Palliative care budget needs to be better spent

by Stephen Duckett

Published by the Australian Financial Review, Monday 16 April

It is rare that a group of economic hardheads recommends expansion of services, but the Productivity Commission recently did just that. In a report with the somewhat obscure and threatening title of Introducing Competition and Informed User Choice into Human Services, the commission calls for a big increase in palliative care investment.

In particular, it recommends that:

  • State and territory governments increase the availability of community-based palliative care so that more people who want to die at home can get support to do so.
  • End-of-life care should be core business for aged-care facilities, and the quality of end-of-life care in residential aged care should be no lower than the quality of end-of-life care available to other Australians.

The Productivity Commission’s recommendations are unequivocally good. The only problem is they don’t go far enough. Palliative care services don’t just need expansion, they need a revolution.

Expenditure on people in the last year of their life consumes about 10 per cent of public hospital budgets in Australia, and is increasing faster than inflation. Yet the money is not well spent.

Life expectancy increases in Australia have principally been driven by reducing death rates in the early years of life. Increased health care spending at the end of life has not yielded significantly increased life expectancy for people over 85. Life expectancy for women over 85 has increased by less than one month in the past decade, and about three months for men.

Quality of life may not have improved either. Increased medical interventions mean many Australians are dying in ways not consistent with their wishes – too often in hospital, too often unable to speak and say goodbye, and too often leaving family and friends with lingering images of an undignified death.

Significant investment

We need to change the way we manage death. A 2014 Grattan Institute report, “Dying well“, argued for a significant investment in palliative care. Hesitant steps have since been taken in that direction. The Productivity Commission report should provide a further stimulus.

More money for palliative care is necessary, but not sufficient. The way the money is allocated needs to change. Palliative care funding needs to be redesigned so it aligns with the policy objective of enabling as many people as possible to die where they want to, rather than where the health system wants them to.

The Productivity Commission also calls for a comprehensive review of standards in palliative care. This is long overdue. Too often palliative care in Australia has overlooked the needs of the patient. The law has long allowed terminal sedation to relieve apparent pain as a person is dying, and yet care providers remain fearful of over-medicating dying patients.

Religious organisations, which have traditionally provided extensive palliative care services under contract to government, will have to come to terms with new, stronger patient rights about how they want their pain managed – not to mention responding to requests for access to assisted dying.

The Productivity Commission’s report received scant media attention when it was released. That is a great pity because it provides sound advice on ways to ensure more Australians die well.