The Community Based Target Model

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2 The Community Based Target Model Integrated Single System Leadership and Management The Core (as a minimum all LCNs should encompass) Working with High Impact Changes Lambeth Serving geographically coherent populations between 50, ,000 Southwark Lewisham Greenwich Bromley Bexley Leadership team All general practices working at scale (federated with single IT system and leadership) All community pharmacy Voluntary and community sector Community nursing for adults and children Social care Community Mental Health Teams Community therapy Community based diagnostics Patient and carer engagement groups Strong and confident communities Accessible HOT clinics and acute oncology (urgent and emergency and cancer care) Specialist opinion (not face to face) and clear specialist service pathways Pathways to MDTs Integrated 111, LAS and OOH system (interface with UCCs colocated with ED model) Housing, education and other council services Community based midwifery teams Private and voluntary sector e.g. care homes and domiciliary care Cancer services Children s integrated community team and short stay units Rapid response services Carers And there will be others.. Supporting patients to manage their own health (Asset Mapping, Social Prescribing, education, community champions etc Prevention Obesity, Alcohol and Smoking Improved Core general practice access plus 8-8, 365 Enhanced call and recall improves screening and early identification and management of LTCs Reduction in gap between recorded and expected prevalence in LTC Supporting vulnerable people in the community including those in care homes and domiciliary care Reduction in variation (level up) primary care management of LTCs Reablement Admissions avoidance and effective discharge MDT configuration main LTC groups (incl. MH) and Frail elderly End of Life Care Integrated Pathways of care 2 2

3 The Bromley picture An ageing population with increasing palliative care needs as well as population growth estimated at 14% by 2021 compared to the UK average growth of 9% Inequality in end of life care for people with conditions other than cancer. People with cancer were much less likely to die in hospital than people with other conditions (43% cancer and 65% other conditions). Higher than average number of deaths from dementia, 21% compared with a national average of 17.3% Poor patient feedback for the out-of-hours GP provision 1

4 To commission an End of Life Care Model which facilitates and supports people in their last year of life To allow people the opportunity to die with dignity in their normal place of residence, rather than in an acute setting To improve the end of life care for people with non cancer related conditions who have historically experienced a lower rate of home deaths and, in general, poorer end of life care To commission an integrated model that works with all providers (community, primary, acute) to identify end of life care patients earlier and ensure they receive the right coordinated care Next steps include coordinating with Integrated Care Networks (ICNs) to improve outcomes and quality of care for patients 4

5 Started December 2013, commissioned by Bromley CCG The aims of the service are to: Enable people with progressive and advanced illness or frailty to receive timely and well-coordinated care Help people die with dignity in a place of their choice Provide support to their families and carers Reduce unnecessary hospital admissions 5

6 Service Model Unique Features Impact To enable people with progressive and advanced illness or frailty to: receive timely, wellcoordinated care in the final year if life die with dignity in a place of their choice To provide support to their families To reduce unnecessary hospital admissions Case-finding patients in the final year of life Nurse specialist assessment Advanced care planning and Coordinate My Care record Referral and engagement of other services to support integrated care (including four hour direct access to community equipment) Delivery of care with 24 hours access to advice and support Assigned key workers Monitoring and review with rapid response for those whose conditions change Personal care service up to 6 weeks post-hospital discharge High proportion (83%) of patients dying at home. Avoiding unplanned admissions in the final year of life - two of on average 3 admissions costing 6.5k. Estimated cost of new service supporting a caseload of up to K Increased CMC utilisation - patients have an agreed & accessible plan for the end of their lives from 25 to 51% of expected prevalence and from 64 to 644 recorded deaths in 12 months. 30% of caseload live alone 55% of caseload not known to community or social care at time of referral 6

7 End of life care (based on the Bromley model) Benefits associated with the end of life care intervention are based upon: Reduced A&E attendances Reduced admissions prior to end of life Reduce admissions at end of life These benefits are estimated to be as follows: CCG figures in m A&E saving Admission savings In total, the net saving associated with implementing end of life care across south east London is currently estimated to be 4.94m. This is based on each CCG matching the best overall in-hospital death rate of 43%. Net saving Bexley Bromley Greenwich Lambeth Lewisham Southwark Total Confidential Draft in progress Not for wider circulation 7

8 Slide 8 Improving Palliative and EOL care in the London Cancer geography (North Central, North East London & W Essex) Professor Kathy Pritchard- Jones Chief Medical Officer, UCLH Cancer Collaborative*, including London Cancer *part of the National Cancer Vanguard with RM Partners, and Greater Manchester Cancer

9 Slide 9 Our vision for cancer care Create an integrated system of care providing: Local care (including out of hospital care) where possible, specialist care where necessary High performing, high volume multidisciplinary specialist teams that strengthen local services & provide 7/7 access and advice Training and research opportunities for staff and patients Open and transparent data collection and reporting of outcomes and costs to understand value of whole pathway of care Better informed service users UCLH as the system-leader for specialist centres working with local hospitals, GPs and PHE to improve the patient journey from diagnosis to follow-up care.

10 Slide 10 UCLH Cancer Collaborative: Is embedded in the Trust s cancer strategy as 4 pillars : Early diagnosis London Cancer pathway boards and expert ref. groups Centre for Cancer Outcomes New models of care

11 UCLH CANCER COLLABORATIVE VANGUARD GOVERNANCE AND COLLABORATION NHSE Guiding principle: to ensure a sector approach focussing on where the patient need is greatest. National Cancer Vanguard Group (Manchester, Marsden, UCLH) Commissioners (local and NHSE specialist) CCG 1 Vanguard escalation and assurance UCLH (system leader) Cancer Vanguard Board, includes STP leads Collaboration CCG CCG 2 3 Provider 1 UCLP Exec escalation and updates Provider 2 Provider 3 Early Diagnostics Delivery Group Centre for Cancer Outcomes London Cancer Tumour pathway boards and expert reference groups New Models Delivery Group Programme support System Architecture IT/IG HR/workforce All pathway boards interface with EOLC and PallE8 for whole pathway intelligence and improvement: service and workforce mapping, communications skills training, educational events etc Updates on UCLH Cancer Collaborative available at:

12 Slide 12 Benefits for Patients four pillars Earlier Diagnosis patients diagnosed at an earlier stage of their disease, leading to better survival rates, improved experience Centre for Cancer Outcomes transparent published data on outcomes that matter to patients to drive research and improvements in care London Cancer Pathway Boards/Expert Reference Groups improving quality and reducing variation for every patient; bringing appropriate care closer to home; expanding self managed care and reducing waiting times New Models of Care defining a kitemark for chemotherapy to ensure every patient receives improved quality of treatment; linking radiotherapy providers so all patients benefit from new innovations quicker We want to be able to say that our patients are diagnosed faster, have a better chance of survival, a better experience of care whatever their prognosis and are better informed and supported

13 Report for UCLP CEOs and shared with NCL NEL STPs & W Essex CCG 14 March 2016, Caroline Stirling, End of Life Care lead, UCLPartners

14 UCLPartners EOLC workstream (Caroline Stirling) Education o Two education packages based on 17minute films Milestones and You Matter o Aimed to train generic clinical staff in care in the last days of life in hospital and last weeks of life in the community respectively o Dissemination via Train the Trainer route o Milestones 68 trainers, >1200 staff trained in 29 organisations (Sept 2015) o You Matter 167 trainers, >400 staff trained in 7 organisations (Jan 2016) o Staff confidence data show ~20% positive shift and evidence of sustained/further increase in confidence 3-8months later(milestones only) Acute hospitals EOLC community of Practice o 40 trusts represented o Sharing of and support in training methods & materials, strategies, documentation and measurement o Bereaved carers survey co-developed with CSI to be used pan- London 14

15 Mortality by CCGs for All Malignant Neoplasms London Cancer London Cancer Alliance B & D = Barking & Dagenham, C & H = City & Hackney, H & F = Hammersmith & Fulham, H = Hillingdon, I = Islington, K & C = West London (Kensington & Chelsea), K = Kingston, L = Lambeth, R = Richmond, S = Southwark, TH = Tower Hamlets, W = Central London (Westminster), WF = Waltham Forest 15 London Cancer Intelligence, Katherine Henson, senior cancer analyst, PHE

16 Cancer deaths in London London Cancer: 17,288 (annual average ~5,760 pts) London Cancer Alliance: 26,035 (annual average ~8,670) London Cancer Intelligence, Katherine Henson, senior cancer analyst, PHE

17 2 CCGs with <30% DIUPR and 3 getting worse in 14/15 3 CCGs with >60% death in hospital and 5 getting worse

18 NHS England should ensure that: CCGs commission appropriate integrated services for palliative and end of life care, taking account of the Choice Review and other frameworks National Cancer Dashboard to include a metric on proportion of patients with appropriate Care Plan Opportunities to improve value for the system (and patient), prioritisation and delivery now being considered through STP planning processes

19 7.4 End of Life and Palliative Care: National picture: patient experience & choice 73% cancer patients express preference to die at home Achieved in only 30%, 53% die in hospital Inequitable access to 24/7 community nursing and out of hours specialist services that could help patients die in their usual place of residence (DIUPR) National Survey of Bereaved People (2013) Pain relieved completely in last 3 m of life: < 33% dying at home, c.f. 62% dying in hospice

20 7.4 End of Life and Palliative Care: National picture: cost and support Predicted saving of nearly 1,000 for every patient dying in community vs hospital Equates to > 5 million pa for London Cancer population & ~ 13 mill pa for London 60% GPs rated themselves as not/not very confident about initiating end of life conversations about end of life Help for GP s to identify the 1% of patients who are in their last year of life most of these will be cancer patients. Needs to be linked with care planning, integrated/shared records on choice

21 Engagement with London STPs: the 5 Asks May presentation at London STP SPG meeting Paper summarising case for change in EOLC for London, and 5 asks 1. Increase in the number of people identified as being in the last year of life No. of patients entered onto an EPaCCS 2. Reduction in % of people who die in hospital Reported quarterly by CCG via the National EOLC Intelligence Network 3. Provision of 24/7 community nursing, community pharmacy, Specialist Palliative Care Services in all settings 4. Use of an interoperable communications system to document and share care plans for patients approaching the end of life. Adoption of the Resuscitation Council (UK)/RCN - led ReSPECT process. 5. Improvement in patient and carer experience - decision-making, coordination of care and access help and advice when needed. Single point of contact and/or access to a care coordination centre Caroline Stirling, Clinical Director, EOLC London Region

22 How to make progress together Cancer teams (mainly hospital) Clarity on prognosis & support for LWBC/EOLC Holistic needs assessments Timely Care plan(s) to GPs 7/7 access to advice/info Overall treatment plan and Advanced Care Planning responsive to patient s situation Community and EOLC care (GP/Hospices) Slide 22 Cancer Care Reviews & clarity on who may be in last year of life Knowledgeable and confident HCPs Accessible services 7/7 & ability to escalate when required Recovery package elements applicable to all cancer patients Integrated care records and implementation of CMC Cancer intelligence across whole pathway Integrated planning beyond cancer and whole spectrum of EOLC Staff education and workforce development New models of shared workforce and patient/carer activation

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