What is behind differences in place of death across the UK?

Across the UK, policy for end of life care has aimed to improve proactive care, provide services in community settings, and in doing so reduce the need for emergency hospital care during the final months or days of life. Over time, there has been a shift towards fewer hospital deaths and more people dying at home, which accelerated at the start of the Covid-19 pandemic. 

However, there is significant and unexplained variation in where people die across the UK, with almost half of deaths in Wales occurring in hospital (49%), compared with only 42% in England, where deaths in hospices (5%) and care homes (21%) are higher. Deaths at home are highest in Scotland and Northern Ireland (32% of deaths in each country).

Sociodemographic differences between the four countries do not fully explain the differences. Wales has an older population overall, but England has a higher proportion of deaths in the oldest age groups. Scotland has significantly higher death rates overall. Northern Ireland has the youngest population.

Patterns of social care provision could be an important factor influencing where people die. In Scotland, Wales and Northern Ireland, there has been a greater emphasis on expanding funded home care services, while in England there is more capacity – and a higher proportion of deaths – in care homes. Recent hospital discharge policies in England have also resulted in more people dying in care homes who are temporary residents, as well as providing funding for hospice inpatient care, which is a practice introduced during the pandemic.

Other factors may also be behind differences, such as variation in community services and hospice provision, including whether the latter is via independent hospices or in the NHS (where deaths would be recorded as hospital deaths).

Regardless of the drivers for the differences, current patterns of place of death raise questions about the capacity needed for community services for people at the end of life, and whether services could better enable people to die in their place of choice – which is more likely to be home than hospital, even if not always the case.

Differences across the UK also point to learning for the interaction between health and social care policy and the implications for end of life care – including for the potential to shift resources away from hospital to the community. Providing social care for people at the end of life must be considered alongside health provision.