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

3. = Community Hospitals
24/03/2018
Martin Leiper 3

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

5. Promise 1 Effective and safe clinical care
Action 20
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)

6. 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

7. 4 beds within GP ward

8. Architect’s Impression Cornhill Macmillan Centre, PRI
Living and Dying Well rightly focuses on generalist palliative care, but it lays a firm foundation for the evolving model of Specialist Palliative Services in Perth and Kinross.
This Centre as the hub must provide Specialist Palliative Services and has the ability to become a Centre of Excellence for P & K and NHS Tayside along side Roxburghe House and Angus Specialist Palliative Services.

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

10. Promise 3 Continuity, Coordination and comprehensiveness
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)

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

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

13. Action 8
“DNAR form”

14. 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

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

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

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

18. PCS Demonstration 18 18

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

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

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

23. TAYSIDE Angus Specialist Palliative Care Resources 400,000
Stracathro Hosp
Mac Nurses
Mac Day Care/clinic
Angus CHP
Marie Curie Service
Specialist Palliative Care Resources
TAYSIDE
400,000
Forfar Strathmore Hospice, Whitehills
100 km
Dundee
Ninewells Cancer Centre
Hosp pal care team
-Roxburghe House 25 beds
Mac Nurses
Mac Day Care/clinic
Dundee CHP
Marie Curie Service
Perth
Perth Royal Infirmary
Hosp team
Perth & Kinross CHP
Mac Nurses
Mac House Day Care/clinic
Marie Curie Service
Crossroads
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24. Roxburghe House - 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
24/03/2018
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25. Angus CHP Stracathro Hosp Mac Nurses Mac Day Care/clinic
- Arbroath clinic
Marie Curie Service
Strathmore Hospice
24/03/2018
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