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