Dr David Plume MBBS DRCOG MRCGP Macmillan GP Facilitator for Central

Norfolk

• “Systematic approach”• “Framework”• “Optimisation”• “Gold Standard” care for those nearing the end

of life in the community.• Quality not quantity• Any end stage disease process.• Grass roots initiative from Primary care (Dr Kerri

Thomas), in 2001, to improve generalist palliative care and collaboration with specialists.

• 1, 3, 5, 7• 1 Chance to get this right• 3 Processes.

– IDENTIFY those in need of palliative care input/support– ASSESS their needs, symptoms, preferences/issues– PLAN the care of these patients, with these patients.

• 5 Goals– Patients symptoms are controlled– Preferred place of care and death established– Security and support

• Better advance care planning• Information• Less fear• Fewer admissions

– Carers supported, informed, involved and empowered.– Staff confidence, communication and co-working improved.

• 7 Tasks– C1 Communication– C2 Co-ordination– C3 Control of symptoms– C4 Continuity including OOH– C5 Continued learning– C6 Carer support– C7 Care in dying phase.

• Multi-professional discussion around difficult issues e.g. preferred priorities of care, child bereavement, informal carer support.

• Prevents role blurring• Critical incidents• Avoidance of crisis intervention

• Nominated co-ordinator• Organise PHCT meetings• Supportive care register.• Documentation is complete and up to date

• Also co-ordination of MDT.

To ensure each patient has their symptoms, problems and concerns:

• Assessed• Recorded holistically• Discussed• Action plan

1) OOH provider aware of the patient, their diagnosis, current management and particular problems, concerns and wishes.

2) Anticipation of care, equipment and drug needs to prevent:

1) Crisis situations2) Inappropriate/avoidable admissions to hospital

The primary healthcare team is committed to staying up to date with skills and information relevant to end of life care of their patients.

• Emotional• Practical• Bereavement• Staff support

Carer breakdown is the key factor in prompting institutional care for dying patients

• Recognising their value and importance• Involving them• Informing them• Training them• Supporting them• Helping them to adopt coping strategies –

internal/external• Watching for personal health problems

Patients on the last days of their life are cared for appropriately using the Liverpool Care Pathway

• “complicated”• “time consuming”• “not worth the time/cost”• “we are doing well already”• “more time spent in meetings”• “we haven’t had any complaints”

• “care for people near the end of life is a vitally important area of health and social care, a litmus test for other areas and a humanitarian and economic imperative.” GSF Programme Position Summary Paper for NHS EOLC Programme Nov 07

• The college is pleased to support the Gold Standards Framework, which is having a huge impact on the quality of care at the end of patients' lives. The values expressed in this framework are central to the College ethos of Knowledge with Compassion.”Dr Graham Archard, Vice Chairman Royal College of General Practitioners, March '05

• I fully support the further rollout of GSF within primary care. I have also been impressed by the adaptation of GSF for use in care homes, and the benefits that this can bring to patient care. Professor Mike Richards National Cancer Director and Chair of the Advisory Board on End of Life Care Oct 17th 07

• Implementing the framework enabled processes of communication associated with high quality palliative care in general practice, but there was variation how this worked in individual teams. Interpersonal relationships and communication in primary palliative care. Kashifa Mahmood-Yousef etc al. BJGP 2008;58:256-263

• “this was probably the best thing we have done as a practice as long as I can remember, and certainly the thing that has had the greatest impact on the care we deliver”

• Dr G. Norwich

• 3 Threads• GSF in Primary Care

– The focus of today• GSF in Care Homes

– Does what it says on the tin!– Push to get CH managers into GSF meetings– Phase two studies showed reduced crisis admissions by 12% and

deaths in hospital by 8%• End of life care developments.

– Advance care planning– After Death Audit analysis tools

• The reality when setting up can be very simple!• 1 designated admin lead• 1 meeting, ideally once a month, the duration of

which will depend on the practice.• 2 Forms, one of which even doubles up as the OOH

handover form!• Try to invite a MDT-DN/CSPCN/OT/Physio/SW, and

Care Home Manager if appropriate.

Summary of Palliative Care Patients

Name of patient Name of Carer

Diagnosis(+code)

GP

DN

Problems/ Concerns Anticipated

needs

Information given/ Carer issues

DS 1500 date

Mac-millan Nurse/ CNS

Hospice/

SPC

OOH Hand-over Form Date sent

Preferred place of Care stated + date

Actual place death + date

Bereave-

ment Care

Crisis Events/ Notes

PATIENT SUMMARY

SCR 2

Modified SCR2 Solihull © Gold Standards Framework March 2006

NHS Number Diagnosis / Active Current Problems Name Address Postcode Tel No Patient Aware Y/N DOB

Carer Aware Y/N

Family / Carer Contacts

Current Care Package

Surgery Tel Personnel Involved GP Consultant SPC/ Macmillan Case Manager Hospital DN Other

Present Treatment Base Line Obs Current Medication

Priorities (Problems and concerns) Other Issues (Rescue drugs held, out of hrs care, before considering admission try etc)

Risk Assessment for Home Visit (Pets, parking, access to house, local area, patient/cohabitants)

Preferred Place of Care (Dated) Comments

Signature

Date

• Changes are afoot!• Norwich PBC Consortium working on new

versions of OOH Forms, DNAR Forms etc.• For more info speak to Dr Nick Morton

• Registration with the Central GSF team– Not obligatory to get QOF monies– Dedicated electronic support– Access to PDA tools– Accreditation when available– Source for PCT/SHA when looking at uptake.

• Quality Outcomes Framework– PC1 Register of those in need of palliative care/support.– PC2 Regular MDT case review meetings where all the

patients on the palliative care register are discussed.

• Beyond QOF– As of 2007

• 50% of practices are registered with the Central Team• 2/3 of practices claim to be using GSF• 90% of practices are claiming palliative care QOF points

– Push now is not for coverage but depth and consolidation.– Accreditation for practices, quality assurance.

• Gold Standards Framework Central Team Site: http://www.goldstandardsframework.nhs.uk

• The National Council For Palliative Care: http://www.ncpc.org.uk

• My GP Facilitator Blog Site! http://www.syringedriver.co.uk

• E-Mail Elizabeth or I• Elizabeth.Stallwood@norfolk-pct.nhs.uk• dplume@nhs.net