Postcode lottery in end-of-life care

The proportion of people who die in hospital varies hugely across England, figures published today reveal.

While 45% of deaths in Torbay, Devon, were in hospital, in Waltham Forest, east London, the figure was 78%, research by the National End of Life Care Intelligence Network revealed. Nationally, 58% of deaths were in hospital. The figures relate to the period between 2005 and 2007.

Rates of hospital deaths have remained stable over a number of years, the report found, despite longstanding evidence that many people wish to die in their own homes.

Although these variations reflect factors such as age, disease and deprivation, they also underline differences in service provision.

The previous government’s end-of-life care strategy, published in July 2008, was intended to enable more people to die in the place of their choice through improved care planning and co-ordination, rapid access to urgent care and better training.

As part of this, the network was commissioned by the government’s National End of Life Care Programme to collate and analyse existing data on end-of-life care.

Programme director Claire Henry said there were several reasons for the local variations: “It’s about service provision, how we use the voluntary sector, people’s wishes and what family support is around.”

She said the data should be used as a benchmark by local authorities and primary care trusts to identify local needs and ways in which services could be reshaped to give people choice over where they die.

The study found that people in the most deprived 20% of the population had a 62% chance of dying in hospital compared with 55% for the least deprived. NHS Waltham Forest said the high rates of hospital deaths in its area reflected its high level of deprivation.

It also pointed to a specialist palliative care service in one of the borough’s hospitals, Whipps Cross, which offered hospice-style care and accounted for 15% of recorded deaths. “Things are improving in Waltham Forest,” a spokesperson said. “Our latest published figures show that 17.2% of deaths occurred at home in 2008, up from 15.7% in 2007 and we are doing all we can to enable even more people to be at home for their final days rather than in hospital.”

Torbay Care Trust, which has a large elderly population, attributed its low rate of hospital deaths to staff training and the development of services to keep people out of hospital (see below).

Henry said improving communication between professionals across patients’ care pathways towards end of life was key to reducing the number of people dying in hospital, while cultural change across services and society was also needed.

“It has become the norm to die in hospital,” Henry said. “Sometimes people don’t even know dying at home is an option. People need to have that discussion about choice and advanced care planning. That honest openness is a skilled job and I think social workers have those skills.”

Further figures for 2008 and 2009 are expected in the autumn.

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The Torbay model

Training for staff in identifying patients at the end of life and broaching with patients the subject of dying have played a key part in Torbay’s low rate of hospital deaths.

Dr Sonja Manton, the care trust’s general manager for health and social care in Torquay, said the process starts when the patient is admitted.

“We have discharge co-ordinators on all hospital wards who start planning for discharge on the day of admission,” Manton says. “They are there to make sure that person goes home in a timely, safe and effective way.”

Manton also pointed to the establishment of a rapid response team within the care trust, which aims to discharge people to the place where they wish to die and have the appropriate support in their final days.

In the past two years, Torbay has taken further initiatives to improve end-of-life care. The care trust has instituted a four-week training programme for informal carers to prevent breakdowns of care, which cause hospital admissions.

Another strand of work, presently being evaluated, is a training programme for care home staff. This includes an NVQ-style course in end-of-life care and an organisational element to help managers evaluate whether the care home is meeting the aims of the end-of-life care strategy.

“The care homes have really embraced that and we’d like to roll that out to all the care homes in the area,” said Manton

In addition, the care trust’s intermediate care team has had its remit widened to include end-of-life care patients. In these cases, rather than focusing on reablement for the long term, they focus on improving patient’s quality of life in the community for as long as possible.

HOSPITAL DEATHS: HIGHEST AND LOWEST

Five local authorities with the lowest percentage of deaths in hospital (2005-7)

Torbay 45

Penwith 46

Plymouth 46

South Norfolk 46

Chichester 46

Five local authorities with the highest percentage of deaths in hospital (2005-7)

Waltham Forest 78

Redbridge 72

Ealing 72

Newham 71

Barking and Dagenham 71

Note: All percentages have been rounded up or down to the nearest whole number