Palliative care strategy: Palliative Care Matters for All

Outcome 2: Leaders, stakeholders and delivery partners will work together in partnership, with clear roles and responsibilities, to make sure there is reliable and effective planning, delivery, accountability and improvement of palliative care services and wider support.

Local leadership and planning

Across Scotland, Palliative Care is delivered within an integrated landscape, with joint working across the NHS, Local Authorities and third and independent sector organisations (annex D provides further information about this). Together, partners aim to deliver joined up palliative care which supports the national health and wellbeing outcomes (National Health and Wellbeing Outcomes: A framework for improving the planning and delivery of integrated health and social care services).

The aim of strategic planning is to encourage holistic planning as a way to uphold rights; tackle inequalities; and safeguard, support and promote wellbeing, so that people who receive services and support experience this as joined up at all levels. As a minimum this must include all adult social care, adult primary and community health care and a proportion of adult acute services. The process involves assessing and forecasting population need; linking investment to agreed outcomes; planning the nature, range and quality of future services; and working in partnership to put these in place.

Whole system approaches

Leadership at local levels needs to drive the development of whole system approaches with joined up services and, most importantly, clear and co-ordinated pathways of care between services. This will enable the right care in the right place at the right time, and help to ensure that the changing needs of adults, children and their families, and carers, are met, in line with what matters to them. Comprehensive and co-ordinated models will improve delivery through specialist palliative care units, hospices, community hospitals, primary care, care homes, care at home and the third sector, in partnership with families and local communities. This requires Integration Authorities to develop and plan to meet the palliative care needs of their local populations now and in the future.

Local strategies or plans should set out how people with palliative care needs will be identified and assessed; how health and care plans and future care planning will be delivered; and the range of services with pathways into and between them, in order to direct and commission services to meet identified and assessed needs. They also need to set out how specialist and general palliative care will be integrated and co-ordinated across all places of care, in collaboration with delivery partners. This needs to recognise and include the important contributions made by families, carers, volunteers and communities.

Focusing on what matters to people; where they would like to receive their care; and providing treatments of benefit and value to the person, can provide opportunities to redesign services. Service models across health and social care are moving towards better care at home or in a care home, supported by effective unscheduled health and care, and targeted day care; outpatient services; and hospital admissions that are as short as possible.

Independent hospices are also a key delivery partner, providing specialist palliative care in hospices and the community, commissioned by Health Boards and IJBs. They have shared aims to shift the balance of care closer to people's homes, including hospice at home and community outreach services, supporting people to stay in their own homes. They are system leaders, open to working as partners with Integration Authorities to innovate and reconfigure services to meet current and projected population need. Sustainable arrangements for commissioning and funding independent hospice care are essential to enable them to participate as equal partners in the redesign of services to meet future need.

Population-based plans should consider how to leverage current resources to greatest impact so that people can access the services they need more quickly. Local engagement with communities should make sure changes match needs and preferences. Involvement of local community resources should enhance local and compassionate care.

Reconfiguring services to invest in palliative care and integrating systems and budgets can deliver more effective, high-quality care for adults, children, their families and carers, including shared decision making and building a personalised approach to care in the context of innovation and improvement.

End of Life Care Together Programme in NHS Highland

A partnership of organisations, led by NHS Highland and Highland Hospice, found 75% of NHS expenditure for people in the last year of life went on unscheduled hospital care. This meant 1 in 3 emergency admission beds.

A transformation fund to change this is increasing future care planning and coordinated care in the community. There is now a 24/7 Palliative Care Helpline and access to a responsive, dedicated social care service with support from specialist palliative staff. This innovation is improving satisfaction with care while reducing hospital stays and costs.

Service planning should be underpinned by data on current and projected population needs. With increasing numbers of people requiring palliative care, as well as greater complexity as our population ages and more people have multiple health conditions, it will be necessary for partners to work jointly together to identify and analyse local and national population needs.

Services should be reshaped to meet population needs for palliative care more closely now and in the future. This includes making space to innovate and to target resources more effectively by focusing on what really matters to each adult or child and their family.

It is important to learn from HSCPs and Health Boards that have reconfigured services to achieve more collaborative working across a range of services and sectors, in consultation with users of these services.

Service redesign in NHS Fife

An enhanced and integrated approach to palliative care services in Fife means more people now benefit from coordinated palliative care delivered across health and social care and in all places of care.

Key components include a Social Care End-of-Life Care Team delivering personal care; a 24/7 District Nurse Palliative Care Helpline providing prompt support and symptom management; the Marie Curie Nursing Service providing evening and overnight community care; and a 24/7 Single Point of Access for professionals requiring Specialist Palliative Care advice and/or patient assessment.

This 7-day, Specialist Palliative Care Service has been realised through resource reallocation; reducing inpatient specialist palliative care beds to those needed for people with the most complex needs; and establishing an agile, responsive, multidisciplinary Outreach Team.

Fife's Palliative Care Collaborative, comprising health, social care and third sector stakeholders, ensures connectivity at a strategic and planning level and promotes shared learning. Daily clinical collaboration is supported by shared electronic community patient records; twice daily huddles, including District Nursing, Specialist Palliative Care, Social Care and Marie Curie; and multidisciplinary meetings with general and specialist palliative care providers in acute and community settings.

National Care Service

The proposed National Care Service Board (NCSB) is intended to oversee reformed Integration Authorities (NCS Local Boards) and, through them, the delivery of integrated community health, social work and social care services that they direct. It is intended that the NCSB will bring significantly more coherence and collective focus to strategic planning and delivery of integrated health and social care services to:

• ensure close monitoring of performance;
• drive improvement in transparency of delivery, outcomes and spend;
• improve data sharing to support these aims;
• improve collective learning; and
• support improvement where it is required.

It is intended that the NCSB will have a role to set guidance and standards for integrated health and social care and seek delivery assurance on local strategic plans; to monitor system performance; and to ensure visibility of data and information about services. It will also be able to take material action when monitoring indicates that standards are not met, to ensure services improve for people through a progressive support and improvement framework.

The ongoing development of the NCS provides important opportunities to clarify the delegation of responsibility for ensuring equity of access to general palliative care and specialist palliative care services in all places of care.

As part of the finalisation of the strategy and development of the delivery plan, Scottish Government will work with delivery partners to further develop the following proposed actions, timings and appropriate governance arrangements:

2.1. Develop guidance with IJBs and Health Boards to support the identification of a clinical and a managerial / executive lead, and to establish a Managed Care Network (MCN), updating previous guidance for Health Boards on MCNs.

2.2. Work with Health Boards to establish new requirements for inclusion of integrated specialist palliative care services within annual delivery plans and performance monitoring.

2.3. Work with HSCPs and adult independent hospice organisations to develop a national guidance framework to support and improve consistency of local planning and commissioning of independent hospice services.

2.4. Work with the Scottish Partnership for Palliative Care (SPPC) to establish a national Palliative Care Innovation Network, where people and teams involved in palliative care delivery; community-led initiatives; improvement and research; or education can come together to share learning and ideas for improvement and innovation.

2.5. Continue to engage with palliative care delivery partners on how the proposed NCSB and the reformed Integration Authorities will improve national and local governance, roles, responsibility, commissioning, monitoring and reporting of specialist palliative care services and general palliative care.