Guest writers Anna MacPherson and Louise Forman of St Catherine’s Hospice, Preston, discuss the experience of working within a community palliative care team in light of recent changes to the structure of community palliative care.
Community based palliative care services are growing in importance. As surveys repeatedly tell us most people want to die at home[i], and policy shifts towards enabling that, services based in patients’ homes become more prominent.
Traditionally, district nursing services have mainly provided palliative care for people in their home environment, with medical input from GPs. These services have and continue to provide generalist palliative care. In support, specialist palliative care services have grown over recent years, offering a variable combination of practical care and advice, often led by community specialist palliative care nurses.
Over the past fifteen years there has been increasing medical specialist palliative care input into the care of community patients. As with most aspects of palliative care, this has varied, with practices developing locally, different teams finding different ways of working, with little evidence as to what the best model is.
This article presents one community palliative care team’s experiences of this development, and how one team integrated medical and nursing palliative care. This is not a statement of best practice, but aims to share how one team has developed over a relatively long time of having a dedicated community palliative care consultant in post.
The community palliative care team based at St Catherine’s Hospice, Preston covers a mixture of urban and semi-rural areas of Preston, Chorley and South Ribbleand a population of roughly 370,000.[ii] There has been a community palliative care team in this area for many years, comprised of specialist nurses, managed by a nurse manager from 2003, and under the umbrella of the hospice, with GP and hospice physician support. In 2002 a full-time Consultant in Palliative Medicine was appointed to work solely with this team.
There are now 7 full-time equivalent nurse specialists, each responsible for a group of GP practices. Patients referred from any source are the responsibility of the clinical nurse specialist attached to the patient’s GP practice.
Integrated medical and nursing clinical working
There are several ways in which patient management is integrated to facilitate input from both medical and nursing staff.
A major component of joint working is via twice weekly multi-disciplinary team meetings in which all newly referred and complex patients are discussed, allowing the full team to be aware and have some input into the care of these patients. Monthly, a larger MDT meeting is attended in addition by an occupational therapist, physiotherapist and social worker. This format will need to be adjusted to fit with the NICE quality standards[iii] and peer review measures,[iv] for example involving a second consultant, but this adjustment is relatively minor.
On a regular basis the clinical nurse specialists have “clinical supervision” sessions, consisting of a day of joint visits by the nurse and consultant, with the nurse leading, followed by discussion and feedback. This enables additional input for complex patients, as well as an opportunity to raise any concerns or queries. Twice weekly consultant-led out-patient clinics are attended by the consultant in addition to a nominated clinical nurse specialist, allowing joint review and education.
Integration with other services
Gold-Standard Framework[v] type meetings are seen as key opportunities to engage with local primary care teams, and are attended where possible by the designated clinical nurse specialist. This enables an awareness and discussion of a wider range of patients as well as a chance to build working relationships.
Initial assessments follow a structure, including a period of information gathering and liaison prior to seeing any newly referred patient. Referrals are accepted from various sources, and consulting the patient’s primary care team before the first assessment makes this process more efficient and better informed. This liaison continues throughout; the clinical nurse specialists are not nurse prescribers, which has the benefit of encouraging discussion and liaison about management plans with the patient’s primary care team.
In addition, there has been work with local prisons to build relationships and create structures to enable the management of palliative patients within prison environments.
The community-based, hospice and hospital palliative care teams meet weekly using video-conferencing to discuss jointly managed patients. This involves three consultants, so may provide an opportunity to fulfil the peer review measure on MDT meetings. Again, as well as liaison, this is a chance to improve working relationships.
Education and audit
There is a structured education programme involving monthly sessions covering topics chosen by the team. These are in addition to mandatory training, and provide a chance for tutorial-type discussion of complex cases or subjects. Clinical supervision sessions and joint clinics enable informal case-based discussion and teaching.
The community team participates in several education delivery projects. This includes structured education courses, such as programmes providing education to nursing home staff, district nurses and social workers, as well as clinical teaching to various people who shadow the nurse specialists, including medical students and student nurses. This has been a source for additional funding for the hospice.
The community team have held an annual conference for the past fifteen years, involving outside speakers from different backgrounds about mostly clinical topics. This has attracted attendees from local primary care teams, hospitals, other local hospices as well as staff from settings such as nearby prisons. Again, this has been a source of funding.
The team take part in hospice-wide audits and regional palliative medicine audits as well as audits of topics identified by the team.
A nurse manager is the direct line manager of the clinical nurse specialists. She holds monthly one-to-one meetings with each nurse specialist to ensure they have adequate support and opportunity to highlight any concerns.
The team as a whole has a monthly business meeting, in which non-clinical projects are discussed as well as any proposed changes to ways of working. Non-clinical projects were previously allocated to certain allocated nurse specialists (e.g. audit leads, education leads), but more recently have been taken on by whichever nurse has capacity and interest in that project.
Over the past two years the hospice has introduced and developed a twenty-four hour advice line, available for professionals, patients and carers. This is provided by the hospice inpatient unit, although the community team are regularly involved in follow up of issues raised. Local palliative care teams share electronic records, so patients can access 24-hour specialist palliative care advice from staff with full background information about them.
During the past six months the community team has started seven-day working. A clinical nurse specialist is available 9-5, seven days each week, and during the weekends answers the advice line as well as being available for face-to-face consultations. This change in working practice has led to more “days-in-lieu” during the week, and so increased strain due to less continuity of care, but has also led to clear benefits in service delivery at weekends. This does now comply with NICE quality standards (ref.2, quality statement 10).
The need to be able to measure results is becoming increasingly important, and audits now focus more on measureable outcomes. The proportion of deaths in each location, whether the LCP was used and whether the preferred place of death was met is recorded, and annual statistics for each nurse specialist looked at by the team. Overall the results for the team compare favourably with other local and national statistics (table 1).
Deaths of patients known to community palliative care team Aug-Oct 2011
|Place of death
||Team audit statistics
||Local average 2008-2010[vi]
||England 2008-2010 (ref. 4)
NICE quality standards as well as peer-review guidance have recently been published, with specific recommendations for community palliative care teams. Local palliative care services will need to consider how best to meet these measures, which within the above model will require adjustments to existing practice rather than major changes.
These service developments, and the expectation of increasing deaths and care at home, are on a background of increasing financial pressures. The models of care delivery may need to adjust to enable input to greater numbers of patients from a smaller service. This will provide challenges over coming years.
Given the new financial structure, budget constraints and quality standards, it is becoming increasingly important to provide proof of effectiveness of care. Time and effort will need to be invested into trying to accurately measure effects, along with obtaining service user opinions, to be able to bid for even the same amount of funding.
The delivery of palliative care in the community is highly dependent on teamwork with professionals in primary care and allied health professionals, as well as the provision of social care. These areas are all also subject to rising pressures from increasing expectations and demand, along with increasing financial pressure. This will undoubtedly impact on how much effective palliative care can be provided in the community, and models will need to continually develop to provide high-quality palliative care at home with measureable benefits.
[i] Higginson IJ, Sen-Gupta GJ “Place of care in advanced cancer: a qualitative systematic literature review of patient preferences.” J Palliat Med 2000;3:287–300
[iii] National Institute for Health and Clinical Excellence “Quality Standard for end of life care for adults” November 2011
[iv] National Cancer Peer Review Programme “Manual for Cancer Services: draft specialist palliative care measures” Department of Health; Dec 2011