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					                       LHC Demonstrator Case Study
                 Croydon – Commissioning End of Life Care

                                  Summary Details

Organisations            St George’s Hospital, Mayday Hospital, Princess Royal
involved:                Hospital, South London and Maudsley, Royal Marsden,
                         District Nursing, General Practitioners, Community
                         Matrons, Specialist Clinical Nurses, Pharmacy, Continuing
                         Care Team, St Christopher’s Hospice, Marie Curie
                         Hospital Caterham, Croydon Voluntary Action, Nursing
                         Homes, Residential Homes, Croydoc, London Ambulance
                         Service, NHS Direct, Patients, Relatives and Carers,
                         Social Services, SW London Cancer Network
Short description of     The aims of the programme are:
programme:
                              To end the fragmentation of End of Life care delivery
                               across the Croydon PCT catchment area.
                              Establish the need and relative priority for improving
                               End of Life care for the population of Croydon.
                              To assess and re-design the way in which EoLC
                               services are commissioned.
                              Analyse how EoLC services are currently funded
                               and to review this to support new models of service
                               provision.
                         This is to be achieved through development of a
                         Commissioner-led service specification for end of life care,
                         together with a Provider-led service model to meet its
                         requirements. The PCT led a Steering Group to achieve
                         alignment of these two initiatives.
Project Dates:           January 2007 to March 2008. This Case Study was
                         prepared September 2007
Key Words:               End of Life Care, Strategic Commissioning, Palliative Care,
                         Needs Assessment, Voluntary Sector, Preferred Place of
                         Death
Main Contact             Maggie Ioannou, Director of Community Health Services,
                         Croydon PCT
                         Maggie.Ioannou@croydonpct.nhs.uk
                                         Table of Contents


1     Aim of the Programme ................................................................................ 1
2     Local Health Community Background ......................................................... 1
3     Stakeholder Engagement ............................................................................ 2
4     Key Issues................................................................................................... 2
5     Programme Governance ............................................................................. 3
6     Approach Adopted ...................................................................................... 3
7     Future Vision ............................................................................................... 3
8     Criteria and Measures of Success .............................................................. 4
9     Risks Identified ............................................................................................ 4
10 Programme Achievements .......................................................................... 4
11 Lessons Learned ......................................................................................... 4
12 Remaining work to achieve original aims .................................................... 4
13 ISIP LHC Demonstrator Programme external change consultant ............... 5




For additional materials associated with this document, and to see Case
Studies for other ISIP Demonstrator Local Health Communities, please go to
the ISIP website: www.isip.nhs.uk
1 Aim of the Programme

The aims of the programme are:
       To end the fragmentation of End of Life care delivery across the Croydon
        PCT catchment area.
       Establish the need and relative priority for improving End of Life care for
        the population of Croydon.
       To assess and re-design the way in which EoLC services are
        commissioned.
       Analyse how EoLC services are currently funded and to review this to
        support new models of service provision.

2       Local Health Community Background
The Local Health Community provides services to a population of [across the
following organisations:

Acute:
       St George’s Hospital
       Mayday Hospital
       Princess Royal Hospital
       South London and Maudsley
       Royal Marsden

Community Services:
       District Nursing
       General Practitioners
       Community Matrons
       Specialist Clinical Nurses
       Pharmacy
       Continuing Care Team

Third Sector:
       St Christopher’s Hospice
       Marie Curie Hospital Caterham
       Croydon Voluntary Action

Private Sector:
       Nursing Homes


Croydon End of Life Care                                                     Page 1 of 5
       Residential Homes

Out of Hours:
       Croydoc
       London Ambulance Service
       NHS Direct

Other:
       Patients, Relatives and Carers
       Social Services
       SW London Cancer Network

3       Stakeholder Engagement
Major stakeholder groups consulted were:
       Patients
       Clinicians
       Social Workers (including their managers)
       Voluntary Workers/Carers
       Commissioning Staff
       Finance Managers
In the main, consultation was undertaken through face to face meetings
supplemented by workshops. One of the most significant and innovative
engagement exercises was the “Big Question” week. This was designed to seek
the answer to a single question put to patients and their carers directly by
District Nurses during the course of their work. The question was, “What one
thing would improve the quality of your life right now?”. Further details of this
exercise are contained in the Practical Guide on Stakeholder Engagement (see
www.isip.nhs.uk).

4       Key Issues
The primary driver for the work was the recognition that the delivery of EoLC
was not meeting patient aspirations to the degree that it might. Although
Croydon has a good reputation for ensuring that patients die in their preferred
place of death, there was an underlying feeling that the PCT could improve on
this. Additionally, EoLC is spread across a number of organisations that obtain
their funding from disparate sources thus reinforcing the view resources might
not be being spent as effectively as possible or with the patient clearly as its
focus.
Much time was spent in baselining the current funding across the EoLC
community as well as examining the key elements of service delivery from a
strategic and benefits-led approach. These reviews highlighted a need to:


Croydon End of Life Care                                                 Page 2 of 5
       Improve communication and co-ordination across EoLC services and
        providers
       Clarify what EoLC services are needed and what the different service
        providers should be delivering
       Define measures to assess the overall quality of EoLC

5       Programme Governance
The PCT recognised that there are two distinct pieces of work that need to be
put in place:
    1. The production of a Commissioner-led service specification for EoLC in
       line with the DH “Commissioning Framework for Health and Well-being”
    2. The development of a provider-led service model to meet the
       requirements of the service specification.
With this in mind, together with the key issues identified above, the PCT has
established a Steering Group for End of Life Care in order to represent all of the
key stakeholders and to agree and manage the future workplan.

6       Approach Adopted
Croydon was very fortunate in having the assistance of one of the original
authors of the ISIP materials which ensured that we were exposed to and
utilised a wide range of the ISIP tools. Specific tools used were in the areas of
Strategy and Benefits, Stakeholder Engagement and Governance and
Management, specifically:
       Benefits Dependency Network
       Benefits Realisation Plan (aiming for a Strategic Commissioning Plan)
       Stakeholder Impact Analysis
       Communication Plans leading to the “Big Question” week
       Project Initiation Documents
There is no doubt that the benefits-led approach has significantly affected our
thinking towards planning and service delivery

7       Future Vision
The key developments for the future will be:
       The provision of patient focused packages of care tailored to individual
        needs and requirements
       Better planning and utilisation of resources allocated to EoLC




Croydon End of Life Care                                                   Page 3 of 5
8       Criteria and Measures of Success
Measures of success will be:
       A continuing reduction in the number of people who die in hospital
       An increased involvement of patients and their carers in the shaping of
        the way in which EoLC is delivered
       The development of a strategically commissioned set of EoLC services
        that can be tailored to meet individual needs and requests

9       Risks Identified
The major risk to the Improvement Programme is, and will remain, the issue of
prioritisation of PCT work. EoLC has to take its place alongside any number of
other present and emerging demands any one of which could delay our planned
work. We are seeking to minimise this risk by keeping the profile of EoLC high
on the PCT agenda to ensure that it ranks alongside other priorities.

10 Programme Achievements
To date we have achieved:
       A governance structure to involve all stakeholders involved with EoLC
       A commitment to a strategic approach to commissioning end-of-life
        services
       Resources to build upon the ISIP activity
       Resources to deliver the strategic commissioning approach

11 Lessons Learned
The main lessons learned have been:
       The need to ensure that full, accurate and relevant information about
        EoLC activity is recorded by all organisations concerned in order to
        monitor improvements over time.
       That EoLC activity has to put the patient at the centre of the activity and to
        ensure that strategic commissioning and service delivery do not lose sight
        of this patient focus.

Top tip: Use the “Big Question” approach (described above) to elicit
meaningful view from those at the centre of the activity and ensure that
the governance framework commits to delivering these requirements.

12 Remaining work to achieve original aims
The ISIP “experience” has been a very positive one and we have taken a
decision to integrate the benefits led approach into our upcoming Programmes
of activity. Our new Project Manager has already been introduced to the ISIP
concepts and we would look to spread the word across the organisation.

Croydon End of Life Care                                                     Page 4 of 5
13 ISIP LHC Demonstrator Programme external change
   consultant
We benefited immensely from the energy and enthusiasm from our ISIP change
consultant. Her detailed work enabled us to raise the profile of EoLC and her
expertise and independence helped us to apply new approaches to our analysis
and planning. Specifically, through the benefits-led approach she showed us the
importance of being clear about our objectives and to adopt a new chain of
thinking (i.e. “right to left”) that enabled us to be clear about our future direction.
Naturally, having external support took a lot of pressure off of our pressured
internal resources but the enthusiasm for ISIP as applied to EoLC gave us
some fresh and exciting insights.




Croydon End of Life Care                                                      Page 5 of 5

				
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