Palliative and End of Life Care an update
Aims • Overview of end of life care both nationally and regionally – including key documents • Consider where we are now in South Yorkshire and Bassetlaw linking data to service delivery • Opportunity to focus on where we are doing well, where we need to do better, and how we can improve
Overview of End of Life Care
Definition: End of Life Patients are ‘approaching the end of life’ when they are likely to die within the next 12 months. • Approx 1% of GP practice population will die pa • Some deaths are unexpected, many more can be predicted • Cancer accounts for about 25% of all deaths • Approx 25% of all deaths are in a care home
Ambitions for Palliative and End of Life Care: A national framework for local action 2015-2020 National Palliative and End of Life Care Partnership
The Ambitions framework was developed by a partnership of national organisations across the statutory and voluntary sectors. It sets out our vision to improve end of life care through partnership and collaborative action between organisations at local level throughout England.
Commitment for end of life care NHS England is also working with the government and partners across the health and care system to deliver the ‘ End of life care commitment ’ announced by the government in their response to the independent review on choice in end of life care. The government’s six commitments, which closely align to the ambitions, are made to the public and aim to end variation in end of life care by 2020. They are: • honest discussions between care professionals and dying people; • dying people making informed choices about their care; • personalised care plans for all; • the discussion of personalised care plans with care professionals; • the involvement of family and carers in dying people’s care; • a key contact so dying people know who to contact at any time of day.
NHSE: What does this mean for the person? 1. Deteriorating condition is recognised 2. Personalised planning - leading to coordinated action - is offered for treatment, care and support 3. High quality experience anywhere anytime • Staff who know what they are doing • Timely access to medicines, equipment, etc. • Feel safe physically and emotionally • Family/those important to me are supported
National Strategies • Ambitions for Palliative & EoLC: National Framework for Local Action 2015 -2020 • 2017 -2018 Mandate to NHS England: choice in EoLC, expansion of Personal Health Budgets, delivery in choice commitment, metrics in CCG IAFs • Government 6 point EoLC commitment • NICE: Care of Dying Adults in Last Days of Life (2015) Care of dying adults in the last days of life Quality standard [QS144] Published date: March 2017 End of life care for adults Quality standard [QS13] Published date: November 2011 Last updated: March 2017 • National Cancer Strategy supports implementation of recommendations
Context The DH made a national commitment to end variation in EOL care in 2016: “Improving palliative and end of life care (EoLC) will play an important role in the successful delivery of many Sustainability and Transformation Partnership (STP) priorities, in particular those highlighted in the Next Steps on the NHS Five Year Forward View such as mental health, cancer, urgent and emergency care, as well as improving financial sustainability”.
• 41% of STP plans have no mention or little detail of how EOL care will be improved though this is starting to change……..
South Yorkshire and Bassetlaw ICS “Our goal is to enable everyone in South Yorkshire and Bassetlaw to have a great start in life, supporting them to stay healthy and to live longer.” Priorities • Healthy lives, living well and prevention • Primary and community care • Mental health and learning disabilities • Urgent and emergency care • Elective and diagnostic services • Children's and maternity services • Cancer •Spreading best practice and collaborating on support services Planning for End of Life Care - A Workshop for Commissioners 27.02.18
Macmillan Living with and Beyond Cancer Programme, South Yorkshire, Bassetlaw & North Derbyshire Cancer Alliance and NHS England - January 2018 In this next phase of work we are considering those people ‘Living with Cancer’ which will include ‘Advanced cancer’ and people requiring palliative and end of life care.
The scope/aspiration of this work is around streamlining and personalising the pathway for people ‘living with cancer’ (including palliative and end of life care) across NHS, Social care and the Voluntary and community sector irrespective of eligibility.
Regional EoLC Strategic Approach • Dr Bee Wee, NHS England Director for EoLC. • Small annual £ to support identified deliverables • Regional EoLC Leads, supported by clinical leads to progress national priorities & link with national team: – Regional leads: Dr Suzanne Kite; Charlotte Rock (funded 2 hours pw each) – EOL Clinical leads x 2 for each STP footprint (2hrs pw each) until 2019 – For South Yorkshire and Bassetlaw the Clinical Leads are: Dr Sam Kyeremeteng , Consultant in Palliative Medicine St Luke’s Hospice, Dawn Thomas, Lead Nurse for Specialist Palliative Care STH but soon to be replaced by Janet Owen, End of Life Clinical Lead, Barnsley. – Supported by Regional group of providers, commissioners, clinicians, voluntary sector meet 4 x year. • Yorkshire and Humber Children’s Palliative Care Network, Regional Network Coordinator, Davina Hartley
EoLC costs • 30% of inpatients in acute hospitals at any time will be in their last year of life • Hospital Costs are the largest cost elements of EoLC. Final 3 months averaging at over £4,500. Bulk of cost due to emergency hospital admissions in last few weeks of life • IF access to community-based EoLC improved AND emergency admissions reduced by 10% AND average LoS following admission reduced by 3 days… – £104 million nationally could potentially be redistributed to meet peoples preferences for PPoC
National Primary Care Snapshot Audit (2010) Only about 25% of patients who died were included on the GP’s Palliative Care/ GSF register • 75% had cancer Those patients identified early and included on the register received better quality coordinated care
Commissioning • Significant variation (and opportunity) in commissioning and delivery of services that support people at EoL to ensure best outcomes and value are achieve • Voluntary sector important partner (£1 billion invested in meeting palliative /EoL needs) • What should be focus at local level and what would be best done at STP /ICS level to reduce variation……?
Measuring Quality & Outcomes • Care Quality Commission • National Audit Care at the End of Life – Hospitals: NHSE, via HQIP has commissioned 5yr audit round): will be doing feasibility study on community audit • Patient Reported Outcome Measures: not mandatory, variable use (no exact data)
What does the data tell us........
Data to look at Some of key data available (2015) by CCG /across each STP/ICS • Percentage of all deaths • % of deaths in different settings • % of people who have 3 or more emergency admissions during last 90 days of life • Number of people on a GP palliative care register per 100 people who died
South Yorkshire and Bassetlaw Integrated Care System (and the Airedale experience for comparison)
Percentage of all deaths by CCG 14,420 deaths in 2015 40 34.2 35 30 25 21.4 18.6 20 17.2 15 8.6 10 5 0 NHS Barnsley CCG NHS Bassetlaw NHS Doncaster NHS Rotherham NHS Sheffield CCG CCG CCG CCG
Percentage of people who had three or more emergency hospital admissions during the last 90 days of life • National level 7% 12 11.3 10 8.6 8 7.1 7.1 7 6 4.8 4 2 0 NHS Barnsley NHS Bassetlaw NHS Doncaster NHS Rotherham NHS Sheffield NHS Airedale, CCG CCG CCG CCG CCG Wharfdale & Craven
The number of people on GP palliative care register per 100 people who died. • England Value 39.6 80 69.2 70 60 55.7 51 50 40 31.2 30.5 27.5 30 20 10 0 NHS Barnsley NHS Bassetlaw NHS Doncaster NHS Rotherham NHS Sheffield NHS Airedale, CCG CCG CCG CCG CCG Wharfedale & Craven
• Although there appears to be some positive relationship between higher rates of people being on palliative care registers and less people having three or more emergency admissions during the last 90 days of life, this is not conclusive.
Percentage of Deaths in Different Settings by CCG • Note – deaths in STH Palliative Care Unit are classed as hospital deaths • Nationally 22.8% of deaths in 2015 took place in the person’s home 120 100 2.3 1.9 1.7 2.1 2.5 2 2.5 18.9 18.7 21.9 21.3 22.6 23.8 80 32.7 Other 22.1 25.7 21.8 23.3 22.8 21.6 60 Care Home 4.8 9.8 4 4.1 20.3 5.6 6.8 Home 40 5 Hospice 50.2 48.9 49.2 Hospital 46.7 46.9 46.1 20 36.1 0 Nationally NHS Barnsley NHS NHS NHS NHS Sheffield NHS Airedale, CCG Bassetlaw Doncaster Rotherham CCG Wharfdale & CCG CCG CCG Craven
Died in Usual Place of Residence 47 46 45.6 46 45.2 45.1 45 44 43.1 43 42 40.7 41 40 39 38 Nationally Barns Bass Don Roth Sheff
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