Unpicking the costs of end of life care

Last week saw the publication of the findings from the independent review of palliative care funding led by Tom Hughes-Hallet. 

Here at the Nuffield Trust we have been doing work around social care use at the end of life and it is nice to see that work being used by the report team.

We are also about to publish some work looking at the variation in hospital use in the last 12 months of life. One of the observations from this research is that to change the system you need to look back earlier in a patient's history – rather than relying on actions in the final few weeks of life.

Though the UK led the world in establishing hospice care – the current record in delivering palliative care is considered patchy.

The funding report grapples with a seriously complex problem working out how to fund palliative care in a way that gives the right incentives to release money from inappropriate secondary care to invest in alternatives.

End of life care is also unusual in that voluntary sector activity from fundraising and provision is so significant.  I particularly liked the diagram of current funding arrangements (see page 21) which neatly illustrates the complexity of funding flows. 

The solution coming out of the review, proposes a tariff for selected episodes of palliative care. Note the scope is only for the palliative care element and so must be on top of other funding.  

Moreover there may be other issues around fitting around existing commissioning – for example, the suggestion that commissioning for palliative care is based on populations of at least 300,000.

The tariff will be based on a classification that should (ideally) reflect a person’s needs for care. The proposed schema differentiates between different phases and severity of illness, information about functional impairment – and it does also include some variables relating to the type of provider (which are a compromise). 

The classification itself will need to show that it really is about patients needs and does not reward low quality or inappropriate care.  The team admit the information base at present is very limited and propose a process of piloting and testing the approach which I think is wise.  

The interaction between a palliative care top up and 'mainstream' disease-based funding is difficult – there is an argument that the costs of the mainstream need to be recalibrated to strip out the palliative care elements that have been implicit to date.

The report also has some wider resource implications including access to 24/7 community care, coordinators for end of life care, and non means-tested social care for people on the end of life register. The latter is especially timely given the report from the Dilnot Commission on 4 July. 

Our earlier analyses pointed out that around 30 per cent of people in the last year of life used some form of social care.  It will be interesting to see how the costs of care for this group interacts with some of the assumptions in Dilnot.