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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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