The Gold Line A model for coordinated end-of-life care
What is it? The Gold Line service is for anyone in the community in Bradford, Airedale, Wharfedale and Craven in Yorkshire who is thought to be in the last year of their life. Developed by charities including Sue Ryder, the NHS and the local authority, in partnership with service users, the Gold Line is run by a nursing team based at the teleconsulation hub in Airedale General Hospital. Designed around the people who use the service rather than the providers themselves, it provides a 24/7 point of contact for patients and their carers to enable them to access integrated, multi-agency support, help, advice and onward referrals if required, so that they can stay in their preferred place of care, usually home. It is accessed via a dedicated phone number or via a video app on a Gold Line ipad. It has been in place since 2013 and use of the service increases year by year. Primary and secondary health care teams have been provided training in line with the Gold Standards Framework 1 (GSF) (one of a range of tools available to systematically identify and support people towards the end of life) to help identify patients and to support having sensitive and timely conversations between the team, patients and their carers. They are then offered inclusion in their primary care team s GSF register and are automatically eligible for the Gold Line service. This means palliative care is made more widely available than to just those known to specialist palliative care services. What does it achieve? A British Medical Journal 2 article evaluating the Gold Line concluded: The Gold Line provides a personalised service that is particularly valued out-ofhours providing practical advice, support and calm reassurance This support can help people to stay at home, hence reducing the pressure for avoidable hospital admissions and use of other services The service is particularly used by the elderly and those with non-cancer diagnoses further extending the reach of palliative care to a different population. An economic evaluation by the York Health Economics Consortium 3 found, when comparing a sample of Gold Line patients with a sample of patients in the same area who had died prior to the existence of the Gold Line: There was a 23% reduction in non-elective hospital admissions for Gold Line patients, which if extrapolated for all Gold Line patients who subsequently died in May 2014 April 2015, would result in a reduction of nearly 2000 hospital bed days. This would save 440,000, outweighing the annual cost of 240,000 for the Gold Line service for 1000 patients. 1 http://www.goldstandardsframework.org.uk/ 2 A Friend in the Corner : supporting people at home in the last year of life via telephone and video consultation an evaluation, Middleton-Green, Gadoud, Norris, Sargeant, Nair, Wilson, Livingstone, Sall, BMJ Supportive and Palliative Care 2016 3 Economic Evaluation of the Gold Line: Health Foundation Shared Purpose project, Final Report, York Health Economics Consortium, February 2016 2
When considering hospital admissions (excluding primary and community services), the estimated return on investment is around 2 for every 1 spent. (A Nuffield Trust report found that hospital costs were by far the largest cost element of end of life care). 4 Why does the Gold Line work? Many people in the last year of life have rapidly changing health needs that require support and interventions from a wide range of health and care services, across primary and secondary care. This is why Gold Line was set up: to coordinate care so that the needs and wishes of people in the last year of life are met wherever possible, reducing the need for costly and disruptive unplanned hospital stays. This is particularly important in the out-of-hours period when people may find it difficult to access GP support. The Gold Line addresses these issues by: People who are likely to be in last year of life are identified and then given Gold Line information and telephone number. Health care professionals in the area all use GSF to identify people at this stage of life across all health and care settings, thus widening access to palliative care. All relevant information is shared and updated in real time. All patients identified as being in the last year of life have their palliative care information and wishes recorded on a local Electronic Palliative Care Coordination System template, which, following appropriate consent procedures, is shared across all relevant health and care agencies including the Gold Line, via an electronic patient record for all patients, SystmOne. Led by passionate palliative care specialists, the service was developed in true partnership between the NHS, local authorities, service users and charities such as Sue Ryder who provide expertise as experienced palliative care providers. The Gold Line was developed as part of a whole systems approach. Telemedicine was already very well utilised in the area and there was already a palliative care hub in the hospital that provided specialist nursing support. Training and education across all health and care professionals is continual and is provided in partnership. As part of the overall integrated palliative care model, all staff whether a health care professional or not are educated and this is key to driving up the number of people identified as being in the last year of life and thus enabling more patients and carers to access the service. An action learning set has been introduced for the Gold Line clinical staff in 2016, and the team has also received training in communication skills and palliative care. Referrals are straightforward. They are made straight to the Gold Line by primary healthcare teams, specialist palliative care services, local acute and community hospitals and care homes. Quality is monitored and improved. Every quarter 25 calls are reviewed for quality, caring and compassionate communications and safety. The SystmOne record is also referred to, to check consistency. 4 Georghiou T and Bardsley M, Exploring the cost of care at the end of life, Nuffield Trust, September 2014 3
The NHS Executive Team is committed to using telemedicine to improve access to palliative care. The service is funded. Initially it was funded by the Health Foundation, now funding comes from NHS resources. Key facts No. of referrals, by age range 80+, 1259 70-79, 551 60-69, 316 50-59,136 40-49, 42 30-39, 16 20-29, 2 Total 2,322 5 This service is predominantly used by older, frail people who traditionally are less likely to access palliative care than other groups. Of those referred, 45% were not in contact with specialist palliative care services. 6 Of those who died in the last year, the average number of days on caseload was 119 days (approx. 4 months). 7 Monthly totals of number of calls to Gold Line 742 734 423 542 450 621 559 651 640 634 620 626 The service is growing as it becomes more embedded and well known. A M J J A S O N D J F M 2014-2015 2015-2016 8 5 Gold Line Service Year End Report 2015 2016, Airedale NHS Foundation Trust 6 BMJ Supportive and Palliative Care 2016, referring to year 2014-2015 7 Gold Line Service Year End Report 2015 2016, Airedale NHS Foundation Trust 8 Gold Line Service Year End Report 2015 2016, Airedale NHS Foundation Trust 4
Timing of calls (Jan - Mar 2016) In Hours (calls taken between 0800-1800 on working weekdays) Out of hours (calls taken outside 0800-1800 on working weekdays) Although the Gold Line is available 24/7, most calls are made in the out-ofhours period. 9 Outcome of calls Remained in place of residence, 96.9% Admitted to hospital, 0.3% Admitted to hospice, 0.2% Referred to emergency department, 1.8% Ambulance called to assess, 0.8% Other/not recorded, 0.1% 10 The vast majority of people who make a call stay at home afterwards. Onward referral outcomes Community outreach team, <1% Community Matron, <1% District Nurse, 37% Palliative Nurse Specialist, 2% Palliative Consultant, <1% Chemotherapy helpline, <1% Out-of-hours GP, 17% In-hours GP, 5% Of the 7,242 calls made in 2015-16, 38% were resolved by the Gold Line team and did not require onward referral, while 62% were referred on to another professional (mainly in the community). No onward referral, 38% 11 9 Gold Line Service Year End Report 2015 2016, Airedale NHS Foundation Trust 10 Gold Line Service Year End Report 2015 2016, Airedale NHS Foundation Trust 11 Gold Line Service Year End Report 2015 2016, Airedale NHS Foundation Trust 5
Why is this relevant in Scotland? Scotland s Health and Social Care Partnerships now have responsibility for the provision of end-of-life care. This will contribute towards the following Health and Wellbeing Outcomes: People, including those with disabilities or long term conditions or who are frail are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community. People who use health and social care services have positive experiences of those services and have their dignity respected. Resources are used effectively and efficiently in the provision of health and social care services. One of the three key aims of the Scottish Government s Framework for Action on Palliative and End-of-Life Care is: Access to palliative and end of life care is available to all who can benefit from it, regardless of age, gender, diagnosis, social group or location. Sue Ryder s own research shows there is a clear need to improve the provision of coordinated end of life care services in the out-of-hours period 12. So there is a need to improve access to end-of-life care for all at the same time as providing all health and social care services from tighter and tighter resources. And models such as the Gold Line support many of Scotland s priorities for health and care: it is integrated, personalised, improves access in the out-of-hours period, helps reduce unplanned hospital admissions and increases access to palliative care for people who are often excluded because of their condition and age. Not only that, it has the potential to save the health and care system money. Around 500,000 people live in the Bradford, Airedale, Wharfedale and Craven region. It comprises an area of urban deprivation and ethnic diversity, villages and towns with high numbers of older people and a rural area. Much of the Gold Line s impact rests on successful multi-agency input to, and sharing of electronic patient records. With some progress now being made in sharing of records in primary care, now that Scotland s Health and Social Care Partnerships are responsible for the provision of palliative care, models such as the Gold Line should be explored as they could make a real difference to making sure everyone who could benefit from palliative care receives it by 2021. For more information please contact Elinor Jayne, Policy & Public Affairs Manager Scotland, elinor.jayne@sueryder.org / 07773 063291 12 http://www.sueryder.org/media-centre/news/2016/august/improved%20support%20in%20scotland 6