Supporting end-of-life care

Challenge
The National Health Service's Birmingham East and North (BEN) primary care trust (PCT) in England set up a pilot end-of-life service after it asked local hospitals, patients, carers and the public how services could be improved. The feedback showed that people wanted access to a wider range of services that would enable more treatment at home, promote independent living and provide choices for patients on where and when they received care and their preferred place of death. This supported earlier research by the Department of Health, in its 'Delivering Care Closer to Home' report, which revealed that 56-74 per cent of people would prefer to be cared for, and to die, at home.

Solution
The BEN PCT partnered with Healthcare at Home to develop a provision that linked all of the services that a patient at end-of-life might come into contact with.

Andy Donald, chief operating officer for BEN PCT, said: "One of the things missing from our strategy around end-of-life was access to 24/7 care. We asked Healthcare at Home to help provide this."

The provision involved medical services, including social care, housing, befriending services and support for carers. It ensured clear communication between key stakeholders and a smooth transfer of care between providers.

Home-based end-of-life healthcare sought to ensure that patients and their carers received family support and co-ordination, 24-hour nursing triage, a rapid response service and drug access support. 

The patient experience (click image for bigger version)

 

Key features of the service included the care bureau: a single point of access that signposted patients, dispatched the rapid response team, provided telephone support and advice, and scheduled nurse visits and drug delivery. It provided a seamless patient pathway, improving coordination of existing local services and centralised electronic patient records via the care bureau.

The end-of-life service included dedicated family liaison coordinators and a patient advocacy service for communicating with local authorities and other agencies on such things as housing benefits and grant applications.

The service also provided a rapid response team for clinical assessment and patient visits, 24 hours a day, seven days a week.

Alison Wymark, the manager of the care bureau said that the ability to call on rapid response nurses helped patients a great deal. "There will be a nurse available at all times who is able to talk through symptoms with the help of specific algorithms," she explained.

Patients were referred to the service through the Gold Standards Framework (GSF) for end-of-life healthcare: a systematic evidence-based approach to optimising the care for patients nearing the end of life delivered by generalist providers. Patients could also be referred to the scheme by nurses. Patients were assigned a family liaison co-ordinator who organised the care package to suit the patient's needs. The aim of healthcare-at-home was to improve co-ordination and response of services so that unnecessary hospital admissions could be prevented.

The service was piloted in the areas of Kingstanding and Sutton Coldfield and received more than 600 referrals in its first year.

The provision is now being extended to the rest of the PCT area, following its success, enabling up to 3,000 patients to have access to the service each year.

Results
The year-long pilot exceeded expected referral numbers by 12 per cent and exceeded targeted savings by 51 per cent and during the year there were only three admissions to hospital.
In NHS BEN in 2008/09, 604 patients were identified as appropriate for the service, at a cost of £1.9m. Providing these patients with end-of-life healthcare at home could have generated savings of £1.2m for the PCT, representing avoided admissions, calculated using the pre-service average of three admissions per patient in the last year of life.

Comparative costs and potential savings

The results show that the service has been successful in increasing the patient experience, reducing unnecessary hospital admissions, reducing readmissions and the length of stay, saving the PCT more than £1m in its first year.

During the trial 98 per cent of calls were answered within 30 seconds, all callers requiring a rapid response were visited within one hour, referral numbers were exceeded by 12 per cent and targeted savings were exceeded by 51 per cent. 

The trial realised £234,000 of savings in the first five months of operation, only four of the 179 patients on the end-of-life care pathway were readmitted to hospital in the first five months and more than 440 admissions were avoided, with projected savings of more than £1m in the first year.

Demographic information has since been used to scale up the net savings to a national level, finding that England-wide the savings from home-based healthcare for 88,000 such patients could be about £160m.

Client views
"The family liaison service is the organisational glue that makes everything else work, for patients and families, as well as for health professionals. The benefits of it have gone way beyond what was envisaged."
Melanie Young, senior commissioner for NHS Birmingham East and North

"Our care makes a genuine difference to a patient's end-of-life care. As well as supporting patients physically, we also help them in their choice of where and how they want to die."
Deborah Foley,
family liaison coordinator, Birmingham East and North

"Most people have an idea over how they would like to die but no one has asked the question. If we don't ask them then we are failing them. ... We have a saying, you can't put days in their lives but you can put life into their days, and it's those things that we can help with."
Karen Beckett, family liaison coordinator, Healthcare at Home

The Author
Liz Wells, deputy editor of PME, wrote this article using material from the Healthcare at Home and NHS websites

To comment on this article, email pme@pmlive.com