Health & Wellbeing Strategy
Performance Management Framework
Monitoring the indicators of the Health and Wellbeing Strategy for presentation to the Health and Wellbeing Board
END OF LIFECOMMENTARY REPORT: Quarter 2 2014/15
Mark Cook
Public Health Intelligence
Public Health
Dawn Lythgoe
Principal Policy Officer
Chief Executive’s Department
END OF LIFECOMMENTARY REPORT: Quarter 2 2014/15
Whilst we would all aspire to live a healthy long life, death is inevitable and our experience of death is important not only to minimise the individuals personal suffering but also for those who are bereaved.
1.0 HELPING PEOPLE
1.1 PRIORITIES
- End of life and bereavement support services for relatives and carers;
- Implementation of the suicide prevention strategy.
1.2 OUTCOMES
Deaths at home
The most recent release for this indicator has seen a slight improvement from 19.7% of Bolton deaths being at home to 20.9%. Though this proportion is closer to our peer average (21.5%) and our highest peer is just 23.3%, indicating a common problem, the reason in Bolton is largely due to the higher than average number of deaths in hospital (53.6%). In the best of our statistical neighbours (Bradford) 46.8% of all local deaths occur in hospital. Lowering the proportion of deaths in hospital with a view to increasing the number dying at home should be a key outcome of this strategy.
Suicide
The latest suicide rate for Bolton is 11.7 deaths per 100,000. This has fallen from 2009-11 but it remains high and, typical of regions in the North West, is significantly higher than England (8.5). We currently have the 10th highest suicide rate in the country; a notable improvement as last year we had the 3rd highest rate, a peak in recent years (13.1). Also, in 2009-11 we had the highest female suicide rate in the country (8.0 per 100,000 with 32 deaths over the pooled period). On average, there are approximately 30 suicides in Bolton each year.
1.3 PROGRESS ON TASKS
Bereavement services are being mapped as part of the work on the End of Life care Strategy. There are indications that there are some gaps in bereavement services that the strategy will need to pick up.
The suicide audit will be updated (Sep/Oct 2014) and the annual statistical update on trends and intelligence related to suicide will subsequently be produced (Nov/Dec 2014).
Newly developed suicide risk recognition and response training (AScK training) will be rolled out for a range of key stakeholders (commencing September 2014).
Existing stakeholder suicide prevention action plans will be developed and new opportunities for further action plans will be pursued.
Regular updates on progress will be provided to the Suicide Prevention Partnership, Public Health Management Team, and to inform the Health and Wellbeing Board as appropriate.
2.0IDENTIFYING AND DEALING WITH PROBLEMS EARLY
2.1 PRIORITIES
- Identify all people with end of life needs in primary and secondary care through embedding the use of the North West End of Life model, Prognostic Indicator Guide and the Gold Standard Framework.
2.2 OUTCOMES
People with palliative care need identified on GP Palliative Care Register
Bolton performs particularly badly regarding identification of need with only 22.7% of people with a palliative care need identified on the GP Palliative Care Register, compared a peer best of 39.3% (Bradford). A similar picture is seen for the same identification indicator relating to deaths. All our peers within Greater Manchester (Rochdale, Oldham, Tameside, Wigan, and Bury) perform similar to Bolton regarding identification; the notable exception being Salford which is amongst the best of our peer group.
2.3 PROGRESS ON TASKS
Specific work has been undertaken to resolve this and in primary care a clear standard has been set to ensure GPs are identifying people early using the prognostic indicator guide.
In secondary care a specialist resource has been committed from non-recurrent funding for training and education to work on acute wards on implementing amber care bundles which specifically identify people approaching the end of their life and ensure a range of measures are taken to facilitate communication across primary and secondary care about the fact that the individual is at the end of their life and what plans have been put in place.
Work on the Gold Standards Framework (GSF) is ongoing in the community supported by the End of Life Facilitator.
3.0TAKING GOOD CARE OF THOSE WITH HEALTH AND SOCIAL CARE NEEDS
3.1 PRIORITIES
- Ensure people have a dignified and respectful death which supports the individual’s choices and preferences as far as possible and considers the needs of their families/carers.
3.2 OUTCOMES
Number of care homes and beds
When benchmarked against our statistical neighbours Bolton has the lowest number of care homes per 1,000 people aged 75 years and over (2.6) and as the population ages this rate will fall unless more care homes are created. The statistical neighbour with the highest rate of care homes (4.9) is Bury. Also, of the fifteen peers, Bolton has the third lowest number of care home beds per 1,000 people aged 75 years and over (91.3 compared to the rate of our best peer (Bradford) of 143.4).
3.3 PROGRESS ON TASKS
A Palliative and EoLC training programme is delivered across Bolton Foundation Trust by the Palliative and EoLC team. The training covers the four core competencies and principles required by staff to deliver quality Palliative and EoLC: communications skills, assessment and care planning, symptom management, comfort and wellbeing and advance care planning. The Palliative and EoLC team also deliver a care home training and education programme which is currently funded via non-recurrent funding. The priority is to ensure that Bolton health and social care staff has the skills and confidence to respond effectively and sensitively to the needs of all patient and carers affected by a life limiting illness. Good palliative care delivered by a confident and competent multi-professional team will increase the number of patients who die in their preferred place of care, enhance dignity and respect whilst improving support to make informed choices regarding end of life care.
There is an annual programme of study designed to accommodate individual and organisational needs whilst addressing the key common core competencies and principles for practitioners working with adults affected by life limiting illness which includes those adults with dementia.
Work is also in progress to implement the recommendations from the review of the Liverpool Care Pathway and the recent publication ‘One Chance To Get It Right’. Training will be delivered on the five priorities of care for those in the last days & hours of life including implementation of an individual Plan of Care and Support for people in the last days, hours of life.
Work with people at the end of their life is also included in the developments of integrated neighbourhood teams and a range of performance standards are included as part of the service specification in order to improve the delivery of integrated health and social care for patients and their carer’s and families.
From non-recurrent funding in 2014/15 a dedicated resource is to be funded to progress implementation of an Electronic Palliative care Co-Ordination System (EPaCCS). The purpose of EPaCCS is to support the co-ordination of care so that people’s choices about where they die, and the nature of the care and support they receive, will be respected and achieved wherever possible. In addition to communicating key medical information to healthcare professionals involved in patient care, EPaCCS supports conversations about end of life care wishes.
Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR): A unified DNACPR policy has been developed and agreed by the Strategic Clinical Network (SCN) and North West Ambulance Service (NWAS). The policy is now being implemented across organisations and will ensure DNACPR decisions and subsequent completed DNACPR forms will be valid across community and hospital settings. An implementation group has been developed and is aiming to have the policy implemented by 01.11.14 supported by a training and education programme.
4.0ADDRESSING THE NEEDS OF THE VULNERABLE AND COMPLEX
4.1 PRIORITIES
- Provide specialist support for complex needs.
4.2 OUTCOMES
Terminal admissions that are emergencies
Given the relatively high proportion of deaths in hospital in Bolton, this is a vital benchmarking domain for end of life care in Bolton. Bolton tends to perform just slightly worse than average across all relevant indicators (terminal admissions that are emergencies, terminal admissions that are eight days or longer, average number of bed days per admission ending in death) with the exception of terminal admissions aged 85 years and over where we are notably worse than our best performing peers – with 37.4% of all terminal admissions aged 85 years and above compared to 29.6% in Rochdale. Those over 85 years are at a very increased likelihood of living with chronic long-term conditions and as such death may be predictable in many cases, meaning that appropriate planning can work to prevent the end of their life involving and emergency admission.
4.3 PROGRESS ON TASKS
Specialist Palliative Care Services are commissioned to include an integrated service comprising medical and nursing services, both hospital and community-based. The service provides both palliative and end of life care and delivers support to people in their own homes (including care homes) and across several sites including Royal Bolton Hospital, Bolton One Health Centre and Bolton Hospice.
Specialist Palliative and End of Life services undertake two core functions:
- Direct patient treatment and support;
- Indirect support;
- Training, Education and Development.
Specialist services are also commissioned from Bolton Hospice, St Anne’s Hospice, and the third sector to include Marie Curie.
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