Wirral Specialist Palliative Care Service

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(1)

Operational Policy

2012-13

Agreed date:

25

th

September 2012

Review date:

25

th

September 2013

Wirral

Specialist Palliative Care

Service

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Specialist Palliative Care Multi-disciplinary Team

This Operational Policy has been agreed by:

MDT Members agreed this document on 24

th

September 2012

Position: Lead Clinician of the MDT (and joint Host organisation)

Name:Cathy Lewis-Jones

Organisation:Wirral Hospice St John’s

Date agreed: 25th September 2012

Position: Lead Clinician of the Host organisation

Name:Ewen Sim (Medical Director)

Organisation:Wirral Community NHS Trust

Date agreed: 26th September 2012

Position:Core Nurse Members of the MDT (12-3R-112)

Name:David Woods, Dawn Miller, Karen Radley and Liz Watkins

Organisation:Wirral Community NHS Trust

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Contents

Number Measure Page

12-3R-101

Lead Clinician and Core Team Membership

6 - 7

12-3R-102

Level 2 Practitioners for Psychological Support

8

12-3R-103

Support for Level 2 Practitioners

8

12-3R-104

Attendance at NSPCG Meetings

10

12-3R-105

SPCMDT Meeting

10

12-3R-106

SPCMDT Agreed Cover Arrangements

7 - 8

12-3R-107

Core Member (or cover) Present for 2/3 of meetings

8

12-3R-108

Annual Meeting to Discuss Operational Policy

11

12-3R-109

Operational Policy for MDT Discussion

11

12-3R-110

Operational Policy for Key Worker

12

12-3R-111

Specialist Training for Core Nurse Members

9

12-3R-112

Agreed Responsibilities for Core Nurse Members

9-10

12-3R-113

Attendance at Advanced Communications Training

Programme

10

12-3R-114

Extended Membership of SPCMDT

8-9

12-3R-115

Patient's Permanent Consultation Record

13

12-3R-116

Patient / Carer Experience Exercise

13

12-3R-117

Provision of Written Patient Information

13

12-3R-118

Management Planning Decision

11

12-3R-119

SPCMDT Agreement to Network Guidelines on Criteria

for Referral to a Specialist Palliative Care MDT

12

12-3R-120

SPCMDT Agreement to Network Clinical Guidelines

12

12-3R-121

SPCMDT Agreement to Network 24hr Telephone Advice

Service Specification

12

12-3R-122

SPCMDT Agreement to 7 Day Visiting Service

Specification

12

12-3R-123

SPCMDT Agreement to Network Education and Training

Plan

12

12-3R-124

Network Audit

12-13

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1.

Introduction

The Specialist Palliative Care (SPC) Service in Wirral is jointly provided by two organisations: Wirral Hospice St John’s (WHSJ) and Wirral Community Trust (WCT) to form one multi-disciplinary team which serves the population of 309,000. The service is available to all adult Wirral residents and non-residents registered with a Wirral GP. WHSJ, as the local SPC in-patient unit, hosts the consultants in Palliative Medicine who are supported by medical, nursing and allied health professionals (AHPs) to deliver in and out-patient care, day care, domiciliary care and Hospice at Home. The consultants’ contracts of employment are held by Wirral University Hospitals Foundation Trust (WUTH) where in-patients sessions and an out-patient clinic are also delivered.

WCT hosts the Integrated Specialist Palliative Care Team (ISPCT) which comprises specialist palliative care nurses and AHPs with admin support. The ISPCT is responsible for delivering specialist palliative care to patients whether they are in hospital, the hospice, care homes or out-patient settings.

2.

MDT Meetings

Due to this configuration, in which the acute trust does not have its own SPC team, the Multi-disciplinary Team meetings are made up of a combination of SPC team members from the two different organisations.

Therefore the two SPCMDT meetings being put forward in Wirral for Peer Review are:

Integrated SPCMDT meeting – held on Wednesday mornings at WHSJ

This meeting deals with hospice in-patients, out-patients, day-care or Hospice at Home patients and those patients under the care of the community-based ISPCT members that meet the network criteria for MDT discussion.

Acute trust SPCMDT meeting – held on Friday mornings at WUTH

This meeting deals with relevant in-patients at WUTH under the care of the SPC team that meet the network criteria for MDT discussion.

The ISPCT also holds weekly ‘locality’ meetings to discuss their particular patients but these do not constitute SPCMDTs as per the guidelines and are therefore outside the measures for Peer Review.

3.

Patient Pathway

All health and social care service providers in Wirral, including the Specialist Palliative Care Team, use the Wirral Integrated End of Life pathway, below, to denote the stage that a patient is at during their end of life phase and to initiate appropriate end of life tools and the correct anticipatory care. This is based on the Northwest end of life model but has been redesigned into a patient pathway format to include the stages from diagnosis to death.

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Wirral Integrated End of Life Pathway

Treatment Outcome/ Follow Up Advancing disease Palliation (Increasing decline) Dying

(Last days of life)

Diagnosis

ACP LCP

GSF

Curative / Stable Non-curative / Progressive

Patient pathway based on key milestones

Keyworker Keyworker

CANCER/ LTCs End of Life

4.

Purpose of MDT Aims:

•Provision of a comprehensive specialist palliative care service in line with the Supportive and Palliative Care for Adults with Cancer guidance (NICE, 2004), the End of Life Care Strategy (DH, 2008) and NICE Quality Standards (NICE, 2011)

•Provision of timely, effective, multi-disciplinary specialist palliative care, advice and support to patients with advanced, progressive disease

•Prevention of inappropriate or unnecessary hospital attendance, admission or death through proactive assessment and management of patients’ palliative care needs Objectives:

The SPCMDT is committed to achieving the highest standards of care and patient outcomes by:

• Holistic assessment of patients’ physical, psychological, spiritual and social needs at key stages at any stage in trajectory, with a clear plan of care

•Development of individualised care plans with clearly defined outcomes for each patient

•Accurate anticipation and identification of changes in patients’ palliative care needs to ensure they are addressed in a timely manner

•Delivery of care in the most appropriate place, when possible close to a patient’s home/residence

•Support for patients’ preferences regarding their preferred priorities of care and place of death

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•Partnership working with other agencies to avoid delays or duplication of effort / resources (e.g. equipment)

•Commencement of syringe driver-delivered analgesia within 4 hours of prescribing

•Facilitating the ‘rapid discharge to die’ process for those patients wishing to die elsewhere

•Accurate assessment of carers’ needs with referral for appropriate support

•Development and implementation of relevant Peer Review documentary evidence and an Action Plan as per the Quality Standards

•Development of community-based SPC clinics as an alternative to home visits

•Provision of palliative care education and training across health/social care providers in line with the MCCN Education and Training Strategy (2010-2013)

5.

Leadership Arrangements

12-3R-101

The Lead Clinician is Dr Cathy Lewis-Jones and agreed responsibilities include:

•ensuring that objectives of MDT working (as per Manual of Cancer Services) are met

•ensuring that specialists work effectively together in teams such that decisions regarding all aspects of diagnosis, treatment and care of individual patients and decisions regarding the team's operational policies are multidisciplinary

•ensuring that care is given according to recognised guidelines (including guidelines for onward referrals) with appropriate information being collected to inform clinical decision making and to support clinical governance / audit

•ensuring mechanisms are in place to support entry of eligible patients into clinical trials, subject to patients giving fully informed consent

•overall responsibility for ensuring that MDT meetings and the team meet peer review quality measures

•ensuring attendance levels of core members are maintained, in line with quality measures

•providing link to NSPCG either by attendance at meetings or by nominating an MDT member to attend

•leading on, or nominating lead, for service improvement

•organising / chairing annual meeting, examining functioning of team and reviewing operational policies and collating any activities that are required to ensure optimal functioning of the team (e.g. training for team members)

•ensuring MDT's activities are audited and results documented

•ensuring that the outcomes of the meetings are clearly recorded and clinically validated and that appropriate data collection is supported ensuring target of communicating MDT outcomes to primary care is met

•Cross-boundary working to coordinate patient care and facilitate timely hospital / hospice admission or discharge

•Provision of specialist palliative care advice and support to health and social care colleagues

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Dr Lewis-Jones is also responsible for ensuring that recruitment into clinical trials and studies is integrated into the function of the MDT.

6.

SPC Multidisciplinary Team Membership arrangements

12-3R-101

The core MDT members will be listed to correspond with the two separate SPCMDT meetings that take place. The consultants’ job plans can be viewed in the evidence file. Integrated SPCMDT meeting at Wirral Hospice:

Key: * = lead for clinical trials: # = lead for patient /carer issues and information SPCMDT meeting at Wirral University Teaching Hospital:

Key: * = lead for clinical trials: # = lead for patient /carer issues and information

7.

MDT Cover Arrangements

12-3R-106

Cover arrangements for each core team member is listed in the tables below. Integrated SPCMDT meeting at Wirral Hospice:

Name Role

Dr Cathy Lewis-Jones* Lead Clinician /

Consultant in Palliative Medicine Dr Helen Emms Consultant in Palliative Medicine Dr Fawad Ahmad Consultant in Palliative Medicine Karen Radley Clinical Nurse Specialist

Dawn Miller Clinical Nurse Specialist David Woods Clinical Nurse Specialist Maria Lyon # AHP (OT)

Alice Meehan MDT Co-ordinator

Name Role

Dr Cathy Lewis-Jones* Lead Clinician /

Consultant in Palliative Medicine Dr Helen Emms Consultant in Palliative Medicine Heather Aitken # Clinical Nurse Specialist

Liz Watkins Clinical Nurse Specialist

Lisa Brett AHP (OT)

Lois Barnes MDT Co-ordinator / Secretary

Name Role Named Cover

Dr Cathy Lewis-Jones Lead Clinician /

Consultant in Palliative Medicine

Dr William McManus LAS Registrar Dr Helen Emms Consultant in Palliative Medicine Dr William McManus

LAS Registrar Dr Fawad Ahmad Consultant in Palliative Medicine Dr William McManus

LAS Registrar Karen Radley Clinical Nurse Specialist Teresa Smith Dawn Miller Clinical Nurse Specialist Sheila Nugent David Woods Clinical Nurse Specialist Cheryl Parrington

Maria Lyon AHP (OT) Alex Watts (physio)

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SPCMDT meeting at Wirral University Teaching Hospital:

Due to the monthly rotation of ISPCT nurse members the ‘named cover’ for a CNS will not always be the same person but will be the current locality nurse member working within the acute unit that month. For that reason names have not been inserted into the relevant rows above. However there will always be a minimum of two CNSs present for each SPCMDT within the acute trust.

Core member (or cover) to attend 2/3 of all MDT Meetings

12-3R-107

All health care providers involved in the core group are expected to attend and non core members are actively encouraged to attend on a regular basis.

All meeting attendees who attend in person sign the attendance record for each meeting. Attendance records for the two SPCMDTs can be found in the evidence file.

8.

Psychological Support

12-3R-102

The core team members who have completed training to practice level 2 psychological supports of cancer patients and carers are:

12-3R-103

Monthly level 4 clinical supervision has recently been commissioned for the level 2 practitioners / core members. A service specification details the requirements for this service. The dates and times for the first six month’s sessions are in the evidence file.

9.

Extended Team Members

12-3R-114

Name Role Named Cover

Dr Cathy Lewis-Jones* Lead Clinician /

Consultant in Palliative Medicine

Dr William McManus LAS Registrar Dr Helen Emms Consultant in Palliative Medicine Dr William McManus

LAS Registrar Liz Watkins Clinical Nurse Specialist Rotation Nurse from

ISPCT

Heather Aitken Clinical Nurse Specialist Rotation Nurse from ISPCT

Lisa Brett AHP(OT) Diane Jones (Physio)

Lois Barnes MDT Co-ordinator / Secretary Christine Jackson (Senior Admin Support)

Name Role

Karen Radley Clinical Nurse Specialist Liz Watkins Clinical Nurse Specialist

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The extended members of the SPCMDTs who have agreed by the lead clinician as a contact point and will attend the MDT’S as required are as follows:

Integrated SPCMDT meeting at Wirral Hospice:

SPCMDT meeting at Wirral University Teaching Hospital:

10.

Core Nurse Members Specialist Study

12-3R-111

Details of the specialist study undertaken by core nurse members is listed below with certificates placed in the evidence file.

11.

Core Nurse Members Responsibilities

12-3R-112

The responsibilities for the core nurse members agreed by the lead clinician include:

•contributing to the multidisciplinary discussion and patient assessment / care planning decision of the team at the regular MDT meetings

Name Role Contact Details

On rota in Community All ISPCT CNS’s and SNP’s 0151 328 0481

On rota in WHSJ All band 6 nurses 0151 334 2778

Jerry O’Sullivan Inpatient Social Worker 0151 334 2778 Maddie O’Loughlin Community Social Worker 0151 328 0481 Helen Hardwick Psychological Support 0151 334 2778

George Palmer Chaplin 0151 334 2778

Sharon Woodward Bereavement Support 0151 334 2778

Cheryl Currie Pharmacist 0151 334 2778

Dr Andrew Jones Pain Specialist 0151 334 2778

Dr Geraldine Swift Consultant in Psychological Medicine

0151 334 1155

Name Role Contact Details

On rota for WUTH All CNS’s and SNP’s from ISPCT 0151 328 0481

Maddie O’Loughlin Social Worker 0151 328 0481

Andrew Scaife Chaplin 0151 6785111 Ext 2275

Dr Richard Griffiths Consultant in Acute Oncology 0151 678 5111 ext 2920

Dr Andrew Jones Pain Specialist 0151 334 2778

Dr Geraldine Swift Consultant in Psychological Medicine

0151 334 1155

Jackie Edwards Pharmacist 0151 643 5359

Sue Brown Cruse Bereavement support 0151 609 8770

Name Course Year attended

Karen Radley Advanced Award in Palliative Care 1995 Dawn Miller Master of Science in Palliative Care 2012

David Woods Care of the Dying 2012

Heather Aitken Dissertation in Palliative Care 1993

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•providing expert nursing advice and support to other health professionals in specialist palliative care

•involvement in clinical audit

•leading on patient and carer communication issues and co-ordination of the patient pathway for patients referred to the team - acting as the key worker or responsible for nominating the key worker for patients dealing with the team

•ensuring that results of patients’ holistic needs assessments are taken into account in the decision making

•contributing to the management of the service

•utilising research in specialist palliative care

12.

Advanced Communications Skills Course

12-3R-113

The core team members of the SPCMDT with direct patient contact who have attended (or are booked to attend) the national Advanced Communications Skills Course are listed in the following table:

13.

MDT Attendance at NSPCG meetings

12-3R-104

Dr Lewis-Jones is the nominated clinical lead who attends the NSPCG meetings with Julie Gorry also attending as WHSJ Chief Executive. Wirral SPCMDT’s attendance at the NSPCG meetings can be seen in the evidence file.

14.

MDT Meetings

12-3R-105

The Integrated SPCMDT meetings are held every Wednesdays at WHSJ between 9.30am -12.30pm. Attendance is recorded by means of an attendance sheet which the MDT coordinator is responsible for completing and collating.

The Acute trust SPCMDT meetings are held every Friday at WUTH between 9.30am – 12.30pm. Attendance is recorded by means of an attendance sheet which the MDT coordinator is responsible for completing and collating.

Name Role Date attended

Dr Cathy Lewis-Jones Lead Clinician / Consultant in Palliative Medicine

July 2006 Dr Helen Emms Consultant in Palliative Medicine Booked for 21st/

22nd March 2013 Dr Fawad Ahmad Consultant in Palliative Medicine 2011 Karen Radley Clinical Nurse Specialist Sept 2009 Dawn Miller Clinical Nurse Specialist July 2009 David Woods Clinical Nurse Specialist July 2009 Heather Aitken Clinical Nurse Specialist July 2009 Liz Watkins Clinical Nurse Specialist June 2011

Maria Lyon AHP (OT) April 2010

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Patients that require a care planning decision before the next scheduled meeting are dealt with according to the following procedure (see evidence file):

• Telephone discussion with the relevant treating consultant or their deputy • Formal written letter to follow telephone discussion as a permanent record • The patient will be discussed at the next scheduled SPCMDT meeting

15.

Operational Policy for MDT Discussion

12-3R-109

The Operational Policy for MDT discussion can be found in the evidence file.

Patients are listed for discussion at the SPCMDT meetings if they meet the following criteria:

•All new patients to the service that week (within past 7 days)

•Patients of particular concern to any SPC team member

•Patients where a team member seeks the support/advice of the rest of the team

•Patients who are about to cross a care boundary within Wirral

•Patients who need the skills of the MDT to remain in their desired place of care

•Patients who have died or been discharged from the service The focus of the MDT discussion will include:

1. Name

2. Diagnosis/Disease extent

3. Estimated prognosis i.e. where on End of Life Care Pathway 4. PPC

5. Outcome of discussion and Management Plan

The MDT coordinator is responsible for ensuring the list of patients is generated, based on in-put from the clinical team members, in advance of the meeting.

16.

Individual Management Plans

12-3R-118

Following SPCMDT’s discussion the outcome of individual patient’s management plans are recorded by a core member of the MDT on the outcome sheet which includes the identity of patients discussed and the multi disciplinary treatment planning decision. This is placed in the patient’s case notes by the MDT Co-ordinator. Anonymised examples can be found in the evidence file.

A copy of the SPCMDT meeting outcome is faxed to the relevant health and social care professionals involved in the patient’s care. The patient is informed of the outcome of the discussions by the key worker and this is documented in the patient’s case notes.

17.

Operational Policy Meeting Arrangements

12-3R-108

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prior to the publication of the final Peer Review measures, to discuss their specific operational issues.

However, the final measures have led to a re-configuration of the SPCMDT meetings and therefore a subsequent meeting, for the whole Wirral SPCMDT, was held on 3rd October 2012 in order to disseminate the revised NSPCG guidelines and discuss how these might impact on the function of the team (see Annual Report).

18.

Key Worker Policy

12-3R-110

SPC team members do not often act as the key worker for patients, due to the advisory nature of the service, and the assigned key worker may change with the patient’s circumstances, condition and individual needs. However it is important for the patient and their family / carers and all relevant professionals to be aware of whom the key worker is at any one time. The key worker policy can be found in the evidence file which documents the process for agreeing, recording and disseminating details regarding any changes to the key worker whilst the patient is under the care of the SPCMDT.

19.

Clinical and Referral Guidelines

12-3R-119

Wirral SPCMDT has agreed the Network Guidelines on Criteria for Referral to a Specialist Palliative Care MDT attached below.

http://www.mccn.nhs.uk/index.php/groups/view/id/10

12-3R-120

Wirral SPCMDT has agreed the Network Clinical Guidelines

http://www.mccn.nhs.uk/index.php/groups/view/id/10

12-3R-121

Wirral SPCMDT has agreed the Network 24hr Telephone Advice Service Specification

http://www.mccn.nhs.uk/index.php/groups/view/id/10

12-3R-122

Wirral SPCMDT has agreed the Network 7 Day Visiting Service Specification

http://www.mccn.nhs.uk/index.php/groups/view/id/10

The above guidelines have been circulated to the site specific MDTs at WUTH with contact details for the SPC team, in and out-of-hours, attached.

20.

Education and Training

12-3R-123

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education facilitator based at WHSJ. These facilitators share responsibility for education and training with the SPCMDT members.

21.

Audit

12-3R-124

The SPCMDT has agreed to participate in the network audit programme agreed by the NSPCG. A member of the SPCMDT participates in the regular MCCN Audit Group which feeds back to the NSPCG.

The MDS is compiled separately by WCT and WHSJ. Local audits undertaken include:

• PAIL audit (across WCT and WHSJ)

• Blood Glucose monitoring for patients on Steroids (WHSJ)

22.

Patient/Carer Information, Feedback and Involvement

12-3R-116

Patient / carer feedback is obtained using a variety of tools such as:

•Patient surveys/Questionnaires

•Comments boxes

•Service visits

Results of the above, and a report on the actions taken, can be found in the evidence file.

23.

Patient Information

12-3R-117

The SPCMDT is not currently using the NHS Information Prescriptions.

Examples of the types of information given to patients and their families can be found in the evidence file. These include details of local provision of specialist palliative care services and management and care options.

Patients are referred for psychological support if, following assessment, this is deemed necessary. However, leaflets regarding the service are not routinely distributed. A carers group is run by WHSJ for those wishing to participate (see poster).

24.

Patient Permanent Record

12-3R-115

All patients are offered a permanent record or a summary of their clinical consultation. A ‘Record of Consultation’ leaflet has also been developed to be used across the SPCMDT in order for patients to be given a hand-held summary. This is currently in use within the hospice setting and is being piloted by the Community Trust’s SPC members. An example of a completed record can be found in the evidence file.

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12-3R-125

Professor John Ellershaw is the Network Clinical Lead for clinical trials

There is a national portfolio of SPC clinical trials. Currently there are no patients within the network recruited into the national trials. This will feature in the work programme for the clinical network group and the SPC MDTs.

Figure

Updating...

References