Archived decisions

AIM

OBJECTIVES

PERSON RESPONSIBLE

TIME

1. Develop unified model of care ensuring good practice is shared across Hampshire

1.1 By geographical area identify (audit) the current models of care and current levels of service delivery

Initial mapping of service provision.

Consult project steering group on

presentation of mapping information.

Explore ICT options to ensure

accessibility.

Ongoing mapping of service provision and updating of database.

Clare Hooke

Achieved

October 2007

November 2007

1.2 Draft and agree principles for this patient group

Project Steering Group to consider adopting principles in the Department of Health operating framework 2007/08 PCT baseline review of services for end of life care

Jacquie Swanston/

Jill Nother

Achieved

Jun 2007

1.3 Ensure the current patient pathway (mapped across acute, community, social and the third sector) is understood

Identify the current patient pathways for:

Cancer

Heart Failure

COPD

Neurological conditions

Sue Damerell Kewell/

Jill Nother

Sep 07

1.4 Clarify the service delivery models by locality

Undertake Department of Health baseline review of service

Sue Damerell-Kewell

Mar 08

1.5 Establish the gaps in this provision based upon service providers input

Undertake Department of Health baseline review of service

Sue Damerell-Kewell

Mar 08

1.6 Establish the gaps in this provision based on users (carers) feedback

Undertake Department of Health baseline review of service

Sue Damerell-Kewell

Mar 08

1.7 Develop a unified care model, building on the work of the HOSC review

Undertake Department of Health baseline review of service

Sue Damerell-Kewell

Mar 08

1.8 Map good practice locally and nationally

Joint mapping undertaken by Health and Social Care

Jane Pike

Mar 08

1.9 Identify future potential schemes based on good practice locally and nationally

Potential schemes identified jointly by Health and Social Care

Jane Pike

Mar 08

1.10 Re-assess the gaps in service provision based on new model

Undertake Department of Health baseline review of service

Sue Damerell-Kewell

Mar 08

1.11 Address variation in service provision and agree core range of services to patients and carers to be provided by the statutory sector

Undertake Department of Health baseline review of service

Sue Damerell-Kewell

1.12 Development of a users' pathway to help direct users, carers and providers through the services

Undertake Department of Health baseline review of service

Sue Damerell-Kewell

Mar 08

1.13.1 Ensure 24/7 health and social care support is consistent and accessible to people requiring care in their own homes

Address variation in service provision and agree core range of services to patients and carers to be provided by the statutory sector

Elizabeth Emms/

Clare Hooke

Apr 08

1.14 Ensure all patients at the end of their life have a key worker identified

Adapt National Framework documentation due 1 October 200.

Clare Hooke/Elizabeth Emms

2. To develop a joint commissioning plan appropriately resourced

2.1 Identify PCT current spending levels

Undertake a population needs analysis

Identify level of spend on Hospice and Specialist Palliative Care Services across Hampshire

Public Health

John Belden

Aug 07

Aug 07

2.2 Develop interim best practice guidelines

Utilise commissioning section in the awaited DH National EOL strategy.

Sue Damerell-Kewell/

Clare Hooke

Feb 08

2.3 Develop a commissioning plan for this patient group linked to national guidelines

Utilise commissioning section in the awaited National EOL strategy.

Sue Damerell-Kewell/

Clare Hooke

Feb 08

Interim Planning ongoing

3. Develop proposals for joint management arrangements, pooled budgets, joint training and workforce development

3.1 Establish joint project management arrangements

Hold initial discussions between health and social care

Yvonne LeBrun/Richard Ellis

Achieved

Sep 07

3.2 Map current training provision and spend across health, social care, voluntary and independent sectors

Hold initial discussions between health and social care to develop a single training programme in palliative care.

Joint Steering Group established.

Map current training identify duplication.

Lesley Atherton/Tracey Williams/Maria Hayward/Janice Gabriel

Sep 07

Oct 07

Oct 07

3.3 Agree training principles for prioritising staff training needs

Hold initial discussions between health and social care to develop a single training programme in palliative care.

Joint Steering Group established.

Joint Training principles agreed.

Ann Gunner/Tracey Williams/Maria Hayward/Janice Gabriel

Sep 07

Oct 07

Nov 07

3.4 Deliver a joint training programme to ensure consistency across all agencies in Hampshire

Hold initial discussions between health and social care to develop a single training programme in palliative care.

Joint Steering Group established.

Joint Training programme developed.

Ann Gunner/Tracey Williams/Maria Hayward/Janice Gabriel

Sep 07

Oct 07

Jan 08

4. Single synchronised assessment process

4.1 Develop a consistent county wide approach to continuing care assessment responsive to the needs of the patients at the end of life and their carer

Agree a joint assessment protocol for adults at end of life

Link to national framework for Continuing Healthcare

Paul Turner/

Clare Hooke

Apr 08

4.2 Develop and agree assessment documentation for communicating the needs and wishes of dying patients across all agencies

Implement the national screening and fast track documentation

Jill Nother/

Zena May

Apr 08

4.3 Clarify HCC responsibilities for supporting patients and their families at end of life

Agree HCC responsibilities to help patients and clients manage their care at EOL

Link to National EOL Strategy and Guidance

Clare Hooke

Feb 08

5. Ensure information about services and support available to patients who are in the last year or months of life is readily accessible in appropriate formats to formal carers, informal carers and patients

5.1 Audit current information

Rationalise and ensure consistent information available to patients and carers

Elaine Rogers/Clare Hooke/Maria Milton/Kerry Wincott

Jan 08

5.2 Ensure access to specialist palliative care advice and support is identified across all areas and effectively communicated to formal and informal carers, including those providing OOH services

Rationalise and ensure consistent information for patients and carers

Ensure information is shared with OOHs service providers

Ensure information informs commissioning plans

Elaine Rogers/Clare Hooke/Maria Milton/Kerry Wincott

Alex Berry/HCC

Sue Damerell-Kewell/

Clare Hooke

5.3 Develop a carers pack

Pack developed and distributed

Elaine Rogers/ Maria Milton/ Kerry Wincott

Feb 08

5.4 Develop a combined information pack for users and carers

Pack developed and distributed

Elaine Rogers/ Clare Hooke/Maria Milton/ Kerry Wincott

Apr 08

6. To ensure specialist equipment is available in a timely fashion for patients at the end of life

6.1 Link to existing Steering Group taking this work forward

Equipment services readily available to support patients at end of life

Alex Berry/Richard Ellis/

MartinGarbett

Oct 07

7. Ensure appropriate pharmacy support in and out of hours to ensure that the needs of patients in their homes or other community settings are responded to in a timely and appropriate manner

7.1 Project Steering Group to obtain work completed by Central South Coast Care Network Palliative Care Group which has identified gaps in service provision

Plan to meet shortfalls in service provision

Diana Dunsford

Jan 08

7.2 Make recommendations to ensure comprehensive provision

Plan to meet shortfalls in service provision

Diana Dunsford

Jan 08

7 Review the needs for specialist palliative care across all care settings to ensure that an appropriate level of service is commissioned and resourced to support people living in their own homes or the community and reduce avoidable admission to hospital. Use best practice in hospice services and other partnership working across Hampshire to inform this work

8.1 Targets for admission avoidance agreed

Joint commissioning plan for palliative care with agreed joint performance targets

Alex Berry/Richard Ellis

Apr 08

8.2 Monthly monitoring of targets

Agreed monitoring framework and process for shared targets

Alex Berry/Richard Ellis

Apr 08

8.3 Develop a culture of joint risk sharing with patients, carers and agencies

Agreed protocols and mechanisms in place to help families/carers and agencies manage the final 24-48 hours in the community

Agreed Care plan for the final 24-48 hours in the community

Develop GSF and implement across Hampshire

Paula Hull/Sue Kewell/HPCT -N/HCC/Hospice

Paula Hull/Sue Kewell/Jaki Metcalf/HCC/

Hospice

Jane Pike

Apr 08

Apr 08

Apr 08

8 Working with South Central Ambulance, Adult Services, hospice services, Nursing and Residential Homes and OOH services as appropriate, ensure clear protocols are in place to respond to patients requiring transfer who may be in the final stage of their illness. This shall include specific protocols to ensure that there is clarity about the resuscitation status of the patients and to avoid inappropriate interventions or admission to hospital. Mechanisms to communicate these protocols to GPs and other front line staff shall be identified

9.1 Identify current protocols

Agreed protocols and support mechanisms in place to help families/carers and agencies manage the final 24-48 hours in the community

Paula Hull/Sue Kewell/HPCT -N/HCC/Hospice

Apr 08

9.2 Develop a multi agency policy to ensure communication of resuscitation status and avoidance of inappropriate interventions

Policy agreed and implemented and staff trained

Zena May/HCC

Jun 08

9 Use as a resource the SHA audit of patients admitted from nursing homes to hospital at the end of their life which takes account of the appropriateness of admission and the wishes of the patient. Consider extending this audit to include patients admitted through the OOH and emergency services

10.1 SHA to develop plans

Sarah Smart

Mar 08

10 Obtain feedback from patients and carers about care at the end of life services

11.1 Undertake Voices initiative

Joint audit of patient/carer experience at end of life

Customer Services Team/Maria Milton

Mar 08

12 Clarify the way in which informal carers' assessments are requested, who conducts these and any timescales that support this process as well as the means by which client satisfaction is evaluated

12.1 Department of Health guidelines awaited

Develop carers packs.

Seek feedback from Carers Strategy Group.

Packs distributed.

Elaine Rogers/

Maria Milton

Kerry Wincotte

Dec 08

Dec 08

Feb 08

13 HCC to publish a County wide policy setting out the support to be provided to informal carers to include arrangements for supporting patients and carers with social care needs where NHS continuing care is being provided.

13.1 Carers information pack developed

Pack developed and distributed

Customer Services Team/Maria Milton

Apr 08

13.2 Combined information pack for users and carers developed

Pack developed and distributed

Customer Services Team/Maria Milton

Apr 07

13 Hampshire PCT, in liaison with Hampshire County council, shall provide the HOSC with additional information about the support available to informal carers including:

· Access to psychological and spiritual support

· The range of respite provision through the NHS and County Council and how this is accessed

· The lead professional for responding to informal carers' needs

13.1 Develop clarity regarding carers assessments

13.2 Information to be included in Carers information packs

Agree HCC responsibilities to help patients and clients manage their care

Training programme on assessing carers needs and rights delivered.

Pack developed and distributed

Action plan developed as a result of voices audit

Elaine Rogers/

Clare Hook

Elaine Rogers/

Clare Hook

Feb 08

Feb 08

Feb 08

Tbc