NWL STP plans for the last phase of life

NWL STP plans for the last phase of life Dr Tim Spicer, GP & Chair of Hammersmith & Fulham CCG & Toby Hyde, Head of Strategy Hammersmith & Fulham CCG

NW London Sustainability & Transformation Plan Improving care in for individuals in the last phase of life: an integrated, cohort based approach that aims to meet the needs and reflect the preferences of individuals in their last phase of life Dr Tim Spicer

Most deaths in rich countries follow years of uneven deterioration Out of the 2,000,000 people in north west London, circa 30,000 are in the last phase of life There is a consistent gap between what individuals want and what they get. Earlier planning can improve the likelihood that an individual s preferences will be respected and acted upon. Frailty is the most common pattern of functional decline prior to an individual's death Lunney JR, Lynn J, Foley DJ, Lipson S, Guralnik JM. Patterns of Functional Decline at the End of Life. JAMA. 2003;289(18):2387-2392. doi:10.1001/jama.289.18.2387.

A longitudinal view An individual in their last phase of life commonly comes into contact with multiple 'services' in different settings of care In North West London 25 in every 100 individuals over the age of 70 who have an unscheduled admission to hospital will be dead within 12 months

30k people in the last phase of life in north west London 20% in own homes with formal support 20% in nursing/residential homes 60% in own homes with no formal support For a large proportion of individuals in their last phase of life, their primary carer has no clinical training

Gap analysis of current provision With Social Finance, we have analysed what services are available in each borough, by day of the week and time of the day.

Proposed intervention (phase 1) Our intent is to launch the first phase of a 24/7 clinical support in a subset of nursing and residential homes this Autumn. This will be functionally integrated with Primary Care development including Primary Care Homes Re-procurement of 111 and GP out of hours as part of a NWL-wide Integrated Urgent Care function. Process standardisation, including discharge of patients home to assess A system-wide approach to education and training Tim Spicer, SCRO, Improving Care for Older People Programme, NWL STP tim.spicer@nw.london.nhs.uk Toby Hyde, Head of Strategy, Hammersmith & Fulham CCG toby.hyde@nhs.net

NCL STP end of life care plans Dr Caroline Stirling, Interim Clinical Lead for North Central London STP Last Phase of Life project

Last phase of life programme Caroline Stirling, Interim Clinical Lead, NCL STP Last phase of life programme

Population Vision, framework, governance for STP Last phase of life workstream: KPIs Projects Challenges / opportunities

North Central London al London has a complex health and social care landscape N C L Council nt pop ractices /16 OT) 184m Council nt pop ractices /16 OT) 158m Council nt pop ractices /16 OT) 163m Council nt pop ractices /16 OT) 138m Council nt pop ractices /16 OT) 191m m m m m 15/16 OT - 12.4m 0.7m - 8.3m - 51m Stanmore Hospital Barnet General Hospital North London Hospice Edgware Community Hospital Marie Curie Hospice H stead Central Middlesex Hospital University College Hospital London Ambulance Service East of England Ambulance Service BEH Mental Health NHS Trust (main sites, incl Enfield community) Camden and Islington NHS FT (and main sites) North Middlesex University Hospital NHS Trust The Royal Free London NHS FT Finchley Memorial Hospital Highgate Hospital Royal Free Hospital Chase Farm Hospital St Michael s Primary Care Centre North Middlesex Hospital St Ann s Hospital The Whittington Hospital Tavistock Clinic, Portman Clinic, Gloucester House Day Unit St Pancras Hospital 8,000 deaths per year Moorfields Eye Hospital Great Ormond Street Hospital Population: Vanguards 1.44m in scope NCL CCGs activity stats Ethnic diversity Royal Free multiprovider hospital Deprivation model / inequalities -elective Population Accountable movement Care Homelessness clinical network / temporary housing for cancer (UCLH) High rates of mental illness ~50% have 1+ lifestyle related clinical problem Total GP registered population 1.5m 2.5bn health, 800m social care budget 4 acute trusts, 3 specialist hospitals, 3 community trusts, 3 mental health trusts 2 hospices >200 GP practices 243 care homes (> 6300 beds) (207 in Barnet / Enfield (~4900 beds)) NHS deficit = 234m in 2016/17 Our population Our population is diverse and growing. Like many areas in London, we experience significant churn in terms of people using our health and care services as people come in and out of the city. There is a wide spread of deprivation across NCL we have a younger, more deprived population in the east and south and an older, more affluent population in the west and north. There are high numbers of households in temporary accommodation across the patch and around a quarter of the population in NCL do not have English as their main language.

STP Vision: A place where no-one is left behind STP Framework:

Urgent and Emergency Care workstreams: Admissions avoidance and ambulatory emergency care Integrated Urgent Care Last phase of life Simplified Discharge

End of Life Care provision in NCL Generic care provided By health and care professionals and teams in all settings In and outside working hours With support from Macmillan GP Facilitators, LAS, CEPNs, and other professionals / teams With variable availability of support outside working hours Specialist Palliative Care (SPC) support provided By two hospices within the footprint, and two outside By 6 community teams one per borough (two in Camden) By a team in each hospital With variable staffing (~250% variation in medical and nursing staff/ 100 beds or 1000 population) and availability outside working hours 14

Existing EOLC provision and initiatives in NCL Specialist Palliative Care (SPC) in Acute Trusts NHS Barnet NHS Camden NHS Enfield NHS Haringey NHS Islington The Royal Free service NMUH service Whittington Health service within Barnet Hospital CNWL service within UCLH The Royal Free SPC service within RFH 6/7 (7/7 by 09.17) UCLH - 24/7 visiting on call visiting services service (09:00-17:00) with RFH - has 7/7 visiting with consultant on call OOH consultant on call OOH The Royal Free service within Chase Farm Hospital 6/7 (7/7 by 09.17) visiting services (09:00-17:00) with consultant on call OOH No out of hours service. 5/7 09:00-17:00 service No out of hours service. 5/7 09:00-17:00 service SPC in community Community Nursing service Out of hours Pharmacy provision of EOLC drugs Hospice services and admissions Single point of Access for SPC (SPA) CHC fast track process Embedded overnight care Access to equipment in community North London Hospice Two services (NLH). NB: part NHS / part North (RFH team) and South charity funding (CNWL service) of borough 7/7 0900-1700 visiting service with telephone advice outside these hours 24/7 visiting, 1 nurse & 1HCA overnight cover Barnet & Enfield No pharmacy that stocks EOLC drugs out of hours North London Hospice. NB: part NHS / part charity funding 24/7 on call visiting service 7/7 0900-1700 visiting service with telephone advice outside these hours 24/7 visiting, twilight service until 22:00, 2 nurses 22:00-08:00 2 pharmacies stock EOLC drugs, open 7/7, (11:00-16:00 Sunday ) 24/7 visiting, 1 nurse and 1 HCA overnight - NB: part NHS / part charity funding No pharmacy that stocks EOL care drugs out of hours North London Hospice ELiPSe team (part of CNWL service) 7/7 0900-1700 visiting service with 24/7 on call visiting service telephone advice outside these hours 17:00-22:00 twilight nurses, 22:00-08:00 1 nurse overnight and 1 driver 4 pharmacies that stock EOLC drugs, max opening hours (07:00-22:00 Mon-Sat, 10:00-19:00 Sun) Marie Curie Hospice Hampstead: Admissions 24/7, OPD Mon-Fri 1 pharmacy stock EOLC drugs, open 7/7, (reduced hours) North London Hospice (NLH) admissions 7/7 09:00-17:00 St Johns Hospice, admission 24/7 NLH admissions 7/7 09:00-17:00 St Johns Hospice, admission 24/7 St Josephs Hospice, case by case funding, admission 24/7 St Josephs Hospice - admissions 24/7 SPA for hospice admissions, SPC in community &OPD (NLH) Responsive same day agreement for fundingsame day d/c Marie curie nursing service and Pall Care support Within 4 hours Mon-Fri 09:00-17:00 Single number for all community services No SPA for SPC- separate numbers for N and S teams Responsive CHC fast track process brokers up to 24/7 care SPA for hospice admissions, SPC in SPA for EOLC enquiries (Haringey community &OPD (NLH) triage at NLH ends 31.3.17) SPC onward referral or advice No single number for community services, single number for SPC Funding agreed within 24h home Responsive but financially limited Moderate responsiveness from hospital within same day Marie curie nursing service and Pall Care support Marie curie nursing service and Pall Care support CHC fast track process brokers up to 24/7 care 7/7 within 4 hours Within 1 working day Within 4 hours 7/7 within 4 hours

DIUPR, NCL, 2010/11 2015/16 50 45 40 35 England London SCN Enfield CCG Haringay CCG Islington CCG barnet CCG Camden CCG 30 25 Q4 2010/11 to Q3 2011/12 Q4 2011/12 to Q3 2012/13 Q4 2012/13 to Q3 2013/14 Q4 2013/14 to Q3 2014/15 Q4 2014/15 to Q3 2015/16

Last phase of life workstream Key Performance Indicators: 1: Reduction in ED attendances: ED attendances in NCL, July 2015 June 2016 = 509,900 Assume 0.6% of these are in last phase of life = 3059 Interventions to reduce ED attendances in patients in the last year /months of life have resulted in ~38% fall in ED attendances Thus target reduction (2020/21) = 1160 attendances / year 2: Reduction in Non Elective admissions: 0.6% of population are in the last year of life ~8600 52% deaths occur in hospital currently = 4474 Average number of admissions during the last year of life ~3; ie 13,416 Interventions to reduce NEL have resulted in ~33% fall in admissions Thus target reduction (2020/21) = 4462 admissions / year

BENEFITS REALISATION Initiative impact trajectory to 2020/21 Initiative impact trajectory - Activity Initiative POD ACTIVITY - Impact (gross savings achieved by year) Admission Avoidance and Ambulatory Emergency Care 16/17 17/18 18/19 19/20 20/21 NEL Nil 3,900 9,100 14,300 20,000 Integrated Urgent Care A&E Nil 10,200 20,500 30,700 40,900 NEL Nil 1,900 3,800 5,600 7,500 Frailty Units (a) NEL Nil 0 0 0 0 Last Phase of Life A&E Nil 200 300 600 1,100 NEL Nil 200 1,300 2,700 4,500 Simplified Discharge XBD Nil 0 21,800 43,600 43,600 Initiative impact trajectory - Admission Avoidance and Ambulatory Emergency Care Initiative POD - Impact (gross savings achieved by year) k - 16/17 k - 17/18 k - 18/19 k - 19/20 k - 20/21 NEL Nil 5,358 12,121 18,883 26,113 Integrated Urgent Care A&E Nil 716 1,433 2,149 2,865 NEL Nil 1,979 3,959 5,938 7,918 Frailty Units (a) NEL Nil 0 313 730 1,043 Last Phase of Life A&E Nil 16 23 45 75 NEL Nil 800 5,910 11,821 19,701 Simplified Discharge XBD Nil 0 5,316 10,632 10,632

UEC programme - overall financial and activity impact Gross Saving ( k) 17/18 18/19 19/20 20/21 1. Admission Avoidance and Ambulatory Emergency Care 5,358 12,121 18,883 26,113 2. Integrated Urgent Care 2,696 5,392 8,088 10,783 3. Frailty Units - 313 730 1,043 4. Last Phase of Life 821 5,933 11,866 19,776 5. Simplified Discharge - 5,316 10,632 10,632 8,875 29,074 50,198 68,348 Investment ( k) 17/18 18/19 19/20 20/21 1. Admission Avoidance and Ambulatory Emergency Care 2,706 6,359 10,011 13,979 2. Integrated Urgent Care - - - - 3. Frailty Units - 700 700 700 4. Last Phase of Life 340 2,339 4,489 4,489 5. Simplified Discharge - 600 1,200 1,200 3,046 9,998 16,400 20,368 Net Saving ( k) 17/18 18/19 19/20 20/21 1. Admission Avoidance and Ambulatory Emergency Care 2,652 5,762 8,872 12,134 2. Integrated Urgent Care 2,696 5,392 8,088 10,783 3. Frailty Units - - 387 30 343 4. Last Phase of Life 481 3,594 7,377 15,287 5. Simplified Discharge - 4,716 9,432 9,432 5,829 19,076 33,798 47,980

Interventions to achieve KPIs 1. Care home support: Aims: Increased support of care home staff and established generic teams Increase identification, communication with and care of care home residents in the last months of life, and those important to them in order to avoid unnecessary transfers to hospital Interventions: Liaison and planning in 2017/18 STP-wide and borough-specific JDs agreed, workshop completed, procurement plan being developed, PPI engagement planned Band 6/7 nursing staff (7 in last 6/12 of 2017/18, 15 WTE thereafter) Recruitment likely to be delayed Administration support (2 WTE 2018/19 onwards) Consultant support (1.5 WTE 2018/19 onwards) To be brought forward

Interventions to achieve KPIs 2. Single Point of Access / Specialist Palliative Care support: Aims: Development of a Single Point of Access linked with STP- wide SPA Reduction in inequity of provision between services Provision of 7/7 working service in all settings, with advice 24/7 Interventions: Planning and re-configuration (if needed) of SPC services in 2017/8 SPA scoping and liaison initiated, workshop complete SPC staffing baseline established - 250% variation Discussions between services planned Initial costings were for SPC staff to be reviewed in light of SPA development Band 6/7 staff members (8 WTE, 2018/19, 15 WTE thereafter) Medical consultants (2 WTE, 2018/19, 5 WTE thereafter) Nurse consultants (1 WTE, 2018/19, 2 WTE thereafter) Administration support (1 WTE, 2018/19, 3 WTE thereafter)

Interventions to achieve KPIs 3. Development of telemedicine: Aim: To increase the number of patients / carers / professionals supported at home / in a care home, in line with the rising demographics Interventions: Planning / scoping of model to implement, linking with other projects within NCL (2017/8) Liaison with digital workstream and mapping of digital requirements complete Liaison with other telemedicine projects initiated Pilot in 2018/9 Scale up thereafter if effective

Opportunities and Challenges: Project management support Ambitious timings Scrutiny and reporting Variation between boroughs services, commissioner engagement Source of investment

STP governance