DR LINDA WILSON (CONSULTANT, AWC)LIZ PRICE (CNS, BRADFORD)

WENDY LAYCOCK (FACILITATOR, AWC)

Clinically Based Education and Training

Initiative

PCTs CCG reconfigurationAiredale hospital –started GSF for acute hospitals

programmeAiredale hospital -Transforming community services, EOL as

1 of 5 workstreams -EOL strategic groupEOL Pathway developed Health Foundation Shared Purpose Project

Communication skills training (Sage and Thyme) EPaCCS Gold Line

System 1 adopted within Airedale Hospital and all GP practices in AWC (16/17, last one May 14)

Non-recurrent funding bid for GSF in 30 Care Homes

Background Scene 1 AiredaleCARE AFTER DEATH and BEREAVEMENTNICE QS 12, 13, 14

IDENTIFYLikely prognosis ≤ 12 months, add to GSF register

NICE QS1

DISCUSS

NICE QS2

ASSESSHolistic assessment (advance) care planning

NICE QS3

SUPPORT & COORDINATE CARE Physical, psychological, social, emotional, financial, and spiritual support. Access to drugs and equipment, 24/7 . Reduce avoidable hospital admissions and shorten number of bed days

NICE QS4, 5, 6, 7,8, 9, 10

LAST DAYS OF LIFE

NICE QS 11

SOCIAL CARE

SPIRITUAL CARE

AIREDALE,WHARFEDALE AND CRAVEN (AWC) END OF LIFE PATHWAY Dr L Wilson/ AGH EOL group

CARER SUPPORT

INFORMATION FOR PATIENTS AND CARERS

STAFF SUPPORT AND EDUCATION NICE QS 15,16

Synergy: Several individual events coming together

CCG reconfiguration

GSF in 30 Care homes

GSF Airedale Hospital

Going for Gold in 12 GP practices

Communication Skill training

• Sage and Thyme

• Difficult C

onversations Training

Telehealth hub / Gold Line

System one across care settings /EPaCCS

Background 2

Managed Clinical Network (MCN)

Non recurrent funding for Gold Standards Framework (GSF) in 30 Care Homes and subsequently in Going for Gold in 12 GP Practices

National Transforming End of Life care in acute hospitals programme

Background 3: Bradford Hospitals

Pilot Last Year of Life ProjectBaseline audit 4 Workstreams developed to implement

project Identification of patients in the last year of life Discharge & SystmOne – sharing information Education Patient & carer experience

Roll out across TrustRepeat audit

How we used the MPET Funding

GSF facilitator Airedale Hospital

GSF facilitator AWC community

GSF facilitator Bradford community

Incorporated to Specialist Palliative Care

CNS role in Bradford Teaching Hospitals

Facilitators promoting GSF as a way to encourage Identification, Assessment and Planning of Care

MPET in Community Posts

Communication Skills training

EPaCCS Template training GP’s /DNs / Practice teams

Supporting GSF meetings

Gold Line Service

Audit and evaluation

• Baseline questionnaires and data

• GSF Good Practice Guide

• EPaCCS training-EOL template for all practices

• 2 day Mandatory training DNs and others

Key Outcomes so far

• Airedale /Bradford Community• EoLC Template training -194 nurses and 42/87 GP practices• Articles and information at events • GSF meetings attendance, 17 registered for Going for Gold

• Airedale Hospital• Audits- LYoL, MPET • Increasing confidence to identify and offer ACP• Flag system and increased liaison of EoLC information

• Bradford Teaching Hospitals• Increased number of patients identified as being in their last

year of life• Greater sharing of information across primary & secondary

care• Communication skills sessions for senior clinicians

Lessons learnt

A vision for the whole pathway but broken down into manageable parts

Joining up primary and secondary careHigh level “buy in” – executive support from

hospital; commissioner involvementCommunication- consider all stakeholders

Lessons learnt cont…

Persistence and resilience

Engaging staff / knowing your audience

Collaboration: within and between

organisations

Data to support, convince and provide

ongoing funding

Be realistic!

Challenges/Future issues

Keeping the dream alive

Education, Education, Education –

competencies???

Media misinterpretation of LCP etc…

Social Care agenda still to address

Short term non-recurrent funding

How do you eat an elephant ?

Questions?