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27th February 2012

End of Life Care – Service Delivery

This article is the sixth in a series about end of life care. The first article in the series is “End Of Life Care - an Introduction”, which set out the framework to be expanded in the series.

In that article we noted that there were a number of sources of information regarding end of life care.  These include the NHS National End of Life Care Programme, the National Gold Standard Framework, and the Social Care Institute for Excellence (SCIE) resource “Dementia Gateway”.   The second article is entitled “End of Life Care – Elements of Care”, and considers the four elements of care which should be present throughout the six steps of the Programme. The third recent article, entitled “End of Life Care - Discussions as the End of Life Approaches”, dealt with the need to open up frank and transparent communications at the very beginning of a person’s journey towards the end of their life.  The fourth article, entitled “End of Life Care – Assessment and Care Planning ” briefly revisited the principles of care planning, with particular reference to end of life care.  The fifth article, “End of Life Care – Service Delivery” dealt with the critical importance of co-ordination between the various agencies and personalities who become involved in end of life care.

In this article we examine service delivery.

As a reminder, the NHS National End of Life Care Programme lists six steps in the end of life care pathway:

  • Discussions as the end of life approaches
  • Assessment and care planning
  • Coordination of care
  • Service delivery
  • Last days of life
  • Care after death

The Programme also lists four elements of care which should be present throughout the six steps listed above.

  • Support for carers
  • Information for patients and carers
  • Spiritual care
  • Social care

Service delivery

The NHS National end of Life Care Programme web page on this subject states:

“Individuals and their families may need access to a complex combination of services across a number of different settings. They should be able to expect the same high level of care regardless of the care setting.”

The NEoCLP web site quotes a survey undertaken in North Tees, which found that of all the patients on the Liverpool Pathway for end of life care, only 4% had been properly assessed for their spiritual needs.  While the case study goes on to describe the response to this finding, which obviously included a better planned spiritual support service, the underlying and more general point is that many end of life services, if examined, may show variations in the effectiveness of various elements of the full service.

The lesson from this observation returns us to the fourth article in the series, “End of Life Care – Assessment and Care Planning”, where it was argued that assessment and care planning were the lynchpin of effective end of life care.  Without excellent wide ranging assessment the full needs of the service user were unlikely to be consistently met, and care planning would not be comprehensive.  Without comprehensive care planning, effective care was not possible.

The second case study on the NEoCLP web page on service delivery shows us another of the most important elements in achieving consistent and holistic service delivery.  The case study describes the efforts which Barchester Health Care has put into the training of their staff in end of life care.

Barchester have decided to introduce an end of life programme in each of its care homes, a sensible decision given that in any care service the challenge of end of life care is likely to occur, and if it does in a situation where pre-planning for its support has not already taken place, then it is already too late to remedy that shortcoming.

The Barchester approach appears to rely heavily on staff training.  The importance of staff training in the context of end of life care was made in a previous article.  In Barchester’s case they are utilising an e-learning package for end of life and “Do Not Attempt Cardiopulmonary Resuscitation” (DNACPR).   The e-learning appears to be based on the North East NHS area educational resources.

There are a variety of resources similar to this available.  Many local NHS organisations open their internal end of life training to the private and voluntary sectors as a part of their commitment to consistent service delivery in all settings.  However, it is often difficult to obtain this training and education on a scale sufficient to include all staff.  A previous article argued that effective end of life care requires that all staff, not only senior or nursing staff, receive adequate training.  Barchester themselves appear to have run into this problem, because the case study notes that “all nurses, home trainers and their deputies will have been through the course”.  The case study also refers to stage one of the programme, therefore it is possible that wider training will be put into effect at a later stage.

The NHS based approach is a useful starting point, but the comprehensive nature of the training required for end of life care argues for internally delivered training.  In this way it is possible to involve all staff, track their progress more effectively, check that they are using the skills, fine tune the training to the particular circumstances and priorities of the service, and produce the positive team building effects which often accompany internal training programmes.   The advantage of the external, NHS, route is that attendees receive some insight into the way in which organisations other than your own service work in this area, making it easier to properly co-ordinate all services.  Possibly a blend of the two is the ideal;  have a number of staff attend the specialist external training  events, and have those staff cascade the knowledge throughout the rest of the organisation through planned internal training events and continued mentoring and specialisation.  Those readers who have assiduously applied the QCS Training Policy and Procedure will be familiar with this approach, which is supported by experts in training and organisational dynamics as being a very effective method of promoting “Learning Organisation” principles and effects.

For those with a need for more information urgently, sources of further information are:

Social Care Institute for Excellence (SCIE) Dementia Gateway.

The Gold Standards Framework.

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