The St Margaret of Scotland Hospice is the biggest hospice in Scotland. It opened in Clydebank in 1950 as a non-denominational unit which has developed into a facility with 60 beds – 30 continuing care beds for frail adult patients who require ongoing complex medical and nursing care and 30 palliative care beds. The hospice believes these two types of provision are complementary - the same qualified nursing staff provide care for both groups of patients. Both relatives and patients are extremely satisfied with the care provided by St Margaret’s.
In 2000 Greater Glasgow Health Board consulted on proposals for a new facility on the site of the former Blawarthill hospital. This followed pressure from Glasgow City Council and local residents concerned about the entire site at Blawarthill being sold to housing developers and commitments regarding Blawarthill given during the consultation on an earlier closure at Knightswood. The proposal put forward for the new facility at Blawarthill referred to ‘a number of NHS beds for the frail elderly and elderly mentally ill people but also social care beds and other services’. This was in line with ‘current thinking on elderly services i.e. not creating stand-alone new NHS continuing care facilities’ (Board paper 2000/126). There was no indication at that stage that any decision in connection with specialist care provision at Blawarthill would impact on provision at St Margaret’s.
Subsequently, a study of need for elderly care was commissioned. The Glasgow Joint Community Care Committee published the findings from this study in the ‘Balance of Care’ report in 2005. The report argues that there is a reduced need for NHS continuing care beds (i.e. for the type of frail elderly patients cared for by St Margaret’s) and increased need for other forms of residential care including care provided for patients with various forms of dementia. Given the earlier proposal on which the Board had consulted referred both to elderly mentally ill patients and to social care beds and other services, one might have expected these needs would have been reflected in revised plans for Blawarthill. However it was decided to concentrate NHS frail elderly care for the North of Glasgow on three sites, one of which was to be a facility providing 60 NHS continuing care beds at Blawarthill, alongside sheltered housing and residential care. Apart from the Health Board, the partners in this venture were Glasgow City Council, with which the Board shares responsibility for the provision of different forms of residential care, and Southern Cross, which is best known as a specialist provider of residential care.
The new unit at Blawarthill, owned by Southern Cross but staffed by the NHS, is intended to replace previous provision at Blawarthill (to be reduced from 90 to 60 beds), provision at St Margaret’s Hospice (30 beds) and provision at Almond View Nursing Home in Drumchapel which ceased to provide 30 continuing care beds in September 2005. The Health Board has benefited from the sale of surplus land and Southern Cross, which owns Almond View, were able to retain an income stream as owner of the new Blawarthill facility. As indicated earlier, there had been no mention of any impact on St Margaret’s Hospice in the formal consultation over the 2000 proposals. According to the Health Board, extant guidance requires public consultation where there is ‘significant service change’ entailing the closure of a hospital site. The Board’s view on the implication of the Balance of Care report was that there was no requirement for a formal consultation despite the very significant impact on existing provision at St Margaret’s
The Health Board has told the Hospice that it (the Board) wants to keep elderly care beds at St Margaret’s – ‘but use them in a different way to meet the changing needs of our older population and ensure we are able to provide the range of services they require’. The evidence base on which the Board is claiming there is a decreasing need for continuing care beds north of the river is highly questionable. The chart produced by the Board in the ‘Balance of Care report shows a reduction in bed numbers from 658 to 390 between 1997 and 2003, with a further reduction to 300 in 2004-05. The closure of the beds at St Margaret’s would see the number reduced to 180 beds in North Glasgow, a level of provision which the Board acknowledges would only be sustainable if the number of delayed discharges continues to fall. Any capacity for patients awaiting discharge will be required to be added to any model otherwise, according to the Board, acute beds will become blocked. The consequences of any removal of ring-fencing from delayed discharge money may invalidate the Board’s assumptions.
The Board’s argument that the need for continuing care beds in North Glasgow is declining at this rate is not reflected in any reduction in demand for the continuing care beds at the Hospice, which has a 100% occupation rate. As shown earlier, the Board could have adapted plans for Blawarthill in line with the evidence generated for the ‘Balance of Care’ report, allowing St Margaret’s to continue unaffected. Instead the Board has intimated to the Board of St Margaret’s that funding for continuing care provision will be phased out, which the Hospice estimates would reduce its income from public funds by £1.2 Million. The Health Board has suggested that amongst alternatives the Hospice should consider are becoming a provider of care for older people with a mental illness or a provider of a care home with nursing.
Either of these options would involve a significant reduction in income from the Health Board, jeopardising the viability of St Margaret’s as an organisation and putting at risk its provision for the terminally ill. The hospice currently has to raise in excess of £30,000 per week to fund provision for terminally ill patients. Unlike other hospices in Scotland it has no financial reserves to draw on and, as we will see later, it receives substantially less per terminally ill patient than some hospices under the current arrangements. The unique ethos of the Hospice is particularly well suited to the needs of continuing care patients who have life-limiting conditions. The changing needs of such patients can be met within the hospice without them having to be moved other than within the hospice itself.
The hospice provides a model of care which is holistic and geared to the needs of the patient, rather than fragmented by the categorisation and medical specialisation that dominates hospital provision. Inspection by the Care Commission has found that the Hospice exceeds the Care Standards and many patients and relatives have drawn very favourable comparisons between the approach adopted at St Margaret’s and their experience elsewhere. The Hospice Board is unwilling to abandon this integrated care model, or be forced to change the skill mix of its staff or to run the risk of altering its ethos in the absence of better planning and a more inclusive approach from the Health Board. Adapting services in the light of changing need patterns should not involve the sacrifice of outstanding care provision for both continuing care and palliative care patients at the St Margaret of Scotland Hospice.
A recent written parliamentary question concerning hospice funding indicates an expectation that the Scottish Government will contribute 50% of the running costs of hospices. However these matched funding arrangements give rise to significant disparities in the amount contributed per patient from the public purse, creating particular problems for St Margaret’s as the largest hospice in Scotland.
Palliative Care
Mary Scanlon (Highlands and Islands) (Con): To ask the Scottish Executive what support it will give to any hospices faced with service cuts in palliative care due to funding shortages. (S3W-2341)
Nicola Sturgeon: Funding arrangements for specialist palliative care provided by independent voluntary hospices in Scotland are set out in HDL (2003)18. This guidance was agreed between Hospices, the NHS and the Scottish Government. Since 1990 there has been a commitment that NHS boards should meet 50% of the agreed running costs of hospices providing specialist palliative care for adults. This 50% target was set so as not to compromise the independence of hospices. It is a matter for individual hospices to agree their funding requirements with their local NHS board.
St Margaret’s has welcomed increased funding from the Health Board resulting from these new arrangements. However the mechanism of meeting 50% of agreed running costs gives rise to very significant disparities in the amount per patient hospices receive. The table overleaf sets out the funding received by different hospices in Scotland in 2005-06. It shows a huge variation in funding per bed and in cost per bed. It is difficult to understand why, for example, St Margaret’s with 30 hospice beds should get less from the Health Board than the Prince and Princess of Wales hospice with 14 beds. It would appear that the current matching arrangements mean that hospices with the highest fundraising income per bed also get the highest contribution from public funds. As the largest hospice in Scotland, located in one of the poorest areas, St Margaret’s is always going to face an uphill struggle because geographically it has a limited funding base.
St Margaret’s has raised concerns about these inequities within the Hospices Forum but those who benefit from current arrangements were reluctant to move away from the 50% formula that works so heavily to the disadvantage of St Margaret’s. It is argued that the current 50% arrangement protects the independence of Hospices. But it is difficult to see how the St Margaret of Scotland Hospice can ever break out of the double bind it finds itself in if this arrangement determines funding levels. Throughout the NHS, funding for health provision is based on a calculation of the cost of providing that service. It seems that for palliative care, the amount received from the public purse is linked to how much the hospice can contribute to the costs of treatment. This seems neither fair nor reasonable and we urge the Committee to investigate, bearing in mind the entrenched interests within the Hospice movement have meant that this issue has not been addressed through normal channels.