Waiting times add to A&E pressure for terminally ill people

by Scott Sinclair Policy and Public Affairs Manager Scott Sinclair, Policy and Public Affairs Manager

Sir Bruce Keogh’s report Transforming Urgent and Emergency Care Services in England examines the one of the biggest challenges facing the NHS – the unprecedented use of accident & emergency (A&E) services. These pressures were brought into sharp focus by the fact that  the NHS missed its waiting time target for A&E in the first three months of the year, with 313,000 people waiting more than four hours and some hospitals setting up temporary waiting areas in car parks and store rooms. This was the worst performance by the NHS on waiting times in nine years. Of course, A&E services are vital for terminally ill people and their families. Many people at the end of life experience a crisis and need urgent hospital care.  Around 346,000 people in the last year of life have an emergency admission to hospital, with 9.4 million bed days occupied by people in the last year of life following an emergency admission.

Unnecessary admissions

However, we know from our experience as a provider of palliative and end of life care that not all emergency admissions of terminally ill people are necessary or what the patient and their families want. People who experience an emergency admission at the end of life are also far more likely to die in hospital. Eighty-nine per cent of people who die in hospital do so after an emergency admission, and 50% of those do so after a stay of eight days or longer. In the UK more than 50% of people die in hospital, despite less than 5% of people saying it is the place they would prefer to die. One estimate suggests that 40% of people who die in hospital have no clinical need to be there. This often happens because terminally ill people have a crisis that their primary carer – usually a family member, loved one, or friend – is unable to cope with and so they call an ambulance. Once they are in hospital, they often find it incredibly difficult to get out again and get home or into a care home or hospice.

Enhanced community services

Because many of these emergency admissions are avoidable, it is extremely welcome that Sir Bruce Keogh has highlighted the need to enhance community services for people with urgent needs. He has also pledged to deliver an improved NHS 111 service which people with urgent care needs can ring for advice. For terminally ill patients, we think the Government will need to go further. Marie Curie has long called for the Government to support 24/7 availability of specialist palliative care services, as proposed by the Palliative Care Funding Review and again by Baroness Neuberger’s Review of the Liverpool Care Pathway. So often the hospital emergency admission of a terminally ill person is due to fact that the primary carer or generalist healthcare professional cannot get access to specialist advice about how to best support someone who is terminally ill. We also need to acknowledge the role that social care plays in helping terminally ill people avoid admission to hospital. Research by the Nuffield Trust has suggested that, when people have access to social care funded by the local authority, they are less likely to use hospital care.

Crisis management

This suggests what we know from our experience as a provider of palliative care: when people have access to high quality social care, they are more equipped to manage the crises that could otherwise result in emergency admission to hospital. For this reason, we continue to call on the Government to make social care free for people in the last six months of life. Sir Bruce Keogh’s review is a welcome first step, particularly for terminally ill people, because it places an emphasis on community services and readily available advice, which we know can have a huge impact for terminally ill people and their families. But the Government will still need to do more specifically for terminally ill people to ensure that everyone has the opportunity to be cared for and die in the place of their choice.