Dying well at home: the case for integrated working
Costs of dying at home
The economic impact of people dying at home
Reducing reliance on acute care could release resources and better meet people’s preferences.Health economist 
- The NHS should have a better evidence-based understanding of the relative costs of specialist and generalist care at the end of life, analysed according to place of care delivery.
- Time spent in hospital in the last year of life is the most expensive factor in end of life care. Policy makers and commissioners should concentrate on interventions to keep people out of hospital if they do not need to be there, and to discharge them as early as possible.
- Economic analyses should reflect the ‘cost’ to family members of caring, and should consider how savings to the state can be harnessed to support carers to continue to care at home.
Key points from research and policy
Difficulties with costing
- Providing good-quality care to people at the end of life is not primarily a matter of cost but one of social and societal values. However, in present circumstances, the relative cost of dying in different settings is important. The limited evidence on costs suggests that dying at home is less expensive than dying in a hospice or hospital, with hospital care the most expensive option.
- Available evidence on the relative costs of delivering end of life care at home, versus in hospices or hospitals, is flawed, because, for example, it tends to take account of the cost to the taxpayer . The analysis model used in most cost comparisons is based on patients physically spending time in different locations: therefore it does not take account of the cost of new models of hospice care that are delivered in people’s homes.
- A major omission of economic modelling in end of life care is the value of the huge input made by family carers, which may involve lost earnings, 24-hour care and sometimes physical and mental health consequences from which they may never fully recover. A National Audit Office study  quotes an estimate of £71 billion in 2007 for the value of unpaid care by families, friends and relatives (although this is not limited to care given to people in the last year of life). If the value of this input were made more transparent, it could justify the cost of better support to carers to help them to continue to provide care at home.
- The exact costs of end of life and palliative care are unknown, but in 2006–07, primary care trusts spent an estimated £245 million on specialist palliative care services . This figure does not include the costs of ‘generalist’ health and social care staff (people who do not have specialist palliative care training). The overall cost of end of life care to the public sector is likely to amount to billions, and is unknown.
Potential for cost savings
- Most cancer patients experience admission in the last year of life. The National Audit Office  modelled the cost of caring for cancer patients in the last year of life, and found that the highest costs arise from hospital admissions and length of stay in hospital. A small fall in hospital admissions (e.g. 10 per cent), and reduction of the average length of stay (e.g. by approximately one-third), would deliver cost savings of around £151 million a year.
- Other reviews (of non-cancer patients  and European and United States studies ) show consistently that people in the last year of life often do not need to be in hospital, and that care delivered at home is likely to be cheaper than that delivered in hospitals and hospices.
- A further review of international literature  suggested that even in hospital settings, palliative care delivered by trained palliative care staff was cheaper than the care delivered by generalist or other specialist hospital staff. This suggests that investment in palliative care in both hospital and community settings may save money.
- A National Audit Office survey  concluded that primary care trusts’ expenditure on specialist palliative care services does not reflect the pattern of need.
- Practice example 8. An economic and qualitative evaluation of the Midhurst Macmillan Specialist Palliative Care Service suggests that the service is cost-effective as well as offering maximum choice to people at the end of life.