Introduction This paper presents findings from part of a larger qualitative study involving (1) older people, (2) clinical staff, (3) multi-faith spiritual mentors and (4) policy-makers/-influencers in Wales (N=56).¹

Aims and Methods Taking a whole-systems approach, a major aim was to identify older peoples' expectations of first-class end-of-life care in the hospital setting. Phase 1 comprised in-depth interviews (participant groups 1–3). Phase 2 involved consultation workshops with older people. In Phase 3, policy-makers/influencers developed road-maps for change during summative consultation workshops.

Results The hospital hierarchy plays an immense role for the older patient/loved one. A minority experienced excessive frustration when striving to obtain optimal care. Many remained voiceless due to fear of repercussions. Importantly, for the majority there appeared to be a conflict in wanting to comply to the system as best they could, but were unsure of what the modern NHS expects from them.

Conclusions There is a bias in the health-care system, particularly where actual preferences are age- and/or culturally/faith defined. We question how the NHS puts patient-centred care and patient choice into practice. Whilst hierarchy and (mis-)use of power between and within clinical staff groups is a deep-rooted cultural issue, we conclude that the older person approaching end-of-life and their loved ones have, in many cases, different expectations to clinical staff. The patient is tasked with meeting NHS needs, rather than the NHS meeting the patient's needs. 1. Dobbs C. et al. (Final Report under review) End-of-life-care for older people in Wales. NISCHR Grant No. HA09/006.