Meeting of the Parliament

Meeting date: Wednesday, January 8, 2020

Official Report 1047KB pdf

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Palliative and End-of-life Care (Research Projections)

The first item of business is a members’ business debate on motion S5M-20209, in the name of Miles Briggs, on research projections into place of death in 2040. The debate will be concluded without any question being put.

Motion debated,

That the Parliament welcomes the publication of the report, The impact of population ageing on end of life care in Scotland: Population-based projections of place of death and recommendations for future service provision, by Marie Curie, the University of Edinburgh and King’s College London; praises this research, which explores projections for place of death by 2040; recognises that projected trends suggest that two thirds of people will die outside of hospital settings by 2040; acknowledges the report’s findings that more investment in community-based care is needed, particularly an increase in care home capacity, to support this shift in care; further acknowledges that terminally ill people and those at the end of their lives should be a high priority for those that commission health and social care services, and notes the view that sustainable funding of services is needed; further notes the recommendations from the research that there is a need to upskill the health and social care workforce in palliative and end of life care through education, training and valuing of their work, explore digital solutions and technologies to support people in the community, and mobilise communities to support people needing care; commends Marie Curie’s proactivity in encouraging early conversations about dying, death, bereavement and grief, and notes calls to encourage further public debate so that people have early conversations about end of life, and enable them to plan to die in their place of choice.

I thank colleagues for supporting my motion and enabling today’s debate to take place. The topic that I have brought for debate is perhaps not the most cheery for the start of the new year, but it is of vital importance to our constituents and their families.

I welcome to the public gallery representatives of Marie Curie, and I pay tribute to the work of that charity and all its staff, nurses and volunteers, who do so much for our constituents in every part of Scotland.

I visited the Marie Curie hospice in Edinburgh in the run-up to Christmas and, once again, was incredibly impressed with the quality of care that its staff provide to terminally ill people in the Lothian region. I was also impressed with the support and advice that it gives to family members at such a difficult time.

Improving the care and support that we offer to people at the end of their lives is something that every MSP in the chamber supports. I pay tribute to members for the campaigning that they have undertaken on the issue, including David Stewart, who is looking to have a debate on the issue in the future.

I commend the authors of the place of death report: Marie Curie, King’s College London and the University of Edinburgh and, specifically, the lead authors Anne M Finucane of Marie Curie and Anna E Bone of King’s College London.

The report identifies that there will be nearly 16 per cent more deaths in Scotland by 2040, with an increase from 57,700 to 65,700, and that 45 per cent of all deaths will be of those aged over 85. Currently, around 45,000 people a year die of a terminal illness and require some form of palliative care or pathway. Therefore, the increase in the number of people dying will bring with it an increase of thousands more people each year who need palliative care. We also know that the number of people living and dying with dementia, cancer and frailty will increase considerably and that more and more people will live with multi-morbidities. The challenge in getting the care right for such people is already a massive one, so we clearly need to start planning for the future, which is what I hope that today’s debate will look at.

The Marie Curie-led research makes an important contribution to understanding what the future might look like and how the Government and the health and care sector can respond to the challenge. The research shows that, by 2040, if current Scottish trends continue, community settings are likely to be the place where two thirds of all deaths take place. Hospital deaths would account for the other third. Currently, around half of people die in hospitals, so that change would be aligned with the Scottish Government’s ambitions for shifting the balance of care from acute to community settings. We support that shift, as do members across the chamber.

However, it is vital to highlight that the research concludes that the scenario of people being able to die at home is very unlikely to happen if community support and capacity are not radically increased. The research suggests that, if capacity is not increased in the community, more and more people will die in hospital, potentially peaking at more than 37,000 people dying in hospital by 2040—representing 57 per cent of all deaths—which would be an increase of more than 8,000 hospital deaths from 2016.

The numbers of care homes and care home places in Scotland are currently falling. The number of care homes for older people fell by 10 per cent between 2007 and 2017, and the number of care home places has fallen to just 37,278. The sustainability of the care sector is an important issue for us to consider.

General practitioner numbers are also under pressure, and other professional groups, including district nurses, allied health professionals and social care teams, struggle to provide care for their patients as their numbers decrease and vacancies take longer and become more difficult to fill. All those professional groups are essential in providing support and the multidisciplinary team that is needed for people living with a terminal illness across our communities.

A unique aspect of the research was the sharing of data with 27 experts—including policy makers, clinicians, health service managers, social care workers and educators—in drawing together the findings. The experts were asked to identify priorities to support the shifting of care from acute to community settings, and, by consensus, they identified three key priorities to support that outcome. The experts said that the following needs to happen. There needs to be an increase in, and an upskilling of, the community health and social care workforce through education, training and the valuing of our care workers; we need to build community care capacity through informal carer support and community engagement; and we need to stimulate a realistic public debate on death, dying and sustainable funding for those services.

In his response to the debate, it would be useful to hear from the Minister for Public Health, Sport and Wellbeing how the Scottish Government is responding to those key priorities and what actions ministers are going to take in those areas. Specifically, it would be helpful if the minister pledged to write to all health and social care partnerships, asking them to publish their plans for palliative and end-of-life care. Some of them have already done that, but many have not and it would be useful to find out what our health and social care partnerships across Scotland are looking to do in the future.

The Government has pledged that everyone who dies of a terminal illness should have an advanced care plan in place. That is another ambition that everyone across the chamber supports. However, the Government has just 12 months in which to make that happen. Currently, only around half of those who die in hospitals have such a plan in place, so we have some way to go. I hope that the minister will also respond on that ambition and say what work is being undertaken to achieve it.

Getting the environment in hospitals right is incredibly important. All members will have had it fed back to them by constituents and families that it is vital that dying people and their friends and families get the space and dignity that they need. The study also highlights the role of hospices in caring for people at the end of their lives. It is clear from the research that the in-patient capacity of hospices will not grow significantly in the years to come, although they will nonetheless care for 5 to 7 per cent of all deaths in their in-patient facilities. All of Scotland’s hospices have already begun to increase their out-patient and community services, to ensure that they reach many more people beyond their in-patient cohort. Those services, and those of charities such as Marie Curie, will be needed in the future as we support the shift in the number of deaths—which is suggested in the research—from an acute setting to a community one.

Hospice UK suggests that Scottish hospices currently care for around 19,000 of our fellow Scots every year. With many hospices across the UK facing financial struggles, and with some closing, there is a real danger both that in-patient capacity could be reduced and that support in the community could be withdrawn, putting additional pressures—yet again—on the acute care setting. Given that the role of hospices is vital in the care of people living with terminal illnesses, how can the Scottish Government work with hospices to ensure a sustainable financial future for them not just in this decade but beyond?

To conclude, I thank all parties for their support of today’s motion, which I welcome. We support the Scottish Government’s vision that, by 2021, all those who need palliative care in Scotland should have access to it. There has been some progress, which we should acknowledge, although it has not been fast enough. Without real effort over the next 16 months, there is a danger that we will not meet that 2021 vision. Even if we do, without making palliative care a much higher priority for the Government and for health and social care partnerships, we could start to fall behind again quickly. We should not let that happen.

We will also face very significant challenges in responding to an increasing number of deaths as time goes on.

You must conclude.

I hope that the report and today’s debate help to kick-start a productive discussion about how we build capacity and develop sustainable services. [Applause.]

I ask those in the public gallery not to take part in the proceedings.

13:24  

I welcome the opportunity to speak in the debate and congratulate Miles Briggs on securing it. I welcome members of Marie Curie to the public gallery and recognise, and congratulate them on, the joint research that was published by Marie Curie, the University of Edinburgh and King’s College London into projections of place of death in Scotland by 2040.

The research is very insightful and detailed, as Miles Briggs highlighted, and it makes a good basis for discussion of and debate about social care, anticipatory care planning and how best to manage lifeline social care services in the future.

I remind members that I am a registered nurse and that, as the deputy convener of the Health and Sport Committee and a regular attender of the cross-party group on palliative care, I have a particular interest in our social care sector. I feel passionately about ensuring that we equip the sector and, indeed, our population for years to come.

Across Scotland and internationally, we are seeing our population ageing better and people living longer lives and generally becoming healthier. Although that is welcome, it presents challenges, because with age come a greater risk of health complications and other health co-morbidities and a greater need for social care support and services.

The Health and Sport Committee is about to start an inquiry into social care in Scotland, and it will be interesting to see how we address many of the issues that we will highlight today. One of the main themes is that, as a society, we must be smarter and better prepared to deal with our ageing population. The evidence suggests that there must be an onus on healthcare professionals to have realistic conversations with people about their retirement, their wishes and their future care needs in order to best support them to stay at home or in a homely setting and to provide the care that best suits their needs.

I am pleased that the joint research that was published by Marie Curie suggests that, by 2040, two thirds of Scots—66 per cent of the population—will die at home, in a care home or in a hospice. That is encouraging. However, there are several steps that we must take to ensure that those projections become reality.

I am pleased that the Scottish Government, local health boards and local authorities are already taking action. Research from a consultation that formed part of the information that was published showed that experts, including clinicians, policy makers, health service managers, academics, social care workers and patients, suggested that, to meet the target of more people dying at home, we must increase and upskill our community health and social care workforce through education but also by valuing care work and recognising caring as an invaluable profession; we must stimulate a public conversation about planning for the future—that is also referred to as anticipatory care planning—and discuss realistic medicine; and we must increase and build on community care capacity through informal carer support and community engagement.

I agree with all of those outcomes, and I am pleased that many actions are already being taken. I will highlight some of the work that is going on across Dumfries and Galloway, in my South Scotland region.

NHS Dumfries and Galloway has several community-based projects that are aimed at educating the public, families of people with complex health needs, carers and individuals about health and social care. In July last year, NHS Dumfries and Galloway and I worked together to provide an event in Stranraer to show people what care is out there for them. We demonstrated a baby box and had Marie Curie and palliative care discussions. That was a great way in which to engage the professionals as well as the public on what care is out there.

Another event is coming up in which anticipatory care planning and power of attorney—which is really important—will be looked at. If we can start to get people to talk about their future wishes, I strongly recommend that we take that work forward.

I know that my time is short. I look forward to hearing members’ contributions and the minister’s response.

13:28  

I, too, thank my colleague Miles Briggs for bringing the debate to the chamber, and giving us the opportunity to discuss a very important and difficult topic. Discussing our mortality is never comfortable. It is my intention to hang around for as long as possible—if only to continue to annoy and occasionally embarrass my children and grandchildren. We all must have our fun.

The report highlights the fact that there will be a significant increase in the number of people who will die outside a hospital setting. We need to consider how we will create a system that will adequately enable that to happen. As has already been mentioned, projections say that two thirds of people will be in that situation.

I accept that, for politicians, 2040 is a world away. To be frank, I say that most of us here cannot see past 2021 and what policies to put in place to ensure electoral success. However, in all our political manoeuvrings and machinations, we need to find the time to consider the bigger picture.

The care home sector already plays a huge role in the care of people who are in their twilight years, but it is under extreme pressure. We are all aware, from our areas, of closures of care homes that put the system under greater strain.

There has also been a fundamental change in how care homes are used. Gone are the days, just a few decades ago, when they were sometimes seen as “granny farms”. These days, people who use care homes tend to enter them later in life and with much more complex health needs. We should recognise the skill set that is now required for care home workers and ensure that staff are upskilled, as the report suggests.

The way in which care homes are funded also needs to be reviewed. I have met several care home operators who are struggling to keep them open. They have very little say in how the homes operate: for example, they are told what they are allowed to charge, and what they receive from the council and the required staffing levels are also controlled. In other words, there is little room for manoeuvre, and with staffing costs now exceeding 80 per cent of budget in many cases, any small change can push them over the edge.

We have to look at the sustainability of the system if we are serious about developing a long-term plan, and we have to recognise that a cost is associated with that. The development of integration joint boards should be a part of an integrated solution, but currently there is little evidence to suggest that that is the case. In fact, the evidence suggests that the system continues to struggle under increasing pressure.

There is also the role of the third sector, including Marie Curie, to consider. I thank it for its extensive work in developing the report that has sparked off this debate. There will have to be an increased role for third sector organisations that offer palliative end-of-life care, but we all know how difficult it is for them to maintain funding for the services that they currently offer, let alone to get funds to expand them. I am sure that we all recognise the incredible work that they do and the care that they take of families and their loved ones as they approach the end of life. The compassionate way in which they deliver the service is a model for how it should be done. We will need to consider how we can enable and support that level of service in the long term, and how the third sector is to be integrated into health solutions.

On delivering that change, Presiding Officer, you will know how passionate I am about developing a health technology system that will support the move towards our taking more of a community care approach. That must be the first step. Without a platform that supports good data in, and good accessible data out, it will be much more difficult to work out an effective solution.

Technology in the home is much talked about, and there have been incredible advances, but adoption of such tech is very slow. Their being able to monitor room temperature remotely, or to know whether the kettle or the TV is switched on, helps people to stay longer in their homes. Wearable technology can feed back in real time much health data that currently requires a trip to the general practitioner, hospital or even residential care.

This is a complex issue for which there is no magic bullet, but I believe that the solutions are all there. We must just have the resolve and the courage to make the changes. If we do not start planning for what is detailed in the Marie Curie report, we will sleepwalk into a healthcare crisis that will be very difficult to get out of.

13:33  

I also congratulate Miles Briggs on securing this afternoon’s important debate, and on the quality of his opening speech. I echo his comments congratulating the work of Marie Curie and its staff, some of whom are in the gallery.

The issue has long interested me. It has fundamental public health implications for Scotland. Being able to die at home is, in my view, a basic human right that accords with the European convention on human rights.

Parliament has rightly been praised for its legacy of policies on matters including free personal care, the smoking ban and minimum unit pricing for alcohol. A right to die at home could join that illustrious group of legacy policies that parliamentarians and constituents of the future could look back on with pride.

In a recent Marie Curie opinion poll of Scots, 61 per cent said that they would prefer to die at home. In my region—the Highlands and Islands—many GPs who are trained in palliative care support that wish.

Does David Stewart also accept that a significant number of people want to be in a care home but are being forced to stay at home?

I certainly agree. The shorthand that I used was “die at home”, but I would extend that to include community resources including care homes.

Dying Matters, which is an English and Welsh consortium, shows that about 70 per cent of people would prefer to die at home, but about 50 per cent of people with terminal illnesses die in hospital.

We all know that more and more people are living longer, and with increasingly complex conditions. It is estimated nationally that about 44 per cent of adults in the last year of life have multiple long-term conditions

I was interested to read the Marie Curie briefing earlier this morning, which makes it clear that

“without substantial investment in community-based care including care home capacity. Without this investment hospital deaths could rise to 37,089 (57%) of all deaths by 2040.”

I have been working closely with Shetland GP Susan Bowie, who recently raised with me her concern about the gap in hospital-at-home care for patients, and I have received similar reports from other concerned front-line practitioners from across my Highlands and Islands region. Shetland currently has no charities or carers providing hospital-at-home care. Other areas might be in the same position, especially rural and remote areas.

Dr Bowie told me that, previously, when someone wished to die at home, she was able to organise volunteer help for families in caring for their relatives, because children often find it difficult to take care of their parents’ personal needs. A list of trained people would be available to help occasionally if required, and to give relatives a break. It was a great low-cost service. However, that service in Shetland was closed years ago. Social care could not fill the gap, so carers are not available at night or at weekends.

In fairness, the situation has moved on. I spoke to the Cabinet Secretary for Health and Sport, who told me that the current model of on-call nursing in Shetland is to be extended to a waking night service, which will start this year. That service uses advanced nurse practitioners alongside care staff to support people in the community. However, despite reassurances to the contrary from Shetland IJB, I hear that there are still not enough carers and nurses, especially during weekends and evenings. The situation can only get worse with an ageing Highlands and Islands population.

I agree with Marie Curie that care of terminally ill people must be given higher priority, and that there must be more sustainable support services. As the motion rightly says, a public debate on death, dying and bereavement is also needed. However, we need to shift the balance so that we not only train more carers and nurses to be available to support people who wish to die at home, but make sure that those carers are better paid for the valuable job that they do.

Parents currently have the right to have their child born at home and the national health service provides midwives, but we do not have the right to carers to enable us to die at home. I see a real policy gap, there.

I am very conscious of time, Presiding Officer, and of your very relevant stare.

I say in conclusion that there can be few more important policy areas in health than one that provides certainty to people who are suffering from terminal conditions, and which gives them choice about their place of death and the ability to spend their last days and hours at home with loved ones, rather than in hospital with strangers.

I think that I will stare at Mr Cole-Hamilton before he starts.

13:38  

I, too, thank Miles Briggs for bringing the debate before Parliament today. I also thank Marie Curie, and particularly its nurses, who have touched my own life at a time of great sadness, as they have touched the lives of many members in the chamber.

In his book “Being Mortal”, Atul Gawande describes human life as a story that is defined by its key moments and the sum of its parts—not the day-to-day balance of pain and pleasure or success and defeat. As with all good stories, the ending matters. He writes:

“It is not death that the very old tell me they fear. It is what happens short of death—losing their hearing, their memory, their best friends, their way of life ... ‘Old age is a continuous series of losses.’”

The debate speaks to the heart of that reality. In general, people want things on their own terms in life, right up to the end. We live lives filled with choices of our own design, and yet, in our society, the choices that are available to us begin to evaporate as we near death, particularly if we have not had the conversations that Marie Curie is so rightly asking each of us to have with our loved ones.

That is why talking about the end of life matters and why I am very grateful to Marie Curie for building this campaign. Without an expression of will, the families around those who are dying will take difficult decisions that are based in the moment and shrouded in fear and in grief, which are not always to the benefit of the person who is actually dying.

Medicine has traditionally capitulated with that. Until recently, clinicians focused on what they could do to fix the failing body in the final weeks and months of life, and decisions were disproportionately weighted to the wishes of the surviving relatives. One more intervention might prolong a person’s life for a couple of weeks, but that often comes at the expense of a person’s comfort, dignity and even their own wishes as to where they die.

In every case, death is an enemy that will inevitably prevail and, as Gawande puts it, in that final battle:

“You don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knows how to fight for territory that can be won and how to surrender it when it can’t, someone who understands that the damage is greatest if all you do is battle to the bitter end”.

That is finally being recognised in the realistic medicine agenda, which has been authored and promoted by Scotland’s chief medical officer, Dr Catherine Calderwood. It recognises that when confronted with the reality of the situation, end-of-life clinicians often choose one course of action for themselves and another for their patients. Realistic medicine encourages doctors and surgeons to treat their patients as adults and to credit them with the maturity to understand the reality and the finality of their situation. With that knowledge, a surprising number of patients will choose to stop treatment; instead, they will take a palliative care package and go home. The problem is that, by necessity, those life-extending interventions have to take place in an intensive clinical setting, but given the choice a significant majority of Scots would choose to die at home. However, less than a third of people are currently afforded that luxury.

Where people die really matters. A great deal of empirical academic evidence shows that being allowed to die at home eases not only the suffering of the person who is dying; it eases the suffering, and the bereavement process, of those around them. Those who are surveyed six months after a family member has died at home report that their mood is better, they are less likely to be prone to bouts of significant depression and they have been able to move on with a certain amount of closure that is attached to the belief that they granted their family member their wishes at the end of their life.

This is about those conversations. Marie Curie is putting that challenge to us in its campaign, and our answer to that is really important. The debate speaks to that, because we need to front load investment in social care if we are to properly answer the question. We know that there is a social care crisis in our society. It causes an interruption in flow throughout the national health service and things will get worse, given that the death rate will increase by 16 per cent in a very short period of time.

We need to provide support to those who give care to people who are at the end of their life. We need to make people understand that it can be a tremendously rewarding profession that is shaped by moments of poignancy and unexpected joy. We need to ensure that they are well rewarded and properly supported by armies of volunteers. The chamber often focuses on every aspect of life’s journey, but seldom looks at its end. With helpful interventions—like that of Marie Curie and the research that it carries out, and this afternoon’s debate in the name of Miles Briggs—we can go some way to remedying that.

13:43  

As a fellow deputy convener of the cross-party group in the Scottish Parliament on palliative care, I congratulate Miles Briggs on bringing the debate to the chamber. I have a very strong interest in the issue. He was right to say that the subject might not be cheery, but it is a necessary subject because it deals with life’s greatest certainty—the fact that it will end. Although we have no say on how we come into this world, we should strive to afford as much agency as possible to individuals to decide on how and where they leave it.

Miles Briggs spoke of the pressures that are faced by front-line health professionals. That is a debate that often occurs in the Parliament, across a range of areas. One of the pieces of work that I found ahead of this debate was an evaluation of the Marie Curie nursing service in England, which found

“evidence of lower total care costs for someone receiving the service compared to a similar individual in receipt of usual end-of-life care”.

Healthcare savings of around £500 per person were identified. Extrapolating from those figures, that could result in annual savings of around £4.2 million in Scotland—money that could then be redirected. There is promising evidence that shows that palliative care interventions are cost effective but also that they also have improved outcomes such as reduced symptom burden and an increase in people dying in their preferred place. As a consequence, there could be reductions in acute care costs and pressures.

One of the issues that needs to be wrestled with in relation to the issues that have been highlighted in the debate is data and ensuring that there is good data available to drive the policy decisions that are made. The national survey of bereaved people in England contributes a considerable amount of evidence, which was used in a review that was conducted by the London School of Economics and Marie Curie. However, no similar survey is undertaken in Wales, Northern Ireland or Scotland, which potentially presents gaps in evidence bases for the devolved nations. Has the minister considered seeking to extend the survey to Scotland or conducting a survey of our own in Scotland, in order to capture some of the rich data that can be used to improve service provision?

Similarly, the minimum data set for specialist palliative care services was another important source of data for the LSE and Marie Curie review, but it provides data only across England, Wales and Northern Ireland and no similar data is currently available in Scotland. I recently asked the minister about the Scottish research forum for palliative and end-of-life care, which has not met since early 2018. Although the minister said that he hopes that the forum will meet early in 2020, I would be grateful if he could update members in the chamber on that. It is important that the research in relation to palliative care keeps pace and drives the improvements in care that we want to see, to meet the aspirations that have been highlighted in the Marie Curie research.

I will highlight a final issue, which is the role of carers—not only paid-for carers, but members of the family who take up the caring role. The LSE review highlighted that having a carer who lived with the patient was the single most important factor associated with home death, whereas living alone or being unmarried increased the likelihood of a hospital death. The number of over-70s who are living on their own is projected to increase significantly, which could lead to pressure on community services and increase the number of people dying in hospital or care home settings.

I will highlight two examples from my constituency case load, both of which relate to individuals with motor neurone disease. The first, H, was admitted to hospital at the age of 81 for a percutaneous endoscopic gastrostomy procedure due to unsafe swallow. They were ready to return home for several weeks and the family was receiving support from MND Scotland. However, due to difficulty in sourcing care providers in the area, the suitable package could not be delivered; as a result, the patient became too weak and frail to get home, and died in the hospital setting.

The second constituent is Olive Mavor. I spoke to her husband and he gave me permission to mention her case in the chamber today. Olive Mavor was admitted to hospital for a PEG procedure but deteriorated and required a full-body hoist and breathing support. She remained in an acute ward for eight weeks, despite being deemed medically fit for discharge, due to a lack of carers being available to allow her to return home. It was only because her husband agreed to take on one of the caring roles alongside the carer who was being provided by the health and social care partnership that she was able to return home and die there.

There is a contrast between the two cases: one individual did not have somebody to fulfil the caring role at home and thus died at hospital, while the other individual, simply because they had someone at home who was willing to fulfil the role, was able to die at home. That inequity needs to be addressed. We need to ensure that if people wish to leave the hospital setting and die at home surrounded by family and loved ones, the services are in place to enable them to do so.

13:38  

On behalf of the Scottish Government, I thank Marie Curie, the University of Edinburgh and King’s College London for publishing the important research. I add my welcome to the representatives who are in the chamber.

I also thank Miles Briggs for lodging the motion and colleagues across the chamber for their thoughtful contributions.

As Miles Briggs and other members have highlighted, the research states that if current trends in where people die continue, by 2040, two thirds of all Scots could die in a homely setting, whether at home, in a care home or in a hospice. As David Stewart said, that is the preferred option of most people. I thank Alex Cole-Hamilton for his very thoughtful contribution that put into context the reasons why that is the choice that many people would make and the benefits of their doing so.

The research also suggests that, if current trends continue, more investment will be needed to ensure that people get care in a homely setting rather than in hospital.

Those messages are striking and make clear the challenges that we face in delivering care and support that meet the needs of our changing population. However, we are well equipped to meet those challenges. Scotland is already recognised as a world leader in the field, and delivering high-quality and person-centred palliative and end-of-life care has long been a Scottish Government priority.

I am proud of the progress that we have made over the past few years under the auspices of our “Strategic Framework for Action on Palliative and End of Life Care 2016-2021”. More specialist staff are in post, which has improved access to services in a homely setting. Through our programme of health and social care integration, we have been putting services under the control of integration authorities, which are working closely with professionals, clinicians and local communities. Through that work, people enjoy greater choice and control over their care. As a result, pressure on NHS acute care units has been reduced, families and carers are better supported and, most important, the people who can benefit from palliative and end-of-life care are increasingly accessing it.

However, as the research illustrates, there is more to do. As Miles Briggs mentioned, our “Strategic Framework for Action on Palliative and End of Life Care” makes clear our ambition that, by the end of 2021, those who would benefit from palliative and end-of-life care will have access to it. To achieve that vision, it is essential that we focus on creating the right conditions nationally to support integration authorities in working with a range of partners in the planning of local palliative and end-of-life care services. Integration authorities are working with local communities and building on the expertise of organisations such as Marie Curie to commission services that are truly designed to meet the palliative and end-of-life care needs of their local communities. By commissioning services in that way, improvements will be driven through meaningful collaboration and partnerships with the palliative and end-of-life care community.

I agree with the contents of the minister’s speech. Is it in the minister’s or the Government’s plans to enshrine in law the right to die in a community setting?

That is an interesting point. I have not given it great consideration but, when Mr Stewart raised it earlier, I wondered whether we should at least consider it. We certainly should consider it.

Our ambition to help to ensure that people get the care that is right for them in a community setting is reflected in our budget this year, which provides investment of more than £700 million to support social care services and speed up the pace of integration. We are on track to deliver our commitment that, by the end of this session of Parliament, more than 50 per cent of front-line NHS spending will be shifted to community health services. I hope that that direction of travel addresses some of the points that Mark McDonald made. I recognise that we are not yet where we want to be, but I hope that we are on a trajectory.

I absolutely hear what the minister says, but does he accept that part of the issue in the points that I highlighted is that, for a number of conditions, the increased complexity and the increased lifespan of individuals living with them mean that it will be difficult to commission services from the current models, so we need to think about different models of commissioning?

That is true, which is why it is important that the work is being driven on a community basis and through partnership. Mr McDonald mentioned the survey that happens elsewhere. I will certainly consider whether it would be appropriate or helpful for us to ask for that survey to be extended to Scotland or to do it ourselves.

Miles Briggs mentioned hospices. The research touches on the vital role of hospices and care homes in delivering palliative and end-of-life care. Hospices have long been recognised as exemplars in the field and, now more than ever, they are developing their services to support the needs of local communities. It is important that hospices are supported in that vital work. That is why we supported the development of the memorandum of understanding between independent hospices and integration authorities. A central tenet of the memorandum is to establish effective reciprocal relationships between integration authorities and hospices. It is envisaged that the approach will help to provide sustainability for hospice services as well as supporting integration authorities in meeting their duty to make the best use of local assets in providing sustainable and high-quality services for their local populations.

That work has concluded at a national level. However, timescales associated with local adoption of the memorandums are expected to vary, depending on the existing arrangements between individual hospices and integration authorities. [Interruption.]

I ask members who are coming into the chamber for the next item of business to have respect for the debate that is going on.

As Emma Harper noted, having a highly trained and valued health and social care workforce is key to the success of delivering palliative and end-of-life care, particularly in care homes and care-at-home services. In April 2018, we published a new palliative and end-of-life care education framework that can be used in all health and social care settings to support staff who care for people with palliative and end-of-life care needs in their professional development. The Scottish Social Services Council and NHS Education Scotland are taking forward work to embed that across Scotland.

Brian Whittle and others talked about the importance of care homes, and we should also remember the importance of care-at-home services. We want to support people to stay at home or in a homely setting for as long as possible near the end of their life, but the role of care homes and care-at-home services in doing that is often not recognised. It is only by providing more palliative and end-of-life care to people in a homely setting that we will be able to meet the care needs of our ageing population. Integration authorities are already making great strides in that area, and many are undertaking work to review their care-at-home services and structures to help ensure that they meet local needs now and in the future.

I am optimistic that, through the work that I have outlined, we will be able to bring about further transformative change in palliative, end-of-life and community care. I look forward to working with Marie Curie on that shared aim for many years to come.

13:57 Meeting suspended.  

14:00 On resuming—