Article Text

Download PDFPDF
50 Barriers to effective implementation of end of life care. A systematic review
  1. Emily Dobson
  1. University of Manchester, UK


Background In reviewing health inequalities it is not sufficient to simply focus on those most affected instead there should be a whole systems approach to have the maximum effect upon the population. (Marmot 2010) Within such an approach ‘the mechanisms giving rise to inequalities are still imperfectly understood’.(Woodward 2000) Further it has been suggested that evidence remains to be gathered on the effectiveness of interventions to reduce inequalities (Godfredson 2004) particularly within end of life care (EOLC). (CQC 2016).

Methodology To understand the mechanisms giving rise to inequalities in EOLC we utilised an adapted process map of the EOLC journey. (Tremble 2010) Within this map we highlighted pinpoints. Pinpoints are places within the journey where a clinician decides whether there is a referral to another service. At each pinpoint a patient profile was taken looking at their basic demographics (including disease and place of death) and index of multiple deprivation score.

Results The initial data review illustrated similarities across all the pinpoints with the exception of hospice care services that showed a significant increase in the number of patients classified within the 7–10 on the index of multiple deprivation and cancer diagnosis.

Further research – on going At present statistical analysis is on going into the differences between the pinpoints. At the same time a literature review sought to analyse if there was evidence of a similar anomaly within another healthcare setting; in which it was identified that implicit bias was a potential cause. (Fitzgerald 2017) The next phase of the research looks to test using an Implicit Association Test method whether implicit biases is present in the EOLC journey and develop an intervention to remove it.


  1. . The Marmot review. Fair society healthy lives [Internet]. Available from: [Accessed: 2017Junuary 19]

  2. . Woodward A, Kawachi I. Why reduce health inequalities?J Epidemiol Community Health [Internet] 2000December;54(12):923–9. Available from: [Accessed: 2017 June 19]

  3. . Linda Gottfredson. Intelligence: Is it the epidemiologists’ elusive ‘fundamental cause’ of social class inequalities in health?J Personal Soc Psycology[Internet] 2004;86(1). Available from: [Accessed: 2017 June 19]

  4. . CQC. A different ending [Internet]2016. Available from: CQC_EOLC_OVERVIEW_FINAL_3.pdf [Accessed: 2017 June 19]

  5. . Trebble TM, Hansi N, Hydes T, Smith MA, Baker M. Process mapping the patient journey: An introduction. BMJ [Internet] 2010;341. Available from: [Accessed: 2017 June 19]

  6. . Fitzgerald C, Hurst S. Implicit bias in healthcare professionals: A systematic review. Available from: [Accessed: 2017 May 25]

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.