How to meet QIPP challenges in end of life care services

NHS Berkshire West undertook a baseline review of its palliative care services in May 2008 and while it revealed that it was well served for patient choice and clinical expertise it did identify that the service was uncoordinated and inequitable across the three PCT localities. Subsequently this review informed a wide ranging commissioning strategy that not only encompassed the aims of the Department of Health’s end of life strategy but also met the QIPP challenge.

The PCT was committed to achieving a better end of life experience for patients, families and carers and in the ensuing two years, the successful implementation of this commissioning strategy has resulted in a highly effective and resourceful end of life service in NHS Berkshire West.

The key features were:

• The separation of specialist palliative care for end of Life Care (EOLC) from community services to the Sue Ryder services
• The establishment of a single point of access to community based EOLC services
• Enhanced nursing service provision through: the expansion of intermediate care services across the PCT; and investment in the district nursing service to provide twilight and evening services to EOLC patients
• Introduction of an overnight nursing service
• Working collaboratively with the three unitary authorities, to provide an overnight sitting service
• Introduction of practice educators into secondary and primary care
• Implementation of the gold standards framework in primary care
• Improved communication and data recording between services
• The development of a primary care information pack

These changes were achieved through:

Transfer of community services to Sue Ryder

Prior to the project initiation the PCT already commissioned a fully integrated service by Sue Ryder. The service was well established and Sue Ryder had proven expertise in this field.

Out of hours service

There was further development of the OOH service to incorporate electronic patient records using Adastra. The lead GP for the service is passionate about future developments and improvements in patient care and was instrumental in implementing the Adastra template for use in primary care and further development of the locality register. Adastra in out of hours service is an electronic system which delivers the current medical condition of the patient direct to a Blackberry device and informs the GP and nurses if there has been any change in the patient’s condition.

Enhanced nursing service support available 24/7

There was a need for 24 hour nursing support at EOL, which would enable patients being able to end their lives supported at home and without inappropriate acute admission. This was achieved by providing:

• A single point of access ensuring  support delivered by the correct team in a timely fashion
• Additional specialist palliative care (SPC) consultant time in the acute trust.  This facilitates discharge with co-ordinated support; ensuring all the clinical needs of the patient are organised prior to discharge and relevant support in place. This means that discharge ‘straight to home’ can be achieved and hospice is not used as a stop gap
• Night-sitting service. This was implemented after a pilot scheme was run for three months in the previous year showed that supporting carers in the home had a direct effect on the number of patients enabled to stay at home during the final days of life. The service runs alongside and complements a charity funded service already in existence.

It is estimated this will save:

• 50 per cent of current annual 369 emergency admissions, costing £900k.
• 50 per cent annual 2400 excess bed days costing £250k
• Education delivered on EoL care to nursing homes and primary care. It aims to avoid unnecessary emergency calls to the ambulance service. This was achieved by grasping opportunities available through non medical education training (NMET) funding.

It is estimated this will prevent seven emergency admissions per month.

Roll out of a unified (SHA wide) policy for Do Not Attempt Cardio-Pulmonary Resuscitation   

This policy, ties together many aspects of end of life care across the healthcare environment. The key to a systemic roll out was the end of life locality group ensuring clear understanding of the reasons behind the policy and understanding of how each organisation was progressing with implementation.

Collaborative working

It was clear from the outset that the complexity and multi-factorial of the interlinking projects would need input from across the health spectrum in NHS Berkshire West.

The PCT already had a model that worked well for patients both with EoL and specialist palliative care needs. Most significantly, it had an enthusiastic and integrated end of life care locality group whose members had a clear vision of what the service would look like, and had the knowledge and skills to make the vision work across the environment. The members of the group shared a common vision for the future and ensured stakeholder involvement for all projects by recognising that integration and seamless pathways are the key to excellent patient care.  .

The EoL locality group sought to improve the service, by listening and consulting with both staff and patients; identifying areas for improvement and working together to implement the improvements.

The group has effective leadership in place not only in the chair of the group but in the stakeholder membership. Each, in their own disciplines and environments has empowered their staff to see the benefits of a care pathway which is integrated and has patients at the forefront.

These results were:

• Improved delivery of high quality patient care
• Co-ordinated planning and communication of patients needs
• Reduction on the number of acute admissions at EoL
• Carers supported by an overnight sitting service
• Patients discharged from hospital to home in a timely fashion
• Medical support by SPC consultant to primary and secondary care via 24 hr on call service

The EoL locality group continues to review the EoL care provided, ensuring it is fit for purpose and identifying and prioritising key areas for improvement.

This group will ensure that the work carries on as we move into clinical commissioning groups and will be the legacy of the PCT.