How we can improve our way of death

    22 November 2014

    Of the 500,000 people who die in England each year, about half die in hospital. Many of these people have no clinical need to be there and very few of them want to die in hospital. In fact, 80 per cent of those asked would choose home or a hospice as the place where they’d prefer to spend their last days. It is hardly surprising that most people would opt to die peacefully at home or in the calm environment of a hospice rather than in a busy, often noisy, hospital ward. Indeed there is mounting evidence that the care which a significant number of people receive in hospitals is inadequate. This was highlighted both in Baroness Neuberger’s report on the use of the Liverpool Care Pathway and, more recently, in the National Care of the Dying Audit for Hospitals published earlier this year. These shortcomings in care can be traced to a number of causes, including a lack of relevant palliative care skills among hospital doctors. The truth is that hospitals have a different culture. Their primary objectives are to mend and cure, so it is not surprising that palliative care is not high on their list of priorities. In contrast, palliative care is what hospices are all about. Their sole objective is to ease the difficulties people face as they come to the end of their lives. And they do it wonderfully well. The latest Voices (views of informal carers for the evaluation of services) survey, published earlier this year rated the quality of care provided by hospices as significantly higher than that provided in hospitals — 77 per cent of respondents rated hospice care as excellent. Being shown dignity and respect by staff in the last three months of life was rated highest in hospices of all settings — 89 per cent for hospice doctors and 86 per cent for hospice nurses. So there is a compelling case for trying to reduce the number of people who die in hospital and instead arrange for them to be looked after in a hospice or at home. Indeed, ‘hospice at home’ is the fastest growing area of hospice care and an increasing number of people are benefitting from spending their last days at home while being cared for by their local hospice. This has the added, and considerable, advantage of reducing the burdens with which the NHS is struggling. This is particularly important in the light of the UK’s changing demographics. Our population is aging rapidly with more people living longer, often with multiple, complex health and care needs. The number of people aged 85 and over is expected to double in the next 20 years and the number of centenarians is projected to increase more than eightfold by 2035. The annual number of deaths in the UK is expected to rise by 17 per cent by 2030 and more people will be dying at an older age. So the need to deal with the challenges posed by these developments is increasingly urgent. The government’s stated objective is to ensure that more people are cared for and die in the place of their choosing. How is this to be achieved? Our member hospices across the UK already care for 360,000 people, which includes patients and their families, every year. They do so with limited financial support from the NHS — each hospice, on average, receives only one third of its income from public funds. As a consequence they need to raise £1.8 million a day from charitable sources. The fact that they manage to do this is, in itself, testimony to the high regard in which they are held by their local communities. Yet we believe we can do even more. So Hospice UK, the national umbrella organisation for hospices, is launching a new national programme aimed at reducing the number of people dying unnecessarily in hospital. Our objective is to reduce this number by 50,000 a year. We believe that this will lead to higher quality, better targeted care. It will also greatly improve the patient experience for people at the end of their lives and also help their families deal with their loss. And because the cost of hospice care is so much less than the cost of hospitals, we believe that we could save the NHS £80 million a year. We are keen that this should be a collaborative initiative, and I met with Jeremy Hunt, the Secretary of State for Health, in September to ask him to back a partnership between the NHS and the hospice movement to fund six nationally co-ordinated pilot projects to evaluate the impact of hospice-led interventions in reducing unnecessary deaths in hospital. Individual hospices are already taking steps to achieve this objective in their own areas. In one model of care, St Catherine’s Hospice in Scarborough is piloting four nurse-led end-of-life care beds to help facilitate rapid discharge from Scarborough hospital for patients in their last days of life. This has helped increase patient choice, enabling patients to receive high-quality care in a hospice setting. Woking and Sam Beare Hospices are working with their local hospital — Ashford and St Peter’s NHS Foundation Trust — to increase access to hospice beds for patients who might not traditionally have been considered for referral. The hospice–designated beds are treated like an inpatient transfer from one ward to another, bypassing the usual referral process and all the barriers and delay this can create. This has led to increased access to hospice beds for patients who may not otherwise have been considered for transfer, changing the admissions process and improving awareness of the need for palliative care in the hospital. In addition, some hospices are working closely with care homes to deliver high quality end-of-life care for frail older residents and prevent unnecessary hospital admissions. But these, and other, schemes need to be properly evaluated, which is why we want to set up the pilot schemes so we can test which approach works best. We plan to begin the pilots in April next year and, following evaluation, the scheme could be rolled out nationally in April 2017. The hospice movement is one of the finest jewels in our healthcare crown. But its potential for providing solutions to intractable problems within our wider care system is often overlooked. It is high time we harnessed the sector’s longstanding expertise in end-of-life care and its strong capacity for innovation to make choice a reality for people at the end of their lives and help transform the standard of care they receive across all settings. We in the hospice movement are confident this can be achieved and that in future hospital will become the last resort for people approaching the end of life, not the first.