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Why we must improve end-of-life care



Professor Keri Thomas outlines the opportunities and challenges for commissioners operating in this sphere and the new tools available to enhance decision-making

‘We are all going to die – so how do you want to do it?'[1] End-of-life care affects every one of us – at a personal level, professionally within health and social care but also as a society. For many of us, care of the dying is a litmus test for our health service and our society. At a human level, we have one chance to get this right.

In 2012 we face a predicted rise of 17 % in the death rate as the post-war baby boomers decline, so there has never been a more important time to face this issue.

This is not just about dying. It is also about living well until you die – and the World-Class Commissioning call to ‘add years to life and life to years’ seems particularly apt in this area. Health service costs in the final stage of life are on the rise. The average cost in the final year of life is £19,000 for a non-cancer patient and £14,000 for a cancer patient.

Unless we improve end-of-life care, we will face unsustainable rising costs that put the rest of our health service in peril.

We know that more people die in hospital than would choose to do so. More than half do not die where they would choose and this is most evident with frail elderly patients, especially from care

homes. For commissioners there is a tantalisingly attractive ‘win-win’ here – we can enable more people to live and die where they choose and improve cost-effectiveness.

The overwhelming conclusion now in commissioning end-of-life care services is that ‘doing nothing is not an option’.

But what is the solution? The Department of Health End-of-Life Care Programme and Strategy [2] made many recommendations and supported three main models of best practice – the Gold Standards Framework (GSF) [3] for care in the final year of life, initially in the community and care homes, the Liverpool Care Pathway for care in the final days initially in hospitals [4], and an example of advance care planning, the Preferred Priorities of Care tool [5] (with campaigns to raise awareness of patient preferences and deliver care accordingly).

The GSF Centre was asked in 2004 to develop a prognostic indicator guidance tool to support QOF palliative care points, to improve identification of patients nearing the end of life and code them according to prognosis and needs [6]. This is now widely used across the country and is integral in care homes and hospitals, with use of needs-support matrices. A key focus of this vision involves improving community services and reducing avoidable hospitalisation, for example through GSF accredited care homes demonstrating a halving of hospital admissions and deaths and improving quality of care.

One way of informing end-of-life care commissioning is using the After Death Analysis Audit as a snapshot survey – the recent National Primary Care Snapshot Audit in End of Life Care run by Omega [7] examined every death in 500 practices during two months of 2008, with fascinating results that have informed commissioners of the 15 PCTs involved.

I therefore commend this edition to you as a clarion call to improve care for people nearing the end of life through better commissioning in your local area. We must keep the bigger picture in mind, but most of all maintain the image of the vulnerable patient facing the end of their life.

It could be a member of your family. It could be you

Professor Keri Thomas is clinical champion for end-of-life-care at the RCGP and honorary professor of end-of-life care at the University of Birmingham

Professor Keri Thomas