1. DR LINDA WILSON (CONSULTANT, AWC) LIZ PRICE (CNS, BRADFORD) WENDY LAYCOCK (FACILITATOR, AWC) Clinically Based Education and Training Initiative

2. PCTs CCG reconfiguration Airedale hospital –started GSF for acute hospitals programme Airedale hospital -Transforming community services, EOL as 1 of 5 workstreams -EOL strategic group EOL Pathway developed Health Foundation Shared Purpose Project Communication skills training (Sage and Thyme) EPaCCS Gold Line System 1 adopted within Airedale Hospital and all GP practices in AWC (16/17, last one May 14) Non-recurrent funding bid for GSF in 30 Care Homes Background Scene 1 Airedale CARE AFTER DEATH and BEREAVE MENT NICE QS 12, 13, 14 IDENTIFY Likely prognosis 12 months, add to GSF register NICE QS1 IDENTIFY Likely prognosis 12 months, add to GSF register NICE QS1 DISCUSS NICE QS2 DISCUSS NICE QS2 ASSESS Holistic assessment (advance) care planning NICE QS3 SUPPORT & COORDINATE CARE Physical, psychological, social, emotional, financial, and spiritual support. Access to drugs and equipment, 24/7. Reduce avoidable hospital admissions and shorten number of bed days NICE QS4, 5, 6, 7,8, 9, 10 SUPPORT & COORDINATE CARE Physical, psychological, social, emotional, financial, and spiritual support. Access to drugs and equipment, 24/7. Reduce avoidable hospital admissions and shorten number of bed days NICE QS4, 5, 6, 7,8, 9, 10 LAST DAYS OF LIFE NICE QS 11 LAST DAYS OF LIFE NICE QS 11 SOCIAL CARE SPIRITUAL CARE AIREDALE,WHARFEDALE AND CRAVEN (AWC) END OF LIFE PATHWAY Dr L Wilson/ AGH EOL group CARER SUPPORT INFORMATION FOR PATIENTS AND CARERS STAFF SUPPORT AND EDUCATION NICE QS 15,16

3. Synergy: Several individual events coming together CCG reconfiguration GSF in 30 Care homes GSF Airedale Hospital Going for Gold in 12 GP practices Communication Skill training Sage and Thyme Difficult Conversations Training Telehealth hub / Gold Line System one across care settings /EPaCCS

4. Background 2 Managed Clinical Network (MCN) Non recurrent funding for Gold Standards Framework (GSF) in 30 Care Homes and subsequently in Going for Gold in 12 GP Practices National Transforming End of Life care in acute hospitals programme

5. Background 3: Bradford Hospitals Pilot Last Year of Life Project Baseline audit 4 Workstreams developed to implement project Identification of patients in the last year of life Discharge & SystmOne – sharing information Education Patient & carer experience Roll out across Trust Repeat audit

6. How we used the MPET Funding GSF facilitator Airedale Hospital GSF facilitator AWC community GSF facilitator Bradford community Incorporated to Specialist Palliative Care CNS role in Bradford Teaching Hospitals Facilitators promoting GSF as a way to encourage Identification, Assessment and Planning of Care

7. MPET in Community Posts Communication Skills training EPaCCS Template training GPs /DNs / Practice teams Supporting GSF meetings Gold Line Service Audit and evaluation Baseline questionnaires and data GSF Good Practice Guide EPaCCS training-EOL template for all practices 2 day Mandatory training DNs and others

8. Key Outcomes so far Airedale /Bradford Community EoLC Template training -194 nurses and 42/87 GP practices Articles and information at events GSF meetings attendance, 17 registered for Going for Gold Airedale Hospital Audits- LYoL, MPET Increasing confidence to identify and offer ACP Flag system and increased liaison of EoLC information Bradford Teaching Hospitals Increased number of patients identified as being in their last year of life Greater sharing of information across primary & secondary care Communication skills sessions for senior clinicians

9. Lessons learnt A vision for the whole pathway but broken down into manageable parts Joining up primary and secondary care High level buy in – executive support from hospital; commissioner involvement Communication- consider all stakeholders

10. Lessons learnt cont… Persistence and resilience Engaging staff / knowing your audience Collaboration: within and between organisations Data to support, convince and provide ongoing funding Be realistic!

11. Challenges/Future issues Keeping the dream alive Education, Education, Education – competencies??? Media misinterpretation of LCP etc… Social Care agenda still to address Short term non-recurrent funding

12. How do you eat an elephant ?

14. Questions?