National Peer Review Programme Specialist Palliative Care Ruth Bridgeman / Julia Hill Programme Director/ Deputy Programme Director

Session 1: Introduction and Welcome Introduction and Welcome

Aims of Today To promote an understanding of then national peer review process and specialist palliative care in the new healthcare environment To feedback the evaluation of the peer review self-assessment round 2012/2013. To discuss and agree national core principles for specialist palliative care services To enable teams to cascade to others within their organisations

Sessions 2: Background and Context of the Specialist Palliative Care Measures

The National Peer Review Programme Hosted by NHS England as part of the Delivery Team within NHS Improving Quality (NHSIQ). Positive support to retain the programme and expand the remit to other disease types including Paediatric Diabetes, Paediatric Neuroscience and Stroke Services A long term host will be confirmed in the summer. It is agreed it will be hosted by the NHS IQ until a suitable host is agreed

How Peer Review Fits in the New Health Environment NHS England National Peer Review Programme

The Benefits of the Peer Review Programme Provision of disease specific information across the country together with information about individual clinical teams which has been externally validated A catalyst for change and monitoring of service improvement Provision of a directory of services Speedy identification and resolution of immediate risks and serious concerns to patients and or staff each year

The Benefits of the Peer Review Programme Engagement of a substantial number of front line clinicians in reviews (3,143) Rapid sharing of learning between clinicians Better understanding of the key recommendations in the NICE guidance, NICE standards or National Standards. Provision of timely national benchmarked data, trend analyses and reports that provide accessible public information about the quality of cancer services

The Scope of Peer Review all cancer services: – 2011/ teams reviewed – 1841 clinical teams and services – Additional cross cutting services – Networking groups other disease types and this years business plan covers: – Roll out of a National Programme for Paediatric Diabetes Services Approx. 170 services – Development of a National Programme for Stroke Services – Development of a National Programme for Paediatric Neuroscience

The 2013/2014 Peer Review Cycle The programme will continue in 2013/2014. However, as a result of this transition with strategic clinical networks changes have been made to the programme. – Suspending the network board measures 1A (Some my move to the 1C or 1E measures) – Revisions but maintaining of site specific groups – Suspending some cross cutting network group measures Partnership group Complementary Therapy Psychological Support (Integrate into 1C Measures) Rehabilitation (Integrate into 1C Measures)

NSSGs

Outcomes of Peer Review Confirmation of the quality of services Speedy identification of major shortcomings in the quality of services so rectification can take place Published reports that provide accessible public information about the quality of services Timely information for local commissioning (CCGs) as well as for specialist commissioners (ATs) Valid information which is available to other stakeholders

History and Context of Specialist Palliative Care Peer Review The revised Specialist Palliative Care (SPC) Measures are based on the requirements for SPC in Chapter 9 of the NICE Guidance: Improving Supportive and Palliative Care for Adults with Cancer (2004). The measures have been revised from the previous SPC measures (2004) to take a number of factors into account: – the subsequent developments in SPC practice and network organisation – developments in general supportive care which have been incorporated generically into all site specific cancer measures – the National End of Life Care Strategy 2008 and the NICE EOLC Quality Standard 2011 – strengthening the SPC multidisciplinary team (SPC MDT) so that each one has a requirement for two consultants in palliative medicine as core members – These changes have been undertaken in consultation with the national cancer peer review SPC reference group, and subjected to national consultation.

This data presents a national overview of the findings from the Specialist Palliative Care Review Programme in 12/13. A total of 282 teams were included in the assessment for this period, comprising of 171 acute hospital MDTs and 111 hospice MDTs. 208 teams chose to complete a self-assessment (SA) only, whilst 34 teams chose to complete both a self-assessment and an internal validation (IV). 40 (14%) teams did not complete an assessment (37 hospices and 3 Trusts). Peer Review for SPC 2012/2013 Number of teams Number ReviewedSAIV % compliance (Median) % compliance (Mean) IRSC %75%5 (2%)15 (5%)

Peer Review for SPC 2012/2013 There were a number of high performing teams in 2012/2013; 11 teams (4%) achieved 100% compliance 126 teams (45%) achieved ≥ 80% compliance However, there were also a small number of low performing teams; 11 teams (4%) had compliance of 50% or under

Peer Review for SPC 2012/2013

Sessions 3: Findings and Recommendations from Self Assessment 2012/2013 Vicki Morrey – External Consultant

Support to Networks and Providers Purpose of visits and consultations: Clarify peer review requirements Establish a shared understanding Identify an agreed way forward for 2012/13 Support SPC providers to agree an acceptable definition of the MDT Highlight the benefits and advantages of participation in the Peer Review process

Summary of Support Provided 29 visits were made across 22 Cancer Networks Network visits included: Attendance at Network SPCG meetings Facilitated workshops Discussion groups Presentations One to one discusssion

Introduction to the Report Aim of the report is to provide feedback and make recommendations Main focus is on the Service provider Organisation and SPC MDT measures All respondents remain anonymous

Introduction to the Report cont. The report recommendations take account of: Emerging themes from Self assessment narrative, workshops and discussions Identification of the core aims of SPC services Characteristics of SPC practice Impact of new NHS arrangements Shift of SPC from cancer to a more generic focus

Introduction to the Report cont. The position of SPC in the End of Life Care Pathway Appointment of National Director for End of Life Care as an important point of reference NB There was little or no evidence of resistance towards the principle of Peer Review for SPC. Many examples of creative and inspiring practice

Key Findings 1.Configuration of Services Overwhelming evidence of multi-professional approach across all SPC services. Different configurations in various settings either as a consequence of limited resources (e.g. hospital teams) or as indicated by need (e.g. day services)

Key Findings cont. The Peer Review Measures required: All SPC in-patient services in the network should be covered by one SPC MDT All out-patient/community care services should be associated with one SPC MDT All consultants in palliative medicine should be core members of a SPC MDT

Key Findings cont. This understanding of MDT created most controversy Two clear interpretations of a SPC MDT emerged Self Assessment descriptions reveal either a local (i.e. individual service) or a locality ( also called co-ordinating or super) A Locality team into which others refer is not the usual model of practice

Key Findings cont. No evidence of locality SPC MDTs in 12 networks Only 1 network achieved locality wide MDTs across all organisations Remaining networks demonstrated a mix of service configuration Majority had been established in response to the Peer Review requirements

Advantages of Locality SPC MDT Promoting increased integration Improved understanding of the function of various providers across an area Providing an educational opportunity Sharing of knowledge and expertise Review of complex patients Wider MDT opinion/clinical challenge

Advantages of Locality SPC MDT cont. Improved team working Support for difficult decisions Enabled regular AHP involvement

Challenges of the Locality MDT Inconsistent interpretation of referral criteria – inappropriate referrals Reluctance to refer - benefits not readily understood – low referrals Unconvinced of need or usefulness Inadequate IT and administration Practical requirements onerous Staff time and additional workload considered burdensome Effort outweighed benefit

Summary All services show commitment to multi- professional care Existence of SPC MDT in all units across all services Self- Assessment reports demonstrate two distinct interpretations of the SPC MDT Majority of organisations have measured against a local single service MDT

Summary cont. Majority of Locality MDTs have been established in response to the peer Review requirements Most Locality MDTs have been in existence a short period only and are yet to be evaluated

Contentious Measures Attendance at Advanced Communications National Training Programme The SPCMDT should produce a report at least annually on clinical trials The core team specific to specialist palliative care should include two consultants in palliative medicine

Emerging Themes I.T. Requirements Lack of Focus on Outcomes Cancer MDT Association and References Workforce Issues Core Aims of SPC Services Changes to the role of the Network

Recommendations 1. The report recommended that the following measures be removed or allow increased flexibility in the supporting evidence of compliance. Attendance at Advanced Communications Training Programme The SPC MDT should produce a report at least annually on clinical trials1

Recommendations cont. The core team specific to SPC should include two consultants in palliative medicine MDT agreement to Network 24hr telephone advice service and 7 day visiting service specifications

Recommendations cont. 2. SPC MDT This is central to SPC practice There needs to be greater consistency and shared understanding of the definition and model of practice

Recommendations cont. 3. Specialist Palliative Care Core Aims SPC Peer Review measures would benefit from a clearer statement of the core aims or principles of SPC practice. Suggested as The management of patient care to be agreed through a multi-professional approach, including team discussion prior to decision making

Recommendations cont. An integrated approach to care and robust system of communication between care settings Provision of an equitable out of hours service Management of complexity is also a defining characteristic of the SPC practitioner

Recommendations cont. 4. NHS Reforms The SPC Peer Review Measures need to be aligned with the new NHS framework and to recognise the position of the National Director for End of Life Care as an important point of reference

Recommendations cont. 5. The position of Voluntary Hospices Hospice participation should be encouraged but to acknowledge their limitations with regard to the required level of resource and capacity 6. Focus on Outcomes Revision of the SPC Peer Review Measures should adopt an outcome focused approach

Session 4: Review of the Core Principles

SPC Advisory Group Considerations The majority of clinicians support the concept of peer review and welcome the opportunity to demonstrate excellence in practice. The peer review process is also generally regarded as a constructive mechanism for service development. The report of Mid Staffordshire NHS Foundation Trust Public Inquiry (Robert Francis Jan 2013) pointed out that the creation of a caring culture would be greatly assisted if all those involved in the provision of healthcare are prepared to learn lessons from others and to offer up their own practices for peer review. The current lack of SPC service specification

SPC Advisory Group Recommendations Further revision of the measures Services agreement to Core Principles Maintain momentum for service development by encouraging teams to continue to self assess focussing on measures and statements that support the core principles Work with NCD for EOLC to support the development of service specification

Core Principles Specialist palliative care services are invited to agree to core principles that underpin the delivery of specialist palliative care services.

Core Principles 1. Receive care that is safe, effective and responsive delivered by a multi-professional team who are specialists in palliative care.

Core Principles 2. Experience care that is coordinated and integrated across all settings, with robust handover arrangements and communication between generalist and specialist professionals, involving them in decision making about their care.

Core Principles 3. Be confident of receiving an equitable specialist service appropriate to their needs both during working hours and out of hours.

Discussion of the Core Principles Group Work

Feedback on the core Principles Each table to feedback on each of the principles Completion of the core principles form

Session 5: Next steps

Cancer Peer Review Programme The Peer Review programme will work with the National Clinical Director for End Life Care The Peer Review Measures will be revised during 2013 in light of the evaluation and national policy SPC services will be able to self assessment against the core principles if they wish No External Verification will take place in November/December 2013.

Thank You Any Questions?