PRIMARY CARE CO-COMMISSIONING COMMITTEE 8 SEPTEMBER 2015

Transcription

1 Part 1 Part 2 PRIMARY CARE CO-COMMISSIONING COMMITTEE 8 SEPTEMBER 2015 Title of Report Trafford Palliative care Quality Premium Scheme 2015/16 Purpose of the Report The purpose of the report is to detail Trafford s Palliative Care Quality Premium Improvement scheme for 2015/16, outlining public health need, national requirements, current position and the 2015/16 proposed approach including the results of a preliminary audit. Actions Requested Decision x Discussion Information Strategic Objectives Supported by the Report 1. Consistently achieving local and national quality standards. x 2. Delivering an increasing proportion of services from primary care and community services from primary care and community services in an integrated way. x 3. Reduce the gap in health outcomes between the most and least deprived communities in Trafford. x 4. To be a financial sustainable economy. Recommendations The Primary Care Co-commissioning Committee is asked to note the current CCG and individual practice performance in relation to the Palliative care registers prevalence. The PCCC are also asked to approve the suggested approach in order to reduce the level of variation between practices and increase the prevalence overall.

2 Discussion history prior to the PCCC The Scheme was agreed through the Trafford CCG s governance structure to support the Trafford locality to improve the Palliative care register prevalence. Trafford CCG identified this as a Quality Premium Scheme for 2015/16 with the objective of increasing the current prevalence using the 2013/14 as the baseline. A quality premium palliative care task and finish group has been established to lead the improvement work with membership from the Primary Care interface team, associate clinical directors, data quality, practice management, public health and scheduled care The scheme has been presented to and supported by the Clinical Directors, Primary care Quality Improvement group and the Primary care Strategy Group (PcSG). Regular reports on performance will be presented to the PcSG Financial Implications There is no financial investment required to deliver the scheme Risk Implications The scheme will prioritise practices whose prevalence is below the CCG average. The scheme is set to deliver improvement in the identification of patients who are entering or within the end stage of life in order to improve the quality and cohesion of care they receive. The desired outcome should have reduced variation across practices and increase the prevalence overall. If the programme fails to deliver, there will be no improvement in the prevalence rate and quality of outcomes. This will impact on Trafford s overall position not being improved. This will determine the outcome of the payment performance of the quality premium. Equality Impact Assessment Communicati ons Issues The programme has had a E&D assessment to support access by all relevant individuals within the scheme Following approval communications will be circulated to the practices highlighting Palliative care as a priority for the CCG in order to increase awareness and engagement Public Engagement Summary Prepared by N/A Eve Donelon Primary Care Quality Manager Responsible Director Julie Crossley Associate Director of Commissioning

3 Palliative care Quality Premium Scheme 2015/ Introduction 1.1. Providing high quality end of life care is important for individuals and families. Knowing that one s loved one has died in the place and the manner that s/he wanted, can provide comfort to families and may help in the grieving process. It can also lead to significant reductions in costs by reducing unnecessary hospital admissions. Sadly, for far too many people, this opportunity to make a plan for the end of their lives is not given. 1.2 Most people in Trafford die from conditions that are amenable to end of life planning. It is estimated 1 that only 14% of people die suddenly (that is, there was no obvious prognosis until their last days). Of the remainder, 21% will die of cancer, 4% of other terminal conditions, 19% of organ failure and 42% of frailty described as Multiple co-morbidities accumulating with increasing age leading to a gradual decline and regular exacerbations before last days. The proportion of people dying of frailty will increase as treatments and prognoses for other conditions improves. Other estimates suggest that 75% of deaths are expected While specialist palliative care has an important role to play in end of life care, most people will not want or need to be cared for by specialist teams, or may need only a small element of specialist input or support. For the majority of patients, care can be well managed by themselves, their carers, community nursing and the GP. 1.4 Nationally, there are clear standards for end of life care, using, for example, Advance Care Planning and the Gold Standards Framework. 1.5 Ensuring that people have the end of life care they want requires good communication and co-ordination between the patient, their family, and services. Ensuring that general practice palliative care registers are up to date forms an important part of the quality assurance process in relation to end of life care. 1.6 Improving our end of life care should help patients and families make appropriate preparations and should assist in understanding and expectations regarding worsening illness and exacerbation of symptoms. This should help patients make realistic plans for the care they wish to receive and where they want to die. This in turn is likely to reduce the risk of patients being transferred inappropriately to hospital in their final days. 1.7 For 2015/16, increasing the prevalence and quality of palliative care registers has been identified as a NHSE Quality Premium Local Target for Trafford CCG. 2.0 Public Health Need in Trafford 2.1 The age profile in Trafford, and the relative health of its population, means that Trafford can expect to have more people dying of frailty and old age (including dementia) than many other Greater Manchester boroughs. Nationally, the average rate of patients dying in hospital is 50.71% compared to 60.92% in Trafford. There are fewer patients dying in care homes (12.03%Trafford vs 19.59% England.) and hospices (4.31 Trafford vs 5.59 England) but no significant difference for deaths at home (20.8% Trafford vs 21.54% England) but low for deaths in hospice ( data) 1 National End of Life Care Intelligence Network (2013)

4 2.2 Nationally, the number of people dying in their usual place of residence (at home or in a care home) has risen from under 38% in 2008 to 44.5% in However, pain relief was reported to be inadequate 3 for 53% of people who died at home, compared to 32% of those dying in hospitals, 25% in care homes, and 13% in hospices. Better planning for end of life care should help to address these discrepancies, without increasing the numbers who die in hospital against their wishes. 2.3 Ensuring that end of life care planning is offered to all people where death is expected will improve the quality of people s last days and weeks, and will reduce the risk that they are inappropriately transferred to hospital. By working with practices across Trafford to address variation in practice, we can ensure that there are reductions in inequities in the quality of the end of life services offered. 2.4 Nationally, there is evidence that some population groups receive less good end of life care than the white/majority population. Particular care needs to be given to ensuring that black and minority ethnic people, homeless people and people with learning disabilities get adequate access to high quality services including end of life care planning. 3.0 QOF Registers 3.1 Palliative care is a clinical domain indicator in the 2015/16 Quality Outcome Framework 3.2 (QOF). The indictor has 2 parts as per fig 1: Indicator Records QOF Points Achievement Thresholds PC001. The contractor establishes and maintains a register of all patients in need of palliative care/support irrespective of age 3 NA On-going management PC002. The contractor has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed 3 NA Fig. 1 Palliative care 2015/16 QOF indicators 3.3 These indicators are focused on the maintenance of a register (identifying the patients) and on regular multidisciplinary meetings where the team can ensure that all aspects of a patient's care have been assessed and future care can be co-ordinated and planned proactively. 3.4 A patient is included on the register if any of the following apply: their death in the next 12 months can be reasonably predicted (rather than trying to predict, clinicians often find it easier to ask 'the 'surprise question' 'Would I be surprised if this patient were still alive in 12 months?') 2 Department of Health Actions for End of Life Care National Survey of Bereaved People (VOICES-SF)

5 they have advanced or irreversible disease and clinical indicators of progressive deterioration and thereby a need for palliative care e.g. they have one core and one disease specific indicator in accordance with the GSF Prognostic Indicators Guidance they are entitled to a DS 1500 form (the DS 1500 form is designed to speed up the payment of financial benefits and can be issued when a patient is considered to be approaching the terminal stage of their illness. For these purposes, a patient is considered as terminally ill if they are suffering from a progressive disease and are not expected to live longer than six months). 3.5 The register applies to all patients fulfilling the criteria regardless of age or diagnosis. The creation of a register will not in itself improve care but it enables the wider practice team to provide more appropriate and patient focussed care. 3.6 The aims of multidisciplinary case review meetings are to: ensure all aspects of the patients care have been considered and documented in the patients records improve communication within the team and with other organisations (e.g. care home, hospital, community nurse specialist) and particularly improve handover of information to out-of-hours services co-ordinate each patient's management plan ensuring the most appropriate member of the team takes any action, avoiding duplication ensure patients are sensitively enabled to express their preferences and priorities for care, including preferred place of care ensure that the information and support needs of carers are discussed, anticipated and addressed where ever reasonably possible. 4.0 GM and Local Position 4.1 The latest QOF data currently available relates to 2013/14 Palliative and shows Trafford to have 542 patients on the Palliative care registers with a range of The 2013/14 GM QOF data shows Trafford to be ranked 10 th for the prevalence for palliative care registers and 0.4% below the England average (see fig. 2). 4.3 The 2013/14 QOF data will provide the baseline figure for the Quality premium for 2015/16. GM Rank CCG List Size Register CCG Prevalence 1 Salford 253,783 1, % 2 SMcr 169, % 3 Tameside 239, % 4 Stockport 301, % 5 Bolton 297, % 6 CMcr 213, % 7 HMR 223, % 8 Wigan 320, % 9 Oldham 242, % 10 Trafford 236, % 11 NMcr 194, % 12 Bury 196, % England 0.27% Fig /14 GM QOF position for Palliative Care

6 4.4 The 2013/14 QOF data demonstrates substantial variation between practices, ranging from prevalence rates of 0.00% to 0.47% 0.50% Trafford GP Practice Palliative prevalance rates % 0.40% 0.35% 0.30% 0.25% 0.20% 0.15% 0.10% 0.05% 0.00% Prevalence Trafford CCG England Fig. 3 Trafford GP Practice Palliative Prevalence Rates Palliative Care Quality Premium Scheme Improving prevalence rates in Trafford 5.1 The majority of patients who meet the criteria for the palliative care register should be known to the practice as it is likely the will have one or more conditions for which a register already exists (i.e. cancer, heart failure, COPD, dementia). 5.2 There may be other conditions which do not have a register but the patients may have conditions which already have input from community teams such as MS and district nurses 5.3 By improving the data quality of practices registers and linking with community teams the prevalence of palliative care registers should increase. 5.4 A Quality premium palliative care task and finish group has been established and mandated a trial audit be undertaken in a small cohort of test practices in order to understand whether interrogating existing registers, data sources or searches provided a suitable way of identifying patients who would meet the criteria for the palliative care registers 5.5 The following searches were completed in the test practices: a search on the clinical system using specific drugs, in particular pump injectables to highlight patients who may be receiving palliative care but are not on the practice palliative register a search of non QOF palliative care codes a search of patients seen by specialist HCPs such as Heart failure nurses, dementia nurses, McMillian nurses, MS nurses, MND Nurses

7 a search of patients on the AUA list and understand if any patients are palliative care patients not on the register a search across all disease registers to see which patients are on multiple registers in order to create a list of patients who may be more likely to be approaching end of life a search to look at certain disease stages i.e. Heart failure stage 4, Dementia score of 8, stage 5 renal disease Source a list of Nursing homes in Trafford, specifically with the number of dementia beds and understand which nursing homes have the kite mark assurance Source acute data on death (Planned/unplanned), by usual place of residence (if available), by trust, by condition Analyse data of palliative care prevalence rates and the % of care home patients in order to understand if there is a correlation. Where rates of care homes are high, and palliative care registers are low prioritise practices as a test practice 6.0 Preliminary Audit findings 6.1 After testing the above searches at 3 practices the results as per fig 4 were found: Practice Current palliative care register as of June 15 Associated codes/diagnosis code that would suggest patient should be on palliative care register Practice Practice Fig. 4 Preliminary audit findings from EMIS searches 7.0 Proposed Approached 7.1 Based on the audit findings the task and finish group propose the audits outlined in section 6.4 be undertaken at practices whose palliative care registers prevalence falls below the Trafford average in the first instance. 7.2 Once the approach has been approved communications will be circulated to the practices highlighting the CCGs priority for Palliative care. 7.3 The CCG Senior data quality analyst will undertake the searches on behalf of the practice. 7.3 Practices will be provided with a list of patients who would be recommended to be reviewed in order to determine eligibility for the Palliative care registers 7.4 Where the list of potential patients is large the practice will be advised how best to prioritse them 7.5 Practices will be asked to review the patient s notes/patient in person and add to Palliative care register as appropriate. 7.6 The current palliative care services are under review. The improved quality practice registers will help inform the commissioning of the new contract going forward.

8 7.7 There may be a potential increase in demand on community services and Pennine Community care will be made aware of the scheme 7.8 There may be a potential increase in the use of controlled drugs which could impact the Controlled drugs Locally commissioned service and NHSE will be made aware of the scheme. 8.0 Recommendations The PcSG is asked to note and approve the proposed approach outlined in the paper