An unfair lottery?

The care and treatment of the elderly is becoming one of the biggest political issues the country faces. That’s hardly surprising, since the number of old people in our society is rising fast. Next week a report will be published about the funding of social care. This week it’s the issue of palliative care – how we treat people at the very end of their lives – that is in the spotlight. And what has been revealed is very troubling.

Last year the Government commissioned a report on the matter from the chief executive of the Marie Curie Cancer Care charity, Thomas Hughes-Hallett. He has discovered 'stunning inequalities' in the quality and availability of palliative care in England. Some primary care trusts (PCTs) spend as little as £186 per death; others spend as much as £6,213. It’s estimated that of the 470,000 people who die in England each year, around 355,000 require palliative care but only 171,000 actually get it. Over 90,000 don’t even discuss the matter.

The main result of this is that far more people die in hospital than want to or need to and the focus of the report is to find ways to avoid this.

Mr Hughes-Hallett recommends that there should be universal standards of care for the dying. In particular, there should be a guarantee of what people can expect the state to pay for. And he wants a new set of tariffs established so that PCTs can know the cost of what they are commissioning.

This latter point is important because the idea is that there should be more community-based care available to the dying, from charities and local organisations as well as from NHS hospitals themselves.

What’s needed most for end-of-life care is the availability of 24-hour nursing care, much of which can be provided by community nurses. At the moment only 56% of PCTs provide such care. The report estimates that if such community-based services were increased, the number of people who die in hospital rather than at home could be reduced by 60,000, saving the hospitals themselves £180m a year in the process.

Many charities involved in the care of the dying have welcomed the report, and no doubt most people who have had the often harrowing experience of seeing their loved ones die in hospital will support what is being proposed. But the proposals are not uncontroversial.

The most contentious issue is the suggestion that national standards of expenditure should be set. Those who believe in equal and national-based standards will welcome this opportunity to do away with the postcode lottery in palliative care provision. But there is another approach – that of localism and this is in many ways what underpins the Government’s reforms of the NHS. Rather than have the Government set down national targets which must be universally met, the idea is that decision-making on priorities should be taken locally, notably by GPs. Indeed a central element of the NHS reforms is that PCTs will be abolished.

Some people, therefore, will wonder whether the new report on palliative care could constitute a further attack on what the Government is trying to do.

What’s your view?

  • What’s your own experience of care for those of your loved ones you have seen die?
  • How important would it be for you to know that arrangements had been made for your own death to be at home rather than in hospital?
  • Do you think we should be spending more on palliative care than we do now and, if so, where would you make the savings to pay for it?
  • And who do you think should determine what is spent on palliative care in your area: the Government, by setting out universal standards, or local PCTs or GPs?
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