Further evidence on the cost of end of life care outside of hospital – new Nuffield Trust analysis

Evidence of the costs to the NHS and other care services of supporting people at the end of their lives has emerged in a new report published today by the Nuffield Trust. It indicates that potential savings might be available if community-based support were made more widely available to help people to die in their own homes, where that was their preference.

National surveys have shown that that many people would prefer to die at home rather than in hospital. In 2012, 44% of people in England died either at home or in a care home – this is up from 38% in 2008. The new Nuffield Trust research suggests that enabling more people to die at home (if they wish to) may not have to cost more than if they were cared for in hospital settings.  The study used sample sizes ranging from 10,000 to over 1 million people.

A 2012 study by the Nuffield Trust found that a home-based nursing service incurred significantly lower hospital costs for people at the end of their lives. But the analysis was unable to ascertain whether any potential savings might be offset by increased costs in, for example, primary, social or community care offered to people who were not in hospital.

To test this, the Nuffield Trust constructed a number of models to capture how people were using non-hospital services at the end of their lives.  The approach used a range of information to try to understand the care services people were using at this critical stage. The results provide new insights into the use of non-hospital services including GPs, district nursing and social care. 

Key findings include:

• Hospital costs were by far the largest cost elements of end-of-life care – averaging over £4,500 per person for those who died during the final 90 days of their lives. The bulk of this cost was due to emergency hospital admissions. Hospital costs increased rapidly in the last few weeks of life.
• Approximately two thirds of patients saw their GP at least once during the last three months of life, and there were an average of four to five GP visits per person in this time – costing an average of £147 per patient. Rates of GP contact were much higher for cancer patients. GP contacts appeared to remain relatively stable over the last 90 days of life, with an average of 5 per cent of people estimated to have had some GP contact on any one day.
• Only about a third of patients had a contact with the district nurse recorded in their last 90 days, so the average costs per person were not very high (average £278). However, for some patients using district nurses there was a clear increase in activity in the final days of life. The most intensive 10% of users averaged 40-50 minutes of district nurse time per day in their last few days of life.
• Just over a quarter of patients used local authority funded social care during the last 90 days of their life, but the high costs of nursing and residential care meant this averaged out at £1,010 per person who died.

The study also explored the impact that Marie Curie’s home-based palliative care nursing service might have had on costs at the end of life, revisiting research carried out by the Nuffield Trust in 2012. With important caveats, the study found that even when accounting for the costs of GP, district nursing and social care, the Marie Curie service could save total care costs on the order of £500 per patient compared to normal hospital care.

Dr Jane Collins, Chief Executive of Marie Curie, said: “Very few people at the end of life say that they would want to die in hospital, yet half of people in the UK currently do. This research is really important as it provides further evidence to inform decisions about shifting care for people with a terminal illness away from hospitals into the community, leaving vital hospital resource for people who really need to be there. The lack of data available about the use and cost of different community care services at end of life has always hampered making this shift a reality but this research should give commissioners greater confidence to make the important decisions that are needed.

“We know that hospital costs are by far the most expensive element of end of life care. What this research shows is that even when other community based service costs are considered, using nursing services in the community, like those Marie Curie provide, can bring cost savings to the NHS. It also gives us an insight for the first time into the use of different services, including GP, District Nurse and Social Care, at end of life. All of which help build our knowledge of the reality of end of life care for patients and families.

“Our priority is to ensure that the wishes of patients and their families are met and they have access to the best care at end of life. We hope this research goes some way to making sure people get the right care, in the right place, at the right time.”

Commenting on the research, Nuffield Trust Senior Analyst Theo Georghiou said: “In recent years there has been increasing attention on the part of policy-makers and practitioners to help provide alternatives to hospital care for people who are dying.  We are starting to see a shift in where end of life care is delivered, with more people dying out of hospital.  But as care moves away from hospital, it’s more important than ever that we know how the wider care system is involved in supporting people near to death.

“At the moment detailed information on the care that individuals receive at the end of life is not widely available for services outside of hospital. Our study attempts to assess the patterns and costs of end of life care using the data we do have.  We think our analysis provides a new look at this important area.  However it is important to note that the figures presented in this study are in some areas based on limited data, and our conclusions rely on a set of pragmatic assumptions.”

Theo Georghiou added: “Understanding the costs of services is essential if we want to make changes to the way care is delivered. But we must not forget that the experiences of those who are dying and of the bereaved are also of crucial importance.”