Helen Mooney on addressing the 40 per cent of patients who die in hospital with no medical need to be there
The figures are telling: according to the latest mortality numbers from the Office for National Statistics more than half of all deaths still take place in hospital. This is despite the fact that, when asked, nearly two thirds of the general population say they would like to die at home and nearly a third would like to die in a hospice. Perhaps even more shocking is the fact that in some areas 69 per cent of people die in hospital.
The government’s end of life care strategy published in 2008 stresses that, wherever possible, people should be able to “spend their last days in the place of their choosing”.
There is also no question that someone dying in hospital is more expensive for the NHS than the same person dying in a community setting.
‘One thing that is different about end of life care is that time is limited and if services are not provided quickly enough people will die waiting’
Hospital care for those in their last year of life costs the health service around £3.7bn a year with each patient using around 30 bed days. So why can’t the NHS manage to move more dying people out of hospital and back home or into a community setting before they die, or indeed keep them out of hospital in the first place?
As with many things in the NHS the issues are numerous, yet the main sticking points are often the same across local systems. First, frequently there are not the staff in place to facilitate a co-ordinated and swift approach to hospital discharge and to getting a patient back home and, second, the fear is that if a patient is discharged to primary and community care, services will not in any case be able to adequately meet their needs.
Dawn Tame-Battell is assistant director of patient services at Marie Curie, which has been in vanguard of driving local programmes to allow more patients to die where they choose.
She says that professionals involved in end of life care have a very similar idea about what an integrated end of life care pathway should look like but that the challenge is making it a reality.
“The challenge is about getting the different elements required to provide the right care efficiently and effectively and in a way that responds to patient need.
“It is about how you pull services together around the patient. However, one thing that is different about end of life care is that time is limited and if services are not provided quickly enough people will die waiting.”
She is optimistic that the changing commissioning landscape: the birth of clinical commissioning groups promises to drive more integrated working around end of life care and, if palliative care funding pilots result in a per-patient tariff, providers will in any case be forced to work in a more integrated way.
“CCGs and commissioning support units will have much less capacity [than PCTs] and they will be pushed to buy bundles of services as they won’t have the bandwidth to commission lots of bits and pieces of end of life care,” Ms Tame-Battell explains.
The numbers say it all. A recent study by the King’s Fund highlights that using hospital beds more efficiently could save the NHS at least £1bn a year and deliver benefits to patients.
And a 2007 National Audit Office analysis of patient records in one PCT found that 40 per cent of patients who died in hospital did not have a medical need to be there. Nearly a quarter had been in hospital for over a month.
Ms Tame-Battell says that one of the main barriers to effective locally integrated end of life care pathways is the fact that budgets and resources are in still in “silos”.
“People often still approach it from the view of disparate organisations,” she says.
“We have to move care from acute to community settings and hospitals will have to surrender resources.
“This is about joining together all providers and bringing together their resources and knowledge to create the same view of this which transcends ‘our bit or your bit’… Let’s start acting as if we are a consortium.”
Joining up the gaps
Ms Tame-Battell says that Marie Curie feels that it can offer the necessary expertise and project management skills to commissioners of end of life care programmes to join up the gaps and work across boundaries so that patients do have a choice about where they die.
A recent Nuffield Trust study examined the hospital use and place of death of over 30,000 patients who had used Marie Curie’s nursing service.
It found that patients using the service were more than twice as likely to die at home and the rate of emergency admissions and A&E attendances was just one third of those not using the service.
Marie Curie has also developed a scheme - the Delivering Choice Programme (DCP) - working across 19 UK sites, to develop its expertise in end of life care service design.
Ms Tame-Battell says that, through DCP, Marie Curie has built up the knowledge and understanding of what it takes to bridge traditional boundaries and work in partnership with different and often disparate organisations to achieve better outcomes for dying patients.
She says the DCP helps both commissioners and providers to develop a range of coordinated services for palliative care patients.
These can include 24-hour crisis care and effective case management and coordination so that the right services are in place, especially in the community, when patients and carers need them.
“One of things we do is act as the catalyst; to get an integrated programme in place a catalyst, or experienced and skilled project manager, is needed.”
One thing is certain: with budgets already stretched to breaking point, it seems almost impossible that current models of end of life can cope with the predicted 17 per cent rise in deaths in any one year from now to 2030. Something has to change.
Dawn Tame-Battell on joining up services
Too often patients spend their final days in hospital. Indeed 89 per cent of those who die in hospital do so following an emergency admission. However, as a National Audit Office report found, in one NHS trust 40 per cent of those who died in hospital had no medical need to be there. Furthermore the majority of people would prefer to die at home.
Hospital is one of the most expensive places to care for someone at the end of life, with final year hospital care costing the NHS £3.7bn a year. However faced with £20bn efficiency savings and a forecast rise in mortality rates, the healthcare system cannot continue to function as it does at the moment.
‘The Nuffield Trust report found total hospital costs for those who received MCNS care were £1,140 per person lower than for matched controls’
There are viable alternatives to hospital care. Shifting care from acute to community settings offers positive outcomes. There are two elements to this.
First it is essential that services are integrated and joined up, with the patient at the centre of both service design and delivery. The evaluation of Marie Curie’s Delivering Choice Programme in Somerset found that those receiving an intervention were 80 per cent less likely to die in hospital compared to those who did not receive care from Delivering Choice.
Furthermore emergency admissions to hospital in the last month of life were 39 per cent lower and A&E attendances 34 per cent lower for Delivering Choice service users.
Second, there need to be sufficient community services in place. A recent Nuffield Trust report on the Marie Curie Nursing Service (MCNS) found that home-based palliative care can improve care at the end of life. The study found that 77 per cent of those who received MCNS care died at home and 8 per cent died in hospital. In contrast, 35 per cent of a matched control group died at home and 42 per cent died in hospital.
There is less consensus on the financial implications of shifting care from the acute to community setting. We are confident that if this is done at scale, savings can be made. The Nuffield Trust report found total hospital costs for those who received MCNS care were £1,140 per person lower than for matched controls.
The challenges facing the healthcare system are vast but we know transformational change can be achieved through good integrated service design. For end of life patients the solutions are available; it is not what we do but how we do it that will be the test.
Dawn Tame-Battell is assistant director of patient services at Marie Curie Cancer Care.