Living & Dying Well

1. Living & Dying Well One Year on… The Perspective of an Executive Lead & Chair of A Managed Clinical Network Robbie Pearson, NHS Borders Dr Paul Cormie, Chair of Borders MCN

2. “How we care for the dying must surely be an indicator of how we care for all our sick and vulnerable patients. Care of the dying is urgent care – with only one opportunity to get it right, to create a potential lasting memory for relatives and carers…” Professor Mike Richards CBE

3. An Impetus for Change… • Substantial achievement • A step change in how we think and behave • L&DW has provided a sense of focus & priority for NHS Boards • L&DW Delivery Plans – sharing of good practice & common issues • Executive leads providing a focal point for leadership in taking forward L&DW • Direct Enhanced Service for Palliative Care: building an integrated network of care • Shifting attention to tackling inequity in care and extending care to non-malignant conditions

4. From an NHS Borders Executive Lead Perspective • Active engagement, leadership and involvement of the Board • Identification of successes and challenges from L&DW and Audit Scotland perspectives • Leadership for priorities and delivery through the Managed Clinical Network • With the video diary, using the perspective of the patients journey from diagnosis to the last days of life • How we change our perspective on what matters & tailoring services accordingly

5. Sustaining That Impetus… • Making palliative care matter, whatever the condition, whatever the care setting • Giving a sense of coherence and making the connections to the other strands such as shifting the balance of care • NHS Boards actively tracking & measuring progress – especially the experience of patients and their families with regard to communication and co-ordination in the last phase of life (eg SPSO) • How we introduce & implement the recommendations from the short-life working groups into the service is crucial – a continuation of L&DW, through into implementation

6. General Perspective from an MCN • Focus on specific areas of service delivery: workplans and timeframes • Identify unmet need and plan to address • Facilitate sharing of ideas • Raise profile of palliative care at Health Board level and responsibility for implementation

7. Executive Lead Perspective from an MCN • MCN previously successful in implementing change where little or no resource required • Reality check • Development of business case • Navigation through the Health Board process

8. Activity/Achievement Perspective from an MCN • Non-malignant: initially COPD and heart failure. Now progressing to dementia and frail elderly • End of life care pathway • In-patient palliative care – benchmark to other HBs • Anticipatory social care • OOH – handover sheet further developed to become Palliative Anticipatory Care Plan

9. Activity/Achievement Perspective from an MCN • IM&T for specialist palliative care • Kardex further developed – PRN chart • Drug boxes • Information: website, LTC, leaflets • Conference • Digital stories: individualising care

10. Challenges Perspective from an MCN • DNAR • 24 hour community nursing cover • Equipment – an unexpected consequence of anticipatory care • Resources: training and education both participation and delivery (DNAR, End of life care pathway), accommodation • Keeping the momentum going