The National Audit Office (NAO) has recently published its report on the Government's End of Life Care Strategy. The Strategy itself, published in July 2008, and the Government are to be congratulated for at least recognising, albeit somewhat belatedly, the need to ensure that people nearing the end of life are cared for effectively and with dignity and respect and for outlining a plan for achieving it. But plans are one thing; turning them into reality is something else.
The NHS
It would be a tragedy if a nation that pioneered the modern hospice movement were to prove unable to provide proper care for its own terminally ill people. We should perhaps start by recognising that we have in this country two things that most others do not. Firstly, we have a health service that is available to all, free of charge at the point of need; and secondly, within that health service, we have a palliative care specialism which is capable of delivering and, to a large extent, already does deliver high-quality medicine and ancillary care to both terminally and chronically ill people. The NAO report itself highlights some of the new developments in palliative care as examples of best practice; however, these need to be rolled out so that they are widely available. And there is a need for better targeting and coordination of resources to make good care at the end of life a reality for all.
Resource allocation
Of course, end-of-life care is just one of many demands being placed on the NHS and resources are obviously finite. But resource allocation needs to recognise that there is an inter-relationship between spending in one area of health care and the resultant impact in others. One example, cited in the NAO's report, is the need for emergency and expensive admissions of terminally ill people to hospital when end-of-care services in the community are not strong enough to deal with situations arising with patients at home. Economising on community care for the dying can sometimes just shift the cost of proper care elsewhere.
There is, perhaps, a need also to think more in terms of cost versus benefit. Modern medicine does not come cheap, but some aspects of it are not only less expensive than others but also stand to benefit greater numbers. Ground-breaking and pioneering surgery can be sensational, and there is no doubt that it has a vital role to play in advancing the frontiers of medicine. But how many patients do some of these activities benefit in relation to their high cost? By contrast, we will all of us have to die one day and a large proportion of us will need palliative care, which is a relatively low-cost form of health care. How many people would stand to benefit from a £100 million injection of funds here as against a similar investment in new heart or lung or brain surgery? It is not as if palliative care is just about easing the path of the terminally ill to the end of life. It is also a science that is increasingly coming to be applied to empowering chronically ill people, such as those suffering from heart or lung disease, multiple sclerosis or Parkinson's disease, to lead normal or near-normal lives.
None of this is to argue against the funding of expensive and innovative new medicine or to suggest that end-of-life care should be given priority over other forms of health care. What it does suggest is that in allocating resources to caring for people nearing the end of their lives the Government needs to recognise the savings as well as the costs of good end-of-life care and to assess the relative costs and benefits of different kinds of health care spending.
Coordination
Coordination is equally important, and the Government's Strategy recognises this. Good health care is one thing; but, if it is not complemented by synergistic social services, its benefits can go to waste. For example, good palliative care can empower someone with heart disease to cope with the condition and to lead a near normal life. But, if the person concerned has serious accommodation problems (such as living in a third-floor flat with lifts that are often inoperable), the full health benefits cannot be realised.
The NAO report draws particular attention to the wish of most people to die at home, in contrast with the reality that most people die in hospital, usually after emergency admissions, where they do not always receive the end-of-life care they need. The root of this problem lies in inadequate cascading of end-of-life health care expertise from specialist departments in hospitals to physicians and nurses working in the community. A key priority for the Government's End of Life Care Strategy must be to ensure that the knowledge and skills which this country has in abundance for caring for those who are nearing the end of life are not only kept in specialist hospital departments to deal with complex cases but also spread into the community, where they can be employed for the good of the majority.
Solvable problem
The NAO report is to be welcomed as an injection of realism into the Government's plans. End-of life care is a problem that is within our capabilities as a nation to solve and which the Government has shown commendable willingness to address. We now have a golden opportunity to improve end-of-life care for every patient in Britain. What we need now is some lateral thinking about how to do it.
Care Not Killing
