Why did we do it?

• Healthcare workers were not routinely discussing end of life care with their patients.  There was an uncoordinated approach to training leading to inconsistency in quality.  Terminally ill patients were often rushed into hospital which was distressing for family and carers. Ambulance services were stretched; patients had unnecessary hospital interventions and expensive hospital admissions.

What was done?

• Dr Paul Driscoll led discussions at locality groups with member practices to review benchmarked practice data and present the case for change.
• Clinicians from the ambulance service, out of hours and care homes were engaged in the design of the project.
• Member practices approved the final project through locality groups and adopted the scheme through a staggered roll out.
• The project aimed to enable patients to choose their place of death, reduce patient and carer distress and unnecessary hospital admissions.

How was this achieved?

• Identification and involvement of relevant patients
• Patients likely to die within 12 months were identified by multi-disciplinary teams.  Patient wishes were recorded and individual care plans were agreed and recorded in a yellow folder.
• Communication across health economy
• Individual care plans were shared with the out of hours and ambulance services to ensure patients’ wishes were recorded in their respective systems.
• Clinician education
• A comprehensive approach to training was implemented to increase skills and confidence and a common approach adopted by providers.

What were the benefits?

• Improved integration across end of life services
• This innovation has led to an integrated approach between care homes, GPs, community, out of hours and the ambulance service enabling patients’ choices to be met.
• Evidence of training embedding new practices

Feedback from GPs and care homes has been positive:

• ‘I will be able to initiate the end of life conversations with confidence earlier’
• ‘I can explore the whole concept of end of life in a new way’

Initial benefits

In 2012/13, 54% of people in east Suffolk died in their own home, compared with 48% in 2010/11.

The CCG has compared statistics between non-participant and participant care homes:

• For patients in a participating home at the time of death, 7% of deaths occurred in hospital compared to 19% in a non-participating

The CCG has evaluated the pilot and agreed to commission this service on a permanent basis. The CCG has collaborated with West Suffolk CCG to share this example of innovation and it is now being adopted in the West.