Leading change

The palliative care clinical nurse advisor for Manchester Health and Care Commissioning (MHCC) led with commissioners on the development, commissioning and implementation of a consultant-led, community-based palliative care service in north Manchester. The service has reduced unwarranted variation in practice and led to improved experiences and outcomes for residents in the local area as well as better use of resources in community care.

Where to look

Manchester Health and Care Commissioning (MHCC) is a single, integrated commissioner for health and social care, comprising a partnership between NHS Manchester Clinical Commissioning Group (CCG) and Manchester City Council.

The nurse advisor and clinical commissioners identified unwarranted variation in provision of choice for preferred place of death in the area, with deaths in hospital more than ten percent higher than the national average. Data published by Public Health England (2016) identified Manchester with 55.9% hospital deaths in comparison with the national average of 45.6%. This disparity was in line with there being no hospice services available in North Manchester. The unwarranted variation was also visible by a lack of end of life care coordination, access to end of life treatments at home and generally poor access to psychological support.

What to change

The clinical nurse advisor, in collaboration with the wider commissioning multidisciplinary team (MDT) identified the need to introduce a new service. This service was developed using a new model of consultant-led, community-based palliative care. They worked with Macmillan Cancer Support who had interest in the Manchester Cancer Improvement Programme and established the North Manchester Macmillan Palliative Care Specialist Service (NNMPCSS) and a Local Commissioning Service (LCS) to address the observed unwarranted variation.

The LCS focussed on improving the capability and capacity of primary care to deliver cancer, palliative and end of life support. The NMMPCSS worked alongside this service to provide enhanced access to specialist end of life care for individuals in north Manchester. This was co-ordinated by a Macmillan clinical lead, Macmillan clinical nurse specialist and Macmillan Allied Health Professionals and delivered by a MDT who provided an integrated approach to care.

How to change

The NMMPCSS is one of the Macmillan Cancer Improvement Partnership (MCIP) projects and was funded by Macmillan Cancer Support and NHS North Manchester CCG. The project was developed in partnership with NHS North Manchester Clinical Commissioning Group, Pennine Acute Hospital Trust, St Ann’s Hospice and Macmillan Cancer Support.

The Clinical nurse advisor and the now established NMMPCSS at MHCC, as part of the wider MCIP, aim to improve cancer experiences and outcomes in Manchester by focusing on improving the quality and consistency of cancer care across primary, community and palliative/end of life settings. There is also a specific focus on improving experience and outcomes for breast and lung cancer patients through the redesign of patient pathways.

The main aims of the NMMPCSS were:

• To identify patients at the point when their disease is identified as palliative in their care journey, to undertake a full assessment and to provide palliative and supportive care needs in their preferred place of care;
• Reduce the number of unnecessary hospital admissions in the last year of life;
• Increase collaboration and integrated working between those caring for patients with a palliative prognosis;
• Increase care and support for patients and carers, therefore relieving the pressure, avoiding crisis and enabling patients to live life until the end.

The principles of the redesign were based on the Midhurst Macmillan Community Specialist Palliative Care Service (Kings Fund, 2013) which provides acute-level care at home to patients nearing the end of their lives and wraps services around the patient. Important features are personal case management to co-ordinate all aspects of care, a seven-day service and cross-skilled staff. These transferable principles were adapted to meet the needs of an urban district in North Manchester including the integration of Allied Health Professional (AHP) and Nursing roles so they could work more collaboratively. The nurse leads have advocated the development of new clinical competences and guidance for the new role(s), which has enhanced capacity as well as consistency in practice.

The NMMPCSS team have since:

• developed new pathways of care, embedding clinical triage into daily practice;
• established daily hub meetings with community teams to ensure collaboration;
• established a volunteer model, enhancing the 24-hour helpline;
• revised pharmacy service level contracts and support offers;
• maintained open referral, including self-referral for adults 18 years and over;
• established new clinics including for lymphoedema, complementary therapy, speech and language, occupational therapy as well as a ‘social forum’ for peer support and a bereavement group;
• developed network links with local social services;
• rolled out effective end of life clinical supervision and support for staff;
• developed the education aspect of the NMPCSS practitioner role;
• supported staff to adopt and utilise digital technology;
• introduced an Assistant Practitioner role within the NMMPCSS team.

Adding value

The pilot has achieved several key outcomes which are being evaluated for roll out across Manchester:

Better outcomes – Improved identification of patients and enhanced access to supportive and palliative care has been observed. All patients now have access to services within 24 hours of referral:

• Fewer crisis admissions have been noted with the number of people dying in hospital being reduced from over 20% to 13%;
• A consultant-led review of all patients on the NMMPCSS caseload who have been admitted to hospital has also improved practice by sharing the learning across the team;
• Integrated working with District Nurses has also led to improved discharge pathways for those admitted to hospital;
• The team have successfully managed to support 82% of patients to die in their recorded preferred place, compared with only 59% the year before the pilot;
• The pilot has also resulted in 83% of the NNMPCSS patients having an Advance Care Plans in place and this continues to increase.

Better experience – Patients are now supported through a holistic care approach to care, transport, befriending and other practical needs now that the service has specialist support from a full range of Therapists in addition to Macmillan Nurse Specialists. This means that a holistic offer of care can be made, which is further enhanced by the new Assistant Practitioner role and the new volunteer model. An evaluation of the service demonstrated that the Macmillan service has been positively received. Participants commented that they were very satisfied with the service and would recommend that it be available to everybody. Quotes include:

• “They [Macmillan team] ask me if there is anything that I am anxious about, and any worries I have… they put me at ease and explains everything to me so I don’t worry…I find that quite reassuring”
• “The thing is with the NMMPCSS service is that they have done everything for us: they tell me what to do, who to speak to and where to go or whatever. Any information, she’s brilliant”
• “it all feels joined up because they all seem to know what the other one is doing. They know when someone is coming and they talk to one another”

GPs reported they are more confident with the care provided to palliative care patients and they are more abreast of available services to support patients. District nurses indicated they are more confident and competent in providing the opportunity to lead multidisciplinary team meeting discussions and care planning.

Better use of resources – Better integration and coordinated care as a result of the daily clinical triage meetings across services has played a key role in allocating the appropriate resources to patients at the right time. It has also contributed to capacity building amongst health professionals. A single telephone point of access and close working relationships with Primary Care also helps establish a streamlined referral system. Financial impact assessments suggest that the service supported a reduction in hospital admissions, resulting in a potential savings of £629k.

Challenges and lessons learnt for implementation

There are many factors that were crucial to the success of this pilot, including establishing a clear vision for the service, the multidisciplinary nature of the team and the ability of people to adapt and change the way they work to ensure an integrated service.

Key challenges included recruiting new staff to the team, over a short period of time.

Excellent professional leadership, commitment to change and close commissioner/provider working helped to overcome many challenges. Data collection established early in the programme is also recommended as this supports an evaluation. The CCG and provider trust data analysts supported this process.

User involvement is essential throughout a project such as this to ensure choice. It also helps to improve carer experience.

Change is not so much about drawing more resources into the system, it is more about how staff are working and if this can be achieved more smartly.

Moving forwards, MHCC in partnership with Macmillan Cancer Support aim to develop a citywide community based specialist palliative and supportive care model following the success of the North Manchester Macmillan Palliative Care Support Service which was a ’test’ for the rest of the city.

Find out more

For more information contact:

• Janette Hogan, Clinical Commissioning Nurse Advisor (palliative care), Manchester Health and Care Commissioning, janettehogan@nhs.net
• Alicia Waite, Macmillan Palliative Care Service Manager, Manchester Local Care Organisation, alicia.waite@pat.nhs.uk