Managing frailty Last Phase of life in Barnet Dr Jo Brady – Palliative Medicine

Background to this day This time last year – Pan Barnet event focused on Last Phase of life Ongoing action plan via 4 task and finish groups overseen by steering group This year CEPN focus on recognising frailty and advanced frailty relating to Last Phase of life Timely as lots going on: Increasing numbers of frail elderly in barnet Community & Hospital systems overwhelmed Reactive approach rather than proactive People dying not where they want to BILT/Frailty hub decommissioned CHIN 2 Pilot North London Hospice via STP secured additional funding Last year at a pan Barnet CEPN meeting the focus was Last Phase of Life Really useful to get everyone together and share challenges, solutions, ideas The meeting ended up with ideas generated by the group being taken forward and actioned by a steering group with task and finish groups. We have made a start but there is still a long way to go that’s why I was delighted when approached by CEPN to join Shama a local Barnet hospital geriatrican to join this session to focus on frailty and particularly in relation to last phase of life This session feels timely as it feels like there is a lot going on and wherever I am in my split site role (hospital and community) I feel like the challenges of frailty are a very common conversation. In realtion to Barnet we know there are increasing numbers of frail elderly people Both the hospitals and community are overwhelmed BILT and the frailty hub have been decommissioned It is a huge challenge to all involved – BUT Its not all negative The CHIN 2 pilot due to go live – if successful will roll out across the 6 CHINS Shama is going to talk about recognising frailty and advanced frailty and then knowing what we can then do I want to talk about how the hospice secured additional funding and how that may enable us to support you with this challenge

Vision for Barnet Frail Population Work together to identify and recognise frail patients possibly in last year of life Explore and assess their needs, wishes and preferences holisitcally Develop holistic proactive care plans (current and advanced care plans) Commincate with them, those around them and other health, social and voluntary care teams GP Hospitals Social Care Community Nursing Person with moderate to advanced frailty Hospices Voluntary Sector Pharmacys Allied Health Professionals

STP Palliative Care provision Uneven provision of palliative care services across NCL STP Footprint In 2016/17 there were 7889 deaths within NCL footprint (2515 in Barnet) 100,000 more deaths each year in England over the next 25 years – rising proportion of frail elderly with multi morbidity For NCL that would mean ~ 10,000 deaths (85% in age over 65) NHS Mandate related to end of life care for 18/19 is an increase % of people identified to be in last phase of life so EOLC can be improved Evidence that provision of community palliative care services and improved GP access to specialist expertise results in improved experience and reduced costs during the last year of life Not just about the money – improved satisfaction, communication, experience and cost We argued we could help improve experience and outcomes of NCL residents in last phase of life by provision of equitable specialist palliative care Also, extend the reach of the service to a wider population would have significant cost savings Essentially Camden and Islington well funded: BUT Barnet, enfield and Haringey chronic under funding of services Forced us to work at very specialist level and at full capacity – no scope to increase what we do YET more people are going to be dying and in particular more frail elderly with complex multi morbidity Government mandated we need to identify people in last year of life to improve care and outcomes This is based on the fact there is evidence that more community pallaitve care leads to better outcomes and reduced costs (X3 less likely to die in hospital, recuced A&E attendances, less bed days, less total costs LESS CHANCE OF DYING IN HOSPITAL) GOOD COMMUNITY PALLIATIVE CARE SAVES THE SYSTEM MONEY AND HAS BETTER PATIENT FOCUSED OUTCOMES We used that to argue for more money to do more pallaitive care and for equity across the footprint We are at capacity but if the CCGs give us more kmney we can do more that will save the system money Evidence is robust and the 5 CCGs agreed – all have funded this work and the greatest gains are for Barnet and Enfield

More money: so what next - KPIs? Extending the teams reach to a greater number of people 75% of deaths are expected – they want us to have “contact” with 75% of them Mix of specialist and generalist needs so need to consider what that “contact” is Increase in attendance at GP palliative care meetings to support generalists Help identify pts in last phase of life e.g. SPICT tool Increased number of patients dying in their PPD and less patients dying on hospital Reduce non elective admissions in the last 90 days of life Use of CMC This will be driven by several factors: KPIs, recruitment – I do not want to get bogged down in the specifics but give you a flavour

Different pts & different staff More people with generalist needs: more frail elderly, multi morbidity YET hospice model was based on cancer with easier trajectories and prognostication Different case management – need based rather than prognosis Range of patients so need range of nurses Workforce - recruit and upskill a range of staff on mass Huge challenge to recruit and train while maintaining and expanding the service We will be changing what we do and how we work How will this impact you, help you???? Cannot just do the same as we will have different pts and different staff

Hospice Perspective - collaborative working Proactively working with community based care teams to identify and individualise support of patients in last year of life (GPs/DNs) SPICT Tool etc Increase number of patients on GP EOLC register/Frailty register Increased presence at GP GSF meetings, CHINs for identification and advice Develop care plans to avoid inappropriate hospital admissions Support the use of CMC to share decisions/plans Joint working with D/Ns and increased training opportunity Nursing home: pro active rather than reactive - case finding/ palliative care rounds

Hospice Perspective -in house changes Complexity framework - intensive support, low level monitoring, consult visits, advise via meetings/calls Rapid response (Trained nurses and HCAs) to respond to crises to prevent admissions to acute hospitals Moving to 8 to 8 working and a trial of an enhanced overnight service Increased links with hard to reach groups/ improving access Developing Links with other specialists attending other MDTs Nurse – diagnose dying now need drugs, charts, equip, care HCA – family scared, need care, calm hands on care Overnight – quality of advise and assess need for visits alongside limited DN service Still early days and these changes will evolve organically as we understand the need I will leave it there for now as we are limited for time Hopefully given you food for thought for the small locality group work session coming up