In our third article in our series on end of life care in the system, Kathy Oxtoby explores how collaboration has improved care in Kent and Medway ICB
‘End of life care is not just a medical matter – it’s a societal matter,’ says Dr Rakesh Koria, Ageing and Dying Well clinical lead at NHS Kent and Medway ICB and Thanet Acute Response Team GP.
‘Given our diverse communities, integrated care has been the solution born out of necessity. By working collaboratively, we have improved palliative and end of life care (PEoLC) at three levels – patients, professional and processes,’ says Dr Koria.
‘Our patients’ satisfaction feedback is humbling, and our professional numbers have increased because of the holistic satisfaction, reduced moral injury and burnout with the integrated model of care.
‘Our systems’ processes feel most supported as we work seamlessly across primary, community, acute and VCSE. Shared care records, interprofessional trusted support and valuing each team member are vital.’
This began at the inception of the ICB, when a whole system leaders meeting was called by chief medical officer Dr Kate Langford, to ‘review, reflect and renew’ ways of delivery to a radically different compassionate model of care that is sustainable, in what we have referred to as the “Canterbury Manifesto”, according to Dr Koria.
He adds that the ICB is ‘well on our way’ to delivering this manifesto and the PEoLC strategy, which has ‘adjusted to’ the 10 year plan and neighbourhood health.
‘Our priorities are to implement NHS PEoLC objectives of quality of care, access with equity and sustainability, along with the national “Ambitions for Palliative and End of Life Care”,’ says Dr Koria.
‘Ageing and Dying Well’ is a priority programme at Kent and Medway ICB in the context of neighbourhood health, says Dr Koria.
The ICB is utilising population health management (PHM) and the John Hopkins risk stratification tool to identify the 1% of the population who are most frail to receive the following interventions:
- National early warning score,
- Situation, background, assessment, and recommendation,
- Comprehensive geriatric assessment,
- Structured medication review,
- Recommended summary plan for emergency care and treatment plan (ReSPECT).
‘These are shared in the Kent and Medway Care Records and our ambition is that they enable individuals to have a “golden ticket” to access appropriate care 24/7 that is personalised, timely and from appropriate neighbourhood teams,’ says Dr Koria.
‘In the future, we aim to have 24/7 remote monitoring support through co-ordinated teams.’
He says the ICB is ‘on the verge’ of strategically commissioning an end to end pathway for PEoLC using new neighbourhood teams.
‘Often with crisis in this group of patients, it is personal care that is most required, and we are working with social services as well. PEoLC requires 24/7 proactive and reactive support in all settings, and we are evaluating all our existing offers, ensuring resources align for maximal impact,’ says Dr Koria.
The ICB has seen ‘some excellent examples of neighbourhood health delivering joined PEoLC across Kent and Medway in some areas’, he adds.
‘We know these community offers have impacted positively on patients’ compassionate care needs, professionals’ morale and wider processes efficiency savings.
‘It has resulted in less pressure in the hospitals, and calls for more investment in the community services. We want to scale and spread these offers across Kent and Medway,’ says Dr Koria.
A neighbourhood health approach
One such example of neighbourhood health delivering joined PEoLC across east Kent is the Thanet Acute Response Team.
The service is hosted by Thanet CIC and Kent Community Health NHS Foundation Trust. It was founded eight years ago by Dr Ash Peshen, deputy chief medical officer at Kent and Medway ICB, in partnership with a number of stakeholders.
The system-wide, GP-led multidisciplinary team (MDT) works with professionals from across primary care, community care and the voluntary sector with ‘a single vision and purpose of meeting the needs of the person in their care’, says Dr Koria.
Established in 2016, this neighbourhood team takes a population heath management approach. It delivers short-term, clinically-led support at home as an alternative to hospital admission, which hopes to facilitate early discharge for those with the most complex needs, including those with palliative care needs and at the end of life.
The team operates in one of the most deprived areas of southeast England, with the fourth lowest GP-to-patient ratio, according to NHS England.
It has led to ‘improved experience for people and their carers, increased interprofessional support and reduced hospital deaths’, says NHS England. ‘The success has been due to the strong cross-organisational working of the partners; team members collectively focus on the best outcomes for people rather than organisational boundaries.’
The team reports that the number of hospital deaths per population in East Kent has decreased by 16% in the past three years, compared to an average decrease of 6% for the southeast.
The East Kent population currently has the second lowest emergency medical overnight admission rate per standardised population in the southeast for people over 75.
‘The qualitative and quantitative data speak for themselves. We have improved quality of care, access, experience, health equality and saved the NHS much needed resources,’ says Dr Koria.
‘Thanet Acute Response Team is a great example of what is possible when we aspire to a neighbourhood health approach,’ he says.
‘In one of the most deprived wards in the country, we have come together to focus on compassionate care for our communities, working together, regardless of our roles or settings, with impactful outcomes, humbling patient feedback, interprofessional support and system-wide benefits.
‘It is a privilege to be part of such compassionate professionals and shared humanity.’
Future support
For a future healthcare system to improve PEoLC, there should be ‘mandatory training requirements for all our health and care professionals just as we undertake life support and training in many other domains’, says Dr Koria.
‘Just as diagnosing cancer, heart attack, and stroke as early as possible is important, death and dying is equally, if not more important. At present, our PEoLC has some excellent examples of care, but this is not uniform across our regions and systems.’
To provide optimal, timely and compassionate PEoLC 24/7, ‘we have to all work together as a system, and not in our historic silos’, says Dr Koria.
‘We cannot provide continuity 24/7 individually, but we can do this as a team by identifying the individual early, having a personalised conversation to ascertain what matters to them, and writing up an advanced care plan that all professionals can work to 24/7.
‘We must also value our charitable hospices at the heart of the communities, supporting and being supported by the citizens,’ says Dr Koria.
‘We must place the patient in the centre, and all sectors must work together as a relay without dropping the baton – recognising that sometime one section will need to run faster or longer – but ultimately it is all for ensuring that the individual has a dignified death, as we only have one chance to get it right.’
