Operational
Policy
Macmillan Specialist
Palliative Care Team
February 2008
(Review March 2009)
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1. MISSION STATEMENT
To deliver a high quality, accessible palliative care service, providing specialist
support, care and advice to patients and families living with life limiting disease.
To work in partnership with North East Wales NHS Trust, Local Health Boards
and the charitable and independent sectors, in a variety of settings: Acute
Hospital, Community Hospital, Primary Care, Nursing Home and Hospice,
empowering workers in the palliative care approach.
2. PHILOSOPHY
To promote a reasoned approach to decision making in Palliative Care:
Palliative care is a rewarding but challenging field of healthcare. Patients, carers
and healthcare workers are often faced with complex decisions. Working to
support the patients’ autonomous choices the Macmillan Specialist Palliative
Care Team (MSPCT) will endeavor to base decision-making on reasoned ethical
principles and evidence based practice, rather than experience and opinion
alone. The multidisciplinary nature of the MSPCT is strength, and an open
atmosphere of mutual support, sharing and understanding is encouraged.
To provide equity of access and to implement clinical practice that is
effective and consistent:
To constantly strive to address and improve inequities in service. To reduce
delays in access to the service and the potential for poor outcomes. The MSPCT
will work in partnership with other agencies to co-ordinate end of life initiatives
such as the Care Pathway for the Last Days of Life, Gold Standards Framework
and Preferred Place of Care; empowering generic healthcare workers in the
palliative care approach. The practice of the MSPCT will be firmly rooted in the
principles of education and research, informed by audit.
To most effectively implement national guidelines and minimum standards
relating to the provision of Palliative Care Services:
The MSPCT aims to act upon the National Standards for Specialist Palliative
Care, National Service Frameworks, and NICE guidance, identifying deficiencies
in service that could challenge the implementation of these guidelines. The
MSPCT works in partnership with the Trust, Local Health Boards and Cancer
Clinical Networks, identifying gaps in the service and planning for the future.
To work in partnership with, the independent and charitable sector:
Specialist Palliative Care services are supported by NHS Cymru, but also by the
independent and charitable sectors: Nightingale House Hospice, Macmillan
Cancer Relief, Marie Curie Cancer Care and Tenovus. The MSPCT ensures
effective liaison and communication across these sectors.
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3. PALLIATIVE CARE – DEFINITIONS
Palliative care is defined by the World Health Organisation as the active holistic
care of patients with advanced, progressive illness. Management of pain and
other symptoms and provision of psychological, social and spiritual care is
paramount. The goal of palliative care is the achievement of the best quality of
life for patients and their families. Many aspects of palliative care are applicable
earlier in the course of the illness in conjunction with other treatments:
Palliative Care:
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Affirms life and regards dying as a normal process.
Provides relief from pain and other symptoms.
Integrates the psychological and spiritual aspects of patient care.
Offers a support system to help patients live as actively as possible until
death.
Offers a support system to help the family cope during the patients illness and
in their own environment.
3.1. GENERAL PALLIATIVE CARE SERVICES
A general palliative care service comprises a health and social workforce that
adopts a palliative care approach, providing palliative care as a vital and integral
part of their routine practice. That practice is underpinned by the following
principles:
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Focus on quality of life which includes good symptom control
Whole person approach taking into account the person’s past life experience
and current situation
Care which encompasses both the patient and those that matter to that
person
Respect for patient autonomy and choice
Emphasis on open and sensitive communication.
General palliative care services should be able to:
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Assesses the needs of patients and their families across the domains of
physical, psychological, social and spiritual need.
Meet these needs within limits of their knowledge, skills and competence.
Understand when specialist palliative care services are required.
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3.2. SPECIALIST PALLIATIVE CARE SERVICES
Specialist palliative care services are those provided for patients and their
families with moderate to high complexity of palliative care need. They are
defined in terms of their core service components, their functions and the
composition of the multi-disciplinary teams that are required to deliver them.
They are underpinned by the same principles as for general palliative care
services.
3.3. TERMINAL CARE
Terminal care is a continuum of palliative care and is usually used to describe the
care that is offered during the period when death is imminent, and life expectancy
is limited to a short number of days or less.
3.4. SUPPORTIVE CARE
Supportive care is that which helps the patient and their family to cope with
cancer and treatment of it – from pre-diagnosis and treatment, to cure, continuing
illness or death and into bereavement. It helps the patient to maximize the
benefits of treatment. It is underpinned by the same principles as for general and
specialist palliative care.
REFERENCES:
National Council for Hospice and Specialist Palliative Care Services. Specialist
Palliative Care: A Statement of Definitions. Occasional Paper 8, London,
October, 1995.
National Council for Hospice and Specialist Palliative Care Services. Definitions
of Supportive and Palliative Care. Briefing Paper 11, London, September, 2002
Improving Supportive and Palliative Care for Adults with Cancer. National
Institute of Clinical Excellence. March 2004.
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4. MACMILLAN SPECIALIST PALLIATIVE CARE TEAM
Macmillan Lead Nurse / Manager & Lead Clinician for
Specialist Palliative Care
Alison Foster
Consultant in Palliative Medicine
Dr Matthew Makin
Macmillan Palliative Care Nurse Specialists:
 Hospital
Amanda Cunliffe
Vacant post
 Community
Jackie Evans
Jane McGrath
Theresa Richards
Kevin Plimley
Michelle Jones
Amanda Price
 End of Life Care Facilitator
Under recruitment
Hospice at Home Team:
 Team Leader / Palliative Care Nurse
Carol Roberts
 Health Care Support Workers (Flintshire)
Joanne Edwards
Susan Hadj
Susan Smith
 Health Care Support Workers (Wrexham)
Under recruitment
Specialist Registrars in Palliative Medicine
Dr Clare Stockdale
Dr Marlise Poolman
Specialist Palliative Care Social Worker
Under recruitment
Specialist Palliative Care Pharmacist
Elaine Sturman
Macmillan GP Facilitators:
 Wrexham
Dr Rhys Davies
 Flintshire
Dr Mike Bloom
Secretarial Team:
 Macmillan Specialist Palliative Care Team
Wendy Austin
 Medical Secretary (Dr Makin)
Barbara Ellis
 Hospice at Home Team
Under recruitment
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5. LOCATION
Macmillan Specialist Palliative Care Team
Ty Madoc, Wrexham Maelor Hospital, North East Wales NHS Trust,
Croesnewydd Road, Wrexham, LL13 7TD
Direct Telephone: 01978 727177 (answering machine checked regularly).
Fax: 01978 727118
E-mail: alison.foster@new-tr.wales.nhs.uk
6. REFERRALS
6.1. REFERRAL PROCESS
 All referrals should be sent on a referral form to the Palliative Care Team
Office, Ty Madoc. Referral forms are available from this office and can be
downloaded from the Cancer Services Directory on the Trust Cancer Services
website.
 All referrals will be strictly triaged daily, in accordance with the usual MSPCT
referral criteria and level of intervention. Therefore, referrals with the most
complex and urgent needs will be prioritized. The triage duty is rotated daily
between all the Macmillan Nurses.
 Referrals that require direct assessment by the MSPCT will be seen in
accordance with available staff capacity. Although we will endeavor to
respond to all referrals in an appropriate timely manner as specified by the
National Standards for Specialist Palliative Care, it may at times be necessary
for less urgent referrals to be placed on a waiting list. However, the team are
happy to discuss all referrals and provide specialist palliative care advice to
health care professionals in normal working hours.
 In order for the MSPCT to provide an equitable service across North East
Wales, the Macmillan Nurses will all work flexibly across the region.
Therefore, individual GP Practices, District Nursing Teams and Community
Hospitals, wards & departments will access support from the entire team,
rather than a specific Macmillan Nurse. However, maintaining continuity of
care for individual patients will obviously be a priority.
6.2. HOURS OF WORK
The MSPCT are available Monday – Friday, between 9 – 5pm.
For specialist palliative care, out of hours advice:
 For patients living in North East Wales, please contact Nightingale House
Hospice. Telephone number: 01978 316 800.
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For patients known to the Hospice of the Good Shepard, Backford, Chester,
Telephone number: 01244 851 091
6.3. REASON FOR REFERRAL
1. Symptom Management
2. Psychological Support
3. Patient Dying
6.4. LEVEL OF INTERVENTION
Level One
Advice and information may be accessed by professional colleagues, directly
from the MSPCT. The patient will have no direct contact with the team. Level
One includes where patients receive only telephone contact from the team.
Level Two
The MSPCT will undertake a, consultative visit, ideally jointly with the
professional referrer. Unless requested, the patient visits will be single, and
further contact will be with the professional referrer only.
Level Three
The MSPCT will be involved in ongoing care for patients and families with
intractable or complex needs and problems and , supporting staff in stressful
situations.
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7. ACTIVITIES OF THE MSPCT SERVICE
7.1. PATIENTS
To deliver a high quality, accessible specialist palliative care service, working
with other professionals, to support patients and families in a variety of settings:
Acute Hospital, Community Hospital, Primary Care, Nursing Home and Hospice.
Specialist Advisory Team:
Macmillan Lead Nurse
Macmillan Palliative Care Nurse Specialists
Consultant in Palliative Medicine
Specialist Registrars in Palliative Medicine
Specialist Palliative Care Pharmacist
Specialist Palliative Care Social Worker
Specialist Outpatient Services:
Joint Oncology Wrexham Maelor (Medical)
Outreach at Mold / Chirk / Holywell
Community Hospitals (Medical)
Macmillan Nurse Evening Drop-in Service
(Deeside Community Hospital)
Specialist Day Therapy:
Mold Palliative Day Care Group
(Mold Community Hospital)
Chirk Fight Cancer Together Club
(Chirk Community Hospital)
Deeside Palliative Day Care Group
(Deeside Community Hospital)
7.2. FAMILY AND CARERS
Supporting family and carers, at a time of crisis, in a variety of settings, is an
integral role of the MSPCT. The team will work in partnership with other services
such as the Social Work, Chaplaincy, Bereavement, and “Release” team at the
Hospice, Cancer Site Specific Multidisciplinary Teams, and the Primary
Healthcare Teams.
7.3. EDUCATION
Delivery of education to other health care professionals is an integral function of
the team, empowering generic healthcare workers in the palliative care
approach. The MSPCT are involved in a number of local, regional and national
educational initiatives, delivering education to a number of diverse healthcare
professionals (details in our education strategy document). In addition the team is
involved in much informal teaching.
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8. MULTI-PROFESSIONAL MEETINGS
8.1. REGULAR DEPARTMENTAL MEETINGS
Triage Meeting - daily
Specialist Palliative Care MDT - every Tuesday morning (swap to Monday
morning March / April 2008)
Hospital Palliative Care MDT- every Friday morning
MSPCT Monday Afternoon Rolling Programme of meetings:
 MSPCT Meeting – monthly
 Clinical Supervision – monthly
 Reflection – monthly
 Clinical Effectiveness Meeting – monthly
Pain & Palliative Care Joint Review Meeting – every fortnight
Hospice at Home Team Meeting (21:00 – 22:00 hrs, Deeside CH)
Admin & Clerical meeting – monthly
MSPCT / NHH joint Clinical Effectiveness Meeting – every two months
SPCT Management Meeting - every fortnight
Palliative Care Link Nurse Meeting - bi-monthly
MSPCT Away Day - quarterly (business planning/education/prof. dev.)
8.2. LIAISON MEETINGS
Lung Cancer Multidisciplinary Meeting - weekly
Upper Gastro – Intestinal Multidisciplinary Meeting - weekly
Medical Directorate Meeting - monthly
Medical Lead Nurse Meeting - monthly
Cancer Services Senior Management Liaison Meeting- monthly
8.3. LOCAL MEETINGS
Supportive and Palliative Care Implementation Group (SPIG) - quarterly
Nursing and Midwifery Strategy Group - bi-monthly
Bereavement Quality Group – every two months
Clinical Ethics Group Meetings – every two months
Clinical Ethics Interest Group Meetings – every four months
8.4. REGIONAL MEETINGS
North Wales Specialist Palliative Care Disease Orientated Network- quarterly
North Wales Palliative Care Network Clinical Effectiveness Group - quarterly
Wrexham and Chester Palliative Care Services Meeting - quarterly
Deeside and Chester Macmillan Nurse Liaison Meeting – monthly
North Wales SPC Lead Nurse Meetings – every two months
8.5. NATIONAL MEETINGS
All Wales Consultant’s Meeting
Annual Palliative Care Wales Conference (Gregynog)
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9. MANAGEMENT
The MSPCT provides a trust wide service and sits within the medical directorate.
The nursing and secretarial team members (except the Consultant’s Secretary)
are accountable to the Macmillan Lead Nurse / Manager for Specialist Palliative
Care. Other team members report to their respective line managers.
10. PROFESSIONAL DEVELOPMENT
Access and participation in professional and personal development is crucial for
the success of the MSPCT. Members are encouraged to attend appropriate
educational programmes and study days.
The MSPCT is currently establishing clinical supervision for team members.
Reflective Practice is incorporated into team activities. Macmillan Post holders
undergo Macmillan Profiling with Macmillan Institutes of Education.
Nursing and secretarial team members undertake Personal Development Review
(PDR) with the Lead Nurse / Manager, and the Health Care Support Workers
undertake PDR with the Hospice at Home Team Leader. Other team members
access PDR through their respective line managers.
11. PROFESSIONAL CONDUCT
All team members are required to work in accordance with their professional
code of conduct.
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