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Study shows end of life and palliative care nursing services could reduce NHS costs

The latest research by the Nuffield Trust   shows there are potential savings from reduced hospital care for people using the Marie Curie Nursing Service.

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Exploring the cost of care at the end of life, published in September 2014, found that even when costs in other sectors – social care, primary and community care – were considered, the Marie Curie patients' costs are around £500 less per person.

It builds on the Nuffield Trust's 2012 research, which found that people who receive palliative care from the Marie Curie Nursing Service at the end of their lives spend less time in hospital than those who don't receive the service.

Better outcomes

The main findings of that study, of more than 29,000 Marie Curie Nursing Service patients and matched controls, were that Marie Curie patients:

  • spend 2.5 fewer days in hospital during their last 90 days of life
  • are twice as likely to die at home - 77% compared to 35% of matched controls
  • are much less likely to need emergency hospital care - 12% compared to 35% of matched controls
  • are much less likely to die in hospital - 8% compared to 42% of the control group
  • have average hospital costs of £1,140 lower per person than the controls

Those findings were important, as we know from the National Survey of Bereaved People (VOICES) that bereaved relatives rate the overall quality of care people receive at home, in hospices and in care homes more highly than care in hospital.

However, the 2012 Nuffield Trust research did not take into account the costs of other community care services that nursing service patients might need, so Marie Curie commissioned the trust to carry out further research.

There is also the potential for Marie Curie's services to reduce Accident and Emergency (A&E) readmissions by increasing community care for people who are living with a terminal illness.

This latest research shows that, even when other care costs are considered, the Marie Curie Nursing Service is likely to offer NHS commissioners a cost saving.

The research gives commissioners further evidence to inform decisions about shifting care for people with a terminal illness from hospitals into the community.*

On 5 December, we hosted a Twitter chat on how better community services can help prevent unnecessary readmissions, with reference to the Nuffield Trust report.  Read the Storify of the Twitter chat.

2014 Nuffield Trust report - Dr Jane Collins, Chief Executive
Marie Curie Chief Executive Dr Jane Collins explains why the research is important and how it is useful to commissioners.

This research is really important because it starts to be able to tell us how much is spent on community care. This is really important to us at Marie Curie who provide community nursing services, and it starts to show the potential benefits of these services in terms of cost savings. Marie Curie are committed to looking after more terminally ill people and contributing as much as we possibly can, but we know that this is a time of austerity and there is also increasing need with the aging population. So being able to demonstrate some potential savings is really important, and that's why this research is so important to us.

We commissioned this research on the back of some work that we'd done in the past. That was looking at the impact of our Marie Curie Nursing Service on the care of 30,000 people matched with the 30,000 who didn't receive the nursing service, which demonstrated that those people who we cared for were far less likely to use accident, emergency, and hospital services generally.

We recognized at the time that, of course, there was the possibility that that might save the NHS money, but we weren't able to demonstrate it because there's always the possibility that the costs are shifted out of the hospital into the community. So this second piece of research was commissioned from Nuffield, asking them to look to see whether they could quantify the cost of people being in the community looked after more by district nurses and GPs and by services, such as our Marie Curie Nursing Service, and whether that would actually save money. Why that's important to us as an organization is that we know that people don't want to be in hospital.

So we're committed to trying to help people stay out of hospital. So it fulfills that requirement as well because if we can demonstrate to the NHS and commissioners, in particular, that people are able to stay out of hospital with our services, which is what the first piece of Nuffield work demonstrated, and this actually reduces costs. That's good for patients and good for the financial situation we find ourselves in.

The key findings of this research was to show that it was more cost effective to keep people out of hospital. So even taking into account social care, district nurses, primary care, including GPs, as well as the support services that organizations like Marie Curie provide in terms of a nursing service, there is still the potential to save on average 500 pounds per patient in comparison with them needing to go into hospital.

We think this is really important to commissioners. Commissioners are obviously at the moment trying to work out how to provide the very best possible care for their population, but in the most cost effective way. And this seems to me to be very important that we've got these findings at this particular time because this should be able to help them make the right decisions. The right decisions in terms of what people actually want for themselves and their loved ones, and the right decisions in terms of what is the most effective use of their money. So having the potential to save about 500 pounds on each person must make sense to them, and we hope that they will really consider using services such as our Marie Curie Nursing Service and similar services provided by others. 

Nuffield Trust 2014 research - Michael Cooke, Head of Analytics
Marie Curie Head of Analytics Michael Cooke talks about why the research was commissioned and explains some of the key findings.

The research is important for two main reasons. Firstly, there's a sector we don't know enough about the cost of caring for people at the end of life, and commissioners need this kind of information to make informed decisions about where to allocate resources so that we can get the best care for people with a terminal illness within the money that the NHS has got.

Secondly, the work that the Nuffield Trusted in 2012 to evaluate the impact of the Marie Curie Nursing Service on hospital costs left a number of important unanswered questions about the extent to which the hospital cost savings that they identified might be offset by greater costs of caring for people in the community.

The Nuffield Trust used a number of different approaches to analyze the cost of caring for people at the end of life. For some areas of costs, such as the time people spend in hospital, there are large national data sets that we can analyze and link together at the person level. There are other areas of cost such as GP visits and district nursing care. Those large national data sets don't exist. And instead, the Nuffield Trust had to rely on smaller studies, for example, for district nursing, a study that involved one London borough.

But for each of those areas of cost, they looked at how much activity there was for people in the last 90 days of life, applied unit cost to that, and then added them all together. The key findings of the research fell into two main groups. One about the cost of caring for people at the end of life in general, and a second set of findings about what this tells us about the likely cost of caring for people who use the Marie Curie Nursing Service.

So for people at the end of life in general, some of the interesting findings were around the scale of the costs for different elements of care. So the cost of GP visits was about £150 in the last 90 days of life, and district nursing was about £300 per person who died in the last 90 days of life. These are relatively modest compared to the cost of social care which is about £1000 and the cost of hospital care which is about £4000. So it gives us a good indication of the scale of those different costs.

What it also told us was some new information about how those costs change as people get towards the end of life. So, GP visits, the cost of those was relatively consistent over the last 90 days of life, whereas the cost of district nursing care increased considerably in the last month of life.

Secondly, this work filled in some important gaps in the work that was done in the 2012 evaluation of the Marie Curie Nursing Service. And what it's told us is even when you include the cost of GP visits, district nursing care, and social care, for the extra time that Marie Curie Nursing Service patients spend in the community compared to match controls, when you add all of that up together with the cost of the service itself to commissioners, you still find that's still about a £500 saving for the total cost of care, the Marie Curie Nursing Service patients compared to those match controls.

2012 Nuffield Report - Michael Cooke
Michael Cooke, Head of Analytics in our Caring Services team, takes us through the 2012 data and what it means.

So this independent study looked at the impact of the Marie Curie Nursing Service of where people died and the amount of hospital care they use at the end of life. It linked together data that Marie Curie held about its patients and linked that to data the NHS hold and data from the Office of National Statistics about where people die.

This enabled us to study a very large number of patients, 30,000 Marie Curie patients in all, without having to collect any new information about them. What it found was that more than three quarters of Marie Curie patients die at home and less than one in ten die at hospital. So that already told us something that we didn't know already, but the really clever bit of the study was that we used all of that information that we now had about the Marie Curie patients to identify 30,000 other patients who were similar in every way we could measure apart from the fact that control group had care from Marie Curie Nursing Service.

What this showed us is that the Marie Curie group were twice as likely to die at home as the control group, and five times as many of the control group died in hospitals. That shows you that compared to this very closely matched comparison group the outcomes for the Marie Curie group were much better. It also showed us that the control group were much more likely to have a hospital admission and much more likely to go to A&E at the end of life.

One of the other interesting findings that you can only look at because the group was so large was that we were able to compare the outcomes for the patients who had cancer compared to patients who didn't have cancer, and you got an even greater impact on where people died and the amount of hospital use they consumed for the people who didn't have cancer. This is a really important finding because all of the research out there, including the recent National Bereavement Survey tells us that the outcomes tend to be worse for people who don't have cancer. And let's not forget that that's three quarters of all people who die each year.

Vital though the Marie Curie Nursing Service is, it's only one of the services that's needed to enable people to be cared for where they want to be at the end of life. And I'd really encourage you to as well as looking at this piece of work, look at the evaluation of Delivering Choice Programme in Somerset which looked at the impact of joining up whole range of services to better meet people's needs at the end of life.

Marie Curie works with commissioners across the UK to meet their end-of-life and palliative care quality and efficiency objectives.

* Note: The 2014 research has a number of important limitations, notably the fact that the data on different areas of service usage come from different groups of patients. More data linked at the person level is needed to have more certainty about costs at the end of life. Two projects currently underway, the Palliative Care Funding Pilots and the Cicely Saunders Institute C-CHANGE project, will be important in adding to the evidence base.

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