Ensuring a peaceful and dignified death, and improving choice for patients about their place of death, are key concerns for commissioners of end of life services.

Following discussions with patients, the public, GPs and staff at NHS Nene Clinical Commissioning Group, ensuring there was more choice for patients at the end of their life was identified as a significant priority and the key focus in developing end of life services in Northamptonshire.

Research shows that around 70% of people would prefer to die in their own home, but the reality is that around 60% still die in hospital. The end of life service aims to reduce the proportion of people dying in hospital by 9.7% by 2013.

The service is already well on its way to achieving this aim as between 1 April 2011 and 31 January 2012, there was a 9.32% reduction in the proportion of deaths occurring in hospital. There has also been a 26% reduction in excess hospital bed days experienced by those at the end of their life, compared to the previous year. This illustrates the added value associated with timely facilitated discharge for those at the end of life.

Dr Matthew Davies, End of Life GP lead for Nene Commissioning, said: “In addition to choice of place of death, it is also vitally important that adults at the end of their life should receive appropriate, high quality care from services and support that focuses on their individual needs and that of their carers.

“Therefore Nene Commissioning, working with local GPs, acute and community based clinicians and professionals from carer and voluntary agencies, led the redesign of the local services procured which provide:

• A 24/7 Central point of contact where care is coordinated
• A nurse led rapid response service providing domiciliary based care within an hour of referral
• End of Life link nurses in both acute hospitals to support end of life discussions with patients and their family, and facilitate timely safe discharge home where this is the patients expressed wish.”

To help develop the service, public focus groups were utilised to obtain views on services required, and discovery interviews used to evaluate services received.

As a three year business case, the service aims are to reduce the proportion of people dying in hospital by 9.7% by 2013, and costs were calculated assuming an incremental approach to implementation. Over the course of the business case, the total cost of operating the above end of life community services is £3,096,000, thus generating a total net saving of £532,000 over the 3 years. However the sustainable recurrent savings for each year beyond year 3 is £1,697,000 per annum. and recurrent annual costs forecast at £1,335,000 per annum realising sustainable savings of £362,000 per annum.

The husband of a patient who used the End of Life service has praised the service which meant that his wife could die at home. This involved coordinated support from a range of services including Hospice at Home, District Nursing, Age UK, Cynthia Spencer Hospice and Macmillan.

Janet died at home from terminal cancer in October 2011. She went into Cynthia Spencer Hospice in July 2011 but James was keen to have her back home. He underwent training to use hoists and Janet came out of the hospice. When Janet came out she started off with two carers visiting twice a day and a twice weekly visit from the District Nurse.

As the tumour spread and the cancer worsened, Janet received visits from two carers three times a day, as well as regular visits from the Hospice at Home service, GP and District Nurse.

On the day Janet died, James called the Northamptonshire Out of Hours service at 7.30am. They were visited by Age UK and then the District Nurse who had to change Janet’s prescription in the syringe driver.

Janet died peacefully at home at 10.30am. James said: “I had support from all the services, there were so many people that got in touch, I lost count.

“I think more people should die at home really. I had all the support I needed – there wasn’t anyone else I needed really because they were all here.”

The names of the patient and her husband have been changed to protect their privacy.