Division of Medicine and Emergency Care
&
Nursing, Midwifery & Therapies
5 Year Strategic Plan
Palliative & End of Life Care
March 2013
1
1.1
SERVICE PHILOSOPHY AND DESCRIPTION
1.2
SERVICE SWOT ANALYSIS
1.3
PROPOSED CLINICAL DEVELOPMENTS/CHANGES IN NEXT 5 YEARS
1.4
MARKET ASSESSMENT (RESTRICTED CIRCULATION)
1.5
KEY MILESTONES FOR SERVICE CHANGE
1.6
LINKS/IMPACT ON OTHER SERVICES
1.7
THE LONGER VIEW
1.8
FINANCIAL ANALYSIS – INCLUDING FUTURE INCOME AND EXPENDITURE (RESTRICTED CIRCULATION)
2
Document Control
Document Status:
Draft
Document
Author(s):
Dr Anna Lock
Palliative Medicine Consultant
Kate Hall
Nurse Manager Palliative & End of Life Care
Owner:
Client:
File Ref:
Specialist Palliative and End of Life Care Team
Sandwell and West Birmingham Hospitals NHS Trust
5 Year Plan v4 March2013
3
1.1
Service Philosophy and Description
Background
This is the first Palliative and End of Life Care Strategy specifically for SWBH and will provide the direction we will be moving to improve palliative and
End of Life Care (EoLC) across the Sandwell and West Birmingham area. It has been influenced by consultation with stakeholders across the acute
and community sectors which included a Listening into Action event held on the 14th January 2013.
There are around 5000 deaths within Sandwell and West Birmingham area each year. The large majority of deaths follow a period of chronic illness
such as heart disease, cancer, stroke, chronic respiratory disease or dementia (Appendix A). Within Sandwell and West Birmingham inpatient setting,
there are approximately 1900 inpatient deaths per year. Of all deaths approximately 60% are thought to be predictable. Both Sandwell and HoBPCT
had above the national average of patients dying within the acute setting at around 70%.
The core principles of the National Palliative and End of Life Care Strategy, 2008 provide a framework to deliver a co-ordinated systems approach to
a complex process (Appendix B). This pathway approach to care has been taken with SWBH implementing the Supportive Care Pathway (SCP) as
core to delivering care in the last year of life across both acute and primary care sectors. This provides a framework for generalists to help structure
the care needed and is supported by guidance on end of life medication.
Palliative and End of Life Care Service– Supporting a good death
We have high aspirations for this crucial part of life. The key aim is to provide a good death by creating an organisation:

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


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With a cultural acceptance that palliative and end of life care is everyone’s business
That recognises when people are nearing the end of their life
Takes appropriate steps to care for them when and how they need it
Gives care regardless of diagnosis and place of care
Co-ordinates a seamless service during the patient’s journey
Treats the patient as an individual with choices about where they want to be cared for
Provides specialist advice when needed, including 24/7
Provides support after someone has died for those who need help to cope
4
2010 to date: Laying the foundations
5
Current Service Description / Activity
SWBH’s Specialist Palliative Care team works across Sandwell Community and SWBH hospitals. Their key functions are;



Palliative Medicine Consultant led, specialist clinical advice on symptom control supporting generalist clinicians caring for people with life
limiting diseases including cancer and non-cancer diagnosis.
Driving service improvement in End of Life Care, working closely with primary care, commissioners and acute clinicians to improve systems
and processes to facilitate best care.
Educating and developing the generalist workforce in Palliative and End of life clinical skills.
For a detailed service breakdown see Appendix C.
6
Hospital Specialist Palliative Care: Graph of Service Activity by year
1000
45
900
40
800
35
700
30
600
25
500
Referrals
20
400
Length of Stay
15
300
10
200
5
100
0
0
2008/9
2009/10
2010/11
2011/12
For further activity levels see Appendix D.
1.2
Service SWOT Analysis
An extensive SWOT analysis was done (Appendix E) and mapped to the proposed clinical developments for the next 5 years to focus changes
needed.
7
1.3
Proposed Clinical Developments/Changes in next 5 years
Aims
1. An organisational
acceptance that
palliative and end of
life care is everyone’s
business
2.We will recognise
when people are
nearing the end of their
life
Mapping to SWOT
S Clear clinical leadership
and buy in from local
clinicians
W Some clinicians avoid
caring for the dying
O Ageing population will
increase need
T Media storm on the
Liverpool Care Pathway
making people anxious about
using end of life care
pathways
S Nationally recognised tools
available for prognostication
W Recognition of end of life
often very late i.e. hours
rather than months in
advance
O Early recognition
increases the time available
to offer patients choices
about place of care
T Poor information
processes mean that key
prognostic information is not
shared effectively
Intended
Development
1. To achieve 60%
of all deaths using
the Supportive
Care Pathway
across sectors
2. Ability to
demonstrate high
quality End of Life
Care whilst on
SCP direct to
clinical areas
1. Integration of
prognostic
indicator tools into
everyday clinical
practice
2. Enhanced
information
sharing across
settings via
flagging of patients
on SCP
3. Integration of
prognostication
into clinical letters
across key
specialities
4. Develop a 3 year
workforce training
plan with % targets
for compliance &
staff groups.
Key Driver/Rationale
1. National End of Life Care Strategy
highlighted need for a pathway
approach
2. CQUIN target
3. Health works CCG End of Life
Strategy
4. http://www.blackcountry.nhs.uk/wpcontent/uploads/2012/09/SandwellHealth_Works_End_of_Life_Strateg
y_DRAFT_v3.pdf
1. National End of Life Care Strategy
2. To allow access to care and
services patients must be identified
as nearing end of life as highlighted
in NECPOD report Deaths in Acute
Hospitals: Caring to the End? (2009)
Resources
Trust board to integrate
End of Life Care into all
decision making
1. Access to staff to allow
training& develop a 3
year workforce training
plan
2. Development of
Educator skills within
the SPCT
3. Designated Clinical
champions across
chronic disease groups
for EoLC
Timeframe for
Implementation
Ongoing but would
expect to see EoL
in Trust Board
Papers by
December 2013
1.
2.
3.
4.
Dec 2013
Dec 2015
Dec 2015
2013- 2015
8
Aims
3. We will take
appropriate steps to
care for people at the
end of life when and
how they need it
4.Gives care regardless
of diagnosis and place
of care
5.Treats the patient as
an individual with
choices about where
they want to be cared
for
Mapping to SWOT
S Specialist palliative care
teams available across
settings
WVariable clinical skills in
symptom control
O Vertical integration has
increased our ability to
influence community service
knowledge and skills
TFragmentation of the health
service will limit our ability to
target training
SIntegrated SPCT in
Sandwell
WVariable skills depending
on setting, care homes
highlighted as a particular
gap
O Closer links with local
SPCT for seamless service
TIncreasingly frail population
in care homes with patchy
EoLC competencies
S Increased awareness that
patient choice is part of care
WNon cancer patients less
likely to achieve home death
(Appendix B)
O By involving patient early
and informing them can
reduce risk of unplanned
hospital admissions
TEmphasis on community
care may reduce quality in
acute setting if resources are
diverted in an unplanned
manner
Intended
Development
1. All staff will have
skills to deliver
high quality EOLC
2. Develop a 3 year
workforce training
plan with % targets
for compliance &
staff groups
1. Specialist advice
available for all
when most needed
 24/7 telephone
advice
 7/7 face to face
visiting service
2. Provision of
focused education
and support of
care homes
1. Embedding of
Advance Care
Planning
processes and
competencies into
everyday practice
for all services
2. Roll out of ‘My Life’
ACP tool
3. Work with
Resuscitation
team to unify
DNACPR policy
4. Ensure homely
alternative to
hospital available
Key Driver/Rationale
Resources
Timeframe for
Implementation
2013-2015
1. Local SCP audits demonstrate a
variable approach in quality of care
2. CCG Priority – Healthworks
3. Common core competencies and
principles for health and social care
workers working with adults at the
end of life to support the National
End of Life Care Strategy
1. Access to staff to allow
training
2. Consultant support to
drive programme
3. Adequate SPCT to
deliver training
1. GP commissioning prioritising care
at home
2. CQUIN targets to increase %
patients achieving their preferred
place of care/death
3. LIA feedback
1. Funding for 1.5 WTE
CNS’s
2. Consultant On call
payments
3. Continued consultant
presence
4. Dedicated support for
Care homes
1-3. Outcome of
funding request
awaited
4. Dec 2014
1. Clinical evidence shows people
would in general prefer to die at
home
2. National Patient choice agenda
3. Fits the Right Care Model of care
emphasises community care
1. Staff time for ACP
training
2. Printing costs of My
Life
3. On-going investment in
alternative to hospital
e.g. Bungalow beds to
End of Life Care
4. SWBCCG
Commissioning
intentions re Bungalow
EoL beds – yet to be
established
1. Pilot April 2013,
Full roll out by
Dec 2013
2. Unified
DNACPR
across acute
and community
by July 2014
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Aims
6. Which provides
specialist advice
whenever it is needed
Mapping to SWOT
S Clear national guidance on
Service specification
W Insufficient staff numbers
to deliver service currently
O Reduction of inappropriate
interventions
T TSPplans for SPCT
Consultant posts directly
funded by CCG’s – with no
agreement for this to endure
indefinitely
1.
2.
3.
4.
Intended
Development
Expand the SPCT
CNS team to
provide 24/7
telephone advice
and 7/7 face to
face contact
Ensure Consultant
posts are
sustained
Develop Senior
specialist advice
on-call rota with
neighbouring
Specialist
Palliative Care unit
(Hospice)
Develop internal
diverse expertise
and links with
other teams
including
psychology and
full range of AHP’s
Key Driver/Rationale
1. National Peer review standards
2. End of life care strategy: quality
markers and measures for end of
life care (Department of Health
2009)
3. National Cancer Peer Review
Programme Manual for Cancer
Services: Specialist Palliative Care
Measures
4. Research demonstrating high
unaddressed symptom load at
weekends
Resources
1. Bid in for additional
CNS’s and consultant
funding for 24/7 and 7/7
2. Psychologist – 2
session per week
3. Dedicated
physiotherapist for
acute & dedicated
physiotherapist and
occupational therapist
for community
Timeframe for
Implementation
1. Dec 2013
2. Dec 2015
3. Dec 2016
10
7. Provides support
after someone has died
for those who need
help to cope.
1.4
S Lead bereavement post
provides leadership
W Process for rapid release
of body in place but poorly
implemented
O Enhanced bereavement
service to reduce complaints
T Reductions in the 3rd
sector will decrease services
available in the community
1. Increase the
number of people
able to verify death
2. Improve medical’s
staff skills of death
certification
3. Partnership
working with
CCG’s to improve
GP’s use of GSF
(Appendix F)
4. Undertake a Gap
analysis and
develop a
business case for
Bereavement
service/model
1. LIA highlighted issues
2. National End of Life Care Strategy
1. Funding to train
appropriate people to
verify death
2. Potential for staffing
costs for a
Bereavement service
1. Dec 2013
4. 2014/15
Market Assessment
Restricted
11
1.5
Key Milestones For Service Change
Development
Advance Care Planning:
My Life document ratified
Pilot Rolled out
Gather feedback on document
ACP embedded across sectors
Supportive Care Pathway:
60% of all deaths using the SCP
Sharing information on discharge and admission of patients on the SCP across
sectors so that an end of life register is developed
Competent workforce
Strategic approach to education across hospital and community generalist care
Specialist Advice
Increase consultant numbers to population appropriate levels
Obtain resources to deliver 24/7 and 7/7 service for nursing and medical teams
DNACPR
Support Trust development of a unified DNACPR policy and document
1.6
Timeframe
Leads
March 2013
Summer 2013
Summer 2013
End 2013
Kate Hall/Dr Diana Webb
End 2013
End 2014
Sue Law
On going
Dr Anna Lock
End 2014
End 2013
Kate Hall/ Dr Anna Lock
Mid 2014
Dr Diana Webb
Links/Impact on Other Services
Service
 Cardiac
 Renal
 Cancer
 Respiratory
 Haematology
Impact
Opportunities to integrate palliative principles to
 Improve symptom control and quality of life
 Increase patient choice
 Reduce unplanned and often unwanted admissions.
 Reduction in un necessary interventions at the end of life should provide opportunities to
reduce the burden of tests

Care of the Elderly and Stroke

Imaging and pathology
With a projected rapid rise in increasing people living with dementia. Opportunity to
 Work with care homes to reduce improve the quality of Advance Care planning to reduce
un planned admissions
Reduction in unnecessary investigations and use of blood products

Community Services
An increase in care in community setting will increase the intensity of service which primary
care will need to deliver such as district nursing, GP’s and community social carers.
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1.7
Service Development: The longer view
Instil cultural acceptance that palliative and end of life care is everyone's business
Build relationships with the CCGs
IT integration across sectors
Service
&
Quality
Constantly monitor
delivery
Redesign SPC Service
Implement SPC Service
Business case for Research &
Education function
Constantly monitor
delivery
Educations
programmes
deployed
Time
13
1.8
Financial Analysis – including future income and expenditure
Restricted
14
A. Place of death By Diagnosis
End of Life Care PCT Profile for Sandwell:
End of Life Care PCT Profile for Heart of Birmingham:
15
B. Palliative and End of Life Pathway from the National End of Life Care Strategy, 2008
Support for Carers and Families
Information for Patients and Carers
Spiritual Care Services
16
C. Detailed breakdown of Current Specialist Palliative Care Service provision
Since vertical integration in 2011 the Specialist Palliative Care service has been is a unified multidisciplinary team providing Specialist Palliative
Care advisory service for patients in City and Sandwell hospitals, as well as Sandwell community services.
Staffing within the medical and nursing directorate
Dr Anna Lock
Dr Diana Webb
Palliative Medicine Consultants
1.6 WTE
Funded by direct monies from PCT – now CCG
Kate Hall
Nurse Manager Palliative & End of Life Care
1 WTE
Carol Leiper
Lead Nurse
1 WTE
Bereavement &
Supportive Care
Pathway Practice
Development
Team
Sandwell
Hospital
Palliative
Care
CNS
Team
City
Hospital
Palliative
Care CNS
Team
Hospice at Home
Community CNS
Team
Bradbury Day
Hospice
Primary
Palliative
Care
Liaison
Nurses
Band 7 – 1 WTE
Band 6 – 1.8 WTE
2 WTE
2.4 WTE
Band 7 – 7 WTE
Band 6 – 3.4 WTE
Band 6 – 1 WTE
Band 3 – 1 WTE
2 WTE
Additional members of the team include 2 Macmillan Occupational therapists at city and Sandwell sites and SALT therapist in the community
setting. Both services are notable in the absence of psychology and regular specialist physiotherapy and social work input.
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D. Activity and Outcomes
The total number of patients referred by the Hospital Specialist Palliative Care MDT between April 2011 and March 2012 was 898. During the year,
the team undertook a total of 3395face to face contacts, with the majority of these being between a MDT member and patient. The team also
undertook a total of 562 telephone contacts, with the majority of these being between a MDT member and other health care professional.
The team had approximately 74% of cancer referrals and a slight increase at 26% compared to the previous year of non-malignant referrals. The
figures for non-malignant referrals are slightly higher than the average of similar sized teams nationally but significantly higher than other teams in
the West Midlands region
Graph 1 Hospital SPCT activity for non-cancer patients
No. of new non cancer patients seen by the SPC MDT Apr 11-Mar 12
60
56
50
40
38
40
30
22
20
12
10
9
7
0
0
Motor Neurone Neuro Biological
Disease
Conditions
Dementia inc.
Alzheimer's
deaths
Heart Failure
Other heart &
circulatory
conditions
Chronic
respitaory
disease
Chronic renal
failure
All oher noncancer diagnosis
18
A key indicator of the effectiveness of the team’s intervention is demonstrated by a CQUIN target set for 11/12 of improving the number of patients
referred to the team who achieved their preferred place of care by 10%. The target of 66% was based on quarter 4 activity. The team achieved an
overall target of 78%.
The community Specialist Palliative Care service, Hospice at Home saw 1203 new referrals during 2011-2012, of which 791 have died and their
place of death can be broken into:
Place of Death
2012-13
Other, 1%
Hospice,
5%
Nursing Home, 10%
Home, 47%
Hospital, 21%
19
Out of hour’s service
Of note for inpatients at both acute hospital sites the Specialist service falls below national Cancer Peer Review service specifications as there is
no funded weekend or evening specialist advice or weekend face to face review available.
For patients at home the Hospice at Home service provide a weekend day time visiting service. Again there is no funding available for out of hours
cover, falling below national standards.
Bradbury Day Hospice
The day hospice provides a safe and therapeutic environment for patients to express their fears and worries. It includes medical reviews, nursing
assessments and interventions and gives respite for patient, family or carer. The service also provides an opportunity for patients to share
experiences with others and learn new skills.
There were 63 referrals to Bradbury day hospice between the 1st November 2011 and the 31st October 2012 however only 39 patients have
attended with 38% of patients who were either too unwell to attend or declined. Referral activity for Bradbury demonstrates approximately 43%
attendance over a 6 month period and this has been the picture for the past 2-3 years.
In Patient Specialist Palliative Care beds
For residents of Sandwell and West Birmingham when a specialist palliative inpatient stay is needed for specialist support such as symptom
control, beds are funded by primary care in the local hospices of the patient’s choice. There is no Hospice in Sandwell or Heart of Birmingham, and
in the past this has been a focus for local campaigning by Sandwell residents for their own hospice, though this position may have been mitigated
by the development of Bungalow EoL beds; the public desire for a hospice in HOB has not been so obvious, possibly because they are
geographically much closer to the hospices in Selly Oak and Erdington. Historically, for patients in the acute trust, access to the hospice beds has
sometimes been patchy; work to improve cross border relationships has greatly improved access in a timely manner. This has demonstrated that
access is workable without the financial burden of building and supporting a new local hospice.
Primary Liaison Nursing Service
2 WTE Primary Palliative Care Liaison Nurses work within the specialist palliative care team and visit patients who are thought have a prognosis of
6 weeks or less and ensure a swift arrangement of care package to either avoid hospital admission or allow rapid hospital discharge to their
preferred place of care. In 2011-2012 this service had 290 referrals of these 183 were from hospital, 95 from community settings and 12 were felt
to be inappropriate referrals. 70% of patients achieved their preferred place of care/death (195/278).
20
End of Life Care
Within the Hospitals there are approx. 1800 deaths per year of which we would expect 60% to be ‘expected’, which would fit the criteria for the
Supportive care pathway. Currently within the acute sector we have 63% of all deaths being patients who are cared for on the supportive care
pathway (SCP).
The SCP was rolled out in the community setting in Sandwell in 2012,there have been 454 patients to date cared for on the pathway.The team
have achieved 41% compliance for all deaths being patients who are cared for on the SCP.
For those on the SCP there has been a steady rise of patients achieving their preferred place of care/death which will be further developed by an
emphasis on Advance Care planning which is being driven by the team.
Providing a homely place to die and avoiding hospital admission
The community SPCT are responsible for gatekeeping the innovative Pilot of Palliative Care Bungalows (6 beds) in Sandwell, which has over the
period of evaluation ( 6 months) provided alternative homely environment to 43 people to have end of life care, delivered by a social care provider (
Sandwell Community Caring Trust), and primary care services with specialist support.
The aim is to provide a “home from home” setting for patients and facilitates their loved ones being able to spend quality time together and to meet
both physical and emotional needs. The bungalows provide 6 beds across 2 sites for Sandwell patients who need end of life care. Care is provided
by carers who, over the course of the pilot, developed the additional skills and knowledge to care for end of life patients. Clinical interventions were
carried out by District Nurses, Hospice at Home (CSPCT) and GPs.
In the first 6 months, a total of 43 patients were admitted to the bungalows. The majority of referrals came from the community palliative care CNS
team. See Chart: Reasons for Referral to Bungalows.
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Reasons for Referral to Bungalows
Outcomes for patients admitted to Bungalows
n=43
2
3
3
23%
4.80%
72.00%
35
Symptom Control
Support Carers
End of life care
Die in Bungalows
Transferred to Hospital
Returned Home
Care Facility
The average length of stay for patients was 12.6 days although this figure was affected as one patient remained for 101 days due to delays with
social care assessment and placement. Excluding this patient gives an average length of stay of 10.4 days.The pilot commenced with only 3 beds
available, and expanded to 6 beds after 3 months.
The pilot was evaluated from 1st May – 31st October 2012. The complexity of the model has made it difficult to establish the full provision costs
although they are likely to be less than hospice care provision. Further work will need to be undertaken to understand this if the service is recommissioned.
Education and Professional development
The service is increasingly taking a structured competency approach to End of life and Palliative Care learning, which is now available for all staff
across SWBH including, using the Supportive Care Pathway, Advance Care Planning, symptom control, and difficult conversations at the end of
life. This is felt to be one of the keys to cultural change within the organisation.
22
There are opportunities for medical and nursing shadowing, formal longer attachments to deliver on aspect s of medical curriculum such as Care
of the Elderly Registrars and an innovative Band 6 nursing post where a ward nurse has the opportunity to spend 1 year with the specialist
Palliative Care team to take best practice back onto the wards.
The team provides a large volume of easy to access education with recent work being focused on medical staff across the grades. This year there
has been agreement to develop 6 hours per year of face to face teaching to FY1/2 and Core medical trainees, with clinical attachments available
for those with a special interest in palliative care and development of a ‘champion’ role for junior doctors to promote interdisciplinary working and
audit. This is integrated with e learning.
The palliative medicine consultants also provide tailored education for GP trainees from Sandwell and West Birmingham as part of their training
programme.
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E. SWOT Analysis for Palliative and End of Life Care
LIA Event
An LIA event was held on the 14th January 2013 with key stakeholders looking at the EoLC strategy steps (Appendix B) from across primary,
secondary & voluntary/third sectors with 93 attendees. This data has fed into the this SWOT analysis
Strengths
Internal Key Strengths

Strong validated tools available e.g. GSF framework, SPICT, SCP, ‘My Life’ for Advance Care Planning

SCP used extensively throughout acute trust and in Sandwell Community

Permanent End of Life facilitator roles with mandate for cultural change of organisation

Strong clinical leadership

Embedded in NHS with close relationships with acute sector and primary care

EOLC is a part of the CQUIN targets for the trust

Our Specialist team model of working between acute and primary sectors delivers integrated care

7/7 SPCT face to face service in community

Innovative Bungalow beds in Sandwell providing alternative place of death for patients wishing to avoid hospital admission

Strong Internal audit programme of SCP

DNACPR process in place in both settings

Fast Track service in Sandwell allows people home to die in a timely manner

Supportive Senior Generalist clinicians in different specialities with interest in Palliative and End of life Care

Network of Junior doctor champions influencing development of services and educating their peers
External Key Strengths

Recent media conversations on Liverpool Care pathway has opened up conversation on end of life care

Peer review Standards driving reconfiguration of specialist service in line with best practice models, now achieving 44% in Community and 72% within the
Acute sector

Strong National Drivers making EOLC a National priority such as:

NICE Quality standards- End of Life Care for Adults (2011)

High Impact actions for Nursing (2009)

NCEPOD report highlighting over intervention at the end of life in hospital (Caring to the End 2009)

End of Life Care strategy (July 08)


Local Drivers: CQUIN in place– 10% increase in the number of patients referred to the SPCT team achieving their preferred place of care, which has been
achieved
CCG’s have prioritised EOLC with Dr Webb working with commissioners 1 day per week (now under threat)
24
Weaknesses
Internal Key Weaknesses

Threats to continuation for Palliative Medicine Consultant posts

Significant TSP measure due to nursing team 2014/2015

Lack of EOLC skills and knowledge in general staff often means late recognition of end of life restricts opportunities to affect quality of care until last few days
or hours of life

Hospital culture of ‘cure at all cost’ means clinicians may feel uncomfortable recognising end of life and having open discussions or enabling discharge to
preferred place of death as insufficient time

Advance Care Planning is not embedded in culture of organisation

Poor communication of information across sectors on critical information e.g. prognosis, DNACPR and PPC/Death – no integration of IT system

Patient’s with ‘non-cancer’ diagnosis are less likely to have their End of Life recognised and acted upon

Poor information sharing between acute and primary sectors

DNACPR documentation not joined up across sectors

Less integration of specialist services with Birmingham than Sandwell

SCP not always used to its full extent – with communication about Preferred place of care and death and patient’s understanding of illness often not
documented

SPCT fails National peer review measures for 24/7 telephone advice in hospital and community setting in Sandwell and 7/7 face to face visiting in acute setting
External Key Weaknesses

Future of both consultants is uncertain as the roles are directly funded by CCG’s, separately to the block funding with no formal agreement to continue funding
indefinitely (initiated by the now defunct Sandwell PCT)

GP’s have variable compliance with Gold Standard Framework

Lack of strong individual leads in primary care championing Palliative and End of Life Care

Out of hours medical service demonstrates lack of knowledge and skills to care for this group of patients

No IT sharing with OOH services

Generally the cultural aversion to dying in population makes opening conversation more difficult

Birmingham fast track service perceived as inconsistent, reducing the ability to get people to their preferred place of death
25
Opportunities
Internal Key Weaknesses

Use palliative and end of life care education within SWBH up drive up skills and knowledge

New use of E- learning for End of Life Care now integrated into junior doctor portfolios but not used by all so could be promoted further

Integration of Advance Care planning tools into non cancer specialities would be an opportunity into reduce unwanted admissions

Further integration of our service provides opportunity for rapid discharge and admission avoidance

Improving connections with local hospices by sharing medical cover out of hours

Change in demographics of population with increasing ageing
External

New CCG’s are prioritising EOLC

National EOLC strategy increasing profile of death and dying

Care Homes asking for and attending education may provide additional income stream
Threats
Internal

Media scare stories making clinicians less likely to initiate conversations on end of life and avoid the SCP

Out of hours service need to be adequately covered to ensure week day service is maintained at a high standard and education and service delivery continue

Increased referrals may reduce our ability to provide professional development and improve EOLC

Improved skills in generalist colleagues may reduce need for specialist services
External

Expansion of local Hospices trying to expand their market share of community SPC services may encroach on our geographical area

Changing health economy may cause fragmentation of services reducing ability to integrate care

National Palliative Care funding review suggests moving funding out into the community which may leave inpatient services without sufficient care

CCG’s planning to decommission Dr Webb’s time and replace with a local GP reducing our ability to influence service development
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F. Glossary
End of Life Care has been defined as:
‘Care that helps all those with advanced, progressive, incurable illness to live as well as possible until they die. It enables the supportive and
palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement. It includes the
management of pain and other symptoms and provision of psychological, social, spiritual and practical support’ (National Council for Palliative care
2006)
The definition of when ‘End of Life’ begins can be a difficult concept to grasp and varies according to the perspectives of individual patients,
professionals and care services. The suggested professional indicators are:
1. The surprise question: would you be surprised if this patient were to die in the next 12 months?
2. Choice: When a patient with advanced disease makes a choice for comfort care only.
3. Need: When a patient with advanced progressive disease would benefit from a palliative care approach.
4. Clinical Indicators: The Supportive and Palliative Indicators Tool is useful guidance for clinicians assessing disease severity across a range
of conditions.
Palliative care is defined by (NICE Improving Supportive and Palliative Care for Adults with Cancer 2004) as the active holistic care of patients
with advanced, progressive illness. Management of pain and other symptoms and provision of psychological, social and spiritual support is
paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of Palliative care are
also applicable earlier in the course of the illness in conjunction with other treatments.
Although the terms ‘palliative care’ and ‘end of life care’ are closely linked and can be used interchangeably, specialist palliative care has a
broader role than end of life care. Specialist palliative care encompasses the period when people may be receiving palliative treatment for
symptom control to improve their quality of life, and support for psychological distress and ethical issues in clinical decision making.
Gold Standards Framework
The Gold Standards Framework (GSF) is a systematic evidence based approach to optimising the care for patients nearing the end of life
delivered by generalist providers. It is concerned with helping people to live well until the end of life and includes care in the final years of life for
people with any end stage illness in any setting. In the SWBH foot print it is primarily used by General Practitioners.
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