Identifying dying patients’ preferences can prevent many spending their last days in hospital, says Claire Henry

The place of death for most people over the last century has changed from cottage to cottage hospital and, today, to a large acute hospital.

With the quality, innovation, productivity and prevention agenda, we have the chance to look at whether provision of end of life care is delivering for individuals and families – and in the most efficient way.

Polls consistently show that most of us would prefer to die in a community setting such as our home or a hospice. Yet 58 per cent of people die in hospital; many following admission during the last days of life. Often people have multiple unplanned admissions during the last weeks or months.

Significant variations

The Department of Health review into palliative care funding, being led by Marie Curie Cancer Care chief executive Thomas Hughes-Hallett and paediatrics professor Sir Alan Craft, has as one of its aims the provision of more community-based care for both children and adults so more can remain in their own home (including care homes).

A recent National End of Life Care Intelligence Network report on variations in death and end of life care revealed significant differences in the percentage of hospital deaths between local authority areas. This applied even in neighbouring localities or areas with similar population and socio-economic profiles.

Services commissioned and provided around the six-step pathway set out in the DH’s 2008 End of Life Care Strategy can both improve the care of people approaching the end of life and ensure best use of resources.

The QIPP end of life care workstream is focusing on the first two steps on the pathway set out in the End of Life Care Strategy – identifying people approaching the end of life and planning for their care. The work on the strategy as a whole is critical to success: quality and productivity go hand in hand.

The end of life care pathway emphasises elements such as assessment, advance care planning, early intervention and coordination of care. Such approaches can help put in place the services and support to prevent unplanned hospital admissions and unnecessary treatments that distress individuals and their families and are costly to the NHS.

This means clinicians and managers in hospitals and the community – from both health and social care – working together. This is particularly important at points such as discharge from an acute episode or on diagnosis of the condition and when the patient is reaching the end of life.

The palliative care team at the Royal Liverpool and Broadgreen University Hospitals Trust has developed a rapid discharge home to die pathway. In its first year, 31 patients were discharged home to die with no readmissions – improving care quality and saving 257 bed days.

The pathway allows clinicians to coordinate the rapid discharge home during the last hours or days of a person’s life within a governance and risk framework.

In Oxfordshire, community matron for supportive and palliative care service Liz Clements has also worked effectively to help people receive end of life care (up to their death) in their preferred location.

Funded by NHS Oxfordshire and Sue Ryder Care, the service has been shown to both save money and allow people to die where they wish. Its principal aim is to help people at the end of life manage their symptoms and die in the place of their choice.

In 2008, 49 of the 51 people who identified where they wished to die were able to die in their preferred place.

 An evaluation showed that in 2008 the intensive support Ms Clements provided in the community saved around £41,000 in emergency admissions and a further £23,000 by facilitating discharge from hospital.

Early intervention

Early specialist intervention is also important. A recent US study of cancer patients, published in the New England Journal of Medicine, concluded that those who received palliative care soon after diagnosis reported significant improvements in both quality of life and mood. While generally receiving significantly less aggressive care at the end of life, these patients also had a longer median survival period (11.6 months compared with 8.9 months).

The network is co-ordinating 12 pilots on training in communication skills for workers across health and social care. Its recently published interim report called on commissioners to require specified levels of communications training in all contracts with providers of services for those who might be nearing the end of life – not just specialist palliative care staff.

The report called for local health communities to join with partners in social care and with training providers to conduct a strategic approach to identifying training need and commissioning for that need.

Putting in place systems based on early identification, assessment, advance care planning and co-ordinated services will mean fewer people will die in hospital. They and their families will face fewer emergency hospital visits for sudden acute episodes.

That will be good for the patient and family and save the NHS the cost of emergency admissions and unnecessary or unwanted treatments. QIPP can be used to redress a historical trend towards too many people dying in hospital against their wishes – while making the best use of resources.

Claire Henry is the director of the National End of Life Care Programme.