Contact: Martin Combs ex 7479

e-mail [email protected]

1. Summary and Purpose

1.1. The purpose of this report is to provide members with a progress update on the review programme. This update informs Members of work that has continued in Public Health and Wellbeing, and in Out-of-Hours provision subsequent to the end of March when the reviews were taken to Committee, and following the Out of Hours presentation provided to the Committee in May.

2. The Thematic Reviews

2.1. At the Health Overview and Scrutiny Meeting 28 March 2006, Members were provided with a progress update on the health review programme as agreed by the Committee in May 2005 for 2005/6.

2.2. This update incorporates a proposed review of End of Life Care. The Committee has been formally asked to undertake this review by The Executive Member for Adult Social Care. (A review project outline is attached at Annex One)

3. Public Health and Wellbeing

3.1. The Hampshire Public Health Network has agreed to take forward the work initiated by the Public Health and Wellbeing review.

3.2. The HOSC has facilitated the progression of this public health and wellbeing them by convening a meeting with representative stakeholders from the PCT, Eastleigh Borough Council and HOSC officers to explore the way in which Public Health and other information can and should underpin locality commissioning.

3.3. The following key points were agreed at the meeting:

3.3.1. The potential roles and inter-relationships of HATs, LSPs and local democratic representation in relation to locality commissioning need to be explored and developed.

3.3.2. Significant, useful information is gathered and produced by Public Health and other sources that needs to inform locality commissioning, the work of HATs and delivery of LAAs.

3.3.3. A number of examples of effective local working already exist, Eastleigh being a prime example. There is an opportunity to explore how existing good practice can inform the commissioning agenda and shape the broad principles underpinning effective engagement/networking locally, with ability to influence at a Hampshire-wide level.

3.4. The following way forward was proposed:

o Share initial thoughts on the process with organisational leads

o Explore the possibility of a day to focus on strengthening locality commissioning, with a view to identifying:

_ Sources of information and intelligence about local health and community needs.

_ Existing partnership arrangements.

_ Existing good practice, and the way this could inform the development of principles to support the adoption of good practice in the delivery of locality commissioning across Hampshire.

4. Out-of-Hours

4.1. Following the presentation to the Committee on 30 May 2006, the SHA reports considerable progress by the SE Cluster PCTs with the collation of information in support of the drafting of the service specification, all current providers and commissioners have been consulted. All services have also shared activity data for the winter period 2005/6 to update the knowledge base on demand.

4.2. The planned performance management processes continue to be led by the SHA in examining the quality of service provision in use now.

4.3. The draft specification is to be taken to the OOH Implementation Group the 3^rd week in July. It will then go to the Clinical Reference Group later in the month. The first consideration and discussion of the formal service specification content will be the main item, supported by the communications and implementation plans and wider discussion of the audit remit to be approved.

4.4. It is anticipated that plans will be finalised by mid September.

5. End of Life Care

5.1. The Executive Member for Adult Services has asked that the Committee reviews this issue. There will, however, be a consequential impact on the other reviews planned by the Committee.

5.2. The purpose of the working group will be to review the services and care provided for patients/clients aged 65 or more, who have been diagnosed as being near the end of their lives. The working group will review the services and care provided in Hampshire, and make appropriate recommendations as stated in the Terms of Reference for the group.

Recommendation

5.3. The Committee is requested to agree:

5.3.1. The Terms of Reference for the Review (see Annex One: Appendix 3)

5.3.2 The formation of a Working Group of Members, key stakeholder representatives and advisors as set out in Annex One.

5.3.3. That the Committee delegate its powers to the Working Group for the purpose of this exercise.

5.3.4. That the Working Group reports finally back to the Committee in January 2007.

Annex One

End of Life Care Review Project

Working Group Membership

County Councillors

Ray Ellis (Chairman)

Robin McIntosh (Vice Chairman)

Jane Frankum

Keith Chapman

Phrynette Dickens

Dennis Wright

Support Officers

Denise Holden

Martin Combs

NHS

PCT Chairman

Prof Martin Severs

Independent Expert Advice to Cover:

Secondary Care

Primary Care

Adult Services

Palliative Care

Other issues as appropriate

Prime Purpose

The purpose of the working group is to review the services and care provided for patients/clients aged 65 or more, who have been diagnosed as being near the end of their lives. The working group will review the services and care provided in Hampshire, and make appropriate recommendations as stated in the Terms of Reference for the group (see Appendix 3).

Source Documents

The review will be undertaken against the backdrop of National standards and policies that comprises a set of independent guidance and expectations for the delivery of health and care services for this vulnerable cohort of patients/clients.

Key Documentation:

o NSF for Older People (esp. Standard 2), March 2001

o `Our health, our care, our say: a new direction for community services', January 2006

o `Living Well in Later Life: a review of progress against the National Service Framework for Older People', March 2006

o `Terminal care in care homes', SCIE Research Briefing 10, August 2004

o `Introductory Guide to end of life care in care homes', National Council for Palliative Care, March 2006

o `National Survey of Patient Activity Data for Specialist Palliative Care Services', National Council for Palliative Care, February 2006

Suggested Outline Project Structure

Preparatory Phase

o Review literature

o Identify key issues

o Agree Terms of Reference

Decision-making and project direction phase

Working Group meetings

Meeting 1: Initial housekeeping and planning for work programme:

· Agree Terms of Reference

· Discuss and agree Scope

· Allocate Working Group members to Evidence Gathering tasks

· Agree target timescales/milestones, including frequency/timing of next meeting(s)

Evidence Gathering Phase

Invite key stakeholders to give evidence at `Select Committee' sessions

Sessions

1. NHS Commissioners: PCT

2. NHS Providers: Acute, PCT

3. HCC Commissioners: Adult Services

4. HCC Providers: Adult Services

5. Voluntary and Charity Sector

6. Private sector ?

Key elements:

· Relevant stakeholders (eg. Appendix 1)

· Question sets for stakeholders to answer (eg. Appendix 2)

· Question sheets for Members of relevant questions

Need a combination of what does stakeholder A provide/buy, and what is A's experience vis-à-vis stakeholders B, C and D?

Consolidation phase

Meetings 2: Consolidation of evidence gained from `select committee' sessions

· Identify Key evidence and source(s)

· Conclusions drawn from evidence gathered, ie. what does it tell us?

· Identify roadblocks

· Identify evidence gaps

· Provide direction for further consolidation, further evidence gathering and timing/outcomes for following meetings

Meeting 3: Debrief and consolidation from Evidence Gathering

· Agree a composite picture from initial analysis and further evidence

· Agree Key positives (strengths and opportunities)

· Agree Key issues (weaknesses and threats)

· Advise on tone and content of report

· Identify next steps and timings

Reporting phase

Meeting 4: Review and comment on preliminary draft report on Hampshire `Care at the End of Life' services, analysis and comparison against national standards/policy.

· Review paper in separate groups

· Agree/comment headline statements

· Agree/comment detail

· Agree/comment political messages and sensitivity issues

Meeting 5: Agree/comment on draft Review report for feedback

· Read and comment draft Review

· Agree any changes

· Agree circulation list for initial feedback

Meeting 6: Review feedback and final draft Review

· Read and comment feedback and updated draft

· Agree any changes

· Agree for adoption by full HOSC

· Agree suggested next steps

Caveat

The above programme of meetings is indicative and relatively high level in so far as the project is substantial and will contain many unknowns and challenges at this time. However the programme does provide a framework or structure that can be adapted as the result of experience. Apart from the inherent complexities and sensitivities because of the subject and players involved, there are particular unknowns in terms of how easy or difficult it may be to obtain useful evidence.

Appendix 1

Key Stakeholders

o NHS Commissioners

o NHS Providers

o LA: Adult Services Commissioners

o LA: Adult Services Providers

o Hospice Providers

o Relevant Voluntary and Charity Organisations

o Relevant Private Sector Organisations

o P&PI Forums and other local support groups as appropriate

Appendix 2

End of Life Care

Questions for Evidence Gathering

Question Sets

Question sets could be developed for appropriate groupings of stakeholders who could be asked to respond to the Working Group as a `select committee'. At that point is might then be possible to ask further questions such as experience of working with partner organisations, etc.

Question	Responding Stakeholder	Notes
What, if any, opportunities do you provide to patients or carers for OOH advice?	· Community teams · OOH GP Service · Hospice/charities · Commissioners
What, if any, opportunities do you provide to patients or carers for OOH support?	· Community teams · OOH GP Service · Hospice/charities · Commissioners
What, if any, opportunities do you provide to patients or carers for OOH crisis management?	· Community teams · OOH GP Service · Hospice/charities · Commissioners
Could you comment on how patients access the care you provide?	· Acute hospitals · Community hospitals · Community (dom) services · Hospices · Carer orgs
Could you comment on how access to services may be facilitated or otherwise by the proximity of the patient vis-à-vis locations of services?	· GP OOH · GP care · Acute hosp ( + relatives issue) · Community hosp (as above) · Community (dom) teams · Hospices ( + relatives issue) · LA/AS · Carer orgs · Other supportive orgs
Could you comment on what proportion of your care staff and care managers have specific training for End of Life care? (by type and level of staff if possible)	· GP care · Acute hosp · Community hosp · Community teams · Hospices · LA/AS · Carer orgs · Other supportive orgs
Could you comment on the positive (strengths, opportunities) and negative (weaknesses, threats) aspects/experiences with Multi-disciplinary team working?	· Community teams · Acute hosp · Community hosp · GP care · LA/AS
Could you comment on the positive (strengths, opportunities) and negative (weaknesses, threats) aspects/experiences with joint commissioning arrangements?	· PCT commissioning · LA/AS commissioning · GP care
Could you comment on arrangements for pain control and the symptoms experienced by patients/clients?	· GP care · Acute hosp · Community hosp · Community teams · Hospices
Could you comment on how psychological, spiritual, or social support is offered or initiated by your service?	· GP care · Acute hosp · Community hosp · Community teams · Hospices · LA/AS care teams · Carer orgs · Other relevant orgs
Could you comment on whether or how much choice is given to your patients concerning where they might die?	· GP care · Acute hosp · Community hosp · Community teams · Hospices
Could you comment on the information that is offered to patients in your care, and how communication is facilitated for patients and their families?	· GP care · Acute hosp · Community hosp · Community teams · Hospices
Could you comment on what support or information about support to carers and respite care is provided to carers?	· GP care · Acute hosp · Community hosp · Community teams · Hospices · Carer orgs · Other relevant orgs
Could you comment on to what extent you offer individualised, person centred, care planning and support for patients and their carers?	· GP care · Acute hosp · Community hosp · Community teams · Hospices

Other useful questions could include:

· How many patients diagnosed

· Types of diagnose

· Ages of patients

· How long patients stay in a particular location (home/community hospital/acute hospital/residential or nursing home/hospice)

· If they move settings where, when and why do they move

· Who makes the decisions or gives advice about patients/clients settings

The purpose of the questions

The purpose of the questions will be to build an accurate a picture as possible about the services and care available to people who are coming to the end of their life. The answers to the questions will inform the Review concerning:

· Services offered by the NHS in different settings

· Services offered by Local Authority Adult Services

· Services offered by voluntary and charity organisations

· Arrangements for joint working and funding

· Experience of patients/carers or representative organisations of EoL care

Appendix 3

Care at the End of Life Review

Working Group

Terms of Reference:

Purpose

The purpose of the working group is to review the services and care provided for patients/clients who have been diagnosed as being near the end of their lives.

Scope

The cohort of patients/clients will include those aged 65 and over

The review will include services provided by:

o The NHS

o Local Authority Adult Services

o Voluntary Sector

o Private Sector

The review will consider how working arrangements between different services and service providers contribute to meeting national standards, best practice, and related national policy.

The review will consider current practice, but will also be informed by data and trends where these suggest changing patterns in how or where care is provided.

Key areas for consideration will include:

o OOH access to advice, support and crisis management

o patient pathways for accessing palliative care (query- are there rurality issues here)

o Training to staff (NHS, adult services, vol org & private)

o Multidisciplinary team (MDT) working and joint commissioning arrangements

o Pain control and symptom management

o Psychological, spiritual and social support that is culturally sensitive

o Choice in place of dying

o Information and communications for patients and their families

o Support to carers and access to respite

o Individualised person centred care planning and support and support

o Perceived role and impact of the single assessment process

Output

The Working Group will:

o Provide a detailed analysis of current services and arrangements for the care of people over 65 at the end of their lives

o Suggest recommendations where appropriate for service improvement and improved working arrangements between service providers

o Identify issues of financial challenge and offer recommendations for better sustainable funding where appropriate.