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A detailed health needs assessment (HNA) for end-of-life care (EoLC) services was led by public health in Leeds to inform a commissioning strategy. To answer the question: are we delivering the best possible EoLC services within the resources available? Mixed methods were used with three approaches: epidemiological, corporate and comparative. More people from deprived communities die in hospital. 18% of people who die each year are on a palliative care register, reflecting a lack of recognition and planning for EoLC given that 75% of people who die need EoLC. Over 100 staff, patients and carers were interviewed and over 200 staff returned questionnaires. Staff highlighted concerns about capacity of services; pressure on out-of-hospital care; problems at physical and electronic interfaces between services; suboptimal hospital discharge; need for earlier recognition of the EoL stage for patients. Patients and carers stressed the importance of communication, coordination and continuity of care; full involvement in care planning; honesty and support for the bereaved; an advocate for patients and families; accessible information; improved urgent care; integrated team working; pain relief, dignity and respect. Issues from comparator sites included the need for sustainable leadership for change, lack of interoperability between IT systems; building advance care planning into working culture; gaps in psychological services, bereavement and pastoral support; integration within all clinical areas; lack of district nurses; few investment opportunities; getting home care support right; concerns about 111; incentives for general practitioners to deliver EoLC; variability in service and the Liverpool Care Pathway controversy. Ethical approval was not sought as the HNA was undertaken as a service evaluation. Local policy is that ethical approval is not required for service evaluation.

Background Recognising that people are entering the last phase of illness isn't always straightforward, and having conversations about treatment aims and planning for future care is not easy. In light of this a Senior Clinician Development Programme was established, comprising 7 consultants in different specialties and a GP to give a community perspective, facilitated by 2 palliative medicine consultants. This ran for 18 months from October 2011. The following audit specifically looked at oncology, assessing if there was improvement in communication between secondary and primary care. Method All letters to GPs of patients over 18 with a Leeds postcode previously under the care of an oncologist and who died in January 2010 (n=79) and January 2014(n=82) were included. Patients whose treatment was curative and more than 10 years before their death were excluded if they died of an unrelated cause. The improvement plan implemented between the two audits involved an oncology consultant participating in the development programme working alongside a GP in an Action Learning Set and spending time with District Nurses to understand their roles. He then worked with colleagues to highlight the importance of communication with GPs, patients and carers. Results There was a statistically significant improvement in all desired characteristics of the letters between 2010 and 2014. This was most marked in recommendation to add the patient to the palliative care register. There was also a major improvement in documenting discussions with patients about the palliative nature of the disease and emphasis on quality of life. Conclusion This audit shows that educational initiatives with system change can alter consultants' behaviour. This was a sustained effect, as funding for the development programme finished 2 years before re-auditing. Whilst other factors may contribute, it does demonstrate that long term change in consultant behaviour is possible, particularly when initiated by their peers with insight into department specific issues.

To implement the National End of Life Care strategy and enable more people to express and achieve their preferences about care at the end of life, senior clinicians outside palliative medicine need to make it a routine part of their practice. However, it is acknowledged that recognising that people are entering the last phase of their illness is not always straightforward, and having conversations about aims of treatment and planning for future care may not be easy. In order to begin to address these challenges, funding was sought from the Yorkshire and the Humber Strategic Health Authority (SHA), and subsequently Health Education England, Yorkshire and the Humber (HEEYH), to pilot a development programme in 2 acute trusts. 2 palliative medicine consultants shared the trainer role at each site, supporting hospital consultants from a range of specialties, with a GP to give a community perspective. The programme involved individual clinicians identifying their own learning needs and specific issues for end-of-life care in their patients. The group met together monthly in action learning sets to discuss issues in a safe yet challenging environment. Following evaluation using a combination of training needs analyses, feedback questionnaires, audits and service evaluations, it was modified slightly and repiloted in 2 further trusts as ‘Rethinking Priorities’. This paper describes the programme and its outcomes, especially in relation to participants' learning, service development and leadership. It also highlights the challenges, including different learning styles, the concept of action learning, obtaining funding and dedicated time, and how to evaluate the effectiveness of a programme. Overall, it suggests that an educational initiative based on clinicians identifying their own learning needs, and using an action learning approach to explore issues with other colleagues, with the addition of some targeted sessions, can result in positive change in knowledge, behaviour and clinical practice.

ObjectivesTo understand individual prescribing and associated costs in patients managed with the Edinburgh Pain Assessment and management Tool (EPAT).MethodsThe EPAT study was a two-arm parallel group cluster randomised (1:1) trial, including 19 UK cancer centres. Study outcome assessments, including pain levels, analgesia and non-pharmacological and anaesthetic interventions, collected at baseline, 3–5 days and, if applicable, 7–10 days after admission. Costs calculated for inpatient length of stay (LoS), medications and complex pain interventions. Analysis accounted for the clustered nature of the trial design. In this post-hoc analysis, healthcare utilisation and costs are presented descriptively.Participants10 centres randomised to EPAT (487 patients) and 9 (449 patients) to usual care (UC).Main outcome measuresPharmacological and non-pharmacological management, complex pain interventions, length of hospital stay and costs related to these outcomes.ResultsThe mean per patient hospital cost was £3866 with EPAT and £4194 with UC, reflecting a mean LoS of 2.9 days and 3.1 days, respectively. Costs were lower for non-opioids, Non-steroidal anti-inflammatories (NSAIDs) and opioids but slightly higher for adjuvants with EPAT than with UC. The mean per-patient opioid costs were £17.90 (EPAT) and £25.80 (UC). Mean per patient costs of all medication were £36 (EPAT) and £40 (UC).Complex pain intervention costs were £117 with EPAT per patient and £90 with UC. Overall mean cost per patient was £4018.3 (95% CI 3698.9 to 4337.8) with EPAT and £4323.8 (95% CI 4060.0 to 4587.7) with UC.ConclusionsEPAT facilitated personalised medicine and may result in less opioids, more specific treatments, improved pain outcomes and cost savings.

Aim Polypharmacy is common in palliative care and is associated with an increased risk of potentially harmful drug interactions. In order to identify common interactions and explore the SPC approach to polypharmacy we surveyed hospital inpatients receiving input from an SPC advisory service. Methodology The notes and drug charts of 50 consecutive patients referred to the SPC team between May and August 2012 were retrospectively reviewed. Potential interactions were identified and classified according to their clinical significance as minor, moderate or major using the website http://www.drugs.com/ Results The median number(range) of medications per patient at the time of initial assessment was 12 (5-23). In total, there were 628 potential interactions, 53 major, 505 moderate and 70 minor. Potential interactions were seen in 90% of patients and 62% had a major potential interaction. The median number (range) of major, moderate, and total potential interactions per patient was 1 (0-5), 8 (0-28), and 11 (0-32) respectively. There was a positive correlation between the number of medications and the number of potential interactions (p<0.0001). Common interactions in the major group were: QT interval prolongation (26%), enhanced serotonergic activity (18%), cytochrome P450 inhibition (16%), increased bleeding risk (12%), and reduced seizure threshold (5%). Common drugs implicated include haloperidol, cyclizine, levomepromazine, metoclopramide, opioids, benzodiazepines and ondansetron. Although at risk, none of the patients included in the study had evidence of major or moderate adverse events due to drug interactions. In only 14% (5/37) of patients taking potentially unhelpful medication, like antihypertensive, antiplatelet, and cholesterol lowering agents had SPC advised the medicines to be stopped. Conclusion This study demonstrates that majority of acute hospital inpatients receiving SPC are at risk of clinically significant drug interaction although the clinical importance is less clear. The study highlights the need for SPC teams to be vigilant for common interactions and to minimise polypharmacy by stopping medications of little benefit.

Background End-of-life care is essential to medical practice. Encouraging behavioural change in senior doctors who are trained to cure, and may see death as failure, is crucial to improving care and may benefit from novel approaches. Action Learning is a recognised tenet of management development but is rarely used within the education and development of doctors. Aim To evaluate the role of Action Learning as part of an end-of-life care development programme, bringing consultant colleagues together to encourage reflective practice, surface and resolve problems, share and consolidate learning. Method This SHA funded pilot involved 2 trusts, each including 6 or 7 consultants and a GP. Both groups were facilitated by 2 consultants in palliative medicine, meeting monthly for 18 months. The programme was evaluated using training needs analyses at the beginning, middle and end, participant questionnaires asking for anonymous feedback and audits of practice and service developments. The 4 facilitators met together 6 weekly with a consultant in Organisational Development from the SHA in their own Action Learning Set and completed reflective diaries. Results The use of action learning was highly valued by participants, many of whom had never previously met nor encountered this method of learning. The group provided an opportunity to discuss issues and \"try out\" difficult conversations in a challenging yet safe environment. Sets were very well attended, and regular meetings provided the impetus to complete agreed tasks. Some facilitators initially struggled with the concept, but confidence grew during the learning process and as genuine peer learning enabled participants to help each other. Discussion This pilot supported the idea that action learning can address learning needs and support behavioural change in senior doctors. This approach could be considered to address other areas within health care where organisational change is needed.

Aim To explore who responded to the Leeds Teaching Hospitals Trust (LTHT) bereaved family survey. Background The LTHT Specialist Palliative Care Team (SPCT) locally adapted a bereavement survey for families (Worcestershire Acute Hospital NHS Trust, 2012). This was developed to give bereaved relatives the opportunity to provide feedback on their experience of the care their relative received at the end of life in the acute setting. The LTHT SPCT Bereaved Carers Service User (BCSU) group contributed to the design of the survey at the outset. Method Over a 10 week period, March to May 2013, the survey was given to bereaved relatives of adult patients when they collected medical cause of death certificates from the bereavement office. Patients who died in A&E were excluded. Results There were 146 respondents (response rate 23%).Trends identified from the demographics were that respondents tended to be from children of the deceased (son 23%, daughter 40%) and most responses came from older peoples' services (27%). The most prevalent age of death was 86-90. There was a low response rate from oncology wards (1%). Results were presented to the BCSU group. Conclusion The highest response was from daughters of older adults. Further exploration is needed into the low response rate from oncology, and spouses of the deceased. The timing of the survey may have influenced the group of respondents. It may have been too early on in their bereavement. Delaying the time that the survey is sent to bereaved relatives/carers may help increase the response rate. Opinions from the BCSU group and experience from other hospital trusts will be considered to inform changes to the next survey to gain feedback from a more representative population and improve the care patients receive at the end of life.