Palliative Care (Scotland) Bill: Financial Memorandum
Item 3 is to take evidence on the financial memorandum to the Palliative Care (Scotland) Bill. I welcome to the committee Gil Paterson MSP, who is accompanied by David Cullum, head of the non-Executive bills unit. I invite Gil Paterson to make an opening statement.
I am grateful to the committee for inviting me to give evidence on the Palliative Care (Scotland) Bill. Given the committee’s affection for figures, I thought that it would be best to start by quoting a few that set out the context of the bill. More than 55,000 people in Scotland die each year. Eighty per cent of those deaths occur in patients aged 65 years and over; 60 per cent occur in those aged over 75 years. The number of people aged 75 and over is projected to increase by three quarters by 2031. Coupled with the trend of both older and younger people living longer with life-limiting conditions, the bill is timely and compassionate.
The bill has two main policy objectives: to place the Scottish ministers under a statutory obligation to provide palliative care for those with life-limiting conditions and their family members, and to set up reporting arrangements so that the palliative care that is provided can be monitored by the Scottish ministers and the Parliament. The bill gives legislative effect to the key intentions of the Scottish Government’s living and dying well strategy, the aim of which is to extend provision of palliative care to all who require such care, regardless of diagnosis, age or geography. Both the Government’s strategy and the bill are founded on the World Health Organization’s definition of palliative care as
“an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
The bill imposes no additional duties on health boards or local authorities but converts into a statutory right an existing right that the Scottish ministers have given through their strategy. The costs of implementing the living and dying well strategy should, therefore, cover the bulk of the costs of implementing the bill. I would have preferred to come before the committee today with precise figures for the implementation of the Government’s strategy, but that was not to be as the required information is not held centrally, but I have been able to cost the one aspect of the bill that imposes new requirements. The financial memorandum highlights the fact that some costs will be associated with the collection of performance indicator information. Before I deal with the figures, I will explain why it is necessary to incur that small but critical cost.
The bill seeks, through the annual reporting of specified information, to standardise and collate information on the delivery of palliative care, in line with recommendations by Audit Scotland and the Public Audit Committee. Page 10 of the Audit Scotland review of palliative care recommends that the Scottish Government
“work with NHS boards, councils, voluntary hospices and the Information Services Division (ISD Scotland) to ensure information is collected consistently across all services and used to improve planning.”
Such information would help to provide joined-up care for individual patients. The bill will facilitate such standardisation and consistency by ensuring that there is a focus on delivering best-practice palliative care and that we learn from the best, the most efficient and the most effective. If such an approach is adopted, provision is less likely to be eroded over time or, indeed, threatened in harsh economic times.
Back to the figures. I have estimated that it will cost the Scottish ministers around £50,000 in year 1 to establish a database. Thereafter, the running costs will be £10,000 per annum. The estimate for set-up costs is based on the costs of other recently established databases that have been created under legislation, taking account of the fact that much of the information that is required is already collected, although collation is poor and cross-authority comparisons are difficult to establish. I estimate that there will be minimal costs to health boards and that they can be absorbed.
I set out the conclusions on the potential cost savings that were identified in a recent study, which found that palliative care can generate substantial savings for the health service through cost avoidance. An American study also demonstrates that there would be savings through increased palliative care, because it reduces the number of emergency interventions.
I thank the committee for giving me the opportunity to demonstrate why the bill would be well worth supporting.
Thank you. I invite questions from members.
Good afternoon. Congratulations on the work that you have done so far. It is an incredibly worthwhile piece of work.
We have received submissions from the same type of bodies in different parts of Scotland. Some say that there is a lot of extra money involved and explain at length why it would be difficult to provide such a service; others who are in exactly the same line of work say that it is fine and that they can just get on and do it. Which ones do you think we should listen to?
I understand the anxiety that some people feel about the proposals. On the surface, it appears that a lot of money is involved. The bill is predicated on the Government’s living and dying well strategy; it does not put any additional pressures on health boards and it does not ask for any more than is expected from the Government’s living and dying well strategy. From the information that I have to hand, it seems that that strategy is progressing through health boards at the present time.
At present, the benefit that someone would get from palliative care depends on where they live and what illness they have. The purpose of the bill is the same as that of the Government’s strategy—anything that I say about the bill today is true of the Government’s strategy. We are trying to identify different illnesses in respect of which people do not benefit from palliative care. There is a 90 per cent certainty that a cancer sufferer would benefit from good-quality palliative care, whereas there may be a 90 per cent chance that someone with another life-limiting illness would not benefit from such care. The purpose of the bill is to enable the Government’s strategy to gain traction. It does that by asking for two things. It may sound flippant, but the bill is the Government’s strategy with bells and whistles—no, not bells and whistles, but a bell and a whistle. If we had the indicators and then the reporting of the indicators by health boards, we could see how different boards were performing and in which areas—whether geographical or illnesses—we needed to do a bit more work.
To answer your substantive question, as far as I am concerned, because the bill is the Government’s strategy, there would be no additional costs. There are already costs to the delivery of the Government’s strategy but, apart from those that I have mentioned, I cannot identify any others.
So, although some health boards have said that the proposals will cost more money, in reporting to the lead committee the Finance Committee should be perfectly comfortable in saying that the bill will not place any additional burden on existing resources?
I would say that that is exactly the case; it assists and enables delivery of the living and dying well strategy.
15:30
I agree with Tom McCabe about the importance of the issue. David Cullum was supporting evidence to the End of Life Assistance (Scotland) Bill Committee this morning; now he is here to talk about palliative care. It is one of those cheery days that requires the non-Executive bills unit’s support. However, it is a profoundly important proposal.
If I understand it properly, the bill would make a statutory duty of what is currently a Government strategy. Part of the evidence that we have to sift through is from health boards, who have talked about the potential costs of the Government’s strategy and whether they have the resources to implement it. One of the difficulties that I need to get clear in my own mind is, although that will not be a direct cost of the bill, the costs would be a consequence.
You have probably seen all the information that the health boards have sent to the committee. NHS Greater Glasgow and Clyde’s needs assessment says that there should be an additional 10 palliative care consultants and a substantial rise in the number of specialist nurses. Do you accept that, as a consequence of the bill, health boards will incur additional costs in delivering what they believe is an underresourced strategy?
I must point out that there are 63 palliative care specialists in operation in Scotland at the moment. It would be simple to identify the number of people who are benefiting from that provision, how many areas need to be supplied and then to do the calculations to establish how much money we need to give the specialists.
The bill is not about the specialist element of palliative care. The Government’s strategy is about driving up in a generalist fashion how nurses and clinicians, not specialists, engage in their everyday work and how training should be brought in so that the front, rather than the specialist, end gets the benefit, and so that costs are not driven up.
This might answer a couple of questions. I was at a bishops conference in Largs two years ago. Bishop Kelly from Liverpool was there. He mentioned that a particular hospital in Liverpool had had many complaints about palliative care. The hospital needed to recruit nurses, so it recruited 20 Filipino general nurses. When they came into play, instead of getting a lot of complaints the hospital got a lot of plaudits. It received letters saying how good the service had been. There was no cost attached to that because the nurses were generalists.
There is no question but that our nurses are as good as Filipino nurses—and that Filipino nurses are as good as ours—but they had a different ethos and way of operating from day 1. The Government strategy and the bill are about a change in the way of operating. If you told me that we would have to open X number of hospices or that NHS Greater Glasgow and Clyde needs other specialists, I would say that that is not what I am asking for; I am looking at what we already have and how we can benefit from change within. That is exactly what the living and dying well strategy is about.
NHS Greater Glasgow and Clyde has given us its assessment of what it needs to meet the requirements of the living and dying well strategy if implementing that strategy is to be a statutory duty.
Boards have told us that the financial memorandum overestimates their capacity to absorb the reporting mechanisms that would be required. How do you respond to that?
We looked at two new databases and we provided the most accurate figure that we could provide. I read the submission. Boards seem to be suggesting that the information is not currently gathered. However, we currently gather most of the information, although we do not collate, utilise and report on it. If we want to make a difference and identify issues to do with the areas where people live and the illnesses that they have, we need a mechanism that enables us to scrutinise the data and understand what is happening.
I am fairly certain that the work that has been carried out in relation to the bill has produced figures that are robust. I do not agree with what health boards said.
Why do you think the Government is not supporting the bill? Why does the Government think it unnecessary?
You need to ask the Government about that. It has a strategy on palliative care. I think that I am doing the Government and health boards a great service, because I am trying to home in on certain issues, through the provision of a database.
There might be reports of good palliative care in one hospital, but care might not be as good in another hospital in the same health board area. We need to understand why, so that we can try to drive up performance. Everyone would benefit from understanding why performance varies and why a patient who has a particular illness does not benefit from palliative care.
I am not sure why the Government has not said that it will support the bill. As I understand it, the Government has not said that it will vote against the bill, so there is still a prospect of the bill progressing.
I should have worded my question differently. The Government did not say that it would not support the bill; it said that it has no intention of introducing a bill on palliative care. I guess that that is different.
The Government might have been talking about a bill that would provide for a mandatory approach. I think that it wants to drive forward its strategy, and I think that my bill would help in that regard, particularly in relation to reporting. We need to understand why some health boards outperform others and what lessons we can learn from them. We can do that only by collating the information, analysing it and reporting on it.
The bill would give the Government the right to amend the indicators. Some people think that there are too many indicators in the bill; others think that there are not enough. I will be frank and say that I do not know whether we have got that right. However, I accept that as time goes on the Government might need to make changes, so the bill provides for that to happen.
The Government said in its submission to the committee:
“there are sufficient existing legal powers and policy arrangements”.
It went on to say:
“a statutory obligation may limit the flexibility of NHS Boards to plan and provide palliative and end of life care services in accordance with local circumstances.”
I agree with the sentiment of the second part of the quotation. I would not want to put in place anything that interfered with boards’ flexibility; flexibility is why we benefit from quality palliative care in some areas. The bill does not disturb flexibility, but we and the Government also need to understand why one area is lying fallow and another is doing very well. The collation of the figures is almost a must. The bill is modelled on the living and dying well strategy. We would not want to disturb health boards’ ability to make their own decisions.
I assume that you anticipate that the set-up cost of £50,000 and the running cost of £10,000 for the database would come from central Government.
Yes, I anticipate that the Government would support the database and provide that additional money.
As Jeremy Purvis said, you will have seen the submissions from various health boards. You say that you model the bill on the Government’s living and dying well strategy, but NHS Tayside tells us that the financial implications of that strategy
“have not been funded by the Scottish Government.”
It goes on to say that whatever additional costs there might be if the bill were adopted
“should be met through an additional allocation of funds to NHS Boards.”
There is clearly a bit of a dilemma. The health boards do not—well, at least NHS Tayside does not—believe that the living and dying well strategy has been funded and they say that, if there are additional costs, they should be funded by central Government. Do you agree with that?
I agree that we need to find additional money for the provisions in my bill—£50,000 for set-up costs and £10,000 per annum. I would not want to put additional pressures on health boards to fund that. That is the starting point.
Since I inherited the bill from Roseanna Cunningham, I have visited hospitals, hospices and care homes and spoken to clinicians, professors, doctors, nurses, managers, patients and family members in the east, west and north. I have been to Inverness, Oban, Edinburgh and as far south as Greenock. My view is that, however the living and dying well strategy is funded, it pays dividends.
I am a great supporter of the strategy. I like what I see in it and the feedback is that it is delivering. You would need to ask the Government how the funding is managed but, if you agree that my bill is the living and dying well strategy in another guise, you must agree that there is no need for additional funding apart from what I identified. I have asked parliamentary questions seeking information on costs. There are no answers to those because the information is not collected centrally. That takes us back to my harping on about indicators and the need to collate the information. Whether or not my bill is passed, it would be money well spent.
There are no further questions. You have left us in no doubt about your sincerity and personal motivation in promoting the bill. Do you wish to make any final comments?
No. I have harped on about the same thing. I thank the committee for being exceptionally hospitable to me and giving me plenty time to answer the questions. I am grateful for the time that you have given me.
I thank David Cullum and Gil Paterson for their evidence.