Improving end of life care through co-designing and scaling new approaches

Helping health and social care systems support more people to live well whilst ill, and die well. 

Since 2015 we have enabled the NHS to introduce eight social outcomes contracts, supporting the co-design and scaling of improvements in end of life care in different areas of England. 

Why are we doing this?

End of life care supports people with advanced, progressive, incurable illness to live as well as possible until they die and to die a good death’. For many a good death’ involves being without pain, in a familiar place with friends or family and being treated with dignity and compassion. 

  • Every year, around 550,000 people die in England, two thirds of them aged over 75. Three quarters of these people die after a long-term illness and need end of life care.

  • The average cost of care in the community in the last three months of life is £1,000 per person who died, while in hospital it is £4,500 per person who died (source: The Nuffield Trust).

  • Of the 79% of people who would prefer to die at home, only half are able to due to:
    • A lack of community-based services to support people at the end of life.

    • Disparities and inequalities in provision of services.

    • A lack of integration between services such as hospitals, community care and private care.

As a non-profit organisation responsible for developing the world’s first social outcomes contract, we were invited to work in partnership to see if this approach could improve end of life care and be effective and useful in the NHS. 

We worked with organisations including the Department of Health and the NHS Confederation, with support from Professor Bee Wee CBE, National Clinical Director for End of Life Care for NHS England and NHS Improvement. 

Why use social outcomes contracts to improve end of life care?

Social outcomes contracts are a funding approach where money is invested at risk and only repaid if and when certain outcomes are achieved – such as enabling more people to die in their preferred place.

They can be a really effective way to bring about change where different organisations or services are involved and aren’t well integrated. This is because social outcomes contracts align incentives across multiple partner organisations and help to build collaborative working relationships. 

In this case, they also offered other important benefits, including:

  • Upfront investment that wouldn’t have been possible through NHS funding processes.

  • Longer-term funding that wouldn’t have been available otherwise – NHS projects tend to be funded in one-year cycles.

  • A way to secure investment in something new and unproven that had strong potential to bring about change – without risking money from the public purse. The investment is only repaid if agreed outcomes are achieved.

  • Freedom to adapt and innovate according to the needs of different situations, projects or local areas within an overarching funding framework and with a unifying focus on outcomes to benefit people at the end of their lives and health and social care systems. 

A social outcomes contract is an innovative way to finance projects where funding is not tied to specific activities and outputs, but to the outcomes it is aiming to deliver. It can support long-term projects and needs three partners:

  1. An impact investor who can provide at risk, upfront funding with no guarantee they’ll get it back – often a private philanthropic organisation or individual.

  2. An implementing organisation to deliver the programme – often service providers or charities.

  3. An outcomes funder who will pay back the investor if and when the project achieves the desired outcomes – for example a government or commissioner.

Learn more about social outcomes contracts.

What are we doing?

We have co-designed, tested and delivered eight end of life care social outcomes contracts across different parts of the UK. Three projects have successfully completed and five are still running. 

We work in partnership with experts and advisors, through a special purpose vehicle – a company – called the End of Life Care Integrator (EOLCI). The work of the EOLCI is supported by investment from Macmillan Cancer Support and Big Society Capital through the Care and Wellbeing Fund. 

The Care and Wellbeing Fund was created to support and test the potential of social investment to improve health and social care systems.

It also supports our Healthy Communities project and a new project Macmillan Cancer Support have launched themselves using social investment to improve end of life care after they saw the impact that we had together. 

The fund is closed to new projects and existing projects will all be completed by 2027.

Read a retrospective report on the Care and Wellbeing Fund

Through developing and delivering the eight outcomes contracts, we have provided: 

  • Upfront investment and support for community-based projects to improve outcomes for people at the end of their lives and for health and social care systems that support them.

  • Access to expertise and rigour in planning, developing business cases, partnership working and performance management for the duration of the contract.

  • Data analysis to track the outcomes for people and understand the value of the new ways of working to health and social care systems and services.

  • Dashboards to support continuous learning and empower people to make change.

  • Advice on how to develop contracts for outcomes-based commissioning of services.

people supported by our services 
NHS and charity partners to deliver new services 
£3.4m and £9m
invested in eight projects 

Impact and insight

We have shown that social outcomes contracts can work well to fund and support community-based services within health and social care systems, including the NHS. 

The contracts we developed have:

  • Enabled thousands more people to live as well as possible with advanced, progressive and incurable illness by reducing health inequalities and reducing time spent in hospital through:
    • Better coordination between service providers such as care homes and hospitals.

    • Greater integration of decision-making.

    • The creation of new services to support community-based care, for example a service providing rapid access to community-based end of life care, so people can still die in their preferred place even when their situation changes quickly.

    • A reduction in emergency admissions by proactively identifying end of life residents, influencing their management and helping document their wishes. 

  • Enabled thousands more people to experience better care in the last year of life and die in their preferred place by:
    • Helping more people create advanced care plans so when they become ill towards the end of their life there’s a plan ready, agreed with family, that can be acted on quickly.

    • Creating community-based support.

Finally, we’ve helped to transfer key skills into the team at Macmillan Cancer Support so they can develop and manage social outcomes contracts themselves. 

Macmillan, in partnership with Sobell House, have since launched a new £9m EOLC project using social investment after seeing the impact we have had. It is the biggest social outcomes contract in the NHS and the first one directly contracting with a provider – Oxford University Hospital.

About our team

The End of Life Care Integrator is run by Social Finance along with a team of independent experts and advisors, including clinical and NHS staff with a wealth of experience in palliative care, healthcare management, strategy and finance. The EOLCI team at Social Finance has a wide range of backgrounds including NHS senior management, central government policy experience and clinical leadership.

Dr Sarah Russell RGN (strategic advisor)

Co-chair Advisory Group, Lead Nurse Palliative Care, Portsmouth Hospitals University NHS Trust.

Nigel Hopkins (Chair of EOLCI board)

Experienced non-executive director.

Adrienne Betteley (strategic advisor)

Strategic Advisor Macmillan Cancer Support and Co-Chair of National Ambitions Partnership.

Dr Iain Lawrie, (strategic advisor)

Consultant & Honorary Clinical Senior Lecturer in Palliative Medicine. President, The Association for Palliative Medicine of Great Britain & Ireland.

Dr Pauline Love (strategic advisor)

EOL Clinical Lead Derby & Derbyshire CCG. Macmillan GP Advisor. East Midlands Derbyshire LMC representative.

Sam Cheverton (strategic advisor)

Director of Strategy and Impact, Marie Curie UK

Diane Laverty (clinical specialist)

Diane has worked in palliative care for over 30 years and has experience in all organisational settings, including specialist cancer trust, acute trust, community and pre hospital care.

Diana Howard (clinical specialist)

Diana is a palliative care nurse who led and developed the hospital palliative care team at Imperial College Healthcare NHS Trust. She was also Director of Nursing at Coordinate My Care, an electronic palliative care coordination system.

Owen White (contract and finance specialist)

Owen is a chartered accountant / finance director with 30 years post qualification experience in the NHS and commercial sectors. They have health experience on both the provider and commissioner side.

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