Ref: Business Case Reference Version 5.0 24th July 2014 ...

1 Page 1 of 19 Ref: Business case Reference Version 24th July 2014 Business case title integrated palliative care Service Responsible Manager Rachel Lissauer Borough/Directorate Haringey/Commissioning Sponsor/Clinical Lead Dr Kate Rees Proposed Start and End Date October 2014 September 2017 Approval process Date Outcome Reviewed by Haringey Senior Management Team (SMT) June 2014 Preferred Option was to deliver proposed service via a procurement waiver Reviewed by Haringey CCG Clinical Cabinet (Clinical Model)

2 July 2014 Endorsement of clinical model Reviewed by Haringey CCG Finance Committee July 2014 TBC Revision History Version Revision Date Summary of Changes July 9th 2014 First Draft July 14th 2014 Re-draft following meeting with NMUHT July 16th 2014 McMillan funding confirmation / revised NMUHT costs July 17th 2014 Changes to provider submitted costings and establishment data. Phasing of staffing provision and activity avoidance Page 2 of 19 July 24th 2014 Updated following Finance and Performance Committee Section 1: Description Background The purpose of this Business case is to recommend a flexible and responsive 24 hour, 7 day a week integrated palliative care Service for the local population of Haringey.

3 palliative care is the comprehensive care of those with serious or life-threatening illnesses. The focus of palliative care is on improving quality of life through the alleviation of pain and suffering. In 2013, HCCG identified palliative care as a key area for improvement and drafted a specification to address these service improvement challenges. Multi stakeholder liaison via the palliative care Steering Group has produced a proposal for an integrated End of Life Service with North Middlesex University Hospital Trust (NMUHT) acting as the Lead NHS Provider.

4 The proposal has been jointly prepared by the 5 partner organisations : North Middlesex University Hospital Trust (NMUHT) (Lead) North London Hospice (NLH) Marie Curie Hampstead Whittington Health (WH) an integrated care Organisation (ICO) St Joseph s Hospice Rationale Excellence in care for people at the end of life is one of the core challenges faced nationally in light of the aging population. For commissioners there is a potential win-win in finding the right combination of services to enable support for patients to die in their place of choice (usually home) whilst avoiding high cost of admissions and re-admissions to hospital Benchmarking exercises, carried out within the Steering Group through 2012 and 2013, revealed areas of good clinical practice but also highlighted key gaps in the service.

5 Benchmarking data revealed: Projected population growth in over 75s in Haringey over the next 10 years (16% increase projected 2014-2021) Higher than average rate of death in hospital, by comparison with London average of (ONS data, see below) High spend per hospital death ( 2,250 compared with NCL average of 2,050), probably linked to higher length of stay in hospital than comparators Rates of deaths in care homes that are significantly out of step with England average (ONS data, see below) Deaths at home and in hospice that are in line with England average (ONS data, see below) Benchmarking of service levels revealed.

6 Non-compliance with NICE Quality Standards for EoLC (Nov, 2011) due to lack of 24/7 access to palliative care nursing support, an insufficient multi-disciplinary team and lack of bereavement support Page 3 of 19 Non-compliance with Commissioning Guidelines (Dec, 2011) which recommend 10-12 WTE clinical staff (medical and nursing) for a population of 225,000, together with social work / OT / physiotherapy input. Haringey have medical and nursing staff and social work input on a temporary basis.

7 Non-compliance with the early work carried out to prepare for End of Life care Peer Review as part of the National Cancer Programme Haringey palliative care service had fewer WTE staff overall than any other service in North Central London In 2013 investment was made in District Nursing to develop a 24/7 service. Without this extension the palliative care offer for patients was compromised and the service was in breach of the NICE guidelines. St Joseph s hospice was commissioned to provide 24/hr access to specialist palliative care advice for clinical staff (targeted particularly at District Nurses).

8 A LES was also put in place to encourage GPs to use Co-ordinate my care (an electronic record of the care plans that GPs make with patients when they are approaching end of life. Co-Ordinate my care is a computer system that allows shared access to these plans between primary care and emergency / Out of Hours services so that all partners know what plans are in place. These developments have been seen as a significant step forward. Monitoring of the District Nursing 24/7 service indicates that the primary use of the District Nursing service (which sees on average around 12 patients/wk between 12midnight and 8am) has been for palliative care .)

9 However, the short-staffing of specialist palliative care still left the service exposed. In 2013/14 the service experienced destabilisation as a result of staff retirements and the locum Consultant post becoming vacant. This exposed the vulnerabilities of a small service and resulted in some reports from GPs that the service had become more difficult for them and their patients to access. The Office of National Statistics (ONS) Report May 2014* provides the following data for Haringey and place of death for years 2010-2012 *(Metadata for the Clinical Commissioning Group Place of Death End of Life care Profile National End of Life care Intelligence Network PHE) Table Place of death (England wide) Place of Death London wide Place of Death HCCG (ONS 2010-2012)

10 ONS Comment/rating Actual ONS 2012 activity Home Not significantly different from England 250 Hospital Significantly higher than England 673 Page 4 of 19 care home Significantly lower than England 74 Hospice Not significantly different from England 109 Other Not significantly different from England 38 Haringey s approach to commissioning EoLC In Haringey the approach that is taken to commissioning EOLC will be driven by the following: A commitment to commissioning for outcomes.