Agenda Item 7
Report on End of Life Care in
Salford for Salford City Council
Community Health and Social
Care Overview and Scrutiny
Committee
Steve Ingle - Local Implementation Officer Palliative Care
Salford and Trafford PCTs
Robin Gene - Integrated Care Pathway Facilitator for the Care of
the Dying (Primary Care & Care Homes)
Salford & Trafford PCTs
August 2005
INTRODUCTION
This report has been written in the context of providing an update to Salford
City Council Community Health and Social Care Overview and Scrutiny
Committee in relation to end of life care and place of death for Salford
residents for the period April 2004 – March 2005.
BACKGROUND
In October 2003, the Health and Social Care Overview and Scrutiny
Committee published a review of palliative care in Salford. The review was
instigated through concerns raised by a member of the public. Following this,
the committee established a sub-group to gather and receive evidence in
relation to the following:






Current palliative care services in Salford
Key determinants of the level of service commissioned by the Primary
Care Trust
Comparisons with other areas in the country
Recent/key developments in the proceeding three years
Results of audits/reviews/surveys undertaken
Strengths and weaknesses of services
The review, whilst acknowledging the excellence of existing services,
culminated in eight key monitoring recommendations (not repeated here).
The Scrutiny Committee has formally reviewed the implementation of these
recommendations on two occasions (Reports presented in March 2004 and
March 2005).
At the last formal review a request was made by the committee for an update
on place of death statistics for Salford residents against those presented in
the original October 2003 Report.
This brief Report on behalf of Salford Royal Hospitals NHS Trust and Salford
Primary Care Trust presents these updated statistics within the context of
national and local End of Life Care quality improvement initiatives.
By way of further context, in is important to state that the statistical evidence
relating to place of death in the October 2003 Scrutiny Committee Report
referred only to cancer deaths. This Report reviews national and Salford
specific place of death statistics relating to cancer deaths and deaths from all
causes. This is of significance because the provision of palliative care in
Salford is not confined to people with a diagnosis of cancer (irrespective of
care setting).
The National End of Life Care Programme has been established within the
NHS by the Department of Health in 2005. It should be noted that the End of
Life Care models/tools that comprise the programme were being implemented
in Salford well in advance of this (from 2001 onwards - with the exception of
Preferred Place of Care, which developed later). This Report outlines the
positive outcomes from the implementation process in Salford to date.
1
STATISTICAL UPDATE ON PLACE OF DEATH
Figure 1 compares percentages included in the October 2003 scrutiny
Committee Report with deaths in Salford 2004 – 05 (cancer deaths only).
Figure 2 compares actual numbers of Salford cancer deaths for the same time
periods.
Figure 1
100
90
80
20
60
2
5
70
%
24
29
6
4
25
Hospice
23
19
50
Other/Unknown
Care Home
40
30
Home
50
46
Cancer Deaths
England & Wales
2000
Cancer Deaths
Salford 2000
47
20
Hospital
10
0
Cancer Deaths
Salford 2004 - 05
Figure 2
Place of Death
All Cancer Deaths
Salford 2000
All Cancer Deaths
Salford 2004 - 05
Hospice
221
157
Other/Unknown
7
-
Care Homes
33
36
Home
140
147
Hospital
336
307
TOTALS
737
647
2
Figure 3
1
100
90
4
10
80
11
19
70
%
6.5
9.5
18
Hospice
Other
Care Home
Home
Hospital
60
50
40
64
57
30
20
10
0
All Deaths England & Wales 2002 03
All Deaths Salford 2004 - 05
Figure 4
Place of Death
All Deaths England &
Wales 2002 - 03
All Deaths Salford
2004 - 05
Hospice
22, 891
166
Other/Unknown
50, 746
20
Care Homes
56, 622
241
Home
97, 485
474
Hospital
305, 783
1,591
TOTALS
533, 527
2, 492
In comparing the percentage of cancer deaths from 2000 (Figure 1) with those
from 2004-05 in Salford there is:



An increase in percentage of people dying at home and in Care Homes
Little change in the percentage of people dying in hospital
A reduction in the percentage of people dying in the hospice
3
Figure 3 represents the most recent place of death statistics for England and
Wales (all deaths) and compares this with Salford in percentage terms for
2004-05 (see table for numbers). From this we can see:

A greater percentage of people in Salford die at home and Hospice than
nationally
 The percentage of Salford residents (2004-05) dying in hospital exceeds
the most recent national statistics (includes road traffic accidents,
suicides, sudden unexpected deaths and deaths of children).
In 2004 – 05, of Salford residents who died, 48% died in Hope Hospital and
16% died in other hospitals across the region and the country. It is not
possible to infer from this how many of these people were in receipt of
palliative care and could have died at home.
(Total deaths (all causes) by place of death in England and Wales 2002 –
2003 - Office for National Statistics Series DH1 no. 35, 2004 – Crown
Copyright. Total deaths (all causes) and cancer deaths in Salford 2004-05 Public Health Department, Salford PCT).
OVERVIEW OF THE NATIONAL END OF LIFE CARE PROGRAMME
The End of Life Care Programme (2005) has been established within the NHS
by the Department of Health in order to improve end of life care for all patients
regardless of disease. This is as a result of the following:

Evidence suggests that of 50% of patients wishing to die at home fewer
than 20% do so
 The majority of referrals to Specialist Palliative Care Teams are for cancer
patients
 People with other terminal conditions do not currently receive the same
level of specialist palliative care
 Most palliative care is provided by non specialist staff (generalists – e.g.
GPs, district nurses, hospital doctors and nurses, care home nurses and
carers) – skilling up these staff is a key factor in enabling people to die at
home
Anticipated outcomes for the End of Life Care Programme are:


Greater choice for patients in their place of care and place of death
Decrease in the number of emergency admissions for patients who have
expressed a wish to die at home
 Decrease in the number of patients transferred from a care home to
hospital in the last week of life
 Generalist staff skilled in the use of models of care tools to improve end of
life care
The Programme promotes implementation of three models of care, which can
be used jointly to ensure that patients receive all the care they need:
4
Model
Details


Gold Standards
Framework (GSF)
Developed from within primary care
Identifies patients nearing the end of life (last 6 – 12
months)
 Assesses care needs and preferences
 Develops a proactive plan of care
 Promotes 7 key tasks to improve communication,
continuity of care, advanced care planning, patient
and carer support and team working

Preferred Place of
Care (PPC)
Patient-held record helping patients and carers to
discuss and agree preferred care and end of life
care
 Records patient’s thoughts about illness and
choices available to them
 Enables patients to express what they do not want
to happen

Liverpool Care
Pathway (LCP)
For use within hospital, community, care homes
and hospice
 Empowers generalists to care for dying patients in
the last days of life
 The Care Pathway document replaces all other
notes and is used by all staff involved in the care of
the dying person
 The Pathway defines standards of terminal
care/quality outcomes which can be audited
THE APPROACH TO IMPLEMENTATION OF THE NATIONAL END OF
LIFE CARE PROGRAMME IN SALFORD
Gold Standards Framework (GSF)


GSF Facilitator in post from September 2004
Identification of GSF Coordinators within GP Practices began in
September 2004
Preferred Place of Care (PPC)


In initial stages of implementation planning
Implementation Group identified
5
Liverpool Care Pathway (LCP)
Community
 Commenced in 2001
 LCP Facilitator in post from April 2003
 District nurse/GP training completed
Hope Hospital
 Commenced in 2001
 LCP Facilitator in post from October 2003
 Hospital staff training completed
St. Ann’s Hospice, Little Hulton
 Commenced in 2001
 All staff trained in use of the LCP
Care Homes
 LCP Facilitator for Care Homes in post from February 2005
 Pilot implementation commenced June 2005, Swinton Hall
Nursing Home
 Partnership working with Salford Primary Care Trust and the
Commission for Social Care Inspection
OVERVIEW OF RESULTS TO DATE

By 2004 63/63 (100 %) GP Practices in Salford using the LCP

By 2004, all wards within Hope Hospital using the LCP

Development of LCP within Hope Hospital Intensive Care Unit 2005

LCP fully implemented within St. Ann’s Hospice by 2003

By August 2005 40/63 (63%) of Salford GP Practices are using the GSF

Regular audit has been established to measure achievement against
standards of care for the LCP and GSF

Action plans from audit of LCP identified and implemented across
Hospital, Community and Hospice
In order to gauge the effect of LCP use and education in improving End of
Life Care skills a questionnaire was distributed to professional users of the
LCP across Salford and Trafford (November 2004). Of the 542 doctors and
nurses who responded, 382 had used the LCP and responded to the
following questions:
6
% That either
Question
Agreed or
Strongly Agreed
Helped the Team decision between doctor and nurse re:
71%
diagnosing dying
Helped my communication with patients and carers
68%
Improved psychological care to patients and carers
72%
Enabled doctors to prescribe more appropriately for dying
90%
patients
Encouraged multiprofessional team working
79%
Helped me to recognise when to seek specialist advice
61%
Improved standards of care for the dying and their families
84%
and carers
Overall, the LCP has empowered me in caring for dying
73%
patients
From this survey and wider audit evidence from implementation of the LCP it
becomes clear that:

The confidence, skills and abilities of generalist staff in providing high
quality end of Life Care for Salford residents have increased

Clear evidence is evolving that staff are addressing the 4 main symptoms
associated with dying - pain, agitation, respiratory tract secretions and
nausea and vomiting

It is becoming standard practice to have pre-prescribed symptom control
medication available - particularly within the home

There is evolving evidence of a reduction in crisis admissions of dying
patients to hospital (a random sample of 20 patients from the 2005 audit
of the LCP all died at home)
CONCLUSION
There is a small but significant increase in percentage of cancer patients
dying at home in Salford (2004 – 05). A greater percentage of people die at
home and in Hospice in Salford when compared to the most recent national
figures (deaths from all causes). These trends will be monitored, as it is too
early to assess the full impact on place of death of the three End of Life Care
tools.
Significant progress has been made in Salford in implementing the
models/tools from the National End of Life Care Programme. Doctors and
nurses across acute and primary care have expressed greater confidence in
providing this service. There is evidence of improved symptom control (in
hospital, at home and in hospice) and evolving evidence of a reduction in
crisis admissions to hospital at the end of life.
7
From February 2005 the process of improving quality and choice in end of life
care for people in Care Homes began. To improve choice generally for end of
life care for the residents of Salford, the challenge over the next few years will
be to implement the Preferred Place of Care tool. Ultimately, all three tools
will be combined in order to promote maximum choice and benefits for all
patients with life-limiting illness (regardless of diagnosis) and their carers.
8