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Death, like conception and birth, is one of the few universal human events. In England, where there are about 500 000 deaths a year, there is evidence that some 120 000 people would benefit from palliative care in their terminal illness. How many of them actually get it? My train of thought turns to my time as Dean of Southampton Medical School. After all, it is at medical school that many of the attitudes of doctors are formed. Did we at Southampton give comparable emphasis to the end of life as we gave to its beginning—human reproduction and obstetrics? Fortunately a hospice with exemplary standards was at hand, and all students visited it. But was that enough? It certainly should be a minimum for everyone. The burden of palliative care cannot be borne wholly by the specialty, although it must give the lead. Almost everyone who undertakes clinical work will sooner or later be involved in the care of someone who is dying.
My next point concerns social equity. Do we in the UK distribute the slender resources of palliative care according to need? If experience in other fields is a guide, this is unlikely: in terms of most other aspects of health and social policy ours is one of the most unequal societies in the developed world.
Let me offer two examples that are well evidenced. In both men and women the difference in expectation of life between professional people and labourers has continued to grow in recent decades so that the difference in men is now almost 10 years—surpasssed only by one other developed country, the USA. In women the social differences in life expectancy are less but are also growing. Likewise for many areas of healthcare. Within London, the uptake of health promotion initiatives is the reverse of what is needed—greatest in the wealthiest parts of the metropolis, least in the poorest. Another example is coronary artery surgery, where services do not match the great geographical variation in need1.
It is an almost universally applicable rule that, unless corrective action is taken, all policies relevant to health and healthcare will be taken up to a greater extent by the better off than by the poor. Palliative care is unlikely to be an exception. Therefore, all the new instruments created by the present British Government to address the need for greater equity within the National Health Service should take account of palliative care. A national service framework might be created for it and the National Institute for Clinical Excellence might also address it.
Finally, what is the environment in which most people would wish to die? In comfort and warmth, with nearest and dearest at hand, if this is possible; but where? At home or in hospital? For some, ‘home’ means neither warmth, comfort, support nor indeed love. In that case a good hospice should truly become their home.