The Suffolk Marie Curie Delivering Choice Programme

Transcription

1 The Suffolk Marie Curie Delivering Choice Programme Phase III A report on progress and achievements Date: April 2012 Author: Sandy Barron Project Lead Manager Design and Development - MCDCP 1

2 Table of Contents Page No. 1 Executive Summary 3 2 Purpose of Document 4 3 Overview of the Marie Curie Delivering Choice Programme 4 4 Background and approach to Suffolk MCDCP 5 5 The Marie Curie Delivering Choice Programme and QIPP 6 6 Progress of Project 8 7 Conclusion 15 8 Appendix 16 Acknowledgements I would like to thank the members of the Executive Board and Stakeholder Steering Committee of the project who have provided such good support for the project team. Within the community, the community palliative care team, the district nurse teams, community matrons, GPs, care homes, social workers and ambulance service staff have embraced, provided and helped coordinate our efforts to implement the proposals. The staff of the hospitals members of the palliative care team, St Elizabeth Hospice and St Nicholas Hospice Care provided us with a great support and enthusiasm, as did the local Marie Curie Nursing Service, and other voluntary sector organisations. Finally I would like to thank the patients and carers. Improving NHS Suffolk Deaths in usual place of residence: Year % Start of project April April 2011 February

3 1. Executive Summary I. This document provides an overview of the implementation of the Suffolk Marie Curie Delivering Choice (MCDC) programme. This programme was commissioned by NHS Suffolk to increase understanding of palliative care and end of life need, across all life limiting conditions, and to improve the provision of choice at end of life regarding the place of care / death. II. III. The programme links to and is an articulation of the Suffolk response to the national, regional and local strategic framework for palliative and end of life (EOL) care. The MCDC programme commenced in April 2010 and completed in March Numerous stakeholders have been involved, including hospitals, nursing homes, hospices, Ambulance services, Out of Hours providers, local GPs, social services, patient support organisations and patient/carer representatives. IV. The Marie Curie Delivering Choice methodology comprises of three phases: i) whole system needs assessment ii) redesign, and iii) implementation and evaluation. V. Phase I showed that palliative and end of life services in Suffolk, both specialist and non-specialist, are of a high quality. Stakeholders engaged in Phase I all demonstrated a strong commitment to providing the best possible care for patients and their carers and have highlighted many examples of existing good practice, as well as taking time to reflect on the scope for improving services. VI. VII. VIII. IX. In Phase II, an end of life care pathway was designed. Following a system wide agreement to implement, working groups designed proposals to support the pathway. Phase III has been concerned with implementing the pathway via cost neutral service improvement; this work is to be continued within the QIPP plan via CCGs. The implementation of the MCDC programme has raised the profile of palliative and end of life care and allowed the agreement and implementation of local plans for improvements to the quality and choice of care/place of death for people affected by a life limiting illness. The MCDC programme will form a firm basis for further collaborative working across the local stakeholder organisations. There is ongoing implementation action and QIPP plans arising from the MCDC service improvement workshops and discussion with End of Life clinical leads which will improve quality, choice and deliver cost savings based upon a reduction in inappropriate admissions to the acute care setting in the last year of life. The challenge for GP commissioners will be to continue to lead and maintain the momentum that has been established around the MCDC programme so that the local population can be confident that high quality, well co-ordinated, palliative and end of life care will be provided in an equitable manner, 24/7, to support the delivery of patient choice at the end of life. 3

4 2. Purpose of Document The purpose of this report is to present a summary to date of progress and achievements relating to the Suffolk Marie Curie Delivering Choice Programme, one of the seven workstreams sponsored by the East of England Towards the best, together Palliative and End of Life Clinical Programme Board in partnership with participating PCTs. The report includes an overview of the Suffolk Marie Curie Delivering Choice Programme and a summary of how the programme is supporting delivery of the Suffolk Programme in relation to end of life care. The differing demographics, geographies and particular challenges relating to Suffolk are set out in the Phase I report. This information was gathered as part of the extensive investigation into the current state of services carried out in Phase I of the programme and during Phase II a number of service improvements were developed in order to effect whole system change and these are presented in this report. The plans and progress in relation to Phase III implementation and evaluation of the improvements designed and developed (as far as these have been developed) are also set out in this report. 3. Overview of the Marie Curie Delivering Choice Programme Background "Our aim is to develop and provide the best possible services for palliative care patients, allowing them to be cared for in the place of their choice." The Marie Curie Delivering Choice Programme was launched by Marie Curie Cancer Care in The overriding aim of the programme is to develop and help provide the best possible palliative care services to support patients with terminal illnesses (irrespective of diagnosis) in making choices over their place of care and death. Most people in the UK (64 per cent) would choose to die at home if they had a terminal illness, yet more than half still die in hospital. With this programme, Marie Curie Cancer Care aims to double the number of terminally ill people who are able to die at home. In making palliative care in the community a genuine option and reducing the occupancy of hospital beds, the expectation is to provide opportunities for cost savings in the acute sector over the long term. The programme aims to play a role in optimising partnership and better communication across all partner organisations to promote more accessible and integrated care for patients. Working in partnership with a broad range of local service providers, including the NHS, social services and the voluntary sector, the programme aims to achieve three key objectives: 1. To develop patient-focused 24-hour service models that serve local needs and ensure: The best possible care for palliative patients Improvements in equity of access to services Appropriate support services for palliative care patients and their carers 4

5 Choice in place of care and death is available to all Information on choice is available and known to all Improvements in coordination of care among stakeholders 2. To evaluate the economic impact on healthcare services of more patients receiving palliative care at home as compared to hospitals 3. To disseminate findings to other health and social care providers, leading to replication of solutions across the UK Whole system approach Palliative care is typically provided by a range of organisations and professional groups. Traditionally, improvements in care focus on the individual service, often without reference to the complex relationships between services. The Delivering Choice Programme s service redesign methodology is based on whole system thinking (also referred to as systems thinking ). Using this holistic approach, the programme helps care providers and commissioners to examine the whole structure of palliative care delivery, with an emphasis on the interactions between services. One of the main objectives of the programme is to share findings generated from other projects. This has been achieved by using a toolkit that provides comprehensive information on service models that have been implemented in MCDC projects, including operational guidelines, evaluations and other valuable learning. 4. Background and approach to the Suffolk MCDCP Together, we will develop and help provide the best possible service for palliative care patients allowing them to be cared for in the place of their choice. Marie Curie Cancer Care initiated the Marie Curie Delivering Choice Programme in order to see better planning, choice and co-ordination of high quality palliative care for patients. The programme involves the collaboration of health, social care and other organisations across a locality with the aim of making significant improvements in palliative and end of life care across the whole system. 'Towards the best, together (2009), the strategic vision for the NHS in the East of England, set out the following goals for end of life care: Deliver world class standards in choice of place of death Set and monitor core best practice standards for all end of life providers Create and extend support services for all families and carer s including bereavement support Ensure needs assessments and advance care planning for all identified as being in their last year of life 5

6 Guarantee better access to supportive and palliative care services, particularly out of hours Work with the public to raise awareness of end of life issues Establish a palliative and end of life care board and create end of life care networks The National End of Life Care Strategy (2008) and the National Audit Office End of Life Care Report (2008) both highlight the importance of adopting a co-ordinated system wide approach to the commissioning and delivery of services for end of life care as these are delivered by a variety of health and social care providers across the statutory, voluntary and private sectors often resulting in fragmented care. The End of Life Strategy recommends the Marie Curie Delivering Choice Programme as an example of good practice. Describing the programme as a service development model which can be used to guide commissioning, the strategy comments By using a whole systems approach and introducing interventions which impact on the whole patient pathway, the programme has increased the number of patients supported to die at home and has decreased the number of emergency admissions to hospital in the areas where the interventions are in place. Recognising the ability of the Marie Curie Delivering Choice Programme to enable delivery of the vision and outcomes expressed in 'Towards the best, together' and the National End of Life Strategy along with the programme's potential as a key commissioning resource, an SHA wide model of implementation was developed with Marie Curie Cancer Care (MCCC). All PCTs across East of England were invited to participate in this regional model. Suffolk was one of the first PCTs to sign up. To support the overarching programme approach to implementation of the programme in the East of England, Suffolk joined a project network that was set up with the aim of bringing together all of the MCDCP projects across the region. The project network has provided the opportunity to: Share information, experiences and lessons learned across all projects and localities, avoiding duplication of effort wherever possible. Resources The programme was jointly supported and resourced by the SHA and NHS Suffolk. The SHA signed a contract with Marie Curie Cancer Care on behalf of the participating PCTs for 2 years from July This included the MCDCP toolkit licences and support of the MCDCP programme manager and expert advisory service. The SHA also provided the support of an overall programme manager. The PCTs were each expected to fund a fulltime project manager and full-time project support and cover any additional project costs. 5. The Marie Curie Delivering Choice Programme and QIPP The aims and objectives of the Marie Curie Delivering Choice Programme align well with the core principles of QIPP: Avoiding unnecessary referrals and admissions 6

7 Early discharge Care closer to home Choice Integrated provision around the patient Minimal handovers No duplication of input or service Improved health and wellbeing experienced by individuals accessing the service They also fully support and enable delivery of the National End of Life QIPP Workstream agenda with its emphasis on: Early identification of people approaching the end of life and support for clinicians to know when and how to have conversations about end of life care Assertive planning and management of end of life care Minimisation of inappropriate interventions at end of life Strategic investment in community support, undertaking analysis of PCT investment, presenting evidence base for alternatives The programme in Suffolk has been embedded within local QIPP delivery plans for End of Life Care which has been developed in line with national and regional requirements including: Key performance indicator identified that being:- Number of patients dying in their usual place of residence (home or care home) 20011/12 EoE QIPP target - Suffolk KPIs - Table 1 This work identified the real potential for palliative care services to reduce expenditures associated with hospitalisation, whilst at the same time accommodating the expressed preferences of patients. The Key Performance Indicator for QIPP monitoring was developed using Suffolk data requiring a reduction of 202 in number of emergency admissions in the last 8 weeks of life and an increase of 202 at home/care with nil increase in other areas for 2011/12. Q1 Q2 Q3 Q4 Total 2011/12 Proportion of deaths in usual place of residence 44.0% 46.0% 48% 51% 47.3% 7

8 Deaths among NHS Suffolk residents between Jan 2010 and Dec 2010 (Provisional data) Source ERPHO & NHS Suffolk - Table 2 Apr May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Total Trajectory (Deaths at home) % Number of deaths at home Difference The Suffolk programme has also worked to ensure that developments were closely aligned with any other projects and initiatives where there may be overlaps and the potential to work together. For example work around, Dementia, Urgent Care and Transforming Community Services. Deaths at home, among Suffolk residents - Table 3 % Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Progress of Project Project Timescales Getting Started & Set Up Apr May 2010 (2 months) Completed Phase I Phase II Commissioning Phase & Phase III Jun Nov 2010 (7 months) Completed Dec Mar 2011 (4 months) Completed Commenced mid April March 2012 Background A full time project manager was recruited and in post by April 2010, some administrative support has been available to support the project manager and an additional resource for the project during Phases I and II was also provided by Suffolk County Council Adult Care Services. Phases I and II (including delivery of Phase I and Phase II reports) were completed to plan. 8

9 Following completion of Phase II and approval of the proposals by both stakeholder committee and executive project board a summary paper outlining them was presented to the NHS Suffolk Executive Management Team on 23 May Approval to proceed to Phase III implementation was given for some of the proposals within the proposed integrated service model, the remaining elements will be sought for implementation through CCGs. The project team have been working, planning and implementing the proposals approved so far using a phased approach. The progression of the MCDCP projects into Phase III implementation has been impacted by the changes underway across health and social care: Change to government June 2010 Changes to commissioning - from PCT led to GP led, planned disbanding of PCTs and development of GP commissioning consortia (now clinical commissioning groups) Transitional changes to organisational structures within PCTs and PCT clustering. Service Proposal 1: Care Pathway for end of life patients It was agreed to implement the Suffolk End of Life pathway 1 to provide health and social care staff with a mechanism to provide care in a flexible and responsive way whilst still maintaining high quality care throughout the 24 hour period. The pathway is inclusive of all palliative care patients irrespective of disease type or their identified home. The implementation of the end of life care pathway will ensure that palliative care patients and their carers/families receive seamless care with a coordinated multi-professional approach. Assessment forms a key part of providing person-centred care. It was agreed to utilise the GSF Colour Coding system wide and identify the group of people who might be in their last year of life potentially by using the GSF surprise question. Version The former West Suffolk Commissioning Federation, now known as the West Clinical Commissioning Group, GP practices was invited to participate in the second step of the Suffolk End of Life pathway that supports identification of patients who might be in their last year of life. This involvement in the pathway supported achievement of QP11 of the QoF Quality and Productivity indicators in relation to reducing emergency admissions. Work on the pathway was supported by: o An Education session for GPs on advanced communication skills led by local hospital and hospice palliative care consultants organised for one lunch time on with Dr Jenna Kitchen (Consultant in Palliative Medicine, St Nicholas Hospice Care) and one evening with Dr Rosemary Wade, (Consultant in Palliative Medicine, WSHT). 1 Appendix 1 9

10 o The Advance Care Planning team was available to support practice staff by providing education and training sessions on GSF coding, Advance Care Planning documentation including DNACPR and the Liverpool Care Pathway for the dying. This linked with the Yellow folder. 100% of GP practices in the West CCGs participated in the QP11 EoL pathway 2011/12 and significant improvement has been already achieved in a short time of an increase number of patients recorded on the practices palliative care registers. An Ipswich GP development group, formerly Ipscom, also participated a similar education programme to support the rollout of the Yellow Folder. 100% of the practices were represented at the meeting where Dr Kelvin Bengston, (Consultant in Palliative Medicine, St Elizabeth Hospice) with the support of the Advance Care Planning team delivered education on communication skills. At all of the education events an information pack was prepared by the project team - the contents included the Palliative Adult Network Guidelines 2 and guidance to download the quick guide to identifying patients Both local acute hospitals have commenced implementing the EoL strategy with the West Suffolk Hospital developing a patient (alert) identification system and a robust supporting education programme for the workforce. Best practice guidelines include the LCP. End of Life group meetings are held regularly with other stakeholders invited to attend and contribute.ipswich Hospital have recently refreshed their group membership and is lead by the Director of Nursing & Quality. The project lead has been instrumental in the development of the local CQUINs and also contractual agreements that have influenced and supported the pathway developments in both acute and community services. A provider partnership group are presently working together to develop robust discharge processes and communication for Friday pm and weekend discharges from hospitals to GPs and Out of Hours Services. Implementation of a Patient Hand Held Record / Advance Care Plan. In the summer of last year, 2011, a multidisciplinary team, led by a local GP, Dr Will Ridsdill-Smith from the West of the county, entered the Transforming Community Services (TCS) Leadership Challenge facilitated by East of England SHA. Our team Improvement idea was a Patient Hand Held Record / Advance Care Plan known as the Yellow Folder and it was short listed with other teams across the East of England. The team attended the regional event in March 2011and came 3 rd in the competition. The Yellow Folder and its contents were further developed by a working group to become a hand held record that contains core information for all patients with a life shortening illness: Includes: GSF Passport GSF Thinking ahead document 2 3 rd Ed

11 EoE DNACPR Liverpool Care Pathway when commenced This Yellow Folder was piloted with recruited GP practices and their nursing homes. Each practice, associated community teams and their nursing homes received training and education from the Advance Care Planning team. The pilot was also facilitated with the emergency services, out of hour providers, hospices, hospitals and other stakeholders. The distributions of the folders are freely available via the project EoL team and are available to down load on the Suffolk Palliative Care Website. This information is audited and shared with stakeholders. Evaluation of the pilot revealed feedback from the participating practitioners has been overwhelmingly positive; staff felt that the Yellow Folder was instrumental in improving communication and coordination of care, and promoting the use of advance care planning. This is in line with evidence from pilots elsewhere in the country. Evaluation of the ACP project also reveals 96% of staff awareness of the Yellow Folder. Wider roll out of the folder has commenced linked with the GP practices that had signed up to the End of Life Care / Nursing Home Local Enhanced Service in the West and Ipswich area of the county. In East Suffolk a EoL project was incentivised by cost per care plan and the QP11 pathway, with 96% of the East Suffolk practices participating, 550 care plans have been completed using the same Yellow Folder, its documents and the ACP team for multidisciplinary education events and visits to individual care/nursing home. Total Distributed Patient Hand Held Advance Care Planning Yellow Folders 2011/12 2 nd Quarter 1 st June 30 th Sept 3 rd Quarter 1 st Oct 31 st Dec 4 th Quarter 1 st Jan 31 st March 12 Total East Federation Ipscom West Federation Others Total It is accessible by all agencies thus enabling coordination of care, promoting the use of advance care planning and empowering patients to have their choices about their care at the end of their lives respected. Great Yarmouth and Waveney have chosen to pilot the folder. Key worker guidelines have been worked up through the education working group, subgroup to the project. The guidelines have been shared and agreed across all providers. Next steps are to present the guidelines to both CCGs and gain their support to continue with the plans that are in development for road shows by the Macmillan GP Facilitator and the ACP team to support implementation. 11

12 Service Proposal 2: Palliative Care Co-ordination Centre The end of life Care Coordination Centre would act as a single point of access for organising a variety of services. The approach has been developed as a phased approach. Phase I includes the development of a website and an electronic locality End of Life register. The resource of an EoL administrator has been agreed and supports this development. Following work with key stakeholders a Palliative Care Website was designed and launched in July, the website aims not to duplicate but to compliment and link with our local provider and national websites. It has a function to raise awareness of EoL care and has been designed for the general public and professionals. The introduction of the Website has provided a central access to EoL tools and the Yellow Folder that are being implemented across Suffolk. The EoL administrator upkeeps the site. Working groups developed during Phase II proposed the development of a Suffolk wide End of Life Register. At this time the only registers maintained were at GP practices where the size of the list was variable and access limited. Stakeholders requested a Locality register that was an electronic system where important details are recorded about people that have been identified as approaching the end of life. The overall purpose to support the delivery of choice, high quality and equitable services for adults dying in Suffolk by allowing access to real time information including patients preferences to professionals involved in delivering care and support in different settings. During this period of time the Department of Health supported and reported on 8 electronic register pilot sites and have since issued a National Information Standard which given Suffolk National assurance of registers in the future will be electronic and has given Suffolk an opportunity to design a system to suit our local population. The project lead supported the development of a project executive board who have agreed a system vision and a project brief to commence a pilot. This decision followed a feasibility study, IT Mapping, agreement on data content, consent and IT platform to use. A SystmOne EPPCS unit for End of Life care has been designed and made up. Full training programmes with Norfolk and Suffolk Foundation Trust ICT educators have been sourced to support implementation. All stakeholders were supported to be part of the pilot, it was agreed to design the pilot for learning purpose before rolling out to wider partners A pilot was designed, 7 Practices were recruited, following visits to many GP practices, to the pilot, in both the East and West of the county of Suffolk this includes SystmOne and one Non SystmOne practices, supporting community staff, the OOHs provider, ambulance service and a central coordination administered by the EoL administrator. Training and education has been undertaken by the pilot participants, with units added to practice IT systems. Patients to be officially added to lists on 18th April pilot ends 16th May 2012, when outcomes will be evaluated by June 2012 and the report will be presented to the CCGs. A Suffolk bereavement model has been scoped to design as model of a single point of access in West and East Suffolk, through a co-ordinated Bereavement Care Service with Cruse as the lead agency, in partnership with the two hospices and in 12

13 collaboration with other statutory and voluntary providers in Suffolk. Expected outcome is the increase in the level of care asked for and received by the bereaved. Currently Cruse and the two Hospices help, with one to one support, around 10% of those bereaved each year, along side their other work. The main challenge will be to balance publicity with the ability to satisfy the demand and to ensure the long term viability of the project. Funding applications are in progress to support this model. Service proposal 3: Community Based Rapid Response Service The service would provide Suffolk with a county-wide community based rapid response Service. Patients at the end of life, their families or carers, can seek assistance between hours and hours to ensure that their urgent palliative care needs are met. The rapid response service will ensure that there is seamless communication between other health and social care agencies. Developing and extending the role of the Emergency Care Practitioner A pilot of extending the role of the roving ECP was designed to reduce conveyances and admissions to acute hospitals. The ECP caseload reviewed show reduction of conveyance to hospital, 47% patients were over 81 years old. There was illustration of excellent patient feedback and reduction in referral to other services. Further recent development has included provision of End of Life care education and working closer with the local St Elizabeth Hospice. Syringe driver training has been organised and then accessed by the community Rapid Response Team and Verification of Expected Death by Registered Nurses education to both community and nursing care home staff. Integration of services initial discussions/meetings have begun between hospices and Marie Curie Service to prepare a case for integration of provision of services. Access to Out of Hours Palliative Care drugs has been reviewed in the East and the West of the county. The project lead has been supported by NHSS Pharmacist Advanced with Special Interest.The list and locality of the drugs have been explored and discussed with community specialists and the GP EoL Leads. The East has been completed and update information communicated at the end of In the West, a briefing paper is in development to be present to the CCG. Service proposal 4: Commissioning and provision of palliative and end of life education and training One of the main outcomes of the education and training group was the recognition that training and education was a not an isolated challenge in Suffolk. The group worked in partnership with NHS Norfolk and NHS Great Yarmouth and Waveney to propose a series of recommendations to Norfolk and Suffolk County Workforce Groups to ensure more sustainable provision of high quality end of life training and education to all relevant health and social care staff. The second part of this proposal was formation of a Advance Care Planning Project team in June 2011 following a successful funding bid to the County Workforce Development Group by NHS Suffolk, Suffolk Family Carers, two local hospices and Adult Community Services. 13

14 The team aims to facilitate the Train the Trainer model programme and fully implement the nationally defined end of life tools across the community setting. The programme will be implemented by secondment of staff from the two local hospices and 2012/13 will need to fit in with CCG commissioning strategies. Funding has been secured for this proposal. The National End of Life Programme (2009) seven principles which underpin workforce and service development, are actively embraced to meet challenges set out in Towards The Best Together (EOE, 2009), core competences and principles have been incorporated into the education and training delivered by the team to multi professional groups across the Suffolk workforce. The nationally defined EoL tools introduced across Suffolk include the: Preferred Priorities for Care (PPC) Gold Standards Framework (GSF) Thinking Ahead Advance Care Plan East of England (EOE) Do Not Attempt Resuscitation (DNACPR) form Liverpool Care Pathway for the Dying (LCP) Champions from stakeholder groups were identified to join a free training and education programme consisting of workshops and ongoing small facilitated learning groups to implement the cascade model in their work place. In addition, short work based educational sessions, raising awareness of the tools was offered to primary care, other stakeholders and multi professional groups. Emphasis of the success of the team are other achievements that include : A presentation of a funded poster at a DH National End of Life Programme Board conference Short listed and awarded runners up for the Multidisciplinary Team of the Year Category for International Journal of Palliative Nursing Awards 2012 A comprehensive Suffolk Palliative Care Resource Folder has been developed in partnership with both hospices, which will be available to staff in all care settings and includes the agreed documentation of EoL care, information about the EoL care tools, and guidance on symptom control and patient/carer information leaflets. This free resource, supplied by the National End or life Programme Board also compliments other various training resources. Service proposal 5: Commissioning and provision of equipment for palliative and end of life care review funding stream It was proposed to review the present specification and make recommendations to provide a clearly defined pathway identifying a separate funding stream for end of life care. The new specification was influenced accordingly to have a patient/client focus, where all agencies involved in assessing for and providing equipment, can ensure a same day, seamless service that reflects the 24/7 model. It was recommended that the service will have sufficient capacity and competencies in staff required to provide this service effectively. 14

15 Attention was requested to be given in considering and respecting the individual choices of patients and their family carers, in particular where there are issues regarding the use of their own equipment i.e. bed The proposals are for the service to co-ordinate and facilitate the provision of equipment requirements following a suitable assessment. This will link with all of the elements involved in planning care for this group of people with life limiting illness who are (or should be) receiving care according to the Gold Standards Framework This has been completed and the service will have a patient/client focus where all agencies involved in assessing for and providing equipment can ensure a same day, seamless service that reflects the 24/7 model. 7. Conclusion The implementation of the MCDC programme has raised the profile of palliative and end of life care across Suffolk.The framework of the programme has allowed the agreement and implementation of local plans for improvements to the quality and choice of care/place of death for people affected by life limiting illness. This has been evidenced by the agreement of the new pathway and range of proposals for cost neutral service improvement and commissioning. The services developed and the ongoing implementation of the actions plans arising from the MCDC service improvement workshops have already illustrated cost savings based upon a reduction in inappropriate admissions to the acute care setting in the last year of life and an increase in home deaths. The programme has built on the good relationships already identified in Suffolk to work collaboratively to improve End of life services In this respect, the MCDC programme will form a firm basis for further collaborative working across the local stakeholder organisations with CCGs. 15

16 Appendix 1 1