End-of-life care across the socio-economic spectrum

Lord Darzi's report on healthcare in London included a brilliant illustration of the impact of socio-economic conditions on health outcomes:  travelling east on the Jubilee line from affluent Westminster to rather less affluent Canning Town, each tube stop represents nearly one year of life expectancy lost.

While the relationship between outcomes and deprivation has been studied extensively in many fields of healthcare, it has received relatively little attention in end-of-life care. 

That is, however, starting to change. 

Last year, the National End of Life Care Intelligence Network published analyses of the relationship between deprivation and place of death. They found that people living in the most deprived areas are more likely to die in hospital (61%) than people living in other areas (54–58%), and are also less likely to die in hospice (4.5%) than people living in the least deprived areas (6.4%). The relationship between deprivation and home / care home deaths was more complex. Given that hospital is very rarely where either the general public or dying patients say they would want to die, this may indicate that patients from more deprived areas are receiving a lower quality of care at the end of life. 

However, place of death will only ever be a limited proxy for a 'good death'. For example, we know that some aspects of patient experience, such as good pain control, are more difficult to achieve in the home environment than in hospital or hospice.  This makes it important to understand not just deprivation's impact on place of death, but also its impact on patient experience. 

The Office for National Statistics recently published further analysis of the 2011 Views of Informal Carers – Evaluation of Services (VOICES) survey, examining the relationship between end-of-life care outcomes recorded by the 22,000 bereaved carers who responded to the survey and the Index of Multiple Deprivation score of the deceased's usual residence. 

They found that the overall standard of care of patients living in most deprived areas was less likely to be rated as excellent than for patients living in the least deprived areas. They also found that patients who lived in the least deprived areas were more likely to be rated as having had enough choice about where they died (54%) compared with those who lived in the most deprived areas (44%). Bereaved relatives were also less likely to report that GPs had always treated the patient with dignity and respect if the patient lived in the most deprived areas (64%), than if they lived in the least deprived areas (77%). 

Reducing health inequalities has long been a goal of the NHS, and these recent publications show the challenge of delivering on the End of Life Care Strategy'scommitment to: 

"…make a step change in access to high quality care for all people approaching the end of life. This should be irrespective of age, gender, ethnicity, religious belief, disability, sexual orientation, diagnosis or socioeconomic deprivation.