I am embarking on a full-time PhD looking at the provision of clinical and palliative care at the end of life and specifically asking how the patient voice can be used to effectively influence the way care is delivered.The study will use a realist methodology to pose questions about the comparative value of curative treatment and palliative care, exploring these issues from the perspective of older people at the end of life, clinicians and policy makers. In the current system, the method of determining allocation of funds both within the health system (for example in dividing funds between clinical interventions and nursing care) and between health and social care, is both complex and lacks transparency. The study will explore the rationale behind aspects of health and care decision making and whether the cost of clinical intervention is consciously or unconsciously privileged over that of relational care.

At a time when government is moving increasingly towards more integrated health and social care, evidence based information to inform decisions around budget allocation, relating to treatments offered at the end of life, will be particularly pertinent.

Through analysis of the differences between the views of users, medical practitioners, managers and the reality of current practice, the proposed study will both explore the reason for prevailing NHS culture and pose questions as to whether any action should be taken to redress the balance in the allocation of scarce financial resources. It will also consider how: the way choices are presented to the patient; the level of involvement of the patient in the decision-making process and the types of methods used to plan treatment, may influence choices made. Attention will be paid to the impact that initiatives such as ‘Coordinate my Care’ and the use of ‘Advance Health Care Directives’ may have on influencing treatment options at the end of life.

The changing pattern and pace of dying offers opportunities for patients to participate in planning care for the end of their lives; for ensuring that the burden of unwanted or unnecessary intervention is reduced; and for addressing symptom management, psychosocial and spiritual needs.