Hospital and Ambulance Service use by people in their final year of life in Northern Ireland

Executive summary
Rising chronic illness and an ageing population are increasing demand for end-of-life care in Northern Ireland (NI). Many people require use of hospitals and emergency services in their final months, highlighting the need for better coordination and patient-centred care. However, there is an important gap in understanding how people in their last year of life use acute healthcare services such as the Northern Ireland Ambulance Service (NIAS), Emergency Departments (EDs) and hospitals.

This report was funded by Marie Curie and produced as a collaboration between Queen’s University Belfast (QUB) and NIAS. We report findings from population-based healthcare data on hospital and ambulance use for people in their last year of life in NI. For hospital admissions and ED attendances, this report used anonymised Health and Social Care (HSC) data, linked to death records from the General Register Office for all deaths* in NI between 2014 and 2023. Data were obtained from the Honest Broker Service (HBS), the secure data environment for HSC NI. Ambulance service data was compiled by a keyword search of 999 call records, which were used to identify people receiving palliative and end-of-life care (PEoLC) at the time of the 999 call.

This report also provides system-level cost estimates for hospital, ED and ambulance service use by people in their final year of life in NI.
Our findings show that many people in their last year of life attended ED or were admitted to hospital, often multiple times. This included admissions in both the emergency and elective (planned) settings, with frequent involvement of the ambulance service. This report explores patterns of care, identifies gaps and provides a foundation for future service planning.

Key findings
Hospital activity
1. Of the 161,375 people who died in NI from 2014-2023, 82.1% had at least one hospital admission in their last year of life. There was a total of 607,034 hospital admissions among individuals in their last year of life, an average of 3.8 admissions per person. Of these admissions, 47.9% were elective day cases, 46.0% were emergency admissions, while the remainder were elective inpatient (4.2%) and other (1.9%).
2. Admissions among individuals in their last year of life accounted for 10.5% of all NI hospital admissions (10.0% of elective day cases and 11.1% of inpatient admissions) during the 2014-2021 financial years.
3. The annual number of hospital admissions for patients in their last year of life increased from 58,860 to 62,166 from the 2014-2021 financial years, representing a 0.7% increase per annum.
4. The most common reasons for emergency admission in the last year of life for people who died in Northern Ireland from 2014-2023 were infection (30.2%), cancer/metastatic disease (10.3%), respiratory causes (9.2%), and cardiac causes (8.5%). Individuals in their last year of life had, on average, 1.7 emergency admissions per person. The majority (90.2%) of emergency admissions had a longer stay in hospital (defined ≥24 hours), with an average length of stay of 13.8 days.
5. One in two (51.0%) of emergency admissions were from males, and people aged 80 and older (49.9%). Emergency admissions were more common in deprived areas of NI, with 22.3% occurring in the most deprived areas compared with 17.9% in the most affluent areas. Northern and Belfast Health and Social Care Trusts made up the greatest proportion of emergency admissions (24.7% and 22.7% respectively).
6. Of the 161,375 people who died in NI from 2014-2023, eight in ten (81.6%) had at least one ED attendance in their last year of life. There was a total of 364,484 ED attendances among individuals in their last year of life, an average of 2.3 attendances per person. Two in three ED attendances (67.8%) resulted in emergency admission to a hospital ward. Over two thirds (68.2%) of patients arrived at ED by ambulance. Three in five (59.3%) ED attendances occurred out of hours (outside 9am-5pm Monday to Friday). The most common primary reason for attending ED was infection (20.6%).

Ambulance service use
7. In terms of ambulance service usage by people identified as receiving palliative or end-of-life care, nearly 1 in 4 (24.0%) emergency calls came from areas of highest deprivation.
Approximately 1 in 5 (19.2%) emergency calls occurred in the morning between 9am and 11am and 57.1% of all calls occurred out of normal working hours.
Over half (58.3%) of people who interacted with NIAS were transferred to hospital by ambulance with 30.8% being referred or discharged by a NIAS clinician, and 10.9% having died at scene.
It is estimated that 19.9% of the NIAS emergency workload relates to people in their last year of life; however, this includes deaths not directly related to palliative or end-of-life care i.e. death from sudden causes such as trauma or cardiac arrest.

Costs
8. Emergency and acute care for people in the final year of their life generated an estimated £1.73 billion in health-system costs for people dying between 2014 and 2023. Hospital admissions dominated expenditure (85%), with ambulance (9%) and ED (6%) costs comprising a smaller share.
Expenditure was concentrated in prolonged emergency inpatient stays (90.2% were longer than 24 hours), demonstrating that system pressure and costs at the end of life are driven more by length of stay than by the high volume of short-stay, day case, or ED activity


*Note: the hospital data included all people who died, regardless of cause of death or underlying health conditions, and were not limited to people receiving palliative or end-of-life care.

This report was supported by Patient and Public Contributors:
Tim Kerr - Northern Ireland Cancer Research Consumer Forum
Michael McGreevy - Northern Ireland Cancer Research Consumer Forum
Kim Elliott - Marie Curie Research Voices Group