Bridging the gap: Acute and community partnerships in end of life care

by David Shaw
Head of Service Development






The separation of health and adult social care services and the organisation of care across the three sectors of the health service (primary, secondary and tertiary), has often led to a lack of service co-ordination and patients experiencing a discontinuity of care - particularly when they are transferred from hospital to home.


The fragmentation between services becomes especially apparent at the end of life, where it is not uncommon for a terminally ill person to spend extended periods of time in hospital, because of a shortage of basic community resources and a lack of discharge co-ordination. In 2007, a National Audit Office examination of patient records in one Primary Care Trust found that 40% of patients who died in a hospital did not have a medical need to be there. Nearly a quarter had been in hospital for over a month.

The National Survey of the Bereaved (VOICES) also highlighted this lack of co-ordination. It asked bereaved carers and family members whether hospital services worked well with GP and other services outside hospital. The ratings were low with only 33% of people responding ‘yes-definitely’.

Although the last few years have seen small gains in the proportion of people who are able to die at home, more than half of all deaths still take place in hospital, with older people and those from deprived areas more likely to die in this setting. Furthermore an ageing population with multiple co-morbidities will exacerbate the challenges facing end of life care.

Recent studies indicate that acute hospitals can realise productivity gains by working collaboratively to reduce admissions, re-admissions and lengths of stay. A study by the King’s Fund highlights that using hospital beds more efficiently could save the NHS at least £1 billion a year and deliver benefits to patients.

However in order for a patient to be transferred out of hospital to a less distressing and expensive setting, other services, including social and community care, must be in place. There is therefore a strong impetus for acute hospitals to consider partnership working with community end of life care providers to realise benefits for themselves and their patients.

Marie Curie is in a unique position to do this. Though the organisation is not an acute trust, or a commissioner, as a charity it can work across systems in order to deliver the best services possible for terminally ill patients and their families. Marie Curie has an ability to shift the balance of care from acute to community settings, improving the quality of care and patient experience, as well as reducing hospital activity.

Marie Curie is currently working in partnership with acute trusts and other partners in Lothian, Liverpool and Glasgow, to deliver a supported discharge model. It is an integrated solution which spans the acute and community, and health and social care sectors. Supported discharge puts a rapid package of care in place to get people at the end of life home. Marie Curie Case Managers (who are Registered Nurses), support the identification and discharge of patients and arrange appropriate packages of care to support seamless transition from hospital to home. Once at home, Marie Curie Health and Personal Care Assistants provide care for patients and their families for a defined period of time, post-discharge, until longer-term care can be provided. Marie Curie is currently in the process of evaluating its partnerships with acute trusts.

Acute hospitals are evidently integral to any whole systems approach to palliative and end of life care. No single component of the system can meet all the challenges alone and ensure that patients receive the best care possible. The answers lie in greater partnership working and the integration of services with the patient at the centre of both service design and delivery. Because of this Marie Curie is also keen to work within wider partnership initiatives; supporting trusts in their potential aims to become the lead provider in End of Life Care.

Joined up services are a priority for terminally ill patients and their carers and as the changes in the NHS come into place, the healthcare community must work collaboratively to ensure that integrated care is not rendered a buzz-word but a reality at the end of life.

This post first appeared on the commissioning.GP blog on Tuesday March 12.