BLOG - Location of death in 2020: a changing trend from hospitals to homes

This week, SCADR researcher, Dr David Henderson, discusses how the COVID-19 pandemic has changed the patterns in location of death and the various questions this raises.

From February 2020, Government bodies and Health Boards prepared for an influx of very unwell patients due to the effects of COVID-19, resulting in an unprecedented reconfiguration of hospital services at rapid speed. During this time, when the effect of lockdown measures was an unknown quantity, concerns were rightly raised that acute and critical care NHS services could be stretched beyond their capacity.

Reviewing figures reported by National Records of Scotland (NRS) in Scotland, has shown two striking differences occurring, when compared to the same time (weeks 11-20) in previous years:

1. Emergency admissions to hospital had fallen below normal levels – particularly for non-COVID-19 conditions
2. Subsequently, deaths in hospital not attributable to COVID-19 are much lower than average. 

Whilst hospital services have understandably focussed on prioritising COVID-19 care, the question about ‘where’ these 'normal deaths' have occurred has arisen. Using the statistics on location of death, published by the NRS, we can illustrate location of death in the figure above.

We can see that in the first 10 weeks of 2020, deaths by location were, by and large, similar to the average in the preceding 5 years. The first death from COVID-19 in Scotland was recorded in week 12. For weeks 11-20 that deaths in hospitals not attributable to COVID-19 are markedly lower, whilst those in Care Homes and, particularly at home, or in non-institutional settings have increased.

It is important to note that the above figures do not include deaths due to COVID-19 which significantly affects the overall numbers of deaths in Hospital and Care Homes. The purpose of excluding them here, is to try and understand how the location of 'end-of-life' has shifted for "normal" deaths.

The increase at home and community settings raises numerous questions about how primary care, social care, and care home services have been affected by the reduction in hospital-based deaths – particularly where there was a need for palliative care.

Whilst aggregate statistics published by NRS are very useful for identifying crude trends, linking individual-level administrative data has the potential to offer stronger analyses. Currently we do not know how many care home residents have died in hospital due to COVID-19. Other questions to explore include:

• What services did those dying at home require in their last-days?
• Will the trend of dying at home persist beyond the pandemic, or will hospitals return to being the “normal” place of death?
• Will the barriers that were broken in securing rapid transfer out of hospital remain after the pandemic, or will the level of delayed discharges rise once again?

Further details - article on Scottish Care Homes and COVID-19 available here.

What next?

The questions above are just some of the questions that the Scottish Centre for Administrative Data Research (SCADR) researchers will aim to answer over the coming months and years, using administrative records to enhance our understanding of end of life patterns and care and the ways we might need to adapt or enhance our services and support in this area.

If you would like to discuss these findings, please tweet @_davidhen