Concerns over inconsistent palliative care provision across England

Palliative and end-of-life care are not being considered as core services by clinical commissioning groups (CCGs) in some parts of England, with a vast degree of variation across different services and regions, reveals an analysis published in BMJ Supportive and Palliative Care.

The results show CCGs are not using standardised information about their population to commission services and there is confusion about who is responsible for service provision. This means patient choice at the end of life cannot always be honoured and it creates a 'postcode lottery'.

The study reveals that out-of-hours services rely heavily on hospices rather than NHS funding and less than half of CCGs have plans to review or update services.

Previous work has identified recurrent failings in the provision of end-of-life and specialist palliative care. However, since the 2012 Health and Social Care Act came into force, which requires CCGs to provide such services, there has been no assessment on the provision of palliative care services across England.

Therefore, a team led by Professor Baroness Ilora Finlay sent freedom of information requests to all 209 CCGs across England in 2015 to assess their commissioning of palliative and end-of-life care services.

The findings reveal:

• Of 81 CCG respondents, only 29 provided information about the number of patients with palliative care needs in their population
• CCGs had budgets ranging from £51.83 to £2,329.19 per patient per annum for palliative care services. The fluctuating budget supports concerns about a 'postcode lottery'
• Of 204 CCG respondents, 83% commission 7-day specialist palliative care services in patients' own homes, but out-of-hours services rely heavily on hospice-led services
• Of 204 CCG respondents, 31% commission pain control teams, but the majority of these only operate in regular working hours
• And 68% reported commissioning palliative care education for healthcare professionals, but the type of educational support was hugely varied
• Under half (45%) of the 194 CCGs that responded said they do not have plans to update or review their palliative care services. Furthermore, there is "no current national initiative in place to monitor how often services are reviewed, or to support CCGs in developing their services and sharing best practice"

"This study goes some way to provide evidence that while there is excellent specialist palliative care provision in parts of England, there is a vast degree of variation across the country," explain the researchers.

"Most strikingly, there is little uniformity in the data CCGs are required to hold, and disparity in the responsibility of service provision between CCGs, Trusts and local hospices."

"As a result, a paucity of services means that patient choice at the end of life cannot always be honoured and unless national guidelines are put in place to support CCGs in commissioning care, the deficits described in the Parliamentary and Health Service Ombudsman report Dying without Dignity will not be addressed," they warn.

They recommend the Welsh Palliative Care Strategy should be used as a best practice model, in which staffing levels have been determined within the available funding, and a dedicated number of palliative care beds ensures fair access to palliative care across 7 days.

The authors conclude "devolution of decision making down to CCGs suggests that palliative care provision is not being considered as a core service in some parts of England. Despite much evidence of its cost efficacy, the provision of specialist palliative care is in need of a national framework to ensure that patients achieve good end-of-life care everywhere."