Costs of palliative care in the community, in hospitals and in hospices in the UK

The provision of health care in the UK is undergoing significant change as the 1997 White Paper ‘The new NHS. Modern. Dependable’ [1] is enacted in law and implemented in practice. The reforms replace purchasing with commissioning as they seek to reconfigure the NHS around a model of integrated care as opposed to internal markets. The research reported in this paper was carried out before this shift. However there is not evidence to suggest that pressures on health care resources in the UK will decrease and all health care decision makers will need to be aware of both the effects and the costs of alternative health care expenditures [2]. Knowledge of the costs was particularly important in the setting of contract prices by providers and in their appraisal by purchasers [3] and is likely to remain crucial under a commissioing approach.

There has been no patient specific costing of palliative care services. A MEDLINE search in 1995 failed to identify any relevant studies appraising the costs and/or effects of palliative care in alternative settings. One of the obstacles to accurate costing is the manpower and financial resource requirements necessary for the collection of patient specific data. This study provides an excellent opportunity to monitor resource usage by patients receiving palliative care in different settings. As well as resource usage the study collected data on quality of life, satisfaction with care, anxiety and depression and pain. Data were collected from patients and lay carers as well as health care professionals. Findings in areas other than resource use will be reported elsewhere [1].

Palliative care has always been a feature of health care. However, it is only in recent years that the specialist provision of such care has developed. From its beginnings in the late 1960s the modern hospice movement in Britain has grown very rapidly. By 1998 there were 215 UK hospices with adult inpatient facilities. In addition there are over 700 specialist palliative care services in the UK and Ireland (numbers compiled from 1998 ‘Directory of Hospice Services’). Palliative care is also provided in non-specialist settings, such as hospitals, by generic health care providers.

Government support for the development of palliative care has been most tangible in ring-fenced allocations of monies, beginning in 1990. Ostensibly this ring-fencing was designed to support the charitable component of many palliative care services but it was also designed to help these services adjust to the demands of the then new regulated market in health care [4]. From April 1994 this ring-fencing of money ceased and purchasers were then free to procure palliative care services from any source deemed appropriate.

It appears likely that new providers will enter the market. NHS hospitals, community trusts and private nursing homes are possible future competitors for existing services. In this context information about costs is of considerable value. The provision of palliative care is complex both in terms of the range of needs it responds to, the variation in treatment possible and the challenge of measuring effectiveness. It appears to be vital that providers and purchasers are clear what the breakdown of costs is, not least because this would defend against a straightforward reduction in expenditure through contracting for lower cost tenders that might not contain the necessary component parts for holistic palliative care.

This paper presents analysis of the costs of palliative care in the community setting and identifies salient patient characteristics that are associated with increased costs of care. The importance of taking full cognisance of the role of carers, often members of the patients own family, is emphasised. The paper continues with an examination of the costs of palliative care in inpatient settings, both hospitals and hospices. At the outset it is crucial to note that in offering figures about costs in different settings we are not seeking to imply that we have the basis for a comparison of costs, still less any route to a measure of cost-effectiveness. Two features of palliative care are crucial here: (1) It is likely that any individual would receive care from two or possibly three care settings during the palliative phase of their illness and so purchasers will need to have information about each setting. (2) Although it may be the same person receiving care in each setting their needs will change. With the optimum allocation of staff and with these staff having received appropriate training a wide range of services can be, and are, offered in the community. However the overall nature of services offered in a hospital or a hospice are different. One can not compare because one is not comparing like with like, either in terms of needs or services.