Medical royal colleges unite to warn new palliative strategy is 'unrealistic’ without funding as pressures mount across NHS 

Medical bodies representing GPs, consultants in emergency medicine, pharmacists and nurses have united with charities to warn the UK Government that its new plan for palliative care in England will need to be backed by funding to redesign services. 

Since taking office Prime Minister Andy Burnham has recognised the need to ‘fix palliative care’ and his government is expected to publish a Modern Service Framework this autumn setting out plans to end the postcode lottery of end-of-life care in England. According to research by Marie Curie, the UK’s leading end of life charity, almost 1 in 3 people die without end-of-life care, a figure expected to rise by 24 % by 2050 due to a rapidly ageing population. 

Brought together by Marie Curie, the signatories include the Royal College of Emergency Medicine, Royal College of Physicians, Royal College of General Practitioners, Royal College of Nursing, Royal College of Pharmacists, Queens Nursing Institute and Society of Acute Medicine.    The collective, which also includes Age UK, Sue Ryder and British Geriatrics Society, say in their letter addressed to Health Secretary Yvette Cooper and Chief Secretary to the Treasury Emma Reynolds, that the government must establish a three-year Palliative Care Transformation Fund, supported by at least £200 million per year ‘as a catalyst for change and implementation’ to deliver the MSF. They argue that without this it would be unrealistic for the government to fulfil its ambition to reduce non-elective admissions and hospital bed days for people at the end of life by 10%, which could generate annual acute trust savings of between £775 million and £790 million.  

Gaps in end-of-life care create pressures on multiple areas of the NHS, especially crisis care such as emergency departments, and this is costly. Of all healthcare expenditure on people in their final year of life, 56% is spent on emergency hospital care, while only 11% is spent on primary and community care. In short, terminally ill and dying people are turning to ambulances and A&E in moments of crisis due to a lack of alternative help. In some cases this can be due to difficulties in accessing end of life medicines.  

Dr Ian Higginson, President of the Royal College of Emergency Medicine, said:

“We only get one chance to give a patient the dignified and comfortable death that every single person deserves. In most cases, an Emergency Department is not the ideal place for this.   EDs are often noisy, crowded spaces which do not offer the privacy which someone at the end of their life ought to have and there is typically a lack of available palliative care specialists.  

“The palliative needs of these patients, and their loved ones, can therefore go unmet if they end up in A&E. Yet, an ED is all too often the only place they can go for the immediate support, be it pain relief or something else, they need.   Vast improvements to the quality and availability of palliative care are long overdue in this country. We call on the government to back their much-needed plans in this area with the funding and resources it needs to succeed.”    

Professor Victoria Tzortziou Brown, President of the Royal College of GPs, said:

“As with all Modern Service Frameworks, the success of the End of Life Care MSF will depend on matching ambition with the resources to deliver it. Funding should reflect the evidence and the true cost of delivering care across all settings, including general practice. GPs play a central role in providing palliative and end-of-life care, supporting patients and their families, managing complex needs and coordinating care across services, and if we expect community services to do more, they must have the capacity and investment to deliver it.”

There are already examples of approaches leading the way on delivering better outcomes for patients and reducing pressure on acute services. These include delivering support in people’s homes out of hours, embedding palliative care in GP surgeries to catch people ‘upstream’ and specialist teams working in emergency departments.    But, the letter argues, ‘such approaches remain the exception rather than the rule’. The collective believe a Transformation Fund would enable the testing and scaling of such approaches that could then be commissioned and sustained through mainstream funding arrangements in the longer term.  

In the UK around 90% of people who die need palliative care, but almost one in three of don’t receive it. Those missing out is expected to rise by 24% by 2050 as the population ages and more people live and die with frailty, dementia and multiple complex conditions.    The MSF is expected to be published by the end of the year.  

Dear Chief Secretary and Secretary of State,

We are writing as a coalition of organisations working across primary care, community services, nursing, pharmacies, emergency medicine, hospice and palliative and end of life care.

We welcome the Government's commitment to developing a Palliative Care and End of Life Care MSF which represents the first national plan for palliative care and the care of people at the end of their lives in England since 2008 and a once-in-a-generation opportunity to transform palliative care for every person who needs it and those closest to them.

The need for action is clear. Around 90% of people who die each year have palliative care needs, yet recent evidence suggests that nearly one in three people in England die with unmet need for palliative care. At the same time, demand for palliative care is expected to grow significantly over the coming decades as the population ages and more people live and die with frailty, dementia and multiple complex conditions. The key areas of focus for the MSF are absolutely the right ones. Improving equitable access to high-quality palliative care services, identifying people earlier as they approach end of life, reducing unwarranted variation, tackling health inequalities and ensuring care is shaped by what matters to people and those closest to them are all crucial to improving palliative care in all settings - from GP surgeries, social care and pharmacies, to ambulance services, hospices and hospitals.

The MSF will set out a bold ambition for change and system delivery. The interim statement reinforces the aims set out in the recently published Neighbourhood Health Framework to increase the number of people identified as approaching end of life by 10%, and reduce non-elective admissions and hospital bed days for this cohort by 10% over the next 3 years.

But a major ambition like this requires a major delivery effort. That’s why, to support implementation of the Framework and enable the scale of service redesign required, we are calling on the Government to establish a three-year Palliative Care Transformation Fund, supported by at least £200 million per year as a catalyst for change and implementation. This would represent a substantial but proportionate investment in helping local systems deliver the improvements in palliative care envisaged by the MSF, while supporting –the Government's wider ambitions for more joined-up, community-based care.

Analysis by the Nuffield Trust and Health Economics Unit found that public expenditure on people in the last year of life amounted to £9.5 billion across England. Yet current patterns of expenditure remain heavily weighted towards managing crises in hospital. Of all healthcare expenditure on people in their final year of life, 56% is spent on emergency hospital care, while only 11% is spent on primary and community care.

If the Government delivered on its ambition to reduce non-elective admissions and hospital bed days for people at the end of life by 10%, this could generate annual acute trust savings of between £775 million and £790 million. However, without transitional investment to support more strategic commissioning, service redesign and the implementation of new models of care, it is unrealistic to expect current patterns of care and expenditure to be reshaped at the scale required.

There are already examples of approaches leading the way on delivering improved outcomes for patients and reducing pressure on acute services. Such approaches exist across all settings, often involving specialist palliative care expertise, from delivering support in people’s homes out of hours, through to embedding palliative care in GP surgeries, delivering improvements in the way paramedics respond to patients at the end of life, and transforming emergency department responses to people who are terminally ill.

But such approaches remain the exception rather than the rule. A Transformation Fund would provide systems with flexibility to test, scale and embed approaches that improve care and reduce avoidable and unwanted hospital use, through earlier identification of need, improved care coordination, equitable access to support and advice and adoption of effective community-based services. In the longer term, approaches that demonstrate effectiveness should be commissioned and sustained through mainstream funding arrangements.

Importantly, a Transformation Fund should be viewed as a catalyst for implementation rather than a substitute for the wider reforms needed to deliver the MSF. Alongside action on workforce, strategic commissioning, and accountability across all settings, it would help create the conditions necessary to realise the Framework's ambitions and support the Government's wider shift from hospital to community care. By supporting local systems to make better use of the substantial resources already spent on care in the final years of life, the Fund could act as a highly effective catalyst for reshaping current patterns of expenditure and supporting more strategic commissioning.

We therefore urge the Government to establish a Palliative Care Transformation Fund of at least £200 million per year for three years, allocated through Integrated Care Boards in return for credible, evidence based and costed plans to improve access, quality, sustainability and equity in palliative care across all settings to support delivery of the MSF and its ambitions.

How we support people towards the end of their lives is a key marker of a civilised society. It shows our true sense of community and fellowship. The MSF presents a rare opportunity to deliver lasting improvements in palliative care and care at the end of life, and we cannot afford for it to end up as a bold ambition that was never delivered in practice. Dying people depend upon it.

Yours sincerely,

President of Council

Royal College of General Practitioners

President

Royal College of Emergency Medicine

Chief Nursing Officer

Royal College of Nursing

Chair, English Pharmacy Advisory Council

Royal College of Pharmacy

President

Royal College of Physicians

Chair

Association of Palliative Care Social Workers

Committee Chair and Consultant Pharmacist – Palliative and End of Life Care

Association of Supportive and Palliative Care Pharmacy

President

British Geriatrics Society

Chief Executive

Queen’s Institute of Community Nursing

Chief Executive Officer

Marie Curie

Chief Executive Officer

Sue Ryder

Chief Executive Officer

Hospice UK

Charity Director

Age UK

Chief Executive Officer

The Brain Tumour Charity

Director of Support, Research & Influencing

Pancreatic Cancer UK