How much do we spend on patients at the end of life, across different care settings?

Dr Wikum Jayatunga is Public Health Registrar based in London. Here he discusses his Age and Ageing paper 'Health and social care costs at the end of life: a matched analysis of linked patient records in East London'.

It is a commonly accepted principle that demand for healthcare always outstrips resources, and so in the UK’s publicly funded health system, it is important to look at how and where costs are being incurred to make sure we are making the best use of limited resources. We know that a large proportion of hospital use is concentrated in peoples’ final year of life, as deteriorating health in this period often leads to acute hospital admissions. However far less is known about care use in other settings, such as in primary care and social care.

We therefore tried to understand how much the health and social care system spends on patients at the end of life, across different care settings. To do this, we used a novel dataset from the London Borough of Barking and Dagenham which links together data from local government services, health providers and health commissioners at a patient level. Many such datasets are now being developed because they allow health service researchers and planners to uncover new system-wide insights.

Over a six-year period, from 2011 to 2017, we matched 4,360 individuals who died to controls who did not die, but share similar characteristics – matching by: age, gender, neighbourhood deprivation, and number of long term conditions. By taking this approach, the difference in costs between the groups could be more clearly attributed to the end of life period, rather than these other factors.

We found that the end of life period was associated with £7,450 of additional costs in total, across planned and unplanned hospital care, emergency department care, outpatient care, primary care and social care. While additional costs were found across all care settings, unplanned hospital care was the largest contributor, accounting for £4,218 (57%) of this. Such costs in acute settings were particularly seen over the last few months of life, while in non-acute settings such as outpatient care and social care, costs actually decreased over the final few months. Better end-of-life planning might allow more care to be delivered in the community, preventing costly hospital admissions and aligning care to patient wishes.

We also broke down these costs by the age at which people die. As age of death increased, healthcare costs decreased while social care costs increased, such that we see a relative shift in care costs from healthcare settings to social care. This has important implications given our ageing society, growing care demands, and ongoing funding shortages in the social care system.

There are many research questions yet to be explored, including sub-analysis by conditions (such as dementia), place of death, and other settings (such as community, mental health and hospice care). This paper is the first stage of a three-year research programme, more of which can be read about here. It serves as a clear example of how linked data can be used to deliver new and actionable insights about the health system, service use, and population health.