Read how the End of Life Care Together partnership is using a proactive population approach to meet the palliative and end of life care needs of people in the Highlands
End of Life Care Together (EoLCT) is a partnership that is led by Highland Hospice. It includes:
Connecting Carers
Highland Senior Citizens Network (HSCN)
Highland Council
NHS Highland
Marie Curie
Macmillan Cancer Support
Scottish Ambulance Service.
Social Finance.
The partnership is using a population approach to improve services for people with palliative and end of life (PEoLC) needs in the Highlands of Scotland. This involves looking at the needs of the population as a whole and working together to identify and implement solutions, rather than focusing on individual services and organisations.
Outcomes
Thee partnership identified a gap in provision of end of life care for people at home, which was partly due to poor communication of each individual’s wishes. By identifying more people in the last year of life and understanding how they want to be cared for, unnecessary hospital admissions can be avoided.
EoLCT is working together to:
improve screening and identification of those at risk of dying in the next year
develop a single electronic plan of care with read and write accessibility across health and social care providers, and with patient / family access
set up a coordinated helpline that is accessible to patients, families, carers and professionals
increase the provision of community care (whether this is through structured statutory services or through community and voluntary support).
This is underpinned by data collection, which enables EoLCT to see where care is needed and co-ordinate the provision of services.
Facilitators, challenges and advice
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Key facilitators
The organisations involved in EoLCT had been meeting together as the Highland Palliative and End of Life Care Leadership Group before EoLCT was formed. This meant they already had good working relationships. EoLCT enabled them to focus on developing a population approach.
EoLCT has support from the key leaders in the area, such as the Chief Executive of the Health Board, who agree that following a population approach will lead to a better, more cost-effective system.
The partnership is fortunate to have resources that enable the work to continue. They employ a dedicated Clinical Program Manager and Clinical Lead. There has been a significant financial investment from Highland Hospice to support this, as well as funding from Social Finance.
Challenges
It can be difficult to maintain interest and momentum from other partners in a collaboration, particularly statutory partners who have many competing priorities. The phrase “palliative care” can distract from the concept of meeting the population’s needs by improving the system, so it is important to bring attention back to this as much as possible.
Tips and advice
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State your intention. Start with the ambition to improve and focus on your mission for the population you serve, rather than the needs of your organisation.
Get other leaders on board. There is no rulebook for transformation – but all the successful transformations have key people who want to make it happen.
Be a bit audacious! If you stand up and lead, people will often let you!
Maintain stakeholder 'belief'. Most service transformations fail because they are time limited. This is a learning journey and continuing the commitment is key to maintaining stakeholder ‘belief’.
Future development
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EOLCT is learning from initial successes and “rolling out the good bits”. A key next step is accessing statutory funding for the Palliative Care Response Service (domiciliary care at home).
EOLCT has not yet achieved its ambition of a single patient record but they have invested large amounts of time and effort on this, working with Scottish Government and other partners. They are hoping to be able to demonstrate a solution which will be used nationally.
