Innovations to meet the commissioning agenda in end of life care

Innovations to meet the commissioning agenda in end of life care Wednesday 9th December 2015 Paget Room, BMA House

Welcome and introductions Sarah Cox Chair of LCA Palliative Care Group Lead Consultant in Palliative Medicine Chelsea & Westminster Hospital

Developments following publication of New ambitions Simon Chapman Director of Policy, Intelligence & Public Affairs National Council for Palliative Care

INNOVATIONS TO MEET THE COMMISSIONING AGENDA New Ambitions 9th December 2015 Simon Chapman Director Of Policy, Intelligence & Public Affairs National Council for Palliative care @SimonSimply www.ncpc.org.uk www.dyingmatters.org

The UK is the best in the world! 5 categories: Palliative & healthcare environment Human resources Affordability of care Quality of care Community Engagement www.ncpc.org.uk www.dyingmatters.org

Some challenges Rising demand Variation and inequalities Data and outcome measurement Austerity and resources Priority given to end of life care Fragmentation Workforce Commissioning...or procurement? www.ncpc.org.uk www.dyingmatters.org

National Care of the Dying Audit for Hospitals, RCP 2014 21% of sites had face to face access to palliative care 7 days/week Mandatory training: For doctors 19% Nurses 27% Case note review: KPI on discussions with dying person & family/friends not achieved 26% www.ncpc.org.uk www.dyingmatters.org

...Systemic... 7 Organisational KPIs 6 of those were achieved by fewer than 50% of trusts, including: Access to specialist support (79% not achieved) Trust board representation (72%) Clinical provision/protocols promoting patient privacy, dignity and respect (66%) www.ncpc.org.uk www.dyingmatters.org

105 CQC inspections Nov 13 May 15 www.ncpc.org.uk www.dyingmatters.org

Slow pace of change www.ncpc.org.uk www.dyingmatters.org

www.ncpc.org.uk

Asks to HWBs, CCGs & LAs Publicly designate an organisation to lead on making these ambitions the reality for the communities you serve Activate your partnerships with health, social care, commissioning, public health, and voluntary sector organisations Publish a local action plan that includes the tangible steps that you and others will take to bring these ambitions to reality www.ncpc.org.uk www.dyingmatters.org

What is it like to die in your area? Is each person seen as an individual? Does each person have fair access to care? Are comfort and wellbeing maximised? Is care coordinated? Are all staff prepared to care? Is every community prepared to help? www.ncpc.org.uk

Unified End of Life Care documentation and other pan- London projects Caroline Stirling, Interim Clinical Director, End of Life Care Clinical Network, NHS England (London region)

Unified End of Life Care documentation and other pan-london Date projects Caroline Stirling, Interim Director, NHS London EOLC Clinical Network

Unified EOLC documentation for London Aim: Information that is relevant to the current and future care of patients with life limiting illnesses will be recorded using the same documentation, and be valid in all care settings throughout London

Rationale - London Complex care environment Differing forms used to document decisions related to care of patients with life limiting illnesses Only one area where decisions related to CPR are transferable between settings Low uptake of EPaCCS at present Poor outcomes related to EOLC

Rationale evidence base Discussion, recording and communication of preferences, including location and plan confers: Reduced stress, anxiety (carers), and higher pt/ carer satisfaction Reduced number of hospital days in last year of life and hospital deaths Reduced likelihood of emergency admission Reduced cost of care Detering et al, BMJ, 2010;340 Andeleeb et al, BMJ Supp &PallCare 2013;3, 452-5 Abel et al, BMJ Supp &PallCare 2013;3, 168-73

Rationale evidence base Factors that confer improved outcomes related to DNACPR decisions Structured discussion at the time of acute admission Review by specialist teams at time of acute deterioration (PERRT, SPC, Elderly Care etc) Structured ACP discussions in Nursing homes Linking decisions related to DNACPR to overall treatment plans Standardised documentation for decisions Field et al, Resuscitation, 2014;85, 1418-31

Rationale unified DNACPR policies in UK Scotland yes yes yes yes yes Wales - draft yes yes yes yes

Resuscitation Council (UK) Working Group Aims to establish an approach which: Is developed with and acceptable to patients, those important to them, HCPs, carers and public Includes a decision-making framework which supports informed discussions about emergency treatments Ensures that dialogue is central to decision-making Can be used across all settings Can be used for individuals of all ages Is based on evidence /experience of other successful initiatives Considers decision related to CPR within overall goals of care, focusing on choices of treatments to be given.

Resuscitation Council (UK) Working Group Draft prototype form Guidance for professionals Guidance for public Process: Public consultation early January 2016) https://www.resus.org.uk/statements/emergency-care-and-cpr-decisionmaking/ Evaluation Piloting / implementation Likely to be ready for use in late 2016

London-wide Project October 2014 initial stakeholder event Feb 2014-May 2015 support obtained from CCGs, acute and community Trusts, LAS June 2015 2 nd stakeholder event September 2015 Project Delivery Group formed whose aim is to coordinate: Policy to facilitate use of national form, and recommendation of Deciding Right forms to record other decisions Public and patient engagement process Implementation guidance Educational material / programme

Other London CLG workstreams Guidance for safe use of medications at EOL Education and Training Principles for education and training in EOLC (n=18) Case study guide for each principle with contact Workforce review project Transforming Cancer services group Good Care, good death, good bereavement Infogram - Good death Commissioners checklist for EOLC in draft form http://www.londonscn.nhs.uk/publications/

Other London CLG workstreams Engagement and social strategy Engagement with Compassionate City Charter Digital legacy work Organ donation Education support for student teachers Other groups livery companies, faith groups, Cruse, Age UK.

Collaboration and Commissioning in Practice Princess Alice Hospice Night Response Team Lesley Spencer Director of Patient Care and Strategic Development, Princess Alice Hospice

Collaboration and Commissioning in Practice Princess Alice Hospice Night Response Team Lesley Spencer Director of Patient Care and Strategic development

Background and Commissioning 35

Good services Not all in the right place right skill at the right time 36

Background and Commissioning This service is a result of a working partnership between Surrey Downs CCG, Kingston CCG and Your Health, community provider and the Hospice to deliver a night nursing rapid response service, 7 nights a week for palliative and End of Life Care (EoLC) at home. Commenced in July 2014 and initially provided three nights a week moving to seven nights a week in September 2014 via the provision of the Princess Alice Hospice night nursing service. 37 37

Aims The primary aim of providing the Night Response service is to optimise the opportunity for patients to remain at home and prevent unnecessary admissions to hospital when the patient is assessed to be terminally ill and is deteriorating (last few weeks of life) The patient has an urgent nursing need that would otherwise result in an admission to hospital (blocked catheter, burst stoma bag) 38 38

How do they help? The night response team (a registered nurse and a health care assistant) respond to urgent calls throughout the night across Kingston and Central Surrey They provide reassurance, avert panic, ease breathlessness and symptoms and help patients remain in their preferred place of care. They support families, discuss advance care planning and ensure a timely responsive approach to care delivery. 39

Key Results (01.11.14 to 31.10.15) Total number of visits = 1063 with 1092 significant phone calls and 797 faxes communicating care. Total patients = 428 Mainly visiting to provide symptom control and EoLC support but 317 District Nurse support visits to prevent a patient going into hospital 8 Patients were admitted appropriately into Hospital with 501 inappropriate Hospital admissions avoided average length of stay for EoLC patients10-12 days at a basic cost of approximately 300 per night = potential saving of around 1,803,600 118 deaths with the vast majority achieving their preferred place of death (Over 90% of EoLC who expressed a preference) 40

Conclusion Night response is; cost effective, resource efficient delivering a timely responsive service ultimately helped palliative and EoLC patients to remain in their usual place of residence. Accepting that patients and carers will struggle on it is felt that inappropriate admissions into the acute sector have been avoided with significant savings for the health care economy 41