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Cicely Saunders Institute statement on Palliative Care and the Long Term Plan for the NHS

The Cicely Saunders Institute has issued the following statement on the NHS Long Term Plan:

Palliative care must be included within new models of integrated care if they are to be effective. Palliative care services offer high value care (better quality and potentially lower costs) for patients where they need to be.

Our population is ageing, and people are increasingly living with multiple long-term conditions and frailty. Integrated care is needed to deliver appropriate and coordinated services, at the right time and in the right place, according to patients’ individual needs and those close to them.

The Long Term Plan for the NHS plan needs to take account of increasing challenges:

  • In England and Wales around 500,000 people die every year; the Office of National Statistics estimates that this will increase by 25% by 2040, with over 130,000 more people dying each year. More than half of these people will be over 85 years of age. This will put unprecedented pressure on already stretched NHS and social care services.
  • Around 20% of NHS costs are spent in the last year of life. NHS costs increase exponentially towards the end of life, with acute hospital care accounting for the majority of this cost.1
  • While people are increasingly dying out of hospital, still around half of all deaths in England occur in hospitals, even though for most people this is their least preferred place.
  • Due to population ageing, Emergency Department attendance for people in the last year of life is projected to increase by an additional 416 000 emergency admissions by 2041.2 In many conditions, Emergency Department attendance near the end of life is increasing over time, meaning that in reality this figure will be considerably higher.3

    The Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation at King’s College London is the pre-eminent centre for research into palliative and end of life care, including research into new models of care and health economic analysis. Our research has identified responses that are and are not successful:
  • While there has been a reversal in the rising trend towards hospital deaths in recent years, this has not affected people who have two or more health conditions (multimorbidity), for whom hospital is the most common place of death.4
  • Specialist palliative care, delivered in people’s homes, significantly reduces the likelihood of dying in hospital.5 People with cancer who receive specialist palliative care are significantly less likely to attend Emergency Departments.6
  • Uncontrolled symptoms result in admission to hospital. But having two home visits from a GP in the last three months of life triples the odds of dying at home; having three or more visits increases the odds more than six times.7
  • However, spending on palliative care in England is highly variable. Some clinical commissioning groups spend as little as £52 per person per year on palliative care.8
  • Only half of Health and Wellbeing Boards include plans to improve palliative or end of life care in their strategies; just 4% prioritise this.9
  • Health economic analyses show that providing palliative care can save costs overall, particularly when provided early.10

    Strong evidence, from the UK and beyond, shows that palliative care is a high value intervention: it improves outcomes for patients and families, at the same or lower overall costs, particularly for people who have the most complex needs.

    Therefore, for the NHS Long Term Plan to be effective, palliative care must be included within models of integrated care for people living with advanced disease and multimorbidity. This will require investment in multi-professional expert palliative care teams in hospitals and the community, working in new and integrated ways with others. There is a strong argument for supporting local demonstration projects to identify the best ways to do this.
  1. Georghiou T, Bardsley M. Exploring the cost of care at the end of life: Nuffield Trust, 2014.
  2. Bone AE, Evans CJ, Higginson IJ. The future of end-of-life care. Lancet (London, England) 2018; 392(10151): 915-6
  3. Sleeman KE, Perera G, Stewart R, Higginson IJ. Predictors of emergency department attendance by people with dementia in their last year of life: Retrospective cohort study using linked clinical and administrative data. Alzheimer's & dementia : the journal of the Alzheimer's Association 2018; 14(1): 20-7.
  4. Higginson IJ, Reilly CC, Bajwah S, Maddocks M, Costantini M, Gao W. Which patients with advanced respiratory disease die in hospital? A 14-year population-based study of trends and associated factors. BMC medicine 2017; 15(1): 19.
  5. Gomes B, Calanzani N, Curiale V, McCrone P, Higginson IJ. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. The Cochrane database of systematic reviews 2013; (6): Cd007760.
  6. Henson LA, Gao W, Higginson IJ, et al. Emergency department attendance by patients with cancer in their last month of life: a systematic review and meta-analysis. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2015; 33(4): 370-6.
  7. Gomes B, Calanzani N, Koffman J, Higginson IJ. Is dying in hospital better than home in incurable cancer and what factors influence this? A population-based study. BMC medicine 2015; 13: 235.        
  8. Lancaster H, Finlay I, Downman M, Dumas J. Commissioning of specialist palliative care services in England. BMJ supportive & palliative care 2018; 8(1): 93-101.
  9. Sleeman KE, Leniz J, Higginson IJ, Bristowe K. Is end-of-life care a priority for policymakers? Qualitative documentary analysis of health care strategies. Palliative medicine 2018; 32(9): 1474-86.
  10. Smith S, Brick A, O'Hara S, Normand C. Evidence on the cost and cost-effectiveness of palliative care: a literature review. Palliative medicine 2014; 28(2): 130-50.

The full statement can be accessed here.