End of life care: ‘We do more with the same resource’

Case study 1: Bradford

Commissioners in Bradford have been praised for taking a proactive approach to ensuring local health services are skilled in end of life care.

Andrew Daley, consultant in palliative care at the Marie Curie Hospice in Bradford, says that local clinical commissioning groups firmly support palliative care training for primary care staff.

End of life care is also boosted by innovative use of technology, adds Dr Daley, including a CCG-funded initiative to provide 24/7 nursing support for palliative care patients via the Airedale Telehealth Hub.

In part, the efforts of commissioners and clinicians are boosted by some positive local conditions, he says.

‘Patients have the hub number and can speak to a senior nurse who can coordinate whatever care they need, whether it’s a visit from a community nurse or out of hours doctor’

“We’re in a good position in Bradford and Airedale because we have shared patient records across the whole of primary care,” says Dr Daley. “That means we were in a great position to create an end of life register across the district.”

Local palliative care services - with the support of CCGs - are using MPET (Multi-Professional Education and Training) funding to offer learning to all trained community nursing staff.

The two-day course includes sections on identifying people in the last year of life; discussing the end of life register - and gold card - with patients; advance care planning; symptom management; bereavement support; and carer assessment.

“All trained community nurses must attend the course, which is great, and all credit to the CCGs for backing us up,” Dr Daley says.

Home support

The CCGs are also taking steps to ensure patients are supported at home by using the local Airedale Telehealth Hub, staffed by senior nurses 24 hours a day.

“Patients have the hub number and can speak to a senior nurse who can coordinate whatever care they need, whether it’s a visit from a community nurse or out of hours doctor,” he says.

Dr Ian Fenwick, clinical specialty lead for end of life and cancer for the Airedale, Wharfedale and Craven and Bradford CCGs, agrees that end of life care is important to local commissioners: “Our three CCGs - Airedale, Wharfedale and Craven; Bradford City; and Bradford Districts - have various initiatives, working with local partners including the NHS trusts, local authorities, care homes and voluntary sector, including local hospices, to promote excellence of care and treatment for patients and their carers facing end of life issues.

“This includes Gold Standards Framework learning for care homes, primary care and community nursing staff as well as a dedicated helpline for patients and carers, which aims to support end of life patients and their families at home, where they have expressed a desire for this.”

Dr Daley believes that commissioning for palliative care is made easier in the Bradford area because of the relationships that have built up over a number of years.

“We have a well established palliative care managed clinical network, which fosters collaboration rather than competition between the palliative care services. It gives the commissioners one point of contact, and means our voices are really listened to,” he says.

“It means there’s one strategy for the area, and that’s a good thing.”

Case study 2: Wales

A patient-focused approach to end of life care is paying off in the Neath Port Talbot area of Wales.

The innovative scheme has seen a 33 per cent increase in the number of patients seen by the Marie Curie Nursing Service, and a 42 per cent rise in the number of visits, without an increase in overall resource.

The partnership between Marie Curie Cancer Care and Abertawe Bro Morgannwg University Health Board involves the specialist nursing service working more closely with the health board’s community team.

‘If commissioners are serious about wanting to move care from the acute sector to the community, then the services have to be there to support them’

Having moved into the local community resource centre, the senior nurse responsible for the service has direct access to district nurses, general practice and members of the multidisciplinary team, explains Andrew Wilson-Mouasher, Marie Curie Cancer Care divisional general manager for patient services in Wales.

“Co-location means that coordination of care is much more effective,” he says. “We’ve appointed a senior nurse to coordinate and support staff, and she is also linked into the district nurses. It means we can now tailor each package of care depending on the changing needs of each individual patient.”

Traditional commissioning models would tend to involve patients being offered a standard package of care, he says. “But if you actually talk to patients and their families about what they want, and would find useful, then you can tailor the care to their needs.”

Family support

Sometimes a patient who has just left hospital will need fairly intensive support but this can be scaled back as family members become more confident, he adds. In other cases, a patient might need more intensive support as the end of life draws nearer.

“We have found that by wrapping services round the patient’s needs, rather than trying to fit them into our services, we have actually been able to do more with the same resource,” Mr Wilson-Mouasher says.

Commissioning a patient centred service benefits staff, patients, and health services, he says, freeing up staff time to see more patients at a time - and in a place - which suits families.

“If commissioners are serious about wanting to move care from the acute sector to the community, then the services have to be there to support them,” Mr Wilson-Mouasher says. “More can be done with current resources, but people will have to think about services working together, rather than one service being a panacea.”

A similar model is being rolled out in Carmarthenshire, and Marie Curie is in discussion with other health boards in Wales to look at introducing such services elsewhere.

Case study 3: Scotland

Marie Curie nurses in Grampian are working in partnership with out of hours GPs, nurse practitioners and the district nurse team to ensure that patients get access to the right nursing support, at home, when they need it.

The service has enhanced care for patients requiring palliative care (not only those with a cancer diagnosis) and has improved quality and efficiency, says Diana Hekerem, divisional business and service development manager for Scotland with Marie Curie Cancer Care.

‘Often there’s a difference between the needs of cancer and non-cancer patients, and delivering care in this way means we are supporting people who need urgent response throughout the night’

The charity has been working with NHS Grampian (which is both a commissioner and a provider) to streamline out of hours nursing services, and to achieve the aims of the Grampian Palliative Care Strategy, which says that patients should generally receive care in their preferred place.

“In Grampian we’ve been working with the NHS board for a number of years and have regular meetings with senior nurses in the community health and care partnerships,” explains Ms Hekerem.

“By working collaboratively we are able to share best practice from the organisation’s experience elsewhere and how it could improve care in the area. In these meetings, the challenge of meeting palliative care out of hours across a rural area was discussed and how Marie Curie could develop to support these needs.”

Rapid response

The solution was a Marie Curie rapid response service, which works from 8pm to 8am across Aberdeenshire and Moray. Local patients can access nursing support either through the GP out of hours service, or by calling NHS 24, which is Scotland’s gateway to out of hours care.

The service has been adapted to meet the needs of patients with different requirements. “Often there’s a difference between the needs of cancer and non-cancer patients, and delivering care in this way means we are supporting people who need urgent response throughout the night,” says Ms Hekerem. “This collaboration means that in Grampian, more patients who have nursing needs can be supported at home.”

In its first year, the service saw 1,376 patients and delivered 2,702 visits. Evaluation showed that patients and their families really appreciated the service, with 96 per cent of patients and carers feeling it met their needs all or most of the time. Patients were able to die in a place of their choice, with 84 per cent of recorded deaths taking place at home, compared to 7 per cent in hospital.

Ms Hekerem believes that strong relationships are key to the success of the new service, which is now being replicated in other areas of Scotland.

“It’s part of the commissioning process that there will be a steering group [involving Marie Curie nurses, community nurses, GP out of hours services and district nurses]. That ensures there is an ongoing partnership, and that the service is being constantly monitored and improved.

“This way of working means that we are not working in isolation but are integrated into the patient pathway.”