious during the inquiry and the consequent debates that the need for palliative care, increased funding and greater availability was and is fundamental for the care of the terminally ill. My noble friend Lady Cumberlege, who replied to that debate on 9 May 1994, agreed with the committee on the importance of palliative care and confirmed the need for growth in provision of those services within NHS special care units, hospitals, nursing homes and at home.

The Standing Medical Advisory Committee and Standing Nursing and Midwifery Advisory Committee had reported that all patients needing palliative care services should have access to them and that those services, many stimulated by the voluntary sector, should be incorporated at all levels in the NHS. They also recommended an expansion of education programmes in palliative care to assure continued support for higher medical training programmes and advanced nursing studies. In the debate, I noted the increase in funding in 1994-95 of £35.7 million and asked whether there would be any new initiative on funding for palliative care as a result of the report. The Minister replied,

“I regret that I cannot give my noble friend Lord Colwyn or the noble Baroness, Lady Jay, the assurance they seek that as a result of this report and our debate more funding will be forthcoming for this area of work...But the department is determined to see good quality care provided and accepts that delivering this will sometimes be challenging to people working in the field”.—[Official Report, 9/5/94; col. 1407.]

As advances in medical science lead to new technology and new drugs, treatment decisions become more complex for doctors, patients and their families. That has brought about a change in attitude to the role of those making decisions about healthcare and, in some cases, a convincing argument for the voluntary ending of life. The ability to prolong life can now subject the terminally ill to an existence dependent on technology, causing suffering to both the patients and their families and friends.

Although effective pain management measures have been available, misconceptions among health professionals have led to the under-treatment of some patients. There was some hesitancy among doctors and nurses about providing the necessary degree of pain relief because of the concern about drug tolerance or fear of shortening the patient’s life. The relief of physical and mental distress must be the first aim of treatment at the end of life.

Since 1994, I have been reluctant to become involved with proposed legislation on the different aspects of end of life, as sympathetic GPs tend to be able to deal with most of the problems themselves. To make too many rules would hinder rather than help. There is still a need to disseminate the principles of palliative medicine which have developed within the hospice movement. In 1994, the vast majority of the 700,000 people who died each year did not have the benefit of palliative care or hospice support. I am sure that subsequent speakers will bring these figures up to date.

In the debate I referred to earlier, the noble Baroness, Lady Jay, said that the,

“situation must be addressed by the Department of Health in order that our confidence in palliative care can be sustained”.—[Official Report, 9/5/94; col. 1403.]

Since then, she has been Leader of the House of Lords and a Minister in the Department of Health. I look forward to hearing how medical training, funding, research and the development of palliative care services have changed, and how the latest initiative by Professor Richards will ultimately affect us all.

My Lords, I join the noble Lord, Lord Colwyn, in congratulating noble Baroness, Lady Jay, on bringing forward tonight’s debate. It is a most important subject, and her three points were much to the point.

I speak as a layman from a medical point of view but, granted my memory of recent debates in your Lordships’ House on these matters, it is worth saying that I also speak as a member, for nearly 40 years, of a profession with many centuries of experience in the care of, presence with and attention to people who are very ill or approaching death. A palliative care service is effective which makes available to anyone in need of it, and especially to the less autonomous and more vulnerable, the highest quality of scientific, medical and nursing care and a most generous service of time, love, touch, presence, respect and reassurance. They all need to be informed by an excellent understanding of the spiritual, psychiatric and social needs of people who are chronically or terminally ill and their families. Then, whatever the extent of people’s suffering, whether physical, mental or spiritual, they can approach their death with as little pain as is safe—loved, cared for and feeling safe and not alone.

Noble Lords will notice that I made none of the overstated claims to which the noble Baroness correctly made critical reference. I am not arguing that the effectiveness of palliative care services should not be rigorously assessed and evaluated, but I suggest that in this field, as in many others, there is much that is real, true, describable and important, but not, in the end, measurable. On what basis should the Government fund additional services? They should fund additional services so that that quality palliative care is consistently and generally available to those who need it.

I should add in response to what was said by the noble Baroness this evening and by the noble Lord, Lord Warner, in the debate last week—at which I was unable to be present, but which I read—that I shall continue to judge that some choices should remain not open to me, including, as the noble Baroness put it, the choice of when to die.

My Lords, I, too, thank the noble Baroness, Lady Jay, for introducing this short debate on an important subject. Palliative care services present a multi-profession challenge. As the noble Baroness said, obstetrics and maternity care measure outcomes in healthy mothers and babies, but within given parameters. However, at the end of life, outcomes are more difficult to measure because patients are dying and hard data, such as survival times, are not appropriate. The criteria range through symptom relief, pain control, peace of mind, maintenance of dignity and a place of choice.

As a nurse, my observations raise several questions: do all NHS hospitals and community trusts have an end-of-life care policy on each ward and unit? Are all healthcare professionals taught about and proficient in end-of-life care procedures? Is there performance management of end-of-life procedures from the bedside to the board?

Palliative care specialists, medical and nursing, provide expert advice and care, but services are suffering from financial cutbacks. I visited my local hospice yesterday, which is 14 per cent core-funded by government. The national average funding for hospices is 30 per cent. The Hospice in the Weald serves a population of 280,000 in an area of 400 square miles. It operates on a very sound financial basis. It had a 50 per cent increase in cases and an additional two beds in the past five years. It records 95 per cent positive pain relief. The pressing problem on the day I visited was a patient who should have been transferred to the cottage hospital, but the PCT had closed beds and four patients were in desperate need of palliative care. The hospice has made an offer to the strategic health authority and the PCT to manage four of the cottage hospital beds, but has had no reply. This is a situation where joined-up thinking and partnership working should be to the advantage of patients. The hospice also runs a day care treatment centre, a lymphoedema clinic and a domiciliary palliative care service, which is served by 11 community nurses. This impressive hospice is widely respected in the locality but is nevertheless experiencing extreme frustration at not being able to meet the desperate need of so many patients requiring specialist palliative care.

Can the Minister say how Her Majesty’s Government will ensure that PCTs give sufficient priority to commissioning specialist end-of-life care facilities by supporting NHS trusts and the voluntary sector in beds, staffing and the resources to sustain specialists in palliative care? Will they also ensure that there is an effective end-of-life policy across the NHS, that performance management of those policies is in place from the bedside to the board and that the education and training programmes of all professionals include end-of-life care for the benefit of patient experience?

My Lords, I, too, am most grateful to the noble Baroness, Lady Jay of Paddington, for introducing this debate on a very important subject. I declare an interest as a nurse and as a member of the All-Party Group on Motor Neurone Disease. Hospices and what is now known as palliative care have long been interests of mine; a long time ago, my union, the Confederation of Health Service Employees, was an early supporter of hospice care. I wrote much of COHSE’s evidence to the Royal Commission on the National Health Service in the late 1970s. We advocated the rapid expansion of the hospice movement in the NHS and the voluntary sector. I am glad that the hospice movement and palliative care have developed, although there is much more to do. I fully support the concept of voluntary funding and provision, and one cannot but pay tribute to the work done, but I continue to be disappointed at the level of NHS support for hospices and, particularly, at the gaps in provision. It would be good if the Minister could comment on whether there is now any prospect of better support from the National Health Service to increase financial support to charitable hospices and plug the gaps in provision, not least in the availability of paediatric hospices.

I shall concentrate briefly on motor neurone disease. A very close friend of mine—who the Minister would have known as they used to lead for opposite sides on one of the Whitley Councils for the NHS—lived with motor neurone disease for a number of years before his sad death some 18 months ago. That was my first, but not my last, encounter with motor neurone disease. My friend had excellent care from all the relevant agencies, but the care given more recently to the father of a former colleague of mine was deplorable and has scarred his family for a long time to come. Even with six minutes, time prevents me spelling out the full awfulness of what happened in his case. Suffice it to repeat what Professor Sir Liam Donaldson, the Chief Medical Officer, said when he read the report produced by the family, which,

“highlights clear scope for improvement, particularly around communications and the transfer of information between different agencies and communications and the transfer of information for patients and carers ... I would certainly hope that health and social care bodies would learn from this case study”.

One stupidity—which has been resolved as a consequence of that case—was that the specialist motor neurone disease social worker could not visit or help because she worked for the county social services and my colleague’s dad lived within the purview of the city authority.

I am not just putting forward a case for additional funding; a lot can be done by sensible organisation, by improving communications within the National Health Service and social services and by having some continuity of care rather than having a different district nurse on every visit. I understand completely that motor neurone disease is notoriously difficult to diagnose and, certainly, once diagnosed there is no equality of care or availability of care in different settings. It could be argued that this again is our old friend: the postcode lottery!

What is being done to ensure that as soon as someone is diagnosed with motor neurone disease he is included on a GP practice’s supportive care register? I understand that does not happen and that such inclusion would be a more-than-useful start in ensuring access to different aspects of care required.

It is not always possible for people with motor neurone disease to travel to access palliative care. It would be helpful to know what can be done to expand hospice-at-home services throughout the country so that everyone can be offered this service. Returning to funding, what can be done to help charitable hospices to employ sufficient staff to meet the demands and complex needs of nursing people with motor neurone disease, and thus allow these hospices not to ration places—often to one person at a time only with motor neurone disease? Many still do not accept any persons with motor neurone disease.

Finally, I do not know whether my noble friend can say anything this evening about the very real opportunities to develop research into, and treatments for, motor neurone disease. He will know that the Motor Neurone Disease Association is committed to raising £l5 million by the end of next year, and that it has asked the Government to provide £7.5 million towards that total. When will a decision be taken on that?

I conclude by adding my voice in support of the Government coming forward with these moneys—I am sure the whole House will also support that because there is a huge financial and moral imperative to do everything possible to eradicate this most ghastly disease.

My Lords, I, too, join noble Lords in congratulating and thanking the noble Baroness, Lady Jay, on initiating this timely debate. Like speakers before me, I want to speak briefly on the hospice movement within the National Health Service.

The first point worth making is that the hospice is very much the Cinderella of the healthcare movement; certainly it is perceived within the profession as being cynically regarded by Government—this is not a party-political point; all recent administrations have been guilty. The perception is that the Government know that if they keep the funding short, public goodwill towards the movement will see to it that funding is found elsewhere, which almost invariably it is. Your Lordships will be aware that the National Health Service contributes a maximum of 50 per cent to the mainstream running costs of independent hospices. The noble Baroness, Lady Emerton, has quoted the national average of only 30 per cent. The balance has to be found from fundraising, legacies, donations and so forth—and it is an ongoing task. Hospices within the NHS, judging by the experience of some of our neighbours, are under huge pressure to cut costs.

I must declare an interest. I am chairman of the independent Hospital of St John and St Elizabeth in St John’s Wood, London. On the same site and part of the same charity is St. John’s Hospice. Unusually, therefore, the hospice enjoys accommodation support from the hospital and is also the beneficiary of any surpluses from the hospital. The hospice is 100 per cent contracted to the National Health Service through nine primary care trusts north of the Thames. We are fortunate, but many of our fellow hospices find it a real struggle to make up that 50 per cent or more.

So my message to the Minister, not for the first time, is to bear in mind the plight of the hospice movement, on which so many individuals and families in the community depend so heavily, when assessing spending priorities. But there is a more specific point which I wish to leave with the Minister. It is the wish of the overwhelming number of terminally ill patients to die in the comfort and familiarity of their own homes. We at St John’s have pioneered the hospice-at-home movement where we aim to replicate in the patient’s home the care and facilities to be found in a hospice. That involves a three-tier level of care. First, the hospice-at-home carers; secondly, the primary care clinicians; and, finally, support from the specialist palliative care team. It goes without saying that the service is greatly appreciated both by patients and their families. The benefit of this service is that it prevents crisis admission to the NHS acute units which block beds and resources, a problem faced by so many trusts when trying to fulfil their contracts; and it is quick and efficient while avoiding the bureaucracy of continuing care panels and the delay of providing care for a dying patient, for whom time is not in great supply.

But that comes with no government financial help; it is entirely funded by our hospice. I put it to the Minister that this could serve as a pattern for a more widespread service and of course NHS-supported, and I hope that the Minister will consider it. The title of the debate includes reference to the funding of additional services. I suggest that the Government might well consider this development. The Minister would find ready co-operation not only from our own but from many other hospices.

My Lords, I add my thanks to the noble Baroness, Lady Jay, on raising this very important topic. I shall confine myself to the effectiveness of palliative care in relieving suffering because, after all, that is what it is there for.

There is no doubt that my noble friend Lady Finlay of Llandaff and others working together have provided some very good research evidence for the superiority of specialist teams over generic routine services in alleviating suffering at the end of life. It is unchallengeable that we need more services delivered to wider groups. But, as in all other branches of medicine, including my own of geriatric psychiatry—indeed, particularly sometimes my own—there are limits to its success. I hope that noble Lords will forgive me if some of the particulars that I speak of tonight are unpleasantly clinical, but I think that it is important that we are honest about what palliative care can and cannot do.

Research on randomised controlled trials with dying patients is extremely difficult. I understand many of the difficulties that palliative specialists have with that, not least because theirs is a specialty that has developed out of a clinical commitment—a very good commitment to serve patients—whereas other medical specialties have developed out of technology. So, perhaps some of the research evidence is not as well developed in the field as it might yet be.

Let us look at the facts of efficacy. Over 95 per cent of patients with pain will get excellent relief throughout their illness with specialist interventions, whereas we know that about 40 per cent of dying patients have unrelieved pain without specialist care. Nevertheless, for about 4 to 5 per cent, opiates do not work to a sufficient degree and intractable pain, particularly generalised pain, can remain a problem. Less easy to accommodate are the side effects of opiate medication—fuzzy head, drowsiness, constipation and dry mouth. While these can often be avoided by an incremental approach, they cannot always be completely. Some patients forgo pain relief so as not to be befuddled. My brother-in-law, dying of prostate cancer, made the choice to be alert at the cost of considerable suffering.

Other symptoms are far less amenable to treatment. Breathlessness, which affects about 70 per cent of patients, and profound wasting—cachexia—which leads to skin breakdown, ulcers and lack of wound healing, are painful and distressing to experience and witness. Dry mouth can be helped by artificial saliva products but again not completely eradicated. Difficulties in swallowing and choking can sometimes be relieved but remain serious risks for the neurologically compromised patient.

Thirty per cent of patients admitted to hospice care, and a higher proportion of those nursed at home through a terminal illness, have periods of mild confusion, delirium or cerebral complications, which cannot be treated very readily. Finally, there are often new episodes of symptoms, such as coughing up blood, jaundice, paralysis or new fractures. These symptoms can be very distressing.

Palliative care teams of course try to address patients’ concerns about increasing dependence on others and the loss of autonomy, which many find difficult and a few find unbearable.

There are symptoms such as incontinence and the procedures that deal with it; symptoms that relatives find very distressing, such as poor breath, the foul smell of necrotic ulcers and unhealed wounds and the loss of dignity and discomfort of being handled by strangers. They are very difficult to undertake research into to find solutions.

While I was reading through the palliative care literature, I was surprised to find a series of papers from Japan on requested terminal sedation. It seems that it is accepted in Japan and some other countries that terminally ill patients can be put into a coma at their request when they feel that dying has reached an unbearable stage. That happens in the UK, too, although much less frequently, because we follow European guidelines.

Jessica Corner, the director of nursing at the Royal Marsden cancer hospital, has pointed out that we need to be much more honest about what really goes on in palliative care. She said:

“There is a climate of fear and secrecy [which] paradoxically shrouds practice in terminal care”.

We need to be more honest and open about real clinical practice—about what it can and cannot achieve.

I believe that we all agree that everyone with a terminal illness should have access to palliative care through a massive expansion of knowledge across all specialties of how to deal with end-of-life care, but there remain some patients for whom substantial suffering persists for which no physical or psychological solutions have yet been found. There is no simple answer to the revulsion that some patients feel about the process and dependency of dying and their wish to die at a time of their own choosing before the final indignities supervene. I certainly have no easy answers, but I wonder whether the Minister has any answers to that problem.

My Lords, I, too, thank the noble Baroness, Lady Jay, for introducing the debate. I speak as a committed supporter of good and appropriate palliative care and as an admirer of the hospice movement. Such palliative care should be available to all terminally ill patients who want it. I also speak as a layman and rely more than other speakers on the views of experts and researchers.

There is more than one model of palliative care and we need clarity about which model the Government are measuring effectiveness against and which model they want to fund in future. To assess the effectiveness of palliative care services, the Government will also need to look beyond the rhetoric of palliative care and investigate the reality of what it is achieving.

The divergence between rhetoric and reality is a theme in two books on palliative care. The first is by Julia Lawton, a research fellow at the University of Cambridge, entitled The Dying Process. The other is by Dr Fiona Randall, an experienced and respected palliative care consultant; the joint author is Professor Robin Downie, the emeritus professor of moral philosophy at the University of Glasgow. It is entitled The Philosophy of Palliative Care: Critique and Reconstruction.

Julia Lawton writes:

“We cannot assume that the modern hospice movement has had the radical effects that its pioneers intended. As Jennings argues in his recent critique of the ethics of hospice and palliative care, we can no longer afford to regard the movement's commitment as self-evident, non-controversial and in need of little explicit analysis and examination. On the contrary, there is an urgent need for a more rigorous analysis … A somewhat romanticised conception of dying patients resting comfortably in bed, mentally alert, calm and reassured is all too prevalent within [palliative care] literature ”.

Dr Randall, who, incidentally opposes assisted dying, and Professor Downie, write:

“We shall criticise the practice of palliative care for being too elaborate, too intrusive, and too precious. What we shall recommend is a return to the original simplicity of palliative care.

We shall draw attention to the inflated and often contradictory claims made in the literature of palliative care—its rhetoric—and seek to defend its clinical practice—its enduring reality”.

The starting point for part of that rhetoric is probably grounded in the World Health Organisation’s definition of palliative care, which was originally adopted by the National Council for Palliative Care on its website, which talked of impeccable assessment and treatment. That definition was subsequently replaced by the National Institute of Clinical Excellence definition, which is:

“Palliative care is the active holistic care of patients with advanced progressive illness. Management of pain and other symptoms and provision of psychological, social and spiritual support is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families”.

I shall refer to the model to give effect to that definition as the Rolls-Royce model.

On the other hand, Dr Randall and Professor Downie contended that improvement in the quality of life of the relatives of patients should not be an aim of palliative care, although professionals should be ready to offer friendly advice. They do not accept that palliative care specialists should be seeking to treat social and spiritual problems. They propose that competent, non-specialist palliative care ought to be provided by the NHS, together with telephone advice by specialists to all healthcare professionals, and that specialist palliative care professionals should attempt to spread their expertise to others by educational programmes.

The result would be that specialist palliative care could then be concentrated on those patients whose symptoms are difficult to control or whose care requirements can be met only by a specialist team. In making a decision on future funding, the Government must take account of the relative costs of the two models. The only justification for the Rolls-Royce model, which would be far more expensive, would be clear evidence of benefits over the more modest model.

In conclusion, I draw attention to the fact that a relatively small number of terminally ill patients do not want palliative care and would prefer assistance to die, but I recognise that this is a matter of choice and this debate is not the time to develop the case for choice.

My Lords, I recognise the excellent record that we have in this country in the development of palliative care, and the high level of skill and competence of specialist doctors and nurses in this important branch of medicine. It is recognised that care goes on being very important when cure is no longer a realistic option.

It is important that we recognise that the end of life is a very important phase—as important as any other in our lives. Many people are very much more frightened of the process of dying than the thought of being dead. We must understand that that phase is not just a problem that requires a solution but one that needs to be approached in the same way as other major life episodes. We must assume that people have the same rights and capacity to make decisions about their care until they take their last breath.

We all have an ideal view of the perfect, trouble-free death, but we know that people often experience many difficulties, not least of which, as has been mentioned by my noble friend Lady Murphy, is the extreme pain and discomfort that some experience. Other considerations include communicating their wishes. At times, family members may be very unhappy with those wishes. When pain can no longer be controlled, we know that many have reached the critical point where they are incapable of exercising any choice because progressive sedation will have rendered them unconscious.

I therefore very much welcome the end-of-life care strategy, which emphasises the need for individuals to exercise choice until the very end. It states that,

“for most individuals it may be more important to ensure that the care delivered is in accordance with their preferences, rather than to have it delivered in the care setting of their choice”.

The figures show us that only 4 per cent of deaths occur in hospices, and that we need to extend hospice provision in hospitals, in which 57 per cent of deaths and more than half of all deaths involving cancer occur. Most people express a preference for dying in their own home. Yet both in hospitals and at home, patients may not receive the specialist pain management or the total care that they need.

I hope that the Government will, through this very welcome end-of-life strategy, make available much more palliative care, including adequate pain relief, in suitable and comfortable environments with adequate privacy for all of us if and when we need it, and make pain relief a reality for all who want and need it in accordance with their wishes. Whether that pain relief lengthens or shortens the very end of the time they have on this earth, it assures that their choice, their wishes and their comfort are always paramount when the last decisions about their lives are taken.

My Lords, I am grateful for an opportunity to debate palliative care. I cannot possibly refute all the misconceptions in the short time that I have been allocated to speak, but I shall do my best. It was Dame Cicely Saunders who, from the outset, sought evidence for her work more than 40 years ago. She started outside the NHS because she knew that change would be faster. I agree with the noble Lord, Lord Joffe, that change has not been fast enough; it has not been fast enough for many of us. The noble Baroness, Lady Jay, sought evidence, and I will try to give her some.

Early research into morphine revolutionised pain control, and we have led the world in that research. Morphine does not shorten life when used for symptom control. The good news is that a paper is in press at the moment on this very subject, the literature from around the world having been reviewed. There is no such thing as the so-called double effect that shortens people’s lives. People are dying of their disease, although some people are ignorant of how to use morphine properly. Education is the answer to that; it is needed.

Research is being conducted into the 5 per cent of residual, neuropathic, difficult pains, and we are exploring the use of cheaper drugs such as methadone. However, many of these studies have been done on a shoestring in services that were completely outside the NHS, although fortunately the Government have now started the National Cancer Research Institute, which is at last promoting research into palliative care across all groups in the drive to find better ways to relieve distress, wherever the patient is.

It was Cicely Saunders who spoke of total pain—pain that is real and has a physical cause. That pain is made much worse by emotional, social and spiritual factors that can overwhelm the patient. I will tell noble Lords very briefly about one young woman whose pain seemed uncontrollable. She needed so much morphine at night that she was sedated through the day. In the evening, however, her pain returned. I spent not minutes but hours with her. She told me that her 11 year-old was going to be left orphaned. She was a single parent, and she was so worried about the pain that her death would inflict on him. We spoke about how to plan for his care, involved a solicitor, and helped to make plans for how to tell him what was happening to Mum. At 11 pm that night, I returned to the hospital, having been out at a dinner, because I had promised her that I would come back. I tucked her in in the same way in which I would tuck in my own daughter. That was the first night that she slept, because it had been the spiritual and emotional conflicts that had been tearing her apart. The morphine was actually controlling her physical pain well. Noble Lords should remember that palliative care was developed, and by and large remains, outside the NHS, even today. It continues to search for better ways to care and to influence providers.

What about patient autonomy? The whole philosophy is about the impeccable attention to detail to which noble Lords have already alluded. What can the patient achieve within the boundaries now set by the horizons that are shrinking because of disease? That is a reality of life; horizons also shrink with age and with all the infirmities that come along. We have heard only too recently about the vulnerability of the elderly, who are worried about their finances being raided by people whom they trusted and who they thought loved them.

In 2000-01, Professor Irene Higginson and I undertook a systematic review of the efficacy of palliative care teams, to which the noble Baroness, Lady Murphy, alluded. Overall, we found beneficial effects on pain and other symptoms, on home deaths and on carer satisfaction. The beneficial effect on pain and other symptoms was striking, and no study showed an overall adverse outcome. This evidence went on to underpin the NICE guidance on palliative care service configuration. The noble Lord, Lord MacKenzie of Culkein, is absolutely right; attitude and a flexible approach are all. What makes a difference to patients is people being prepared to work outside the boundaries of their indemnity, and so on, to provide what a patient needs. It is misleading to think of palliative care as simply a death-bed science. If it were, the randomised control trials that have been alluded to might be an appropriate research tool. Qualitative methods have evolved in palliative care in particular to try to capture the reality of those subtle, difficult moments that patients and their families experience, and to try to see whether we have made a difference.

Earlier referral to palliative care has proven benefits in improving symptoms and preventing their escalation. Qualitative data back this up, showing benefits to how people are thinking, feeling and coping. Cost savings have also been demonstrated both in the hospital stay-time and in the drugs used. But what about everyday practice? Yesterday, I thought I had better check how my own team in the cancer centre in which I work is doing, so I looked at our audit data. Our routinely collected audit data, collected mostly by a specialist nurse, have shown that 80 per cent of the patients have improved symptom and distress scores within 48 to 72 hours of being seen. You might say that 80 per cent is far too little. I would, but I am a realist and I know that nothing has a 100 per cent success rate in medicine, certainly not first time. Indeed, palliative care has never claimed to be the universal panacea or a magic wand to relieve the suffering that we see day in, day out, and to take it all away.

The point is that specialist palliative care aims to get people home again as quickly as possible, to carry on living as well as possible for as long as possible, however long that may be. Sometimes it is for months, and sometimes, surprisingly, it is for years. Palliative care must be improved across the board, and no one can predict what the future holds.

I ask noble Lords to allow me another minute of indulgence to say a little more. I would like to talk about my mother, who just over a year ago could not be moved in bed without screaming out in pain. It was a nightmare transferring her into the hospice, where in fact she lay for many weeks. Everyone, including my mother, believed that she was dying. She wanted to die. The noble Lord, Lord Joffe, may be pleased to know that she told me that she would have gone for assisted suicide if his Bill had been in place. This went on for about three weeks. I will fast-forward to her birthday, which was this January. She is up and about, living actively. This morning, she spoke to her philosophy class on the meaning of hope. The one thing that she does not do now is drive. She was never a good driver, so we are all relieved. She said that she never believed that her life could have so much quality. Sometimes, those conversations, with her suffering so much, tested me to the limit.

We are trying to roll out to the generalists the lessons that we learn from specialist palliative care. The National Council for Palliative Care is working on the needs of those with dementia, neurological disease, and cardio-respiratory disease. Work on motor neurone disease has shown that patients do not choke to death. The Liverpool Care Pathway has shown that we can roll out good anticipatory care to ensure patients have a calm and dignified death wherever they are. The wish to die at home, as expressed by two-thirds of patients, can be realised. Hospice of the Valleys has a 69 per cent home death rate. The needs assessment to underpin commissioning decisions that have been alluded to in this debate has been undertaken. The national strategy for end-of-life care brings us hope—

My Lords, I, too, thank the noble Baroness, Lady Jay, for securing this debate. I declare an interest as one of the founders and now a patron of the North London Hospice and as former chief executive of the King’s Fund. We all await further news on the end-of-life care plan on which Professor Mike Richards, the cancer tsar, and others are engaged. It was his father, Donald Richards, who first introduced me, as a student, to hospice and who was the source of a lifelong passion for the work that hospice, in particular, and palliative care teams in general, do. I want to express my gratitude to the noble Baroness, Lady Finlay, for her rebuttals of some of the comments that have been made. She is a clinician and I am not, and I do not feel competent to make the same rebuttals.

However, there is a real problem in assessing the effectiveness of some of our palliative care teams. Relatives almost always sing the praises of those teams. Patients are grateful and much comforted. The reputation of Macmillan and Marie Curie nurses is superb. Some of the obvious questions one might ask which would test the effectiveness of palliative care is whether patients get the end-of-life care they themselves desire. But the problem is that that has far more to do with local organisation of services than with the palliative care services themselves. Although 60 per cent of acute care trusts are now using the Liverpool Care Pathway, only 28 per cent of GP practices are doing so. Coverage for all patients rather than cancer patients alone ranges from 50 per cent for GP practices to 97 per cent for community hospitals. Patients do not get their preferred place of care in far too many circumstances, despite the preferred place of care advance planning tool that patients hold for themselves.

Irene Higginson’s excellent work for the National Council of Hospice and Specialist Palliative Care Services made that all too clear. You could judge palliative care by its failure to deliver on that, but it would be wrong to do so. The King’s Fund published an excellent report on palliative care in London in March 2005, which demonstrated all too clearly that it was the organisation of services that is so hugely complex and that much of the service is provided by district nurses, with specialist palliative care nurses in support in some, but by no means all, cases. It also questioned whether the effect of the new GP contract with its changes to out-of-hours cover means that there may be no proper hand-over from day-time care to night-time care, which, in itself, may make for worse palliative care services. Palliative care services can hardly be judged alone for their effectiveness. They can be judged on responsiveness, support to district nurses and how they are perceived by patients and families. In an era where patients are happier to talk about their own forthcoming death than was the case in the past, we ought to be able to research patients’ experiences in this area better than we have in the past.

What do we need? Certainly, we need far more resources for properly constructed, although I fear that it will be largely qualitative, research in this area and much more commitment to funding beyond what is already promised to bring,

“the care of all dying patients … to the level of the best”,

to echo the Government’s own mantra.

We also need patients, and their families and friends, to know much more so they can exercise real choice, which might not be to opt for palliative care, but at the moment they do not know enough to make the choices properly. Only with proper information can you really assess effectiveness against what people actually want. I feel particularly concerned about this as, when I was still chief executive of the King’s Fund, we developed a service called Compass, to be collocated with NHS Direct in south-east London, which would give telephone advice to patients and their families about what might be available for people who are dying and help them to make the choices they want via proper information.

With the cuts in NHS Direct, that service is no longer funded, and although some voluntary sector organisations are looking at picking up the information and data gathering part of this, the superb telephone work that Liz Taylor was doing is now virtually at an end. This matters because assessing services and their responsiveness is not possible by talking only to nurses, GPs and clinical specialists. We have to talk to patients and carers. The noble Baroness, Lady Jay, is right about that, but we have to talk to them when they, too, are armed with information. This is an area where a website simply is not good enough. People need to be able to find out, discuss and then talk to their primary care providers in the light of that knowledge, for all too often primary care providers know only what is available in their immediate area.

For me, the question is not only about how we evaluate palliative care services, but how we do so with informed patients and carers. I do not believe that that is possible without decent, good, rather expensive, I suspect, information services. The King’s Fund put considerable investment into this programme in my time and has since done so under Niall Dickson’s leadership. Will the Government now pick this up and run with it? I hope that the Minister might give me some reassurance about this. I also very much hope that the Government will think hard about how they might ensure the extension of such an information service beyond what was being piloted in south-east London, so that people will be able to make informed choices and the public will be able to judge the effectiveness of all the palliative care options available. I believe that, at best, we have a superb service in this country, but at worst we have inequalities of provision that are shameful and great unfairness to people with conditions other than cancer.

My Lords, I, too, thank the noble Baroness, Lady Jay, for introducing this important subject. I was privileged to propose a toast to the health of a gentleman celebrating his 100th birthday last week. A newspaper reporter asked him, “Have you spent your whole life here in this village”? He replied, “Not yet”. We must never underestimate the resourcefulness, determination and humour of the elderly. Of course, palliative care also involves children and people of all ages. It used to be said that it was the elderly who are responsible for most of the expenditure in the NHS. In fact, it is those who are dying who cost the most, and the majority of people who are dying are elderly.

I would like to draw attention to a number of points. First, it has been said already that the Government fund 30 per cent of the cost of adult hospices, but only 6 per cent of the cost of children’s hospices. The Conservatives intend to correct that inequality. Will the Government follow suit or will they continue with the under-funding? Secondly, the overwhelming support for hospices by the people of this country is amply demonstrated by their donating two-thirds of the costs; that is, more than £400 million every year. This is a very significant endorsement of the hospice movement, which was started by that splendid lady, Dame Cicely Saunders, who was a contemporary of mine. I should add that she was 15 years older, and was already a qualified sister and an almoner—a great person.

I should like to draw attention to research into hospice work, which was done mostly by people working in hospices. They discovered important new treatments, such as maintaining a constant level of pain-relieving drugs in the body, which thereby prevented pain and kept the patient much more wide awake and happier. They pioneered techniques such as drugs applied to the skin—for instance, patches containing Fentanyl—to reduce nausea and vomiting, injecting morphine just underneath the skin or sucking pain-relieving lollipops, which allow patients to be managed at home. Mary Baines worked out a way of managing obstruction of the intestines without the usual unpleasant tube that is put up the patient’s nose. People working in hospices also discovered ways of relieving respiratory distress.

It is worth pointing out again that very little money is given for research into palliative care. Compared with the funds made available for cancer research by Cancer Research UK, the MRC and the Department of Health, hospice care receives only 0.18 per cent of UK cancer research spend, a figure mentioned by the noble Baroness, Lady Finlay. Do the Government intend to remedy this deficiency? On page 216 of an exhaustive NICE report published four years ago, Professor Irene Higginson and the noble Baroness, Lady Finlay, produced a most informative diagram showing conclusively that when all symptoms, patient satisfaction, carer satisfaction and morbidity are considered as a whole, specialist care does have a significant benefit. Moreover, it saves costs and meets people’s preferences. No study has ever shown that it causes harm, which is more than can be said for many of the treatments given to the comparatively well. Considering a single indicator on its own, such as quality of life, may mislead because it measures physical function, which is bound to deteriorate as the patient is actually dying.

I was sorry to hear from the noble Baroness, Lady Jay, about the young lady who was dying. Her account reminded me of a young lady of 26 that I looked after when I was a house surgeon. She was in pain and suffering respiratory distress. I decided that as a doctor my job was to relieve all her symptoms at any cost, so I put a needle into her vein and started very slowly to inject heroin. I asked her to tell me when her symptoms had gone. I administered a considerable quantity of heroin until she told me that all her symptoms had eased. I had given her a huge dose, but to my astonishment not only did the drug not kill her, it gave her a new lease of life.

There is a problem here because many doctors are wary of giving analgesics, especially when there is respiratory distress. I have known some surgeons not to give enough pain relief post-operatively. But the good news is that when these surgeons have an operation themselves, especially an abdominal procedure, they then find out what inadequate pain relief is really like. When they return to work, they roam around like caged lions ensuring that all their patients are relieved of pain and teaching all and sundry how important it is to ensure pain relief. There is no excuse for unrelieved pain, whatever the cause.

My Lords, I thank all noble Lords who have spoken in this excellent debate, and particularly my noble friend Lady Jay. She is of course a distinguished predecessor of mine at the Department of Health and was deeply involved in laying the foundations of the improvements that we have seen come through in the National Health Service. It is a delight for me to respond to her tonight. I start by declaring an interest as a financial supporter of St Mary’s Hospice, Birmingham.

This has been an interesting debate and there has not always been agreement on some of the fundamental issues we are considering here. However, all noble Lords agree that more money should be put into palliative care and I shall certainly respond to that in a moment. But I agree strongly with the noble Baroness, Lady Greengross, about the critical importance of this part of a person’s life and our need to ensure that it is given adequate priority. That is a sentiment with which all noble Lords will agree.

I turn to the question of the definition of palliative care. My noble friend Lady Jay made some interesting observations about the scope and remit of palliative care and discussed what she described as a contemporary definition, and indeed the philosophy and practice of some palliative care practitioners. These are searching questions and I have no glib response to make, but it is important to ensure that there is continuing debate about these matters. The right reverend Prelate offered his own definition of palliative care, as did the noble Baroness, Lady Emerton, and we were treated by the noble Lord, Lord Joffe, to a quote from the NICE definition. I am sure that when we come to debate the Bill of the noble Baroness, Lady Finlay, in two and a half weeks’ time we will again enjoy a discussion of this area, particularly the question of the extent to which palliative care embraces social and spiritual elements. Again, sharply contrasting points of view have been expressed on this in the debate. The noble Baroness, Lady Finlay, spoke of the inevitable links between physical pain and its social and mental impact.

I shall turn to the end of life care strategy in a moment. It will attempt to draw up a definition of palliative care and I will ensure that tonight’s debate is drawn to the attention of the group of people working to address the definition. I think noble Lords will agree that one would not envy those charged with this task, but alongside dealing with the definition they are also helping to develop a strategy that will measure quality of care, including outcomes. I shall also come back to the issue of research later in my response.

My noble friend Lady Jay pleaded the case of the need for evidence-based research, and a number of other noble Lords echoed that request. The noble Baroness, Lady Murphy, talked about some of the challenges faced in doing that and the contrast in outcomes of specialist care and non-specialist care, on which there does seem to be general agreement. She also spoke of the need for openness and honesty about the clinical experience and the wishes of patients. We were also treated to a number of examples of the kind of research that has been undertaken. The noble Baroness, Lady Finlay, referred to some of those research aspects which have shown proven benefits, including what she described as “thinking, feeling and coping”. The noble Baroness, Lady Neuberger, commented on some of the challenges faced by researchers and the inevitability, as she described it, of some research having to be focused on quality of care.

As the noble Baroness, Lady Finlay, outlined, I understand the concerns expressed about the availability of funding for research in this area historically, but the intention of the National Cancer Research Institute is an investment of £5 million in palliative care research over a five-year period. Tonight’s debate will be helpful in ensuring that the parameters of that research take into account some of the interesting, difficult and in effect conflicting views expressed about what kinds of research should be undertaken.

So far as effectiveness is concerned, primary care trusts have local responsibility for commissioning and funding services for their resident population, including palliative care. One of those responsibilities is for PCTs to decide upon and take forward a strategy and commission the appropriate services. In doing so, they must ensure that evidence is available about the potential effectiveness of those services. I suspect that noble Lords will say to me that primary care trusts need a lot of help in determining how to judge effectiveness. One of the conclusions I reach on that is that we must ensure that such research looks at the very practical issues facing individual primary care trusts up and down the land.

I turn now to the end-of-life care strategy. As noble Lords have said, work in this area is being led by Professor Mike Richards, the National Cancer Director, with support from Professor Ian Philp, the National Director for Older People’s Services and Neurological Conditions, and other national clinical directors. I can assure noble Lords that the work will go much wider than cancer; this is an end-of-life care strategy for all people and all categories of care.

The strategy is concerned with delivering increased choice to all patients, regardless of their condition, within available resources. I noted with great care what my noble friend Lady Jay said about choice and the need to work with representatives of patients’ interests. I shall certainly ensure that that happens. I take account of the comments of the noble Baroness, Lady Neuberger, about the lack of consistency in relation to choice—she is right to raise the issue—and about how patients and relatives can be helped to exercise choice. Again, I agree with her and I will ensure that that is a factor of the work that is to be undertaken.

As to her point about Compass, in the time available I have not been able to obtain further information. I shall look at the matter, write to her and let her know what the current position is.

The strategy will build on the programme of action set out in the White Paper Our Health, Our Care, Our Say. Some of its key points concern the need to improve the co-ordination of end-of-life care through effective partnerships between health services, social services and the voluntary sector. I hope my noble friend Lord MacKenzie will take some comfort from that because I certainly agree that it would be ludicrous if agency barriers got in the way of an integrated approach. Palliative care must lend itself to partnerships, and we want to ensure that the incentives are all there to encourage such partnerships.

We also want to ensure that we provide rapid and responsive services to meet patients’ needs and preferences and, in response to the noble Baroness, Lady Emerton, to train healthcare professionals in all settings. I agree with the point that she raised.

So far, an extensive written consultation has been conducted and 170 responses have been received; a major consultation conference was held last October and feedback has been helpful in suggesting the direction of travel; and an advisory board, appointed by Ministers and supported by several expert working groups, will be taking forward various developments in the strategy. I will ensure that the advisory board and Professor Richards and his colleagues are given a full account of today’s debate. The advisory board is expected to report to Ministers with recommendations in the autumn of this year.

One of the working groups is examining the potential of end-of-life care in a variety of settings, a point well made by the noble Baroness, Lady Greengross, and other noble Lords. At present, around 55 per cent of deaths occur in hospital, around 20 per cent at home, around 20 per cent in care homes—and we must not forget care homes, although they have not been mentioned today—and around 4 per cent in hospices. Clearly the challenge is to ensure that good quality palliative care is available in all those settings. This strategy is our best shot at setting a framework and objectives to ensure that that happens.

I accept the point made by the noble Lord, Lord Colwyn, about the need to expand palliative care and what he said about pain-relief services. I expect the strategy to address those issues.

The noble Baroness, Lady Emerton, asked some searching questions about the current availability of palliative services in the NHS. There is a considerable variation in the availability of those services and the aim of the strategy is to get a more consistent approach.

I turn now to the issue of resources. I remember four or five years ago taking part in a debate on the question of resources which was opened by the noble Lord, Lord Walker of Worcester. I echo the remarks of my noble friend Lord MacKenzie about the hugely impressive contribution that hospices have made and the tremendous efforts that they have made and are making to raise funds. I understand a little of the challenges they face and the competition from many other charities. They have done tremendously well and the Government do not take a cynical approach to them.

The responsibility for making decisions has to lie with the primary care trusts. Equally, we have a responsibility for setting a framework and a strategy within which primary care trusts can make those decisions. I accept that the deficits with which the NHS has found itself this year have caused PCTs to make some very difficult decisions. I do not run away from that. We had to deal with the deficits—they could not be allowed to go on—and that is why this short-term action has had to be taken. I am absolutely convinced that we need to do everything we can to give long-term certainty to hospices and I hope that the strategy will help us to do that.

I know that funding from the NHS is not as much as noble Lords want but the Help the Hospices survey showed that, compared with 2000, in 2004 there had been an increase in NHS funding for adult hospices of about 50 per cent, with NHS funding for adult hospices averaging about 38 per cent of expenditure. There are other things I could say about funding, and other initiatives, but time is against me. The issue of funding will of course be addressed in the end-of-life strategy, but difficult decisions will always have to be made.

Children’s palliative care is embraced within the work we set out in the White Paper, Our Health, Our Care, Our Say. That requires primary care trusts to ensure that the right model of care is provided, and we will work to support them in that.

I pay tribute to the noble Viscount, Lord Bridgeman, and the St John’s hospice at home project. My noble friend Lord McKenzie echoed the noble Viscount’s remarks. Many hospices have done valuable work in developing hospice care with staff in the patient’s home. We endorse that, and wish to see it developed further.

This has been an interesting debate. We have heard very different views on the nature and scope of palliative care. I suspect we will have further opportunities to discuss that in your Lordships’ House in the next few months. While I doubt whether the end-of-life strategy will be able to provide a definitive answer to some of those questions, it will set out a much stronger framework in which to deliver a much more consistent approach to palliative care services. Tonight’s debate has been very helpful in informing the people developing the strategy of some of the important matters they need to take account of.

House adjourned at 8.40 pm.