Hospices are well placed to rise to the challenge of leading on integration of health and social care services for people in the last year of life and to take a leadership role to ensure that patients remain at the core of a responsive and cost effective service. They also hold an intellectual capital about death, dying and bereavement which is unparalleled.
The importance of social care for people in the last year of life has been highlighted recently in a number of key documents. The 2008 Department of Health’s End of Life Care Strategy recognised that nothing less than a cultural shift in attitude and behaviour within the health and social care workforce would be required in the delivery of services. The National Audit Office report from the same year also suggested a need for greater input from social care to address ongoing challenges.
More recently, the 2011 reports from the Palliative Care Funding Review and the Commission on Funding of Care and Support (The ‘Dilnot’ Report) recommended that there should be better integrated health and social care for those facing the end of life, and that this should be free at the point of delivery. In February 2013, the government responded to the system proposed by Dilnot, setting the cap on care costs at £75,000, almost double Dilnot’s preferred figure of £35,000.
We live in an aging society with very old age lasting for an extended period of time. A recent publication, ‘Current and future needs for hospice care: an evidence-based report’, tells us that by 2035 deaths in the over 85s will represent half of all the deaths in the UK1.
It is clear that any new end of life service model must include improved partnerships between health and social care agencies. Hospices must challenge themselves about how dying is conceptualised. Viewing dying as the last short period, as opposed to a longer trajectory, will narrow the possibilities for the future of hospices. It is important to note that some hospices in the UK are already leading the way. They have developed their own social care services and agencies which deliver personal care alongside more specialist healthcare, or are working in close partnership with other agencies to address the same issues. We begin to witness a transformed future for hospice care.
St Christopher’s Care
Since the beginning of 2011, St Christopher’s Hospice has been commissioned by Croydon Social Services to deliver a personal care service for people who are in the last year of life. The service was set up with the following aims:
- to provide social care following assessment of need to all referred service users
- to manage and/or coordinate information from the electronic register for end of life to enable care to be delivered
- to develop volunteering opportunities for people from all parts of the community.
St Christopher’s Care has recruited and trained a number of carers, supporting them to deliver personal care tasks similar to those carried out by staff providing care under the Local Authority’s normal contracts. The hospice delivers the service at the same cost as the Local Authority and private agencies, with carers being paid at the same hourly rate. The quality of training and support offered, and the sense of belonging to an organisation with a mission for excellence, furnishes the carers with a sense of motivation and this acts as a unique point of difference. The staff also work closely with GPs to ensure appropriate referrals, and have access to the established community volunteer support service at the hospice.
The success of the service is focussed around a set of targets. Some examples of these include:
- 100% of clients report that their quality of life has been improved
- 100% of clients are contacted within 48 hours
- 70% home deaths recorded, far exceeding the 30% original target
- clients report that they are able to get a response out of hours, due to the pre-existing 24/7 hospice service.
Reducing hospital admissions
Mr A is aged 85 years with COPD and Parkinson’s disease and is receiving twice daily visits. The patient’s wife phoned the service at 9.30pm to say that her husband was breathless and anxious. She had earlier contacted the GP who had excluded a chest infection and thought his symptoms were related to his anxiety. The on-call nurse was able to elicit a full history of the symptoms from Mr A’s wife and have a discussion with the out-of-hours doctor, providing him with background information including his preferred place of care. She was also able to suggest useful medications.
The client was prescribed medication which controlled his breathlessness and lowered his anxiety and he was comfortable to remain at home. Without St Christopher’s Care, Mr A would have been admitted to hospital.
Hospices also have the potential to offer an educational role. We have been working with four local authorities to support social care staff who encounter people at the end of life.
Our training and development programme works at various levels:
- senior and service managers – running ‘away days’ for managers to set general objectives
- leads – identifying ‘lead’ staff to focus on end of life care acting as a resource for the wider team
- other members of staff – running regular one day introductory courses
- broader development work – focussing on working with individuals and teams.
Originally we worked with the older people’s team but more teams have become involved such as day services, learning and physical disability, mental health teams, sheltered and extra care housing and voluntary services. Advance Care Planning projects are also under way.
A DVD showcasing this work has been made with the support of the National End of Life Care Programme and is available to view on St Christopher’s Hospice website.
St Christopher’s Hospice is working with key partners towards developing an end of life care coordination centre. This will work on three levels:
- last year of life referrals will be sent through to the centre at St Christopher’s acting as the main entry point for end of life care
- the centre will provide care packages and will coordinate people’s social and healthcare needs
- the centre will also hold a budget to coordinate planned overnight care.
Hospices cannot continue to do the same as they have always done. There is clearly an opportunity to utilise our unique experience in order to become an effective lead partner developing the future of integrated and cost effective end of life health and social care services.
- ‘Current and future needs for hospice care: an evidence-based report’ Calanzani N, Higginson IJ, Gomes B. Commission into the Future of Hospice Care – Help the Hospices, London, 2013.