Asked by
To ask Her Majesty’s Government what assessment they have made of
the report by the Care Quality Commission Protect, respect,
connect—decisions about living and dying well during COVID-19,
published on 18 March, on decisions about the use of ‘do not
attempt cardiopulmonary resuscitation’ orders for (1) care home
residents, and (2) people with learning disabilities, during the
pandemic.
The Parliamentary Under-Secretary of State, Department of Health
and Social Care () (Con)
My Lords, the department warmly welcomes the publication of the
CQC report on the use of DNACPR decisions taken during the
Covid-19 pandemic. We are pleased to see examples of good
practice detailed in the report across both health and social
care, but this was not true everywhere, particularly for our most
vulnerable people. That is why the department is committed to
driving forward the delivery of the report’s recommendations and
ultimately ensuring that everyone experiences the compassionate
care that they deserve.
My Lords, this report from the Care Quality Commission highlights
that
“unprecedented pressure on care providers”
and the rapidly developing guidance has led to blanket “do not
attempt cardiopulmonary resuscitation” orders being imposed at a
local level, particularly affecting care home residents and
people with learning disabilities. Failure to consult people
about their care betrays a lack of decency and compassion, but it
is also a human rights violation. I am very grateful to the
Minister for his reassurance about the recommendations, but may I
press him, in particular, to assure the House that the
recommendation of a ministerial oversight group will be
implemented?
(Con)
My Lords, I can absolutely reassure the right reverend Prelate
that the Minister with responsibility for patient safety and
mental health care will be heading the ministerial oversight
group to drive forward progress. The group will bring together a
range of stakeholders across both health and care to ensure that
the recommendations are implemented.
(CB) [V]
My Lords, given the significantly higher number of excess deaths
among people with learning disabilities last year, will the
Minister commit to finding out what proportion of those deaths
were associated with DNACPRs? Does he agree that the use of
blanket DNACPRs for people with learning disabilities is an
indication of the extent of the lack of confidence and competence
among healthcare staff to accommodate their needs, and adds to
the urgent need to introduce the Oliver McGowan mandatory
training currently being piloted? A timetable for the widespread
introduction of that training would be very welcome.
The Lord Privy Seal () (Con)
My Lords, I am afraid that we are having questions that are far
too long. Can people please keep their questions brief?
(Con)
My Lords, we will address the audit points made by the noble
Baroness. I completely endorse the importance of training; that
is at the heart of the report and we acknowledge its importance.
We are concerned about the number of people with learning
disabilities who have died during the pandemic, and there will be
a report on what the connections are.
(Lab)
[V]
My Lords, we know that it is unlawful for DNACPRs to be imposed,
and I wonder why the research has not sought to identify why
physicians and care workers continue to impose them in the way
that they have. Does the Minister agree that the solution must
lie in completely clear, unambiguous policy to advance care
planning and DNACPR decisions, and a consistent use of accessible
language, communication and guidance to enable clear
understanding by commissioners, providers and the public?
(Con)
I will gently push back against the noble Baroness: the policy is
absolutely crystal clear. Blanket DNACPR is not the policy of
this Government, as was repeated time and time again in our
communications, which I would list if I had more time. Training
is the issue: we need to give the front-line workforce the skills
it needs to apply these very delicate but critical interactions.
That is the recommendation of the report, and that is where we
are focused on applying the lessons.
(LD)
My Lords, does the Minister agree with Age UK that the report is
the tip of the iceberg and requires the Government to bring
forward proposals as part of a complete overhaul of the advance
care planning system?
(Con)
No, my Lords, I do not accept that the report is simply the tip
of the iceberg; it is very thorough and goes into the matter
extremely carefully. However, there are important lessons on
training to be learned and they will be driven by the ministerial
oversight group.
(Con)
My Lords, the Care Quality Commission wrote up its findings at
the time of the outbreak of Covid-19, which may have made them
less reliable. A number of factors have served to raise exposure
to decisions on whether or not to accept DNACPRs, and these were
taken for groups rather than individually. Such groups included
individuals suffering with dementia and learning disabilities who
needed briefings that they could understand. The Care Quality
Commission report is about how hospitals, care homes and doctors
should support people to make decisions properly about how to
restart. Are the Government satisfied that the decisions in this
territory are now being taken properly?
(Con)
My Lords, the report is crystal clear that we accept that more
training is needed. Front-line care support workers need to be
given more support in their interactions, and we will be putting
that in place.
(CB)
My Lords, I draw attention to my interests in the register, in
particular the fact that I am a nurse involved with the Outcomes
First Group, which supports people with learning disabilities. In
order to increase the population’s awareness of care planning in
relation to living and dying well, will the Government, in
addition to training, consider incentivising healthcare workers
to ensure that they have sufficient time to undertake proper
assessment of individuals with cognitive impairment and learning
difficulties as part of their routine care planning, which should
be recorded and reviewed at least biannually?
(Con)
The noble Baroness makes a very fair point; such care needs to be
in the work plan particularly of those with learning
difficulties, but of all those in care. We absolutely endorse the
approach taken by the Resuscitation Council, which has extremely
good guidance in this area.
(LD) [V]
My Lords, no one doubts the events described by the right
reverend Prelate and noble Lords. By when can we be confident
that the same could not happen again?
(Con)
My Lords, we could not be moving more quickly. We got the report
out before the end of the pandemic; we have acknowledged the
issue and written numerous letters into the system, as I have
mentioned; and we are putting in place the resources needed to
support the necessary training and interactions. We are taking
this extremely seriously and we are moving as quickly as we
possibly can.
(CB)
[V]
As the Minister has suggested, decisions on end-of-life care are
best taken long before they are necessary, so could he encourage
GPs to offer all patients the opportunity to make an advanced
decision to refuse treatment, properly witnessed by two
individuals, if it is to become effective?
(Con)
The noble Baroness is entirely right, and a growing number of
people do take that kind of pragmatic approach. But we have to be
realistic: many people are not prepared to put those sorts of
arrangements in place until much later on in their lives, and it
is often the family and relatives of those in care who have to be
part of those important conversations.
(Non-Afl)
[V]
My Lords, regardless of Department of Health and Social Care
policy and NHS instructions to clinicians, we know that DNACPR
orders were made without adequate consultation and safeguards.
Can the Minister assure this House that the Government will meet
with families who have raised concerns about DNACPRs as the cause
of deaths? Will he emphatically agree with this House and the
families themselves that senior case reviews should be
undertaken, with a panel of experts, of all cases where families
have raised questions? Will he state categorically again that
DNACPR without consent is—
(Con)
We will now hear from the Minister.
(Con)
I reassure the noble Baroness that there has been a huge amount
of stakeholder engagement, with Mencap, Turning Point and others.
It is not the role of the CQC to do individual family reviews,
but I can reassure her that we have learned important lessons
from this process.
(CB) [V]
Does the Minister agree that the ministerial oversight committee
should also consider looking at end-of-life care?
(Con)
My Lords, yes, I do.
(CB)
[V]
My Lords, I should declare my interest as chair of Dignity in
Dying. What plans do the Government have to increase dramatically
the numbers of people who have advanced decisions expressing
their views on medical treatment? Does the Minister agree that
patients’ wishes should be central to DNACPR decisions, and
indeed to all significant medical decisions, particularly at the
end of life?
(Con)
My Lords, we absolutely agree. That is exactly how the guidelines
are written and exactly the guidance sent into the system. The
issue we face is much more pastoral in nature: it is one of
training and creating the space and resources necessary to have
extremely difficult conversations. That is the kind of front-line
support we need to put in place. It is a question of patient
engagement rather than a change of guidelines, but I completely
take on board the noble Baroness’s recommendations.
