SDHI Seminar

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Inequalities in access to inpatient palliative
care

• Tony Gatrell
• Professor of the Geography of Health and Dean of
  the Faculty of Arts Social Sciences
• Lancaster University

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Outline of presentation

• Brief introduction to end-of-life issues and
  palliative care
• Inequities in place of death, with particular
  reference to Morecambe Bay
• Equity of access to adult hospice inpatient care
  in NW England
• An International Observatory on End of Life Care

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Palliative care

• Directed at providing comfort and relief to a
  terminally-ill person, through symptom and pain
  management
• Good care addresses mental and spiritual needs
• It may be offered in specialised settings
  (hospices) but also at home and in hospital
• Focus here is primarily on patients with terminal
  cancer rather than other causes of death

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Place of death among cancer patients in Morecambe
Bay

• Place of death is distributed primarily among
  home hospital and hospice
• But since people terminally ill with cancer, in
  general, prefer to die at home (70) or in a
  hospice, are there inequities in access?
• What factors predict place of death? Study of
  deaths 1993-2000

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Background to study

• Existing evidence of a relationship between death
  at home, and deprivation (work by Irene
  Higginson) next slide
• But there is a geography to this. We need to
  allow for the supply side low rates of home
  deaths may be due to relatively good provision of
  hospice services

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Setting and data

• Three main centres of population
• Lancaster/Morecambe (hospice in Lancaster with 21
  beds)
• Barrow (hospice in Ulverston with 8 beds)
• Kendal (south Lakeland)
• Data postcode, age, sex, place of death, cancer
  site, year of death electoral ward of residence,
  catchment area and Carstairs index added

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Forms of analysis

• Binomial regression models fitted to ward-level
  data, looking at impact of deprivation
  (Carstairs) and other factors
• Binary logistic regression models fitted to
  individual-level data, for each place of death
  (that is, what explains home v other PoD,
  hospice v other PoD etc)

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Figure 1
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Summarising.

• Once we allow for other factors we can picture
  the effect of deprivation on place of death, by
  taking a hypothetical ward located 15 km from
  Lancaster.
• This shows that deprivations has no effect on the
  probability of dying at home (or in a hospice)
  but it does for hospital.

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Figure 2
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Individual level analysis

• Results here suggest that cancer patients are
  more likely to die at home if
• They live in more affluent wards
• They are male
• They are relatively young
• They have a respiratory cancer
• They live in Barrow or south Lakeland
• Note we lack individual data on occupation

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Summarising.

• There are inequalities according to age and
  gender in place of death
• No data on individual occupation, but there is
  evidence that area characteristics playa part in
  influencing place of death.

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Equity of service access

• Access to, and availability of, specialist
  palliative care services is variable and
  inequitable throughout the country
• Looking at hospice care in particular
• a significant proportion of people with advanced
  cancer suffer from a range of complex problems
  physical, psychological, social and spiritual
  which cannot always be dealt with effectively by
  generalist services in hospitals or the
  community
• (NICE Guidance, 2002)

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Equity of service access

• To what extent are hospices in the NW provided
  equitably?
• To answer this we need data on
• Locations of hospices and bed supply
• demand for service (cancer incidence)
• Travel time assumed via road network
  characteristics

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Data

• 27 hospices providing in-patient care (4-36 beds)
• Access score for each electoral ward derived
  using a simple gravity model
• Deprivation scores for 1019 wards
• Age-specific death rates, for all cancers,
  applied to small area population data to predict
  cancer demand

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International Observatory

• AIMS
• To provide clear and accessible research-based
  information on palliative care in the global
  context using social science methods
• To disseminate this information through the
  Observatory website and through other means
• To undertake primary research studies and reviews
  to generate such information
• To develop a small grants programme to support
  academic work in resource poor regions
• To work in partnership with key organisations and
  individuals locally, nationally and
  internationally
• www.eolc-observatory.net

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