The NIK audits to date have shown that not all the persons in need have access to adequate palliative and hospice care. Reasons include a narrow list of diseases – mainly cancers – qualifying them for such care and its low availability in villages as well as the financing limits. That is why, part of patients die without receiving hospice care. Due to the progressive aging of the society, the problem with availability of this form of healthcare may intensify. The forecasted increase in demand for palliative and hospice care is the main reason why NIK has taken up this audit.
Shortages of medical staff
In June 2020, palliative medicine was entered on the list of priority branches of medicine. It did not help make doctors more interested in this specialisation, though. According to estimates of the national consultant in palliative medicine, over 100% growth in the number of palliative medicine specialists was necessary to meet the demand in this area. On average, about 30-40 doctors pass the state specialisation exam in palliative medicine every year and this is a stable tendency.
No evaluation of pain treatment organisation
The Minister of Health in the ordinance of 2023 set out organisational standards of pain treatment in outpatient conditions. Though, he failed to prepare tools to evaluate effects of the ordinance implementation. As a consequence, the Minister could not verify if the ordinance “guaranteed each patient effective execution of their right to pain treatment, in line with the current medical knowledge, regardless of the source of that pain, the patient’s age and the place of their stay”.
The ordinance on palliative and hospice care mentioned only eight untreatable, progressive, life-limiting conditions qualifying adults for guaranteed palliative and hospice care services. NIK established that the Ministry did not take any concrete action in 2022-2024 to expand the list of diseases qualifying for palliative and hospice care. The long-term strategy for the development of palliative and hospice care has not been implemented to date and the ordinance concerning this area has not been changed. The Ministry denied NIK auditors access to the strategy draft, saying that the analyses were not finished, and also that the draft was not an official document and may not be made available. It means that the efforts to provide palliative and hospice care have not delivered tangible effects.
The heads of some audited entities considered the closed list of diseases qualifying for palliative care as one of the factors which made it difficult to provide these services. In several cases it was the reason why palliative and hospice care was denied.
More financing, more patients
The financing of palliative and hospice care was growing in the audited period as a result of efforts taken by the Minister of Health. The total value of services settled in 2022 was PLN 1 billion. In 2023 it went up to PLN 1.7 billion and in the first half of 2024 it was PLN 0.9 billion. The increase of outlays for palliative and hospice care was accompanied by an increase in the number of patients. In 2022, the number of palliative and hospice patients totalled 98 thousand persons, in 2023 it was 105 thousand and in the first half of 2024 it was 70.5 thousand.
As already mentioned, despite access to these data, the Minister of Health did not analyse them in terms of demand for medical staff needed to provide palliative and hospice care and did not establish the number of missing doctors, nurses and other medical employees. The forecasted demand for home-based palliative and hospice care will go up in 2050 as compared with forecasts for 2024 by 22% with the forecasted drop in demand for inpatient palliative and hospice care by 12%.
Lifted limits and financing issues
In response to postulates filed for many years by persons interested in palliative and hospice care, the Minister of Health ordered the President of the National Health Fund to lift limits on providing these services starting 1 April 2024. This decision was not preceded by any analysis of overperformance in palliative and hospice care, its value or compliance by healthcare providers with the requirements concerning the personnel and equipment needed to provide this care after lifting the limits.
In the audited period, financial resources of the National Health Fund covered 62%-100% costs of palliative and hospice care provided by the audited entities. Despite lifting the limits, eight in ten entities did not receive funds from the NHF to pay for the palliative and hospice care services provided above the limits set out in the agreements.
Palliative and hospice care in audited entities
Cancers were diagnosed in most palliative and hospice care patients. The average time of providing care in inpatient hospices ranged from 17 to 159 days, and in at-home hospices it was from 12 to 552 days.
In three audited entities the care was denied in 28 cases, mainly because the given condition was not on the list of diseases qualifying for palliative and hospice care. In the opinion of all the auditees, one of the main problems impairing the provision of palliative and hospice care was too narrow list of diseases qualifying adult persons for palliative and hospice care. As a consequence, the end-of-life patients who require palliative treatment, are formally not eligible for this kind of healthcare financed from the public purse.
The audited inpatient hospices usually had adequate rooms and equipment at their disposal. In three entities, though, the patient room doors were too narrow to transport a person lying on the bed. According to NIK the functioning of a hospice where the patient room doors were 78 cm wide is unacceptable. Also, in three entities the access to the patient’s bed did not comply with the law. All the audited entities had medical and support equipment at their disposal, essential to provide palliative and hospice care services. They also used other types of equipment, not mentioned in the Ordinance on palliative and hospice care. The inpatient hospices covered by the audit took efforts to ensure the highest quality of life to palliative and hospice care patients, including procedures to respect the dignity of dying persons.
The NIK auditors established that expired medications were found in nurse’s rooms in three audited hospices. In one hospice the medications containing opioids were not properly secured. In another one the issues related to documenting the distribution of opioids were not adequately supervised.
In two audited entities running inpatient hospices the doctors’ working time was not recorded. Five entities did not meet their obligations to report and update the data about resources to the National Health Fund.
Recommendations
NIK has addressed a recommendation to the Minister of Health to coordinate and speed up works on solutions aimed at improving access to palliative and hospice care services to all the patients in need.
