Des McNulty MSP

Greater Glasgow and Clyde Health Board have not treated the St Margaret of Scotland Hospice fairly. They carried out a consultation in 2000 over the closure of Blawarthill Hospital in which they were seeking to have the site of Blawarthill released for housing in order to obtain a capital receipt. In response to a local outcry it was agreed that part of the site would be retained for NHS use but at no time was it indicated that this would have any impact on provision at St Margaret’s.

Then in 2005, following a review of care needs, they decided that a reduced number of continuing care beds was needed. Without telling St Margaret’s, they determined that funding for the continuing care beds should be removed from St Margaret’s while taking forward a proposal to build a 60 bed continuing care unit a quarter of a mile away at Blawarthill. The Health Board could have revised its plans for Blawarthill to meet the care needs it had identified but it chose not to.

When the Board finally put its proposals to St Margaret’s, the Hospice Board were understandably furious. Since then there has been a strong local campaign to have the Health Board’s decision reversed. During that time I have raised the matter directly with the Health Board Chief Executive and Chairman, asked Parliamentary questions, secured debating time in the Chamber, met with Nicola Sturgeon the Cabinet Secretary, helped with a petition that secured 110,000 signatures, spoken at demonstrations and taken every step possible to secure the future of St Margaret’s hospice.

In its response to the petition, the Board makes three main points:

• We are committed to funding the palliative care service which St Margaret’s provides.
• We want St Margaret’s to continue to provide care for older people but we have asked them to change the use of these beds to provide urgently needed care places for local authorities.
• Nothing is being asked of St Margaret’s which is any different in objective or nature from what is happening elsewhere in the country and across Greater Glasgow and Clyde.

The reality is that funding for continuing care makes up two thirds of the money the Hospice gets from the Health Board. Palliative care is funded up to 50% of agreed costs so the Hospice has to raise nearly £30,000 a week from charitable donations to keep its much-valued palliative care service going. Removal of the continuing care funding by the Health Board or substantially reducing it the continuing care beds were replaced by nursing home beds would have a devastating impact on the Hospice’s finances.

The Hospice has been asked to consider not only providing nursing care but also to consider providing care for people with mental health problems in place of continuing care. If there is a need for these services in the area, why did the Board not include this provision in its configuration of services at Blawarthill?  The kind of care needed by continuing care patients is very similar to that provided to palliative care patients, indeed many patients could be placed in either category, the difference being whether they have months or weeks to live. It would not be appropriate to put older people who may have years to live, many of whom are mentally alert, in a place dedicated to care for the dying. It is equally difficult to see why the Health Board sees the Hospice as a suitable place to care for people with mental health problems.  If more provision is needed to provide care for this category of patients it would surely be less disruptive to amend the plans for Blawarthill, which have not yet reached the construction stage, rather than impose an unwelcome change on St Margaret’s.

The final claim is the most worrying of all. The Board’s tactics can only be described as bullying. It is to St Margaret’s credit that they have refused to be forced into accepting change that would conflict with the mission of the religious order which established the hospice nearly 60 years ago. The Health Board cannot be allowed to use its control over budgets to squeeze out the charitable sector from providing health care. The Health Board must be made to rethink not just its stance in relation to St Margaret’s but its mode of operation more generally.

In its reply to the petition before the Public Petitions Committee, Greater Glasgow and Clyde Health Board identified eight statements and issues raised by Des McNulty MSP or by members of the Public Petitions Committee at its’ meeting on 12th January, 2010 that they wished to respond to. Read for yourself the Health Board Chief Executive’s responses:

1. NHS Greater Glasgow and Clyde has been “unhelpful” in the way it went about reviewing continuing care provision leading to “tension” between St Margaret’s and Blawarthill.

The original decision to redevelop the Blawarthill Site followed public consultation undertaken in 2000 and the detailed requirements were developed jointly with Glasgow City Council.

The redeveloped site will include 60 NHS beds for frail elderly NHS patients staffed by NHSGGC clinical staff which will directly replace the existing 60 NHS beds at Blawarthill (these beds do not replace or substitute provision at St Margaret’s of Scotland), 60 care home beds for social care, 24 sheltered housing units for Yoker Housing Association and mainstream affordable housing.  There is considerable local community support for this development and it is specifically designed to suit local requirements.

At no point have we ever sought to set St Margaret’s against Blawarthill: it is my understanding that the suggestion that there was some kind of competitive, ‘either-or’ scenario between the two sites originally came from individuals campaigning on behalf of St Margaret’s.  Indeed, we have been at pains to point out that there is no link between the two sites, other than the wider review of service provision for frail elderly patients in response to changing national policy and patient needs that has already seen Blawarthill reduce from 120 to 60 beds.

2. St Margaret’s is looking for “some security to the continuation of the outstanding care it provides” and a “sensible discussion” and not one in which the NHS says “we have made a decision and you have to fit in with it”

It has long been recognised that frail older people are best cared for in community settings.  Additionally, continued efforts between ourselves and local authorities to reduce ‘bed blocking’, where patients remain in NHS beds following successful treatment simply because there is no other place for them to go, have proven effective.  This has driven a reduced requirement for in-patient beds.

NHS Greater Glasgow and Clyde has over the last decade been working closely with private and charitable providers to move away from purchasing continuing care beds.  Our experience of the changeover to new models of care has been very positive and successful: with a range of providers. We have always ensured there is no financial risk to the provider during the changeover period by providing transitional support. Unfortunately in the case of St Margaret’s of Scotland we have not succeeded with that approach.

Emerging trends and models of care define our policies and plans.  Our responsibility to meet patient need and changing demands, require us to change the provision which we commission Put simply, the NHS needs to provide substantially less continuing care beds and that is the justification for our proposals to change the service at St Margaret’s.

However, we along with our partner agencies have tried very hard to generate alternatives that would allow it to adapt to changing circumstances with the least possible disruption – and to provide the very “security” that St Margaret’s are seeking.

Three successive options proposed have been put to St Margaret’s and been rejected. These three options were to provide:-

- care beds without nursing;

- continuing care for older people with mental health problems (such as dementia);

- care beds with nursing support (an option developed between ourselves, Glasgow City, West and East Dunbartonshire Councils).

These options would have given St Margaret’s “security.”

3. It is “extraordinarily difficult” to engage with  NHS Greater Glasgow and Clyde

In November 2009, we wrote to St Margaret’s as follows:

“I would re-iterate our continuing desire to work with St Margaret’s to deliver care to our population.  It is of critical importance to that joint work that your Board concludes which option it prefers in order that detailed implementation planning can begin for transition to St Margaret’s chosen option.  This will need to include workforce and financial issues and how to manage admissions during the transition.

“I would also underline our previous commitment to work with you to identify any additional costs and challenges St Margaret’s may face in the transition period, in order that we can provide any appropriate support.

It is my objective that we reach agreement in principle in early 2010 so that we can jointly announce our new relationship in the spring.

Whilst I have noted your views as expressed in your letter of 8th December, 2008 I would urge that your Board fully consider the options available to you. I would ask that we have confirmation of your preferred option, should the NHS not be in position to expand palliative care provision, as soon as possible.”

St Margaret’s replied in December rejecting our proposed options.

I am clear that this organisation has made every effort to engage with St Margaret’s but while they have attended meetings and provided information on their preferred option  there has been an extreme reluctance to discuss, much less genuinely consider, possible alternatives.

I would refer you to previous correspondence (notably former Chief Executive, Tom Divers’ letters to the Committee of 21st January, 29th July and 10th October,2008 and my own letter of 12th August, 2009) to confirm the extent to which we have tried to engage with St Margaret’s.

4. The petition linked to St Margaret’s is the second largest ever received

Whilst we fully understand the level of public concern about St Margaret’s, we remain disappointed by level of misinformation and misinterpretation that surrounds the issues.  Various assertions have been continually repeated in the media and at community level which do not fully and fairly represent the position.  Clearly, it is very difficult for the NHS, portrayed as working against the interests of spiritually motivated people who are providing care for the dying, to be perceived in a balanced way.  In particular there appears to be a perception that we are intending to ‘shut down’ St Margaret’s hospice services.  We have consistently attempted to make clear that this could not be further from the truth.

5. This is a “significant change in provision” and the Cabinet Secretary should investigate

In previous correspondence we have set out the much wider process by which we have engaged around the balance of provision for older people’s care.  This has resulted in the rebalance of priorities that we have successfully enacted in partnership with other agencies and other external contractors. We have provided Scottish Government with detailed information on our approach.

6. NHS boundaries have changed as a result of the addition of ‘Clyde’ following the dissolution of NHS Argyll and Clyde – this may ensure a different ‘patient flow’ to St Margaret’s.

The boundaries were redrawn in April 2006 – almost four years ago – and did not materially affect the overriding issues relating to continuing care.  There were already plans in place for NHS continuing care for the former Argyll and Clyde populations. Councils have been involved in developing the options we put to St Margaret’s.

7. NHS Greater Glasgow and Clyde has shown “total disregard” to public concern and families of patients

We need to commission services required by older people and we would like St Margaret’s to remain a part of providing those services, albeit in a different way.  As I have indicated, this is due to wider structural changes in requirements for continuing care services and is not unique to St Margaret’s. In my view we have made every effort to work with St Margaret’s to achieve a solution which offers as secure future.

8. Why is NHS Greater Glasgow and Clyde continuing this decision without “full consideration of the arguments” that St Margaret’s makes?

We have fully considered St Margaret’s argument but we cannot accept a position where a provider seeks to continue to be funded by the NHS for services which are not required by NHS patients, or where a provider seeks to undermine a development in another community in order to retain NHS contracts.

We have made it clear to St Margaret’s, that, although we are unable to continue purchase continuing care for the frail elderly from them, we want them to provide other services to our residents.

We have also confirmed that we would provide the transitional support necessary to effect the change to a new model and, if necessary, meet subsequent additional costs for palliative care.   Contrary to the perception of some, and as I have already stated, our intention is to continue to purchase palliative care from St Margaret’s.

We have no desire to see St Margaret’s close and that is why we have put forward these means by which we can effect a successful transition.  In short, we done our very best to respond to St Margaret’s arguments but we cannot commission services we do not require – but we remain willing to help St Margaret’s to provide services that are needed by older people.

In response to Mr Calderwood, I wrote to the Convenor of the Petitions Committee, Mr Frank McAveety on 19th February 2010:

Dear Mr McAveety,

 I am writing in response to the points raised in Mr Calderwood’s letter to the Petitions Committee regarding the St Margaret of Scotland Hospice petition.  I have consulted with the Hospice in drafting this response, feeling it best that a response should go forward in my name since it referred to comments that I and colleagues had made at the Petitions Committee.  Before dealing with each point in turn, using the same enumeration as Mr Calderwood for ease of reference, I would wish to reiterate my view that St Margaret of Scotland Hospice has never been opposed to the redevelopment of Blawarthill Hospital. The Hospice Board has made it clear that it would be supportive of additional services for the most vulnerable people in our society.  However new provision should not be at the expense of the outstanding continuing care provision at St Margaret’s.

 

1.    It is widely known the consultation regarding Blawarthill took place in 2000.  In this consultation, the Health Board provided 2 options in relation to Blawarthill:

“One option would re-provide the remaining 90 places with some new NHS partnership beds in West Glasgow, matched by a transfer of partnership beds to social care elsewhere in North Glasgow, social care places (including enhanced residential care) and a substantial investment in community outreach services.”

 

“A second, alternative option is to reprovide a higher number of NHS beds but this precludes development of a community outreach team.”

 

The consultation paper states “The first option best meets the needs, issues and service models outlined in the paper.”  In the consultation document there was no reference to a reduction in beds in West Glasgow.  In essence, the public were asked “Do you want Blawarthill to close or stay open?”  The response was that Blawarthill should remain as an NHS facility as the Health Board had already substantially reduced the number of NHS beds with the closure of Knightswood Hospital.  The public were not advised of any impact on St Margaret’s.  St Margaret’s were not advised of any impact on the hospice or requested to respond as an interested party. Furthermore, the consultation was carried out over 10 years ago and by the time Blawarthill is complete, it will be 13 years since the consultation.

 

In his letter, Mr Calderwood states the beds at Blawarthill “do not replace or substitute provision at St Margaret’s”.  The Board has not been consistent or straightforward in stating its position on this matter.  During a meeting at the Hospice in June 2009, when the Hospice staff voiced their concerns over the reduction in Continuing Care beds, Mr Calderwood stated “For frail elderly continuing care, we are not proposing to reduce the service – we are re-providing it”.    When challenged on this point, Mr Calderwood stated “I am sorry if my use of language was imprecise, the Board is reducing the provision of NHS Continuing Care beds by 30”.

 

The description of proposed services for Blawarthill was detailed as “60 NHS beds, 60 care home beds for social care, 24 sheltered housing units for Yoker Housing and mainstream affordable housing.”  When he met hospice staff, Mr Calderwood did not share with them the additional and important piece of information that the contract for the 60 NHS beds will only be for an initial period of 5 years.  This information was subsequently revealed in the ‘Scottish Review’

 

The paper submitted to the Board in December 2000 states “the initial phase of the development of the Blawarthill site would include NHS beds for the frail elderly, social care residential services, day services and acute outreach services.  Additionally, further development may be social care day services, sheltered housing, primary care team developments, accommodation/workshops for voluntary sector groups and mental health services.”

 

It now appears that private residential housing will occupy some of the land which was presumably set aside for accommodation/workshops for voluntary sector groups and mental health services in the original plan.  It is not clear when the decision to “drop” the workshops and mental health services in favour of more private housing was taken.

 

• The discussions which took place involved the Health Board and Glasgow City Council. There was no involvement of elected representatives of the residents of East and West Dunbartonshire
• Mr Calderwood’s comment regarding “individuals campaigning on behalf of St Margaret’s” is inaccurate – no-one representing St Margaret’s or, so far as I am aware, campaigning on its behalf has condemned plans to improve Blawarthill, the argument has been that this should not be at the expense of St Margaret’s
• The evidence on which the decisions regarding the needs of patients is flawed because the Hospice bed figures were never included or considered in the calculations.

 

2.      Whilst some frail older people can and should be cared for in the Community, for many others in-patient care is more appropriate. St Margaret’s has never had a “bed blocking” situation as all patients accommodated have been diagnosed by the relevant consultant as being in need of continuing care.  I am advised that in the last 4 years only  2 patients have been discharged from the NHS continuing care unit at the Hospice because the Hospice was inappropriate for their needs; one patient was discharged to be in the same facility as her husband (who did not meet NHS continuing care criteria and therefore could not be cared for in the Hospice), the other was incorrectly transferred to the Hospice by the Geriatricians.  St Margaret of Scotland Hospice is a genuine NHS continuing care facility and does not have inappropriate patients or voids.

 

Mr Calderwood states “… working closely with private and charitable providers to move away from purchasing continuing care beds”.  What he is not admitting to is that the health Board proposal involves renting the beds from a private organisation for a period of 5 years, at a cost which the Director of Finance is apparently unable to quantify.

 

The three care options offered to the Hospice are inappropriate for the reasons stated on numerous occasions.  St Margaret’s delivers both palliative and continuing care in a Hospice environment. Highly skilled, trained and experienced staff provide care for both categories of patient. Loss of funding consequent on the removal of continuing care beds would enforce the redundancy of key members of staff, jeopardising the quality of provision and indeed the future of the Hospice’s provision of Palliative Care due to the formula used to determine Health Board funding of Palliative Care.

 

3.       Mr Calderwood suggests the Hospice has not genuinely considered any of the options put forward.  If the Hospice had not considered the options, they would not have been able to put forward their very detailed reasons as to why these options are not appropriate.  The Hospice has responded to the proposals put forward by the Health Board in detail and in writing. The Health Board on the other hand has failed even to provide a written acknowledgement of the Hospice’s proposal, hand delivered to the Health Board on 21 October 2008.  The Hospice has had no discussions with the Health Board on this proposal, despite its best efforts, and is awaiting information from the Health Board regarding its viability.

 

4.    Whilst Mr Calderwood notes that the Hospice petition is the second largest ever received, he does not comment on why it is being ignored. “The level of misinformation and misinterpretation that surrounds the issues” – to which Mr Calderwood refers, is in my view, the result of NHSGG&C’s refusal to engage. It is not attributable to “misinformation” provided by the Hospice.

 

The Hospice has never “portrayed the NHS as working against spiritually motivated people.”  Mr Calderwood suggests the NHS has difficulty being “perceived in a balanced way” as a result of the Hospice’s religious foundations.  I find this statement worrying. The St Margaret of Scotland Hospice has delivered care to patients of all denominations and none for the past 60 years.  There has never been any suggestion previously that religion could adversely affect the Hospice’s relationship with the Board- the NHS and St Margaret’s have worked in partnership for the 60 years since the Hospice opened in Clydebank.  The reason the Health Board has struggled with public perception of its decision-making process is because to many people it the removal of 30 beds from St Margaret’s is obviously a wrong decision. 

 It is patients and their families who are important and must be the priority.   Mr Calderwood also takes no cognisance of the comments made by Mr John Wilson regarding the “public concern about an issue which it is directly involved”. 

 

 5.     I will reiterate my plea to the Cabinet Secretary that she should intervene when the Health Board’s treatment of the Hospice is debated in the Scottish Parliament shortly.

 

6.     Mr Calderwood notes that Councils have been involved in developing the options put to the Hospice.  This is confusing given both East and West Dunbartonshire Councils have unanimously approved motions supporting the retention of the 30 NHS continuing care beds.  The Review of Balance of Care report was written in 2004 and only takes cognisance of Glasgow City demographics. West and East Dunbartonshire do not seem to have been involved in these discussions.  By their own admission, the Health Board did not include the figures of St Margaret of Scotland Hospice, instead decided to use a proxy based on Mearnskirk Hospital which is misleading since the Hospice has had 100% occupancy whereas Mearnskirk has been used for delayed discharges.

 

7.     This point has been covered exhaustively in previous correspondence but I would reiterate there is no reason why the Blawarthill development, which is not yet built, could not provide the services the Health Board suggests for St Margaret’s.  In addition, contrary to Mr Calderwood’s view, “every effort to work with St Margaret’s to achieve a solution which offers a secure future” – the Health Board appears unprepared to listen to the Hospice nor work with them.  The Hospice is a Charity and its Mission Statement, Philosophy and Core Values are of caring for the very ill and those with life limiting illness nearing the end of life. The Hospice Memorandum and Articles of Association clearly set out that the Hospice provides Hospice Care.

 

8.    St Margaret’s have never suggested the NHS funds services which are not required by NHS patients.  Clearly the services are required as they are proposed to be provided in Blawarthill.  Please see point 7 above.

 

Mr Calderwood chose not to address in his letter the inequity in Palliative Care funding nor the value for money the Health Board and its predecessor organisations have had over so many years from the St Margaret of Scotland Hospice.  I know that the St Margaret of Scotland Hospice is truly grateful to the Petitions Committee for their consideration of this petition.

Yours sincerely,

 

Des McNulty MSP