End of life fast track care is a postcode lottery

Hospitals provide excellent care, but they are not always the best place for people to be cared for at the end of their lives. Research shows just 7 per cent of us say we would wish to die in a hospital setting, with more than two-thirds saying they would prefer to die in their own home.

Fast Track Continuing Healthcare funding is crucial in enabling people at the end of their lives to be discharged from hospital, or to avoid a hospital admission. Often it is the key factor that enables somebody to be cared for at home or in the community in their final days and die in the place they wish to.

A new report by end of life charity Marie Curie has found that, during the 2019-20 financial year — on the eve of the covid-19 pandemic — more than half of English clinical commissioning groups were not meeting the 48-hour standard for delivering Fast Track CHC packages set out in the national framework, on average. For the fourth year, our research found significant variation in the speed at which CCGs were putting Fast Track CHC in place, with delays often leading to CHC not being put in place at all.

These are not simply process failures leading to missed targets. Behind each of the statistics in our report, No time to wait, is a family who’s loved one faced long delays before they could leave hospital at the end of their life. Many will ultimately have become too unwell to be discharged and died in hospital when that was not their wish; we know that despite most people’s preference to die at home, around half ultimately die in hospital. This not only causes avoidable distress to people in their final days but can cause significant distress for their families, knowing their loved one was not in the right place for them at the end of their life.

Many of these people could have been cared for at home or elsewhere had the right care been available in the community for them to leave hospital. Fast Track CHC should enable this, but the data shows in some parts of England it is failing to do so for many patients.

Despite overall improvements across England since our first report in 2017 — with the most significant delays of more than 10 days becoming a rarity — only 46 per cent of CCGs told us they were meeting the 48-hour standard. We have continued to observe a “postcode lottery” across the country, with patients in some areas facing far longer waits than those in others before they can expect to have Fast Track CHC in place and be able to leave hospital.

The data in this report concludes at the outset of the covid-19 pandemic. During the first months of the crisis, significant changes were introduced to CHC to support prompt discharge from hospital — allowing patients to be discharged without a CHC assessment and with the NHS fully-funding all new CHC packages until September 2020.

These changes greatly improved the speed at which patients were able to leave hospital and begin receiving care at home or in the community. The data in this report underlines that, as England emerges from covid-19 lockdowns, we cannot return to the situation in place on the eve of the pandemic — with many patients facing long delays before they could be discharged at the end of their lives and too many unable to leave at all.

The emergency measures put into place at the outset of the pandemic show it is possible for CHC packages to be put into place very quickly — sometimes within hours — when sufficient focus and priority are placed on doing so, and resources are made available to deliver the care patients need. While emergency funding provisions cannot remain in place indefinitely, we welcome proposals in the recent health and care white paper to allow CHC assessments to take place after patients have been discharged.

We also recommend CCGs take steps to improve their delivery of Fast Track CHC — by improving staff training and sharing best practice — and that commissioners ensure that the community services people rely on after they are discharged from hospital are adequately funded in future.

With three-quarters of us likely to need palliative care at the end of our lives, it is vital we address these issues now. Most of us would not wish to end our lives in hospital if given the choice. Fixing the problems in Fast Track CHC is an urgent and necessary step towards ensuring more people are able to die in the place of their choosing in future.