Why do we need to improve care of the dying?
Dr Katherine Sleeman [pictured], National Institute for Health Research (NIIHR) Clinician Scientist and Honorary Consultant in Palliative Medicine at the Cicely Saunders Institute at King's College London, explains why improving provision of palliative care will improve value in our healthcare system.
The demographics of dying are changing and we are facing a crisis. We are living longer, but dying slower and with greater complexity as we survive for long enough to accumulate multiple health problems.
Future projections are sobering: the number of people who die each year is projected to increase by 25% over the next 20 years. There are currently around half a million deaths each year in England and Wales, by 2040 there will be an additional 130,000 people dying each year, most of whom will have palliative care needs. How we care for these people as they approach death is one of the biggest challenges our society, let alone our NHS, faces.
Part of the reason this is such a big challenge is that care for people who are dying takes a lot of resource. It’s estimated that around 20% of NHS resources are spent on treatments in the last year of patients’ lives. Costs of care increase exponentially towards death, with acute hospital care accounting for most of this increase.
We know that most people, if faced with a terminal illness, would prefer to die in their own home. While home deaths have risen over the past decade, still around 50% of people die in hospital. What’s more, other indicators of potentially aggressive end of life care, such as Emergency Department attendance in the last year of life, have gone up.
Shifting the focus
Shifting the focus of care for dying people away from the acute hospital setting and into the community would potentially have the dual benefit of improving quality of end of life care for patients, and reducing costs for the NHS. But how can this be achieved?
Palliative care is the total holistic care of people living with life-limiting illnesses, where the focus is on improving the quality of life for that person and their carers.
There is now strong evidence that specialist palliative care is associated with better outcomes for patients and carers. Patients who receive palliative care have improved quality of life and better symptom burden, they are more likely to die at home, and less likely to attend the Emergency Department in their final months of life.
Good for individuals and the healthcare system
So, palliative care is better for patients. But what about the system?
The value of any medical intervention can be defined as a function of improvement in outcomes, offset by any increase in costs. Palliative care may improve outcomes, but what are the resource implications of providing these services?
This is where things get really interesting, because emerging evidence suggests that specialist palliative care can actually be cost saving. The extra expense incurred by having a whole new team involved in patients’ care is offset by the fact that they have less acute (expensive) hospital care.
So, specialist palliative care is one of those rare things in health care: a high value intervention. It is better for patients, and better for the system.
We must improve the provision of palliative care
And yet we know that not everyone who might benefit from palliative care receives it. It’s estimated that around 75% of dying people have palliative care needs, overwhelmingly more than current services can care for. And there are well recognised inequalities in access to specialist palliative care, including based on diagnosis and deprivation.
In light of the projected increase in the number of people who will die over the next decades and the strong evidence for the value of palliative care, the question we must now ask commissioners and policy makers is not why, but why not.
The King's Health Partners Palliative Care Clinical Academic Group hosts the world’s first purpose-built institute of palliative care.