The latest December-January edition of The Lamp, the magazine of the NSW Nurses and Midwives Association, has raised serious concerns about the integrity of the Silver Chain Group’s move into community palliative care in Western Sydney Local Health District (LHD).

The arrangement means that Western Sydney LHD patients are transitioned to Silver Chain Group’s community palliative care service when it is judged that they have about 3 months to live.

However The Lamp reports concerned palliative care nurses in Western Sydney as saying that the arrangement is really about ‘shifting patients and profits to the private sector’.

“We (currently) have an existing community service delivered by the public health system” they reported a nurse as saying, “years ago we covered people 24/7 but over time it has been eroded and we have had our funding taken off us”.

The previous 24/7 service and the subsequent erosion of funding were not referred-to by Western Sydney LHD Chief Executive Danny O’Connor in his media comments about the launch of the Silver Chain Group’s service in July this year, saying “I’m pleased this service will provide in-home support and make life as comfortable as possible for patients and their families at a difficult time…People should be able to decide where they’d like to spend the end of their lives and this new service gives them the respect they deserve and an option to have their loved ones cared for at home with 24/7 support”.

The Lamp reports the palliative care nurse as saying “we still care for patients in the community but now we are forced to hand them over…there is no continuity of care…It is not about giving patients greater choice; it actually denies them the right to choose”.

Of the recently announced $100 million in enhancements to palliative care in NSW, some $39 million is allocated to Silver Chain Group’s Western Sydney Local Health District service. But this is only for the initial 4 year period.

Silver Chain Group’s service is being funded through a Social Impact Investment, which are facilitated by the NSW Office of Social Investment.

The Office of Social Investment website shows that the Silver Chain Group contract is a ‘payment-by-results’ contract with a  total expected contract value of $80 million over 7.75 years.

The Service will provide 24 hour, seven days a week on-call specialist palliative care services at home including practical support for daily activities, support for families and carers and bereavement support. The service will focus on people in their last three months of life and support patients to die in the place of their choice. The Silver Chain Community-Based Palliative Care Service is expected to support approximately 8,300 people who have an advanced and life-limiting illness. 

According to the downloadable Silver Chain Community Palliative Care Service Factsheet (August 2017) the value of the contract to NSW Health arises from ‘reduced hospital use for people who receive the service, compared to a control group’ because ‘programs that provide community-based palliative care services can significantly reduce costs associated with hospital use’.

What is social impact investment? The NSW Office of Social Investment says:

Social impact investment is intended to save the Government money while improving social outcomes. Part of these savings will be used to repay investors commensurate with the outcomes achieved. Remaining savings can be used to fund other services.

They go on to claim that any savings to government will be returned to the community by improved services in other ways. Much depends on how ‘improved social outcomes’ is measured and the Office of Social Investment says that payments made to Silver Chain Group will be calculated with reference to a comparison or control group:

The service aims to provide patients with quality end-of-life care, enabling patients to be cared for at home if that is their choice, and reducing the time they spend in hospital when it is medically appropriate. Outcome payments made from NSW Health to Silver Chain will depend on the reduction of hospital use by patients receiving the service, relative to a comparison group.

Presumably if the reduced hospital use targets are not met then the community palliative care service reverts to Western Sydney LHD.

The Office of Social Investment goes on to assure reader that decisions about Social Impact Investments (referring to the three initial pilot investments with Newpin, Benevolent Society and OnTRACC) involve a process that is ‘robust, transparent and financially well-structured’ although it doesn’t indicate to whom the process is transparent.

When we spoke with Silver Chain Group about the clinical governance and service delivery issues alluded to in The Lamp their media folk in Western Australia offered this statement:

Silver Chain Group is a not-for-profit organisation and the largest provider of community-based palliative care services in Australia. We have been providing palliative care services in partnership with our public sector colleagues across Australia for more than 30 years, and are excited to be growing our palliative care services in New South Wales and increasing our ability to support vulnerable communities in need.

Community based palliative care in NSW is far from a new concept. Every LHD is doing it. In every case it is designed to help support people at home and to relieve pressure on inpatient care where medically appropriate. So logically the Social Impact Investment model could be applied to every LHD in NSW in the future.

If Western Sydney LHD represents about 12.32% of the total NSW population then by extrapolation the value of all community based palliative care services across NSW is some $650 million over 7.75 years, or about $84 million per year. Here is the breakdown by LHD:

Local Health District LHD population1 % population in each LHD Value of community palliative care $pa
Central Coast LHD 345,377 4.39 3,675,741
Far West LHD 30,620 0.39 325,879
Hunter New England LHD 929,868 11.81 9,896,298
Illawarra Shoalhaven LHD 408,694 5.19 4,349,604
Mid North Coast LHD 222,328 2.82 2,366,168
Murrumbidgee LHD2 294,914 3.75 3,138,679
Nepean Blue Mountains LHD 384,753 4.89 4,094,808
Northern NSW LHD 306,440 3.89 3,261,346
Northern Sydney LHD 915,298 11.62 9,741,234
South Eastern Sydney LHD 928,617 11.79 9,882,984
South Western Sydney  LHD 990,221 12.58 10,538,617
Southern NSW LHD 214,055 2.72 2,278,121
Sydney LHD 654,000 8.31 6,960,320
Western NSW LHD 279,342 3.55 2,972,951
Western Sydney LHD 969,922 12.32 10,322,581
Total 7,874,449 100.00 83,805,332

1 Population is based on 2017 estimates provided at Health Stats NSW.

2 Includes Albury Wodonga Health Service.

Of course, whether community palliative care in NSW is indeed worth some $84 million per year to NSW Health will only be proven if Silver Chain Group can meet their service targets. No doubt there will be considerable interest around the end of their first reporting period in July 2018.

It is hard to see how the Social Impact Investment model will constitute an evidence-based enhancement in community palliative care for vulnerable communities in need.