Transcript Slide 1

Commissioning for high
quality end of life care
Dr Dennis Cox
MA FRCGP
GP & Advisor to Dying Matters Coalition
and The National Council for Palliative
Care
25th September 2012
www.ncpc.org.uk
www.dyingmatters.org
www.ncpc.org.uk
www.dyingmatters.org
QUIZ
www.ncpc.org.uk
www.dyingmatters.org
Unplanned
admissions
People in the last year of life have
a) 1
b) 2
c) 3
d) 4
e) 5
Unplanned admissions to hospital
www.ncpc.org.uk
www.dyingmatters.org
True or False
Currently, around 500,000 people die
annually in England
www.ncpc.org.uk
www.dyingmatters.org
True or False
At any one time, 2% of hospital beds are
occupied by dying people
www.ncpc.org.uk
www.dyingmatters.org
True or False
Up to 70% of people would prefer to die
at home
www.ncpc.org.uk
www.dyingmatters.org
True or False
Annually, in England, around 20% of
people who die do so in hospital
www.ncpc.org.uk
www.dyingmatters.org
Around what % of a GP’s patients will die
in any given year
a) 2%
b) 3%
c) 1%
d) 0.1%
e) 0.5%
www.ncpc.org.uk
www.dyingmatters.org
The Case for Change
Commissioning Principles for EOLC
Examples of successes
Ideas to take home
www.ncpc.org.uk
www.dyingmatters.org
The case for change
Too many inequalities and unmet needs:
• 457,000 people need good palliative care services every year but
around 92,000 people do not receive it (Palliative Care Funding
Review 2011)
• Access is unequal:
- 83% of people receiving specialist palliative care have
cancer. Yet cancer is the underlying cause in less than a third
of all deaths. People with CVD most likely to die in hospital.
- Disproportionately fewer older people aged 85+ access
specialist palliative care than adults aged under 85.
- People on low incomes are most likely to die in hospital.
www.ncpc.org.uk
www.dyingmatters.org
Quality and Fairness
Some patients receive excellent care, others do not
Hospices have set a gold standard for care, but only deal with a
minority of all patients at the end of their lives
There is a major mismatch between people’s preferences for where
they should die and their actual place of death
Only around one third of general public have discussed death and dying
with anyone
www.ncpc.org.uk
The case for change
• Mismatch between
people’s preferred
place of death and
where they actually
die: most people
would prefer to die at
home, but over half
die in hospital.
• The quality of care
received varies
significantly depending
on setting
www.ncpc.org.uk
Place of death (England)
5.30%
in hospital
at home
18.50%
20.80%
53.30%
in a care
home
in a hospice
www.dyingmatters.org
There is a slow trend towards more deaths
in the community but much further to go
Source: Reversal of
the British trends in
place of death: Time
series analysis
2004–2010, Gomes
et al Palliat Med Jan
2012
www.ncpc.org.uk
www.dyingmatters.org
Demographics
Around 455,000 people died in England in
2010, two-thirds of whom were 75 years of
age or older. Deaths in England and
Wales are expected to rise by 17% from
2012 to 2030. A large proportion of deaths
are foreseeable.
www.ncpc.org.uk
www.dyingmatters.org
Population dynamics
From pyramid to coffin
Parliamentary Office of
Science & Technology
www.ncpc.org.uk
Challenges
• Public reluctant to discuss end of life care
• Many professionals do not feel confident to deliver it
• Services are not available to everyone who needs them,
especially on 24/7 basis
• Long-term care system under strain – Dilnot Commission
• Lack of data – Palliative Care Funding Review
• Ageing workforce
• A context of deficit-reduction
www.ncpc.org.uk
www.dyingmatters.org
Lessons learnt and
future issues
• Growing need and complex challenges
• Rise in deaths from 2012
• Major changes in EOLC needed whatever
the scenario
• CCGs have window of opportunity to plan
www.ncpc.org.uk
www.ncpc.org.uk
Aspects of
Commissioning
www.ncpc.org.uk
www.ncpc.org.uk
From NICE!
Emerging evidence suggests that
redesigning local end of life care
pathways …..can result in more people
being able to die in their usual place of
residence …..and is has the potential to
be a more efficient and effective use of
resources.
www.ncpc.org.uk
www.dyingmatters.org
Efficiency (NICE)
commissioning and benchmarking tool
demonstrates that a 10% reduction in the
number of admissions ending in death
could potentially result in a saving of
£52million. These savings can be invested
in alternative, community-based end of life
care services.
www.ncpc.org.uk
www.dyingmatters.org
The End of Life Care Pathway
Step 1
Step 2
Discussions
as the end
of life
approaches
Assessment,
care planning
and review
• Open, honest
communication
• Identifying
triggers for
discussion
• Agreed care
plan and
regular review
of needs and
preferences
• Assessing
needs of carers
Step 3
Coordination
of care
• Strategic
coordination
• Coordination
of individual
patient care
• Rapid
response
services
Step 4
Delivery of
high quality
services in
different
settings
• High quality
care provision
in all settings
• Acute
hospitals,
community,
care homes,
hospices,
community
hospitals,
prisons, secure
hospitals and
hostels
• Ambulance
services
Spiritual care services
Support for carers and families
www.ncpc.org.uk
Information for patients and carers
Step 5
Care in the
last days
of life
• Identification
of the dying
phase
• Review of
needs and
preferences for
place of death
• Support for
both patient
and carer
• Recognition of
wishes
regarding
resuscitation
and organ
donation
Step 6
Care after
death
• Recognition
that end of life
care does not
stop at the
point of death.
• Timely
verification and
certification of
death or referral
to coroner
• Care and
support of carer
and family,
including
emotional and
practical
bereavement
support
Commissioning in the new landscape
Also: Health &
Wellbeing
Boards
Source: BBC News
online Jan 2012
www.ncpc.org.uk
www.dyingmatters.org
Principles of
Commissioning
Understand Need
Procure Services
Manage Performance
www.ncpc.org.uk
www.dyingmatters.org
NICE
CMG42 Guide for commissioners on end of
life care for adults
CMG42 includes an interactive
commissioning and benchmarking tool
www.ncpc.org.uk
www.dyingmatters.org
EOLC
Commissioning
Some Principles
‘Commissioners and providers should note
that emerging evidence is currently
localised and although no single service
model exists that all commissioners can
simply apply, a range of models can guide
service redesign according to local needs
and circumstances’.
www.ncpc.org.uk
www.dyingmatters.org
Principle
End of life care involves a large number of
third sector providers, notably hospices.
Host (lead) commissioning may be
particularly important
These agreements need robust governance
arrangements, and if they exist, they
should link with existing networks[1].
www.ncpc.org.uk
www.dyingmatters.org
ELCQuA
End of Life Care Quality Assessment
Tool (ELCQuA). ELCQuA is a free
online tool for keeping track of
progress in delivering end of life care
services.
www.ncpc.org.uk
www.dyingmatters.org
Help is at hand
www.ncpc.org.uk
Available at
www.endoflifecare-intelligence.org.uk
www.dyingmatters.org
Examples
Co-ordinate My Care (CMC) – electronic
coordination
Co-ordination Centre (Nene)
Register Building in Primary Care (LES)
Dying Matters
www.ncpc.org.uk
www.dyingmatters.org
Proposed Solution
New Community EoL Services
Care Coordination Centre
Rapid Response Service
Enhanced (low level) support
Discharge Link Nurses
www.ncpc.org.uk
Northamptonshire Integrated Care
Partnership (NICP)
Identified top 5 critical success factors
– Reduction in emergency admissions
– Reduction in readmissions
– Reduction in care home admissions
– Reduction in hospital length of stay
– Increase in the number of patients
supported to die at home
Northamptonshire
Integrated Care
www.ncpc.org.uk
Progress to Date: Deaths in Hospitals
Deaths in Hospitals 2010 / 2011
3000
2501
2061
# RiP
2500
2000
1500
1000
500
0
Apr-Aug 2010
Apr-Aug 2011
Deaths in hospital have reduced by 17.6% for the
period Apr-Aug 2011 when compared to the same
period in 2011 (2501 deaths in 2010, 2061 deaths in
2011)
www.ncpc.org.uk
Find the 1%
Register building in general practice
www.ncpc.org.uk
www.ncpc.org.uk
Help is at hand
• Low-cost inventions
can make a significant
difference
• Example: Dying
Matters GP pilot
project
• Before intervention
45% GPs rated
themselves as
unconfident in end of
life conversations, at
end 94% either
“confident” or “very
confident”
www.ncpc.org.uk
www.dyingmatters.org
Dignity Therapy
People want meaning, context and
connection for their lives
A good death involved physical, social,
psychological and spiritual aspects
Innovative Work by Irene Higginson and her
Department at Kings- script of a person’s
life –kind of person, key events, moments
how they would like to be remembered
www.ncpc.org.uk
www.dyingmatters.org
Conclusion: Do
Something!
1. Leadership and strategy: Each CCG must
have a EOLC clinical lead (NCPC)
2. Set up local process/group for strategic
discussions (partnership working)
3. GP initiatives: Register Building in
General Practice (LES)
www.ncpc.org.uk
www.dyingmatters.org
Conclusion: Do
Something!
4. Accelerated learning –generalist
workforce – communication and ACP game changing initiatives
5. Understand need and performance (NICE
and EOLC intelligence network)
6. Electronic co-ordination
www.ncpc.org.uk
www.dyingmatters.org
Thank you
www.ncpc.org.uk
www.dyingmatters.org
www.ncpc.org.uk
www.dyingmatters.org