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TV SCN EoLC Commissioner Forum
May 7 2015
Meeting with Dr Bee Wee, National Clinical Director for End of Life Care
Attendees
Dr Bee Wee
(NCD for EoLC)
Dr Barbara Barrie (chair
TV Clinical End of Life Lead (Generalist)
Dr Stuart Logan
Aylesbury Vale CCG
Dr Ishak Nadeem
South Reading CCG
Dr Anant Sachdev
Bracknell and Ascot CCG
Dr Siva Sitharapathy
Slough CCG
Sara Wilds
Oxfordshire CCG
Jo Wilson
TV Clinical End of Life Lead (specialist).
Rhonda Riachi
TV HEE
Rosemary Martin
TV HEE
Julia Coles
SCN
Kevin Sutch
SCN
Apologies
Dr Jonathan Williams, Dr William Tong, Dr Raj Bajwa.
1. Dr Bee Wee- the meeting was an opportunity for commissioners to meet with the NCD, have an update on the national programme and discuss local issues and challenges commissioner perspective.
Presentation enclosed-
Key messages-
Bee emphasised the impact of EoLC had on both LTC and urgent care. With better communication being a consistent theme, and the affect poor communication has on emergency admissions to A and E.
She outlined work in progress/to be undertaken-
-currently there are no definitive costs or actual individual costs.
-there is a need for new metrics to identify what good EoLC should look like, especially since the publication of One Chance to Get it Right.
Bee queried how many CCG business plans did not include a reference to End of Life Care. She also referred to Actions for End of Life 2014/2016 and using the House of Care framework.
She felt that there were mixed messages in the management of patients with conditions such as cancer and heart failure, and the need to identify when curing activities are reduced and palliative care increases. This requires difficult discussions to take place at the right time. It should be recognised that this is a very important skill, and she emphasised the need for more HCP training at the foundation stage but also continuing throughout. She also referred to the problems in identifying meaningful feedback about the level of service provided.
2. Barbara Barrie and Jo Wilson presented the TV network perspective- summary of work to date and proposals for 2015/16. Presentation enclosed-
Jo presented what the End of Life Network had achieved over the last year. Following this was discussion about what could be done during 2015/16 including alternative ways of delivering presentations with the possibility of using Webex.
Barbara fed back on the presentation she had given to the CCG accountable officers and clinical chairs that morning, on behalf of the network (see below). It was well received and contained many of the themes raised by Bee. Barbara had emphasised to the AO/CC meeting the importance of EoLC being everybody’s business, and urged them to encourage and support their CCG leads to engage with the network.
General discussion
· Slough said that they were actively working with HETV. They were also involved in working with their Health and Wellbeing Board. They would like to see a précis of national documents especially those that come from NHS IQ.
· Aylesbury Vale shared the work they were doing in Primary Care with care and support planning and including an unplanned admissions DES to incentivise providers.
The discussion focussed on the challenge of improving end of life care and how to ensure it was recognised as everybody’s business.
3. Brief discussion on work programme for 15/16
· Continue to share good practice from National Meetings
· Look at different ways in getting the End of Life Care message across Thames Valley
· Share what CCGs are achieving across TV
· Provide précis of important documents and reports.
Plan- proposed programme of activities to be shared with leads.
Thames Valley EoLC
v2 ks.pptx
Palliative and End of Life Care in Thames Valley, May 2015
Barbara Barrie and Jo Wilson TVSCN End of Life LeadsJulia Coles TVSCN Programme Manager Thames Valley Strategic Clinical Network
5 March 2015
1
Our Aim
To engage with you to help realize our joint ambition to deliver end of life care well…….harnessing the resources of TVSCN, the AHSN and HETV
To contribute to the national work e.g. outcomes measures - based on our joint learning with you.
Thames Valley area – 2.37 million people, 11 CCGs, 8 Health and Wellbeing boards
Thames Valley Strategic Clinical Network
End of Life Care Team
Masterclasses 4 arranged 2 delivered Once chance to get it right , Commissioning for outcomes, Spirituality. Palliative care
CCG Locality Meetings -Clinical leads attend and are key members of these groups, providing expert contribution and constructive challenge
Commissioner Forum.
Focussed work with commissioners, national updates and exchange /consideration of local issues. Plus in-depth consideration of specific area i.e. data and information, DNACPR
National Expert Speakers
End of Life Care Launch event
Feedback
Feedback
Feedback
Inform
Inform
Links with National Team
Feedback
Feedback
Inform
Inform
Inform
Health and Wellbeing Boards briefing paper sent to chairs promoting the importance of including EoLC in their strategy refresh
Inform
‘One Chance to get it Right’ Project offer to Commissioners and Providers to scope and plan response .
Offer of help
Feedback
Links to other specialisms CVD, LTC using the House of Care framework
Inform
CCG commissioning intentions- provision of advice and guidance for inclusion in 15/16 plans
Presentation to CCG Accountable Officers Forum in May 2015
Inform
Inform
Feedback
Inform
Feedback
Inform
Influence
Influence
Influence
Top 4 priorities in our region for 2015-16
Priorities
Expected outcome
Improved engagement in locality group and commissioner forum. Evidenced by increased engagement at forum’s, and production of TV wide DNACPR policy and supporting documentation.
Each CCG developing their EoLC strategy, which informs all other CCG workstreams and is cognisant of One Chance and Actions for EoLC. Evidenced by measurable delivery of their plans.
CCG LTC programmes include EoLC, recognising the continuum of the patient pathway. Evidenced by EoLC being a core part of the programme.
The increasing shift to adoption of HoC and care planning in LTC is seen as a precursor to advanced care planning. Evidenced by the increased uptake of skills training across the pt pathway, an increase in advanced care planning and use of the EPaCCS system
Outcome measures embedded in service specifications and monitored to improve patient and carer experience of end of life.
Courses commissioned by HETV (HEI and care certificates) address the learning needed by the workforce
To highlight the importance of good end of life care, and raise the profile of the work of the network by presenting to area team directors and CCG Accountable Officers May 2015
Build the connections of EoLC and Specialist Palliative care to LTC using the House of Care framework
A focus on Actions for EoLC
Joint work with HETV & EoLC Fellow
What we need and what we fear
What we need to help us achieve our top 3 regional priorities
Good links to CCG decision makers
A co-ordinated approach between national and local programmes
A national programme of work that focuses on what can best be done once for the benefit of us all.
What we fear might stop this happening
Locally that pre-occupation with other targets means that EoLC drifts down the priority list and CCGs do not engage
National team working independently of local area teams rather than linking and working in a co-ordinated style to the mutual benefit of all
Lack of buy in from Health& Well being boards
National funding for continuation of
TVSCN roles for 2015-2016 has been found
Electronic Locality Registers
2nd July
Cambridge
Details…..
Palliaitve and End
of Life Care in Thames Valley 2015.pptx
Palliative and End of Life Care in Thames ValleyBarbara Barrie and Jo WilsonTVSCN End of Life Leads
Thames Valley Strategic Clinical Networks 2015
“Care of the dying is the litmus test of NHS”
More people are living with long term conditions
More babies and children with life-limiting conditions live into adulthood
We are all living longer
But ultimately we all die
Therefore care as we approach end of life has to matter to everyone
Health care
Social care
Wider community
Case Study
Case study
Sheila -82yrs old –retired teacher
Type 2 diabetes, peripheral neuropathy, heart failure
Housebound, deteriorating vision, care package
2 recent hospital admissions-expressed a wish not to go back into hospital
Advanced care plan completed –DNACPR
Died at home 4 months letter
5
Background
25% of all healthcare costs are used within the last year of life
Patients on average have 3 admissions in the last year of life, each lasts 10 days on average
National Audit Office showed 40% of patients who died in hospital could have been looked after at home.
Average life expectancy after admission to NH is 10m
Poorer uptake and outcomes for hard to reach (Learning disabled/ BME/homeless)
What is a good death?
34% of patients ranked “dying in preferred place” as important
33% wished to “have as much information as possible”
33% wished to be able to “choose who makes decisions about my care”
What does the data tell us?
What does the data tell us?
VOICES Survey 2013
05/06/2015
Headline ambitions
Getting care as good as it can be wherever the person is - at all stages
Care that matches the person’s preferences as closely as possible and meets needs as far as possible
Staff who have confidence to bring these skills into other parts of care – i.e. further upstream and laterally
Reducing the inequality gap
Everybody feels responsible for playing a positive part in end of life care
New contract measures from 2015
NHS standard contract SC 34 - two items relating to OCTGIR
Policy for death of service user
Guidance re care of the dying
Operational guidance re death of a service user
Engaged, involved and compassionate communities
House of Care framework – for End of Life Care
Engaged, involved and compassionate communities
House of Care framework – for End of Life Care
‘Every Moment Counts’
Engaged, involved and compassionate communities
Metrics to support commissioning – insights, indicators
National development currencies
Commissioning Toolkit
Input to Seven Day Services programme
NHS Standard Contract
Specialist palliative care service specification
Individual-level palliative care clinical dataset
Incorporating EoLC into service specs for specific groups
Knowledge hub
NICE guidance
CQC’s thematic review
One Chance to Get it Right – Priorities for Care
National audit
Care coordination - EPaCCS
Communities of practice
Transform ing EoLC in acute hospitals
Priorities for Care of Dying Person
Guidance personalised care planning
Data and intelligence know-how
Other professional
now-how
Information
Carers
VOICES-SF
PfC – secure and detained settings
Inequalities
17
The Ideal CCG End of Life Strategy
A locally developed and owned vision for end of life care operationalised through strategic plan
Early Identification of patients approaching last months of life
High quality advanced care planning
Electronic Palliative Care Co-ordination system
Use of levers to embed good practice
Alignment with LTC/Urgent Care Programme
The Ideal CCG End of Life Strategy
Alignment with Health and Wellbeing Board
Training Needs analysis
Education Programme
End of Life Locality Group involving all stakeholders with clear accountability
Robust contractual arrangements with third sector
Link with CCGs across TV Network to share good practice
Relationship between Specialist Palliative Care and End of Life Care
Our remit
To set up a sustainable Palliative and End of Life Care Network across Thames Valley
To promote implementation of EPaCCS
To facilitate the implementation of the recommendations of One chance to get it right Report in localities
Thames Valley Strategic Clinical Network
End of Life Care Team
Masterclasses 4 arranged 2 delivered Once chance to get it right , Commissioning for outcomes, Spirituality. Palliative care
CCG Locality Meetings -Clinical leads attend and are key members of these groups, providing expert contribution and constructive challenge
Commissioner Forum. Focussed work with commissioners, national updates and exchange /consideration of local issues. Plus in-depth consideration of specific area i.e. data and information, DNACPR
National Expert Speakers
End of Life Care Launch event
Feedback
Feedback
Feedback
Inform
Inform
Links with National Team
Feedback
Feedback
Inform
Inform
Inform
Health and Wellbeing Boards briefing paper sent to chairs promoting the importance of including EoLC in their strategy refresh
Inform
‘One Chance to get it Right’ Project offer to Commissioners and Providers to scope and plan response .
Offer of help
Feedback
Links to other specialisms CVD, LTC using the House of Care framework
Inform
CCG commissioning intentions- provision of advice and guidance for inclusion in 15/16 plans
Presentation to CCG Accountable Officers Forum in February 2015
Inform
Inform
Feedback
Inform
Feedback
Inform
Influence
Influence
Influence
Provide access to TNA tools/ support educational events
Contribute to Locality Groups
Link to National Team and evidence of good practice locally and nationally
Maximise impact and outcomes of 2% DES
Explore levers(CQUINS /CES)
Resources –AMBER/ Deciding Right/ Commissioning Toolkit
Embedding Care after Death Guidance
Further work on developing guidelines
Support to develop CCG EOL Vision and strategy
Guidance on Commissioning Intentions
Whole system stakeholder events
Developing EPaCCS and sharing good practice
Identifying patient leaders to support workstreams
Once Chance to Get it Right outcomes
Embedding “Ambitions in End of Life Care”
“You matter because you are you, and you matter to the end of your life”
Dame Cicely Saunders (1918 -2005)
Thank you –Questions?
Thames Valley Strategic Clinical Networks 2015
Session
Overall quality of
care
Question
Q51. Overall, and
taking all services into
account, how would
you rate his/her care
in the last three
months of life?
Q14.Overall, do you
feel that the care
he/she got from the
district and community
nurses in the last three
months was excellent?
Q19.Overall, do you
feel that the care
he/she got from the GP
in the last three months
was excellent?
Q46.Were you or
his/her family given
enough help and
support by the health
care team at the actual
time of death?1
Q47.After he/she
died, did staff deal
with you or his/her
family in a sensitive
manner?
Q49. Looking back over the
last three months of his/her
life, were you involved in
decisions about his/her care
as much as you would have
wanted?
AnswerOutstanding/ExcellentExcellentExcellentYes, definatelyYes
I was involved as much as I
wanted to be
England43.21%
78.62%
( 26,000 respondents )
72.40%59.76%93.53%77.93%
NHS Aylesbury Vale41.68%73.33% (n=63)76.85%55.32%94.84%80.90%
NHS Bracknell and Ascot46.55%82.39% (n=21)73.74%59.47%96.14%74.47%
NHS Chiltern43.19%79.08% (n=109)76.45%59.78%94.09%80.41%
NHS Milton Keynes38.40%78.50% (n=73)69.09%53.80%93.12%76.06%
NHS Newbury and District44.81%86.97% (n=37)79.69%54.69%95.75%81.98%
NHS North & West Reading48.20%87.97% (n=47)68.56%66.31%96.34%89.95%
NHS Oxfordshire47.09%80.73% (n=242)74.99%59.03%92.79%78.88%
NHS Slough31.93%55.14% (n=22)56.52%52.70%91.16%63.95%
NHS South Reading26.91%63.01% (n=23)61.56%66.92%91.40%68.41%
NHS Windsor Ascot and
Maidenhead
37.52%82.66% (n=47)65.41%54.44%92.30%76.39%
NHS Wokingham49.08%80.26% (n=57)81.93%59.68%91.31%84.67%
Dignity and RespectSupport for carer and family
Specialist Palliative Care Service Model
Mapping service delivery onto needs complexity
Key
Part of the Palliative Care Multidisciplinary Team (PCMDT)
Chaplin Chaplaincy
CMN Community Macmillan Nurses
Comp Complementary Therapies
CP Clinical Psychologist
Dt Dietetics
DT Day Therapy
Edu Education Programme
FSS Family Support and Bereavement Service
HCNS Hospital clinical nurse specialist (In palliative care)
HIV HIV/AIDS Clinical Nurse Specialists
Lymph Lymphoedema service
OPA Out Patient appointment (medical)
OT Occupational Therapist
PhysT Physiotherapy
SPCU Specialist Palliative Care Unit
SPCU Inpatient
Full MDT
inpatient
assessment and
management
Direct contact with ≥2 PCMDT professionals
(further assessment and/or treatment)
(e.g. CMN or DT plus OPA, OT,
FSS or CP)
Direct contact with a PCMDT
professional
(e.g. CMN, DT, FSS or HCNS)
Clinical support from PCMDT
(e.g. seeking advice from a CMN, HCNS, FSS or
Medical Consultant, but without need for face-to-
face patient contact)
No patient-specific contact from PCMDT
PCMDT activity includes: Clinical education and training, maintaining
supporting information (e.g. clinical guidelines), supporting
local and network strategic development
Increasing complexity
Notes
The service model is underpinned by excellence in
the provision of palliative care by primary care and
hospital teams. Supporting this activity is a key part
of the PCMDT’s role.
“Complexity” does not mean “degree of distress”,
but rather the appropriate part of the healthcare
system required to manage this distress.
Patients are disadvantaged by inappropriate
banding (too low can leave unmet needs, too high
causes unnecessary exposure to increased
numbers of health professionals without additional
benefit to the patient, and reduces service cost
effectiveness). Patients move between bands as
appropriate.
“Clinical support” refers to advice specific to an
individual patient while “clinical education” refers to
advice/training in the general provision of palliative
care
Advice and education given
Advice and
education given
Advice and education given
Advice and education given
Notes
The service model is underpinned by excellence in the provision of palliative care by primary care and hospital teams. Supporting this activity is a key part of the PCMDT’s role.
“Complexity” does not mean “degree of distress”, but rather the appropriate part of the healthcare system required to manage this distress.
Patients are disadvantaged by inappropriate banding (too low can leave unmet needs, too high causes unnecessary exposure to increased numbers of health professionals without additional benefit to the patient, and reduces service cost effectiveness). Patients move between bands as appropriate.
“Clinical support” refers to advice specific to an individual patient while “clinical education” refers to advice/training in the general provision of palliative care
Increasing complexity
No patient-specific contact from PCMDT
PCMDT activity includes: Clinical education and training, maintaining supporting information (e.g. clinical guidelines), supporting
local and network strategic development
Clinical support from PCMDT
(e.g. seeking advice from a CMN, HCNS, FSS or Medical Consultant, but without need for face-to-face patient contact)
Direct contact with a PCMDT professional
(e.g. CMN, DT, FSS or HCNS)
Direct contact with ≥2 PCMDT professionals
(further assessment and/or treatment)
(e.g. CMN or DT plus OPA, OT,
FSS or CP)
SPCU Inpatient
Full MDT inpatient assessment and management
Key
Part of the Palliative Care Multidisciplinary Team (PCMDT)
ChaplinChaplaincy
CMNCommunity Macmillan Nurses
CompComplementary Therapies
CPClinical Psychologist
DtDietetics
DTDay Therapy
EduEducation Programme
FSSFamily Support and Bereavement Service
HCNS Hospital clinical nurse specialist (In palliative care)
HIVHIV/AIDS Clinical Nurse Specialists
LymphLymphoedema service
OPAOut Patient appointment (medical)
OTOccupational Therapist
PhysTPhysiotherapy
SPCUSpecialist Palliative Care Unit
Specialist Palliative Care Service Model
Mapping service delivery onto needs complexity
Specialist Palliative Care Service Model
Mapping service delivery onto needs complexity
Key
Part of the Palliative Care Multidisciplinary Team (PCMDT)
Chaplin Chaplaincy
CMN Community Macmillan Nurses
Comp Complementary Therapies
CP Clinical Psychologist
Dt Dietetics
DT Day Therapy
Edu Education Programme
FSS Family Support and Bereavement Service
HCNS Hospital clinical nurse specialist (In palliative care)
HIV HIV/AIDS Clinical Nurse Specialists
Lymph Lymphoedema service
OPA Out Patient appointment (medical)
OT Occupational Therapist
PhysT Physiotherapy
SPCU Specialist Palliative Care Unit
SPCU Inpatient
Full MDT
inpatient
assessment and
management
Direct contact with ≥2 PCMDT professionals
(further assessment and/or treatment)
(e.g. CMN or DT plus OPA, OT,
FSS or CP)
Direct contact with a PCMDT
professional
(e.g. CMN, DT, FSS or HCNS)
Clinical support from PCMDT
(e.g. seeking advice from a CMN, HCNS, FSS or
Medical Consultant, but without need for face-to-
face patient contact)
No patient-specific contact from PCMDT
PCMDT activity includes: Clinical education and training, maintaining
supporting information (e.g. clinical guidelines), supporting
local and network strategic development
Increasing complexity
Notes
The service model is underpinned by excellence in
the provision of palliative care by primary care and
hospital teams. Supporting this activity is a key part
of the PCMDT’s role.
“Complexity” does not mean “degree of distress”,
but rather the appropriate part of the healthcare
system required to manage this distress.
Patients are disadvantaged by inappropriate
banding (too low can leave unmet needs, too high
causes unnecessary exposure to increased
numbers of health professionals without additional
benefit to the patient, and reduces service cost
effectiveness). Patients move between bands as
appropriate.
“Clinical support” refers to advice specific to an
individual patient while “clinical education” refers to
advice/training in the general provision of palliative
care
Advice and education given
Advice and
education given
NCD
presentation.pptx
Thames Valley: National perspective for palliative and end of life care – challenges and priorities
Professor Bee Wee
NCD for End of Life Care
NHS England
7th May 2015
www.england.nhs.uk
1
Distribution of adults in need of palliative care at the end of lifeby age and disease groups
Source: Global Atlas of Palliative Care, 2014 (WHO)
www.england.nhs.uk
Distribution of children in need of palliative care at the end of life by disease groups
Source: Global Atlas of Palliative Care, 2014 (WHO)
www.england.nhs.uk
Hospital and social care costs
Estimated average cost of care services in each of the last twelve months of life
(n = 73,243)
Source: Understanding patterns of health and social care at the end of life, Nuffield Trust, Oct 2012
www.england.nhs.uk
Average hospital costs per day over final 90 days of life (n = 1.22 million)
Source: Exploring the cost of care at the end of life: Georghiou and Bardsley, Nuffield Trust, Sept 2014
www.england.nhs.uk
5
Multi-aspect challenge
www.england.nhs.uk
Sociological
Demographic
Epidemiology
Scientific
Workforce capacity
Care systems
Additional Challenges
www.england.nhs.uk
Sociological
Demographic
Epidemiology
Scientific
Workforce capacity
Care systems
Ideology
Well-meant assumptions
Challenges for commissioning
End of life care needs to be all-pervasive
Need to commission across whole spectrum: from generic care to specialist palliative care – multiple providers
Plurality of providers:
health and social care (generalist)
NHS and voluntary sector (specialist)
Measurement of outcomes and experience are difficult:
intrinsically difficult because of subject
no suitable tools exist
Incentives and levers can go wrong very easily
Political, public and interest – funding does not always follow
www.england.nhs.uk
Wider context: key developments
Integrated pioneers
Better Care Fund
Personal health budgets
Integrated Personalised Commissioning……
www.england.nhs.uk
www.england.nhs.uk
10
Leadership Alliance for the Care of Dying People
www.england.nhs.uk
11
www.england.nhs.uk
Embedding into daily practice
Public attitude and understanding
www.england.nhs.uk
Priorities for Care
Standards and audit
Regulation
Education and training
Research
Commissioners and service providers
NICE Quality Standard
2008 National Strategy ‘legacy’
www.england.nhs.uk
Headline ambitions
Getting care as good as it can be wherever the person is - at all stages
Care that matches the person’s preferences as closely as possible and meets needs as far as possible
Staff who have confidence to bring these skills into other parts of care – i.e. further upstream and laterally
Reducing the inequality gap
Everybody feels responsible for playing a positive part in end of life care
www.england.nhs.uk
Engaged, involved and compassionate communities
House of Care framework – for End of Life Care
www.england.nhs.uk
Engaged, involved and compassionate communities
Metrics to support commissioning – insights, indicators
National development currencies
Commissioning Toolkit
Input to Seven Day Services programme
NHS Standard Contract
Specialist palliative care service specification
Individual-level palliative care clinical dataset
Incorporating EoLC into service specs for specific groups
Knowledge hub
NICE guidance
CQC’s thematic review
One Chance to Get it Right – Priorities for Care
National audit
Care coordination - EPaCCS
Communities of practice
Transform ing EoLC in acute hospitals
Priorities for Care of Dying Person
Guidance personalised care planning
Data and intelligence know-how
Other professional
know-how
Information
Carers
VOICES-SF
PfC – secure and detained settings
Inequalities
www.england.nhs.uk
17
How do any of these fit together?
www.england.nhs.uk
One example: specialist palliative care
www.england.nhs.uk
Clinical Data Set
Currencies
Improving experience, outcomes and commissioning
Service specification
Another example: Capturing insights: different levels
www.england.nhs.uk
5. National level
4. Locality
1. Individual-staff interaction
3. Organisation level
2. Clinical area
Mapping documents….
27/05/2015
www.england.nhs.uk
NCD focus: system leadership and support commissioning
Contributing to development of Ambitions for End of Life Care: system-wide
Metrics
clinical outcomes
experience
Levers for improving quality and quality indicators
Supporting commissioning
generic end of life care
specialist palliative care
www.england.nhs.uk
Expectations
One Chance to Get it Right: Priorities for Care of the Dying Person
Electronic shared records system (EPaCCS)
Improving end of life care in acute hospitals
Inequities: condition, time of day/night, location of care, population groups
www.england.nhs.uk
Recommended