End of Life Care
The government has made six commitments to the public to end variation in end of life care across the health system by 2020. These are:
- honest discussions between care professionals and dying people
- dying people making informed choices about their care
- personalised care plans for all
- the discussion of personalised care plans with care professionals
- the involvement of family and carers in dying people’s care
- a main contact so dying people know who to contact at any time of day.
Profile update to 2016 (PHE Fingertips)
Derby performs comparably with the national average across the majority of indicators in this theme. However, the percentage of hospital deaths in the under 65 age group is significantly higher than the national average.
The percentage of hospital deaths in the 65 years and over age group has reduced and is now below the national average. However, the number of deaths in this age group in care homes has increased slightly.
Hospitals can be a safe environment for end of life care due to better access to medical diagnosis and 24-hour care by professionals. However, there is evidence that for many people, the last hospital admission before death may have been preventable (Gomes et al. 2011). There is also a risk of both under and over-treatment in this setting.
National evidence indicates that people living in the most deprived quintile are significantly more likely to die in hospital than individuals living in other quintiles. This effect remains when considering the combined influence of deprivation quintile, age at death, gender and cause of death. Locally, the proportion of deaths in other places and hospices is significantly lower than the national average.
Death in Usual Place of Residence (DiUPR)
National research indicates that many people would prefer to die at home, and that few wish to die in hospital. As such, deaths in the usual place of residence serve as a proxy quality indicator for choice and access. Nationally, there is evidence that death in the usual place of residence for the very elderly is the least common in the most deprived quintile.
Within the End of Life Care Profiles, 'usual place of residence' includes the home, care homes and religious establishments. Derby performs comparably across the majority of indicators in this theme. However, the proportion of deaths in the usual place of residence for those under 65 is significantly lower than the national average.
However, the proportion of deaths in the usual place of residence for those aged 65 years and over has increased.
Underlying Cause of Death
Locally, deaths from cancer are the most common cause of death across all age groups, and are closely followed by deaths from circulatory and respiratory disease. The number of deaths from cancer remains close to the England average in 2016 but the number of deaths due to respiratory disease in the 65-74 years age group has increased significantly. The proportion of deaths from circulatory disease has gradually declined across these areas since 2010.
Locally, the proportion of deaths within each cause category is comparable with the national average.
In Derby, the directly age-standardised mortality rate for all age groups is significantly higher than the national average but comparable with the regional average. Previous research suggests that before the age of 65, the ultimate cause of death is more influenced by deprivation quintile than it is after this age. Locally, the directly age-standardised mortality rate for people under 65 is comparable with the national and regional average. The latest mortality rates amongst the older age categories are also comparable with the national average.
Care home use at end of life
Care homes can provide end of life care in which trained staff look after patients during the day and night. They can be managed by voluntary organisations, private companies or the local council.
Local data indicates that the rate of care home beds and of nursing beds for older people have remained the same since 2016. The proportion of temporary resident care home deaths amongst all age groups is slightly above but comparable with the national average.
Dementia and Alzheimer’s disease
Nationally, the recorded prevalence of dementia has gradually increased in recent years. In Derby, the age standardised mortality rate for people over 65 with dementia is increasing and higher than the national average as is the recorded prevalence for this age group. This suggests that locally, dementia is a growing issue that requires effective management in the prevention of avoidable deaths. Derby performs well in the estimated diagnosis rate and comparably with the national average in relation to the proportion of deaths in various settings amongst older people with a recorded reference to dementia. However, the direct standardised rate of emergency admissions for people living with dementia is significantly worse in Derby.
Public Health England also provides a contextual framework for end of life care within their presentation of relevant indicators from other profiles. Derby performs significantly better than the national average across the following indicators:
- Permanent admissions into residential care – 74.9 per 100,000 population aged 18+
- Delayed transfers of care attributable to adult social care – 0.1 per 100,000 population aged 18+ (January –December 2018; CQC LA Profile Report; data from NHS England)
- Total Delayed transfers of care per day – 5.4 per 100,000 population aged 18+ (January –December 2018; CQC LA Profile Report; data from NHS England)
Derby performs comparably with the national average in relation to the following:
- Permanent admissions to residential and nursing care homes – 626 per 100,000 population aged 65+ (2017/18 Adult Social Care Outcomes Framework)
- Adults in permanent residential care services – 392.6 per 100,000 population aged 18+
- Permanent admissions into nursing care – 51.7 per 100,000 population aged 18+
- Excess winter deaths index – 20.3 (East Midlands region 23.9) amongst all age groups (Aug 16-July 17)
- Proportion of the population aged 85+ – 2.3%
The following are significantly higher in Derby than the national average:
- Adults in permanent nursing care supported by adult social services – 193.7 per 100,000 population aged 18+
- Adults in residential nursing care – 313 per 100,000