-
Symptom Management
-
Assessment and Care Planning
-
Equipment
-
Drugs
-
Education and Training
-
Communication and Continuity of Care
-
Feedback for Health Professionals on their Performance
The proposal relates its aims to the stated priorities
of the NHSiS.
The method to be followed in the development of
the MCN is documented.
Associated costs in terms of setting up and running
the MCN are listed and sources of funding identified.
1
BACKGROUND
1.1 MCNs have been set up in Scotland at
a regional level for some of the major cancers with the intention that
this concept is extended further. The Scottish Partnership Agency has
produced a working party report detailing a "Framework
for a Managed Clinical Network in Palliative Care"(4) and areas
to pilot these are being sought. Additionally the Clinical Standards
Board for Scotland (CSB) have produced Core Standards for Palliative
Care(5) and the SIGN
Guidelines for the Management of Pain in Patients with Cancer(6)
have recently been published.
1.2 A recent study looking at Palliative
Care in Community Hospitals in the Borders identified variations in
facilities and practices amongst the seven community hospitals and made
a number of recommendations(1). It has also been identified that there
is a significant variation in the use made of the Specialist Palliative
Care Service and the Marie Curie Out Of Hours Nursing Service between
different primary care teams(2,3). Thus it has been demonstrated that
there is not an equitable provision of palliative care to patients in
all parts of the Borders.
1.3 In the last two years there have been
a number of new initiatives developed by the Specialist Palliative Care
Service and the Macmillan GP Facilitator. These include
-
an ongoing multidisciplinary educational programme
for primary care teams following an audit of educational needs
-
an assessment of out of hours palliative care with
the development of a handover form and the current development of
a network of trained palliative care pharmacists to ensure the provision
of necessary palliative care drugs at all times
-
-
a palliative care website for both health professionals
and patients/carers (www.in-touch.org.uk)
-
an audit of Palliative Care in Community Hospitals
in the Borders(1)
1.4 Future developments include the building of
a new Cancer Resource for patients and carers, which will integrate
the Oncology and Palliative Care Services, and the appointment of a
Lead Cancer Nurse.
2
AIMS
2.1 Primary aim
The prime aim of this MCN would be to support the patient with palliative
care needs at all stages in his/her journey of care and to ensure equity
of access to the highest standards of care, provided by an integrated
multi-disciplinary team. The primary focus will be on the palliative
care needs of patients with cancer and the top priority will be improvement
in the management of pain.
2.2 Secondary aims
In order to achieve this the aims detailed in the SPA's Framework
for the Operation of Managed Clinical Networks in Palliative Care
have been adapted for the Borders MCN as follows:
-
To create effective, efficient communication links
between health professionals and with patients and carers, and to
co-ordinate palliative care provision across primary and secondary
care, including community hospitals and nursing homes
-
To ensure that palliative care of an equally high
standard is available to everyone who needs it throughout the Borders
region
-
To improve standards of palliative care by promoting
evidence based practice, with the management of pain as the first
priority, and by a programme of continuous professional development
for members of the Network
-
To ensure that a system to audit the outcome of
evidence based practice is in place and that results are disseminated
timeously to those in the Network
-
To ensure that patients and carers have the information
and understanding they need to make choices about their palliative
care and, wherever possible, to provide the service and the support
required in an environment of the patient's choosing.
2.3 Other Primary Care oriented MCNs
Existing MCNs are based almost entirely in secondary and tertiary care.
An additional aim of this proposal is to produce a workable template,
centred on primary care, to enable the development of other primary
care oriented MCNs both within and outwith the Borders. It is envisaged
that this pilot MCN could be further developed to provide an integrated
Cancer and Palliative Care MCN for the Borders.
3
WHY DEVELOP A NETWORK?
3.1 The development of a clinical network
in palliative care with managerial support would enable the co-ordinated
development of new initiatives in all parts of the Borders. Enhancing
communication between health professionals at the primary secondary
care interface, and improving the provision of information to health
professionals and patients/carers would undoubtedly raise the standard
of patient care.
3.2 A network would ensure the co-ordinated
implementation of evidence based practice such as the SIGN Guidelines
on Pain, the CSBS Core Standards on Palliative Care and the sharing
of good ideas/practice. It would provide the resource and skills essential
to the effective audit of standards.
3.3 A clinical network would be able to
address those areas of care currently provided on an inequitable basis
and audit the results of the measures taken. It would also ensure the
active involvement of patients/carers in the future development of palliative
care services in the Borders.
3.4 A MCN would therefore unite current
and future initiatives in the Borders, and national guidelines and standards,
within a framework that would enable audit and review of progress. The
co-ordinated implementation of these proposals would be difficult to
achieve without the framework and resource of a MCN.
4
CLINICAL COMPONENTS OF THE NETWORK
These are based on the draft Standards for Palliative
Care issued by the CSBS (relevant standards are quoted below in italics).
The development team intend to address each of these components in the
following ways:
4.1 Symptom Management
"Palliative Care is provided in accordance with relevant SIGN guidelines
or where these do not exist in accordance with good practice guidelines
which are evidence based as far as possible."
-
Promoting best clinical practice by adapting and
implementing evidence based guidelines and national standards.
-
The management of pain will be the first priority
of the network which is committed to locally adapting and implementing
SIGN Guideline 44 Control of Pain in Patients with Cancer.
-
The network is also committed to developing local
evidence based guidelines on symptom management where no nationally
agreed guidelines exist
4.2 Assessment and Care Planning
"All patients with cancer will have their palliative care needs assessed,
documented and acted upon."
-
Ensuring that the patient's most important problems
are identified and recorded
-
Encouraging a multidisciplinary, multi-agency approach
to solving these problems and implementing "Care Management" planning
-
Developing robust administrative systems, particularly
around admission to and discharge from hospital, in order to ensure
seamless patient care.
To facilitate these processes the further development
of the existing nursing patient held record in the Borders would be
a priority, which should be further augmented by suitable electronic
systems enabling audit and sharing of information throughout the network
4.3 Equipment
"All patients receiving palliative care will have timely delivery
of essential equipment."
4.4 Drugs
"Prescribed essential drugs are obtainable when required (including
"out of hours" for patients at home)"
-
Ensuring that the mechanisms are in place for team
members to have access to responsive drug information services.
-
Continuing development and integration of the Palliative
Care Pharmacists Network to ensure rapid access to immediately necessary
drugs
-
Encouraging all professionals to prescribe in accordance
with locally agreed guidelines
4.5 Education and Training
"All health professionals in cancer services
will undertake cancer specific professional education and development
including the principles and philosophy of palliative care."
Facilitating an ongoing training programme based
on the individual needs of all professionals in the network.
Basing education on evidence of best clinical practice
4.6 Communication and Continuity of Care
Good communication between members of the network and continuity of
care between hospital and community are essential to high quality patient
care. This area could be improved by
-
Revising discharge communications to make sure
that both content and mode (letter, telephone, e-mail, fax etc) are
tailored to the needs of the primary care team
-
Formal telephone contact times for health professionals
to contact the Consultant in Palliative Medicine
-
Formal arrangement for 24-hour specialist palliative
care advice
-
Further development of the existing nursing patient
held record
-
Encouraging use of the palliative care out of hours
handover forms (Appendix 6)
-
Increasing the extent of upto date, relevant, clinical
information on the website for easy reference by health professionals
-
Increasing the extent of locally adapted patient
information on the website
-
Continuing to provide a regular newsletter with
information about the MCN, feedback and clinical information (Appendix
7)
-
Implementing regular meetings between specialist
palliative care and all primary care teams. These should probably
be multi-professional case conferences or meetings to discuss the
management of more complex individual patient care. They could either
be practice based or community hospital based.
4.7 Feedback for Health Professionals on their
Performance
"Prospective clinical audit must become an integral part of cancer
services. The aim of clinical audit is to engage all professional health
care staff in the systematic and critical examination of their practice
and to demonstrate quality of care and outcomes."
5
COVERAGE, MEMBERSHIP, STRUCTURE AND MANAGEMENT
5.1 Coverage
It is envisaged that the network will cover the entire Borders Health
Board area. This comprises the Borders Primary Care Trust, Borders LHCC,
Borders West LHCC and Borders General Hospital NHS Trust. It encompasses
22 practices, 7 community hospitals, 17 nursing homes and 1 specialist
palliative care team. There is no hospice within the Borders.
5.2 Membership and Structure
Membership of the network is open to any health professional in the
Borders who is involved in palliative care. All members must be willing
to practice in accordance with the SIGN Guideline on the Control of
Pain in Patients with Cancer, and with any other evidence based guidelines
adopted by the network or local good practice guidelines developed by
it. All members must also be willing to participate in a continuous
programme of audit. Network structure and membership are detailed in
Appendices 2,3 and 4
5.3 Management
The Lead Consultant will have overall responsibility for the operation
of the network. He will be assisted in this role by a Lead General Practitioner,
a Lead Clinical Nurse Specialist and a Lead Pharmacist. For the network
to be successful it is essential that dedicated time is made available
so that these key clinicians can be involved in the development and
implementation of the initiatives set out in this document. A Network
Manager will be responsible for the day to day running of the network
under the direction of the clinicians. These individuals will collectively
form the Palliative Care Executive Group (Appendix 3).
6
INVOLVEMENT OF PATIENTS AND CARERS
Patients and carers will be involved in the network
in the following ways
-
A patient representative is present on the Palliative
Care Steering Group
-
Patients' and carers' views on the service will
be sought by means of questionnaires
-
Patients' and carers' views will be sought on the
development of patient/carer information and the most appropriate
ways of making it available
7
EVALUATION OF THE PROJECT
7.1 Audit Facilitator
To enable evaluation of the project it is essential that the network
has a part-time audit facilitator proficient in setting up databases
using Microsoft Access.
7.2 Baseline Audit
-
A baseline audit is already underway through visits
to all primary care teams in the Borders to identify areas for improvement
and development in palliative care provision. This also takes the
form of a consultation exercise as it was felt essential that primary
care teams' views were sought on how such a managed clinical network
would operate and how it would encompass the Core Standards for Palliative
Care and the SIGN Guidelines on the Management of Pain in Patients
with Cancer. A consultation/audit document has been produced based
on the Scottish Partnership Agency's working party report and MEL
(1999)10 (Appendix 1).
-
-
The data specified in the Clinical Standards Board
for Scotland Standards for Palliative Care should also be collected
as a baseline.
7.3 Audit and Final Evaluation
-
Improvement in the management of pain has been
identified as the top priority for the network. Collection of the
Minimum Core Data Set from SIGN
Guideline 44 will form the basis of the audit to assess to what
extent this aim has been achieved. This will form a continuous audit
throughout the 2 years of the pilot.
-
A repeat of the baseline audits among primary care
teams and of community hospitals will establish the success of these
initiatives.
-
The data specified in the Clinical Standards Board
for Scotland Standards for Palliative Care will be collected at the
end of the 2 year pilot.
-
Finally it is hoped to be able to demonstrate the
following benefits specified in the SPA Report4 by the end of the
MCN pilot
- Improved communication
- More collaborative working
- Increased patient satisfaction and choice
- Better symptom management o Greater continuity
of care across hospital and community o Improved access to specialist
advice and support for health professionals
- Feedback for health professionals on their performance
7.4 Annual Report
The network will produce a written annual report for the Health Board,
Trusts and LHCCs which would be available to the public through the website.
8
CLINICAL GOVERNANCE
The network intends to work in collaboration with
the 2 NHS Trusts and the 2 LHCCs with regard to Clinical Governance.
It is committed to implementing national quality standards and guidelines.
The Borders LHCC is in the process of introducing a pilot scheme for
Continuous Professional Development in Primary Care Teams and this presents
a unique opportunity for working with the MCN to achieve a common goal.
9
APPLICATION FOR FUNDING - HOW DOES IT FIT WITH PRIORITIES?
9.1 The proposal sets out to improve cancer care
by enhancing the provision of effective palliative care and associated
support and information services. It would do this by
-
Equity: working towards equitable provision
of palliative care services for all patients in all parts of the Borders
-
Patients: involving patients/carers in the
development of their service
-
Quality: developing a quality assurance
programme involving ongoing audit of clinical care and collection
of data in accordance with the recommendations of the CSB
-
Audit & Outcomes: Ensuring that audit results
and outcome measures are disseminated timeously to those involved
in patient care in order to enable further improvements in service
provision.
-
Integration: Creating links with the cancer
services in the Borders in order to ensure that the Palliative Care
Managed Clinical Network is an integral part of cancer treatment and
existing cancer networks
-
Consultation: consulting fully with all
interested parties
-
Communication: improving communication between
all members of the network
-
Information Technology: developing and promoting
the use of existing IT, such as e-mail and the internet, to improve
communication and investigating the use of teleconferencing for educational
and clinical meetings
-
Cost effectiveness: ensuring that cost effectiveness
is a consideration in developing the service
9.2 The proposal is also designed to enable the
further development of the concept of MCNs by piloting a network in
palliative care. Most networks are currently secondary and tertiary
care based and this project would therefore be piloting a network based
mainly in primary care. It is envisaged that it could provide a model
for other primary care orientated networks.
10
BIBLIOGRAPHY
-
Cormie PJ. Palliative Care in Community Hospitals
in the Borders. Scottish Borders: Borders Primary Care Trust,
1999
-
Rodgers J. Utilisation of the Specialist Palliative
Care Service. Scottish Borders: Borders General Hospital Trust,
1998
-
Romanes J. Utilisation of Marie Curie Out of
Hours Nursing Service. Scottish Borders: Borders Primary Care
Trust, 1999
-
Scottish Partnership Agency for Palliative and
Cancer Care. A Framework for the Operation of Managed Clinical
Networks in Palliative Care. Edinburgh: SPAPCC 1999
-
CSBS Palliative Care Cancer Project Group. Core
Principles of Cancer Care and Standards for Palliative Care. Edinburgh:
Clinical Standards Board for Scotland 2000
-
Scottish Intercollegiate Guidelines Network. Control
of Pain in Patients with Cancer. Edinburgh: SIGN 2000
Appendix
1
SCOTTISH BORDERS PALLIATIVE CARE SERVICE
PROPOSED MANAGED CLINICAL NETWORK
INFORMATION FOR PRIMARY CARE TEAMS
INTRODUCTION
The concept of Managed Clinical Networks (MCN)
was set out in the report of the Acute Services Review published in
June 1998 and the core principles were further defined in NHS MEL(1999)10.
Definition
MCNs are defined as linked groups of health professionals and organisations
from primary, secondary and tertiary care, working in a co-ordinated
manner, unconstrained by existing professional and Health Board boundaries,
to ensure equitable provision of high quality clinically effective services
throughout Scotland.
Core Principles - MEL(1999)10
-
each Network must have clarity about Network management
arrangements, including the appointment of a person who is recognised
as having overall responsibility for the operation of the Network,
whether a lead clinician, a clinical manager or otherwise. Each Network
should produce a written annual report to the appropriate Health Board
or Trust, which would also be available to the public
-
each Network must have a defined structure which
sets out the points at which the service is to be delivered, and the
connections between them
-
each Network must have a clear statement of the
specific clinical and service improvements which patients could expect
as a result of the establishment of the Network
-
each Network must use a documented evidence base,
such as SIGN guidelines where these are available, and must be committed
to expansion of the evidence base through appropriate R & D
-
each Network must be truly multi-disciplinary/multi-professional
and should include representation from patients' organisations in
its management arrangements
-
each Network must have a clear policy on the dissemination
of information to patients, and the nature of that information, bearing
in mind the role of primary care in helping to lead the patient through
the system
-
all the health professionals who would make up
the Network must indicate their willingness to practice in accordance
with the evidence base and with the general principles governing Networks
-
an integral part of each Network must be a quality
assurance programme acceptable to the Clinical Standards Board for
Scotland (CSBS), which also has a role in ensuring consistency of
standards and quality of treatment across all MCNs
-
the educational and training potential for Networks
should be used to the full, through exchanges between those working
in the community and primary care and those working in hospitals/specialist
centres. Networks' potential to contribute to the development of the
intermediate specialist concept should also be kept in mind, and Networks
should develop appropriate affiliations to universities, the Colleges
and SCPMDE
-
all health professionals in the Network must produce
audit data to required standards and participate in open review of
results
-
all Networks must include arrangements to circulate
staff in ways which improve patient access, and enable professional
skills to be maintained. Each Network should have an appropriate programme
of continuous professional development in place for every member of
the Network, as well as a mechanism for ensuring the programme is
being followed
-
there must be evidence that the potential for Networks
to generate better value for money has been explored
The Scottish Partnership Agency has produced a
working party report detailing a Framework for Managed Clinical Networks
in Palliative Care and areas to pilot these are being sought - see Scottish
Executive HDL (2000) 10. Additionally the CSBS have produced Core Standards
for Palliative Care and the SIGN Guidelines for the Management of Pain
in Patients with Cancer have recently published.
We feel it is important that primary care teams'
views are sought on how such a MCN would operate and how it would encompass
the Core Standards for Palliative Care and the SIGN Guidelines. The
following pages contains some of our thoughts around the establishment
of a MCN in Palliative Care and will form the basis of our discussions
with primary care teams in the Borders.
PROPOSED MANAGED CLINICAL NETWORK IN PALLIATIVE
CARE
DISCUSSION POINTS FOR PRIMARY CARE TEAMS
The following headings are important components
of a MCN. For each component the elements currently in place are listed
first followed by the developments that may be required to form an effective
MCN. We would value your views/suggestions on the following issues and
any other matters surrounding the proposal.
1. Communication
(a) Health Professionals
Elements Currently in Place
-
formal meetings between specialist palliative care
and primary care teams. These should probably be multi-professional
case conferences or meetings to discuss the management of more complex
individual patient care. They could either be practice based or community
hospital based.
-
Formal telephone contact times for health professionals
to contact the Consultant in Palliative Medicine
-
formal arrangement for 24-hour specialist palliative
care advice
-
review the current format of discharge letters.
What content and layout would be most suitable for primary care teams?
By what method would be like discharge information conveyed - letter,
telephone or e-mail?
-
Review methods of communicating patient information
amongst health professionals. Should we have patient held records
for cancer/palliative care or should all health professionals be encouraged
to write in a patient's existing nursing records?
(b) Patients and Carers
Elements Currently in Place
-
leaflets: palliative care service, patient advice
leaflets
-
website: care directory, palliative care service
-
Palliative Care Steering Group: membership includes
the Local Health Council
2. Evidence Based Practice
Elements Currently in Place
-
Pain guidelines
-
nausea and vomiting guidelines
-
"Duns Good Practice Guidelines"
-
guidelines on symptoms other than pain are on the
website
-
specialist practitioners keep upto date with current
research from palliative care journals which is passed on in the newsletter
3. Education/Continuous Professional Development
Elements Currently in Place
-
Multidisciplinary education programme on symptom
control and communication based around Borders Community Hospitals
-
regional topical meetings e.g. ethics, lymphoedema
and palliative care out of hours
-
educational articles in the newsletter
-
educational content on the website
-
an educational needs assessment survey has been
completed for general practitioners
-
an educational programme is underway for community
pharmacists
-
education of patients and carers e.g. in the principles
of pain management is already carried out on an informal basis by
the Clinical Nurse Specialists, General Practitioners and the Consultant
in Palliative Medicine
-
Multi-professional case conferences or meetings
to discuss the management of more complex individual patient care
-
clinical/educational attachments: increase the
exchange of staff between hospital and primary care to increase sharing
of skills and knowledge
-
"Link Nurses"
4. Audit
Elements Currently in Place
-
audits carried out in Duns?
-
Audits in pain management in community hospitals?
-
Surveys: syringe driver protocol, educational preferences
of general practitioners
-
Audit of Palliative Care in Community Hospitals
in the Borders
-
Formal audits starting with pain management and
possibly using the SIGN Guidelines for Pain minimum data set
-
timeous feedback of audits to health professionals
-
audit of palliative care out of hours: use of the
handover form and use of the new pharmacist service
-
audit of operation of service/patient pathways
5. Information for Patients and Carers
Elements Currently in Place
-
Information leaflet on the palliative care service
-
patient advice leaflets: disease, treatments, benefits
-
resource directory on website
-
patient/carer meetings with health professionals
occur on an informal basis in the patient's home, hospital or the
GPs surgery
-
coordination of all available information e.g.
patient packs containing information on the palliative care service,
benefits, disease specific information
-
separate patient area in website
6. Other Areas to Be Considered
The following points also require discussion and
are dealt with in more detail in the proposal document to be submitted
to the Scottish Executive
Appendix
2
Network Structure and Management
Appendix
3
Group Roles and Memberships in the Network
|
ROLES
|
MEMBERSHIP
|
Palliative Care Steering Group
|
- Policy
decisions
- Oversee
planning and implentation of strategy
|
- Borders
Health Board
- Borders
Primary Care Trust
- Borders
General Hospital Trust
- Local
Health Care Co-operative
- Social
Work
- Local
Health Council
- Voluntary
Sector
- Lead
Cancer Nurse
|
Palliative Care Executive Group
|
- Planning
and implementation of policy
- Audit
- Communication
- Education
- Information
management and technology
|
- MCN Manager
- Lead
Consultant
- Lead
Clinical Nurse Specialist in Palliative Care
- Lead
General Practitioner
- Lead
Pharmacist
|
Palliative Care Operations Group
|
- Planning
continuing care in complex cases (local interpretation of MEL
22 1997)
- Management
of associated budget
|
- Assistant
Director of Nursing, Borders Primary Care Trust
- Nurse
representative for Community Hospitals
- Social
Work – Community
- Social
Work – Hospital
- Clinical
Nurse Specialist in Palliative Care
- Community
Nurse West LHCC - 1
- Community
Nurses Borders LHCC - 4
|
Cancer Steering Group
|
- Oversee
planning and development of cancer services in the Borders
|
- Borders
Health Board
- Borders
Primary Care Trust
- Borders
General Hospital Trust
- Local
Health Care Co-operative
- Social
Work
- Local
Health Council
- Lothian
University Hospitals Trust
|
Appendix
4
Management Structure of the Managed Clinical Network
|
Proposed
Managed Clinical Network in Palliative Care in Scottish Borders