Advanced disease care everywhere in our health care

Advanced disease care everywhere in our health care system n n n Patients avoid surprises Patients enabled to plan Professionals are confident and informed.

= Community Hospitals 3/18/2018 Martin Leiper 3

Care settings Home Community Hospitals University Hospitals Angus Dundee City Perth & Kinross 9 Community Hospitals Ninewells Hospital Perth Royal Infirmary Stracathro Hosp 100+ Care Homes Children’s Hospice (independent )

Promise 1 Effective and safe clinical care Home Community Hospitals University Hospitals Comprehensive education and training Patient support and education. Eg Breathlessness Programme Training in Care Homes Training the trainers (800 in health & social work) Action 20

Promise 2 Improve access to the service to ensure you are never overwhelmed by symptoms Home Community Hospitals University Hospitals Acute Palliative Care Unit (NW) Spec Pal Care Unit – (Roxburghe House) Spec Pal Care Unit – (Cornhill Macmillan Centre, PRI) Spec Pal Care Unit – (Whitehills) Spec Pal Care (eg Macmillan) Nurse or Doctor visit

4 beds within GP ward

Architect’s Impression Cornhill Macmillan Centre, PRI

Ninewells Hospital n 3 bed Acute Symptom Control Unit, ward 9, Leader Dr Pam Levack

Action 10, 16 Promise 3 Continuity, Coordination and comprehensiveness Home Community Hospitals University Hospitals Hospital Teams Family Doctor (GP) care Pal Care Electronic Patient Record - development Oncology Electronic Patient Record (Wisdom)

Action 6 Promise 4 (a) Informed, well-prepared to avoid surprises. Home Community Hospitals Care pathway in community hosps Palliative care pharmacy network “Just in Case” boxes Anticipatory Prescribing University Hospitals Care pathway A&E

n n “Just in case box” Discuss with patient GP prescription & DNAR £ 80 In place 4 months– few days before death Leader Elaine Gray 12

Action 8 “D AR N or f ” m

Action 7 Promise 4 (b) You and your family will have access to the information you need about your illness at the level or detail that you want. Home Community Hospitals University Hospitals 320 entries! Carer support schemes

Carer Support n n n Home visits Information Stress relief Group support Moving & handling Difficulty in awareness raising 15

Action 4, 5 Promise 5 Customised care reflecting your choices Home Community Hospitals GP Pal Care Register University Hospitals Discharge Liaison Nurse & Hospital teams “Preferred place of care” Pal Care Electronic Patient Record - in development <- Dedicated palliative care ambulance ->

Palliative Care Electronic Patient Record Up to date info. n Enough information to “Deliver Choice” Across 24 hrs n Across care settings n Across professions n Leader- Kenny Scott 17

PCS Demonstration 18

Palliative Care Ambulance n n n Very popular Same day booking Direct journeys Trained staff 47 - 86% utilisation 89% cancer pts. 95% of end of life journeys are with 15 mins of agreed time Leader Ian Golding 19

Promise 6 Make the most of every day Home Community Hospitals University Hospitals Pal Care Day Care Breathlessness programme Maggie's Centre (independent) & drop in days. Specialist therapists and volunteer teams Maggie's Centre

What do we want in 5 years? n Patients & Carers who feel Secure n Staff who are confident n Palliative Care Embedded in Health & Social Care

Angus Specialist Palliative Care Resources TAYSIDE · 400, 000 Forfar Strathmore Hospice, Whitehills 100 km Dundee Perth -Ninewells Cancer Centre Hosp pal care team -Roxburghe House 25 beds -Mac Nurses -Mac Day Care/clinic Dundee CHP -Marie Curie Service -Perth Royal Infirmary -Hosp team -Perth & Kinross CHP Mac Nurses -Mac House Day Care/clinic -Marie Curie Service -Crossroads M Leiper Stracathro Hosp -Mac Nurses -Mac Day Care/clinic Angus CHP -Marie Curie Service 23

Dundee -Ninewells Cancer Centre Hosp pal care team -Roxburghe House 25 beds -Mac Nurses -Mac Day Care/clinic Dundee Community Health Partnership (CHP) -Marie Curie Service -Pal care nurses Macmillan Nurses Day Care Reception, Physio 25 Beds & information Clinic Roxburghe House - Dundee 3/18/2018 Martin Leiper 7 24

Angus CHP Stracathro Hosp -Mac Nurses -Mac Day Care/clinic - Arbroath clinic -Marie Curie Service -Strathmore Hospice 3/18/2018 Martin Leiper 25