GWENT PALLIATIVE CARE STRATEGY
2015- 2018
ACHIEVING
EXCELLENCE
TOGETHER
Contents
No
1
Foreword
Item
2
Introduction
3
How we developed the strategy
4
Vision and values
5
The communities we serve
6
Current service provision & how we wish to design
future services
7
Our priorities
Aim 1 To support living and dying well: To detect and
identify patients with palliative care needs so timely
intervention can be offered
Aim 2 To support living and dying well: Facilitation of
effective advance care planning throughout the patients’
illness with a focus on end of life
Aim 3 To promote well-organised and co-ordinated
care: Facilitating an integrated, seamless service across
boundaries and settings
Aim 4 To support the family and carers of those who
are receiving palliative care, who are dying or who have
recently died, throughout the end of life care process
and in to bereavement
Aim 5 To ensure an adequately trained workforce who
are educated to deliver excellence, who continuously
improve
patient/service
user
experience
and
demonstrate effective leadership
Aim 6 To promote choice and facilitate Preferred Place
of Care (PPC) / Preferred Place of Death (PPD)
Aim 7 To demonstrate a high quality service through
measurable outcomes and compliance with quality
standards
Page 2 of 42
Page
Aim 8 To engage in the research agenda and to
develop the skills and competencies to generate as well
as implement evidence in practice
8
Knowing we are successful
9
Making it happen
Page 3 of 42
Foreword
“How People die remains in the memory of those who live
on” (Dame Cicely Saunders)
We are proud to present the first Gwent Palliative Care Strategy
which has been developed in partnership by the specialist palliative
care providers in Gwent. This is the first time we have worked
together collaboratively to articulate how we wish to see palliative
care services develop. All the partnership organisations will seek to
develop and maintain palliative and end of life care services of
consistent high quality that reflects the vision outlined in this
strategy.
Patients, their families and carers are at the heart of everything we
do and it is now important that this draft document is shared as
widely as possible across Gwent to ensure that this strategy meets
the needs of the people who use our services.
This is an ambitious strategy, but we believe it can be achieved with
the collective drive of all the organisations involved.
ABUHB
Hospice of the Valleys
Marie Curie Cancer Care
St David’s Hospice Care
Macmillan Cancer Support
Page 4 of 42
Introduction:
This document sets out the strategic direction for developing,
improving and delivering palliative care and end of life services
using a partnership approach in Gwent.
“Palliative Care is the active holistic care of patients with
advanced progressive illness. Management of pain and other
symptoms and provision of psychological, social and spiritual
support is paramount. The goal of palliative care is
achievement of the best quality of life for patients and their
families.”
NICE 2004
Palliative care is provided by all healthcare professionals to those
who have a limited life expectancy throughout their disease
trajectory. Where more intensive, specialised care and treatment is
required, this is provided by the multi-disciplinary Specialist
Palliative Care Teams.
The definition of End of Life Care is, however, less clear; it is often
used to describe care in the last year, months, days or even hours
of life. For the purpose of this Strategy we use End of Life Care as
a general term to encompass preparation for and management of
care at the end of life. It therefore applies to those with increasing
frailty, co-morbidities or advanced old age as well as those with a
life-threatening illness. These will be individuals who are believed
to be in their last year of life. The term ‘last days of life’ is used to
specify the final care of the dying.
We have described how we developed this strategy in partnership in
preparation for going out to public consultation and listening to our
patients and their carers. We envisage that there will be a number
of changes following this process.
We have described our vision and values for this strategy.
This strategy sets out current service provision across Gwent,
provided by a range of partner organisations and highlights the
vision and objectives identified and agreed by partners for
continued development of palliative care services. It also identifies
areas where improvements can be made to improve the delivery of
care to this group of patients and their families.
The range of partners who have contributed to the development of
this strategy include:

Aneurin Bevan University Health Board
Page 5 of 42
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
Hospice of the Valleys
Macmillan Cancer Support
Marie Curie Cancer Care
St David’s Hospice Care
Engagement of all partner organisations has been fundamental to
the development of this document and consultation across service
areas and disciplines has been undertaken wherever possible.
However the strategy group recognises the need for further
engagement of colleagues across all groups providing care to
palliative care patients for the effective delivery of the strategy and
its underpinning action plans.
The aim is to build on work that is already happening within all of
the above organisations which echoes the priorities outlined by the
All Wales End of Life Board.
This strategy consolidates and
proposes a programme that will embrace partnership working to
enable and enhance the provision of palliative care services across
Gwent.
There is a genuine commitment to continuously improve standards
of care and facilitate a supportive environment that enables health
care professionals to develop their skills to enhance the patient
experience.
Page 6 of 42
How we developed the strategy:
This strategy has been developed against the backdrop of the End
of Life Care delivery plan ‘Together for Health – Delivering End of
Life Care’ published in April 2013 by the Welsh Government. The
strategy group was developed out of a collaborative desire to
enhance the palliative care services in Gwent. It was acknowledged
that in order for it to be effective, a partnership approach was
needed. Each organisation has engaged and committed to this
process. The group has met on a monthly basis with the aim of
making this a meaningful working document. The eight strategic
aims identified within the strategy have been mapped against the
six delivery themes from the End of Life Care delivery plan. Each
aim has a detailed work stream which a member of the group has
taken the lead. The performance measures outlined in the strategy
will inform annual progress reports which will feed into the Health
Board’s End of Life Delivery Plans.
Page 7 of 42
Vision & values:
The integrated vision for palliative care services embraces the
concept of partnership working between statutory, voluntary and
independent sector agencies to deliver a seamless service that
optimises patients’ experiences and outcomes. It aims to ensure
that all patients with palliative care / end of life needs and their
families and carers receive a high quality, personal service which is
safe, dignified and respectful. The priorities identified to deliver our
vision are:

To support living and dying well: To detect and identify
patients with palliative care needs so timely intervention can
be offered

To support living and dying well: Facilitation of effective
advance care planning throughout the patient’s illness with a
focus on end of life care.

To promote well-organised and co-ordinated care: Facilitating
an integrated, seamless service across boundaries and
settings.

To support the family and carers of those who are receiving
palliative care, who are dying or have recently died,
throughout the end of life care process and into bereavement.

To ensure an adequately trained workforce who are educated
to deliver excellence, continuously improve patient and carer
experience and demonstrate effective leadership.

To promote choice and facilitate Preferred Place of Care (PPC)
/ Preferred Place of Death (PPD).

To demonstrate a high quality service through measurable
outcomes and compliance with quality standards.

To engage in the research agenda and to develop the skills
and competencies to generate as well as implement evidence
in practice.
Our vision will be achieved through a delivery plan which uses a set
of specific, measurable, objectives. Key to achieving the Strategic
Framework will be collaboration with all organisations working to
improve services for patients.
Page 8 of 42
The communities we serve – the strategic context:
Aneurin Bevan University Health Board is responsible for the
delivery of health and well-being services for people who live in,
work in, or visit Gwent. The Health Board seeks to protect and
improve health and well-being by reducing inequalities, and
ensuring that everyone has equal access to high quality services.
In order to achieve this all strategies and plans developed within
Aneurin Bevan University Health Board (including those for specific
staff groups such as nurses and midwives) need to be cognisant of
the local and national health care context, as well as the key
political and economic drivers for change. Partnership working
across the health and social care community including the voluntary
organisations is fundamental in the delivery of these services.
This strategy has been shaped and informed by the following
stakeholders who share the same vision:





Aneurin Bevan University Health Board
1. Primary care
2. Secondary Care
3. Specialist palliative care – adult and paediatric
4. Pharmacy
Hospice of the Valleys
St Davids Hospice care
Marie Curie Cancer Care
Macmillan Cancer Support
Our shared vision aligns with the broad strategic direction for
palliative and end of life care services in Wales. This direction is
set out in various documents including:
 NICE Guidance
 ‘National Standards for Specialist Palliative Care Cancer
Services 2005’
 ‘Together for Health – Delivering End of Life Care’ (2013)
 ‘Palliative Care Planning Group Wales’ (2008)
 ‘Implementation of Palliative Care Report’ (2008)
The aims of the above documents which in summary are:


People who can be identified as approaching the end of their
life should be given the opportunity to express their priorities
and preferences as part of advance care planning;
Care should be holistic and provided by a multi-disciplinary
team, which assesses and seeks to meet the individual’s
physical, social, psychological and spiritual wellbeing needs
wherever possible;
Page 9 of 42
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24-hour access to specialist support should be available.
Care should be provided within the most appropriate setting,
whether this be an inpatient setting or in the community, and
patients should be facilitated to die within the place of their
choice wherever possible
Palliative and end of life care provision should be linked
closely with other cancer care provision where appropriate,
and also address the needs of patients with non cancer
diagnoses;
All care provided must meet quality standards and seek to
meet or manage patient/family expectations which need to be
realistic and achievable.
Access to detailed information and support is of great
importance to patients and their carers throughout illness and
bereavement.
Page 10 of 42
Gwent Health Needs Assessment: Palliative Care Needs
Aneurin Bevan Health Board Specialist Palliative Care team data for
the period April to November 2013 indicates that the majority of
patients in receipt of specialist palliative care services from the
Health Board (76.2%) have a cancer diagnosis.
Amongst the
remaining 23.8% of patients, almost 1/3 of patients have a
heart/circulatory or respiratory condition.
This correlates with data from the Office of National Statistics which
indicates that the leading causes of premature mortality are cancers
and circulatory diseases.
Leading causes of premature mortality in ABHB, 1998-2009
(ONS)
Place of Death
The table below identifies deaths by place of occurrence. Aneurin
Bevan Health Board’s deaths in hospital (61.7%) were marginally
above the Wales average of 60.1% and third highest in Wales, in
comparison with the remaining 6 Health Boards. Conversely, the
percentage of deaths at home was 22.6%, placing the Aneurin
Bevan University Health Board at the second highest in Wales. This
reflects the use of a robust hospice at home service and the
successful Fast Track Scheme in place in the Aneurin Bevan
University Health Board area. The scheme enables the process of
assessment, quality assurance, funding approval and organisation
of care at home to be undertaken within 48 hours for individuals
entering the terminal phase of their illness and 6 hours for
individuals in the last days of life (less than 7 days) who wish to be
cared for at home.
Page 11 of 42
Percentage of Deaths by area of usual residence, by place of occurrence, 2010 (Source: ONS)
Hospitals1
At Home
Care Homes2
Non-NHS
Hospices
Elsewhere
Cwm Taf
Abertawe Bro Morgannwg
Aneurin Bevan
Cardiff and Vale
68.6%
62.0%
61.7%
60.3%
20.2%
21.8%
22.6%
18.3%
8.4%
14.0%
11.9%
11.9%
0.3%
0.0%
1.9%
7.8%
2.6%
2.2%
2.0%
1.9%
Total Wales
60.1%
21.1%
13.8%
2.8%
2.2%
Betsi Cadwaladr
Powys Teaching
Hywel Dda
57.4%
56.5%
55.5%
19.7%
21.3%
23.9%
16.2%
16.4%
16.9%
4.7%
2.4%
1.4%
2.0%
3.4%
2.3%
Total England
53.9%
20.8%
18.7%
4.8%
1.8%
Health Board Area
1 NHS and Non-NHS Hospitals (accute or community not psychiatric) and NHS hospices.
2 Care Homes (Includes Local Authority and private residential nursing homes) and other communal establishments.
The relatively high number
the limited availability of
population as noted in the
Services Inspectorate for
specialist hospice beds.
of deaths in hospital may in part reflect
nursing home beds per 1,000 elderly
data table below from Care and Social
Wales, and the limited availability of
Care Homes places by Health Board residency, 2011 (Source
CSSIW)
Places per Variation Variation
Health
1,000
from
from
Board
Pop aged
elderly
Wales
Wales
Area
Places
> 65
population Average
Median
Abertawe
Bro
Morgannwg
3,960
93,082
43
1
2.4
Aneurin
Bevan
3,528
100,673
35
-7
-5.6
Betsi
Cadwalladr
6,774
136,795
50
8
9.4
Cardiff &
Vale
2,764
67,706
41
-1
0.4
Cwm Taf
1,975
49,696
40
-2
-0.6
Hywel Dda
3,275
79,792
41
-1
0.4
Powys
1,041
30,371
34
-8
-6.6
Average 42
Median
Total
23,317 558,115
40.6
Page 12 of 42
Current service provision & how we wish to design future
services
Aneurin Bevan Health Board
Aneurin Bevan University Health Board delivers both non-specialist
and specialist palliative care services to approximately 639,000
people in Gwent and South Powys.
Non – Specialist Palliative Care:
The majority of non-specialist palliative care is provided by generic
staff eg General practitioners and District nurses in primary care,
whilst in secondary care it is lead by the medical team and
associated nursing team. Additional services provided by allied
health care professionals, pharmacists, continuing health care and
social services all support the primary teams.
Specialist Palliative Care:
ABUHB provides a hospital specialist palliative care service across
three General Hospitals: the Royal Gwent Hospital, Nevill Hall
Hospital and Ysbyty Ystrad Fawr. The specialist palliative care team
comprises of:
 A team of palliative medicine consultants, who support both
primary and secondary care.
 A nursing team which includes a Lead Nurse, Clinical Nurse
Specialists and Health Care Support Workers.
 Part time Macmillan GP Facilitators to support primary care
and community services
 A Macmillan Palliative Care Pharmacist to provide prescribing
support to primary care.
 A Macmillan Occupational Therapist who supports patients in
the north of Gwent
Community Specialist Palliative Care
Aneurin Bevan University Health Board (ABUHB) works in
partnership with two independent hospices, Marie Curie and other
agencies.
Independent hospices:
St David’s Hospice Care
St David’s Hospice Care provides services across Monmouthshire,
Torfaen, Caerphilly, Newport, and Mid and South Powys. The
services provided are:
Page 13 of 42


Clinical Nurse Specialists (CNS) who work in the community,
are GP allocated and also cover Chepstow, Monnow Vale and
County Hospital
Family Support Team comprising of Welfare Rights advice,
Social Work and carers services

4 Day Hospices offering a range of services from rehabilitation
through to end of life support

24-hour on-call service by CNS

Hospice at Home service which provides 24 hours 7 day a
week care if needed

Complementary therapy across all settings (community, inpatient and day hospice)

10 bedded in-patient hospice beds (medical cover via ABUHB)

Unicorn service for children of patients (includes Blaenau
Gwent) facing a life limiting illness

Support and advice to care homes

Bereavement service
Hospice of the Valleys
Hospice of the Valleys provide specialist palliative care via a wide
multi disciplinary team throughout Blaenau Gwent.

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


Clinical Nurse Specialists in the community, also covering
Ysbyty Aneurin Bevan and Ysbyty Tri Chwm
24-hour on-call service and 7/7 visiting by CNS
Day hospice services in two community venues offering a
range of services in a context of social interaction, support
and friendship as well as specific symptom management
advice
such
as
the
breathlessness
and
fatigue
management programmes.
Volunteer befrienders
Dementia project
Complementary therapies, across all care settings
Support and advice to care homes
Social Work, Welfare Rights Advice and Carer Support
Hospice at Home
Physiotherapy
Page 14 of 42

Bereavement service
Marie Curie Cancer Care
Marie Curie Cancer Care provides hands on palliative care provision
in all areas of ABUHB which supplement other specialist hospice at
home services.
Service Delivery Challenges
Aneurin Bevan University Health Board has been working with its
third sector specialist palliative care providers to develop this
integrated Gwent Palliative Care Strategy to address the needs of
Gwent residents.
The current key challenge is the need for all specialist palliative care
services to work in an integrated way to meet and manage the
needs and expectations of patients their families and carers
realistically with achievable, measurable outcomes.
The current financial context presents a considerable challenge to
all public and third sector organisations providing health and social
care services in seeking to sustain services at their existing level
and to drive forward service development.
The strategy group acknowledges the need to work within the
current resources, and will seek efficiencies within service delivery
alongside exhausting all opportunities for funding mechanisms for
service development. The need to develop sustainability strategies
for projects with finite funding streams is also vital.
The key priorities have been agreed in partnership across Gwent.
The strategy will enhance and support ongoing developments to
improve palliative care services across Gwent.
Key issues to be addressed
The key issues with the current provision of palliative and end of life
care in Gwent, which this Strategy seeks to address are:


Care Planning - the need for more Advance Care Planning for
those who can be identified as approaching the end of life;
Care Co-ordination - the need for improved communication
and co-ordination of care across the whole care pathway
including all care settings; improved implementation and
reporting tools highlighting priorities for Last Days of Life.
Page 15 of 42
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Care environments – enabling more patients to be cared for
at their chosen preferred place of care overcoming barriers
and managing associated risks.
Place of death - enabling more patients to die at their chosen
preferred place of death overcoming barriers and managing
associated risks.
Access – increasing the proportion of patients with nonmalignant disease cared for by the Specialist Palliative Care
Team; ensuring 24/7 access to specialist care and support
when needed;
Quality standards – ensuring compliance with quality and
clinical standards and performance targets.
Training – the need to identify and address staff training
needs to improve skills in planning for and delivering End of
Life Care.
Engagement in the Research and development agenda
Page 16 of 42
STRATEGIC AIM 1
To support living and dying well: To detect and identify
patients with palliative care needs so timely intervention
can be offered
In order to achieve this element of our vision, it is important for all
settings and Primary Care Services in particular to have a
mechanism for identifying those people who may be nearing the
end of their life, and robust processes for communicating and coordinating their care plans.
Approximately 1% people on a GP list will die each year, including a
quarter who will die from cancer; a third from organ failure due to
chronic illness; a third from frailty, dementia or multiple morbidity
and a twelfth will die suddenly. The main triggers for identifying
patients who may be nearing the end of their life and who may have
palliative care needs are prognostic guidance, needs-based coding
and intuitive consideration of whether it would be surprising if the
patient were to die in the next 12 months. Including these patients
on a Palliative Care Register provides a mechanism for recording
and monitoring their needs, and the Register provides a tool to
facilitate team discussions on the individual patients’ changing
needs.
The use of a Palliative Care Register is promoted as good practice
through the Quality & Outcomes Framework (QOF). The QOF aims
to promote and reward the provision of quality care within General
Practice. Participation is encouraged but voluntary. The current QOF
includes the following clinical indicators for Palliative Care:
 PC3 - The practice has a complete register available of all
patients in need of palliative care/support irrespective of age
 PC2 - The practice has regular (at least 3 monthly)
multidisciplinary case review meetings where all patients on
the palliative care register are discussed.
From April 2014, End of Life Care will be one of three National
Priorities within the GP Cluster Network Development Domain. The
2014/15 contract will support the review of the delivery of care at
the end of life through case reflection to identify service
development issues, barriers to the delivery of care and examples
of good practice. Practices will develop plans based on population
need.
Page 17 of 42
Macmillan time limited funding funds 2 Macmillan GP Facilitators to
assess and improve the engagement of primary care in palliative
and end of life care.
WHAT HAS ALREADY BEEN ACHIEVED?
 In March 2012, 36 GP practices reported MDT meeting
frequency as follows – 8 monthly, 2 bi-monthly, 24 quarterly
 As of April 2013, 50 GP practices reported their MDT meeting
frequency as follows – 23 monthly, 6 bi-monthly, 21
quarterly demonstrating a change in practise.
 March 2012: 36 practices reported the number of patient on
their Palliative Care Register (PCR) prior to death. The %
across all 36 practices was 28.2%
 April 2013: 34/43 practices reported % of patients of PCR
prior to death as >25%. Range of reported figures was 1470% for the 43 practices.
 ABUHB has designed an electronic template for use by
practices to enter information from MDT meetings
consistently, and has produced and disseminated guidance on
conducting MDT meetings
 Quality Performance process for End of life care compulsory
for 2 years, focussing on patient identification and carrying
out key tasks – special notes, PPC, DNACPR, assessment of
needs of care home residents
VISION FOR THE FUTURE:
 All practices holding regular, monthly functional MDT
meetings as per QP pathway.
 All practices reporting 5 patients on PCR prior to death and
exceeding AQF 25% target (annual reporting).
 Improved read coding of key tasks around palliative care MDT
meetings (DNACPR, ACP, PPC etc) by production and use of
electronic templates and standardised readcodes.
 Increased inclusion of patients with non malignant disease on
PCR.
 Easily accessible resources and information to support GPs
(Web page etc)
 Secondary Care services are integrally involved in the
identification of patients who would benefit from supportive
palliative care at an early stage.
Page 18 of 42
Key Deliverables




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

Performance Measures
Ongoing
palliative
care
education
programme for GPs.
Support the implementation of changes to
the GMS contract pertaining to End of Life
Care.
Produce standardised read codes and
electronic templates for 2 main GP clinical
systems (EMIS and Vision).
Maintain and update GP palliative care web
pages.
Encourage and promote the involvement
of Community Nurses (DN’s) at MDT
meetings.
Education for Specialist community nurses
(e.g. heart failure, respiratory), district
nurses, hospital specialists, Community
Resource
Teams/Frailty,
nursing
and
residential home staff. The aim of the
education would be to facilitate them to
identify and support patients in need of
palliative care, and encourage them to
engage with GP practices through the
palliative care MDT where appropriate.
Raise awareness of need to identify
patients in last year of life within secondary
care. Provide training and tools/resources
to hospital teams to facilitate this.
Review data collected, and local
development plans produced as part of GP
Cluster Network Development Domain
Page 19 of 42
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QP reports.
Repeat Macmillan GPF
survey.
Practices
to
report
number of patients on
PCR prior to death and
frequency
of
MDT
meetings.
Potential for research
project
looking
at
frequency
of
MDT
meetings and % of
patients on PCR prior to
death;
or
qualitative
study
looking
at
functionality
and
outcomes of palliative
care MDT meetings.
Evidence of identification
of patients by secondary
care
teams
through
analysis
of
communications
with
GPs/discharge
summaries.
NCN End of Life Priority
reports/Local
Development Plans
STRATEGIC AIM 2
To support living and dying well: Facilitation of effective
advance care planning throughout the patients’ illness with a
focus on end of life care.
Once identified, it is our aim to ensure patients are offered the
opportunity to express their priorities and preferences in respect to
their end of life care through Advance Care Planning, and that these
wishes are made known to and respected by all care givers in all
care settings, and family members. For those living in a care home,
it is essential that this care planning is undertaken in partnership
with the care providers.
Co-ordination of the planning and delivery of care relies on excellent
communication across the care pathway by all care professionals
involved, including GPs, the District Nursing service, hospital staff,
chronic conditions specialists and the Specialist Palliative Care Team
both in and out of hours to ensure the patient’s expressed needs
and Advance Care Plan are acknowledged and adhered to at all
times. Good IT systems are essential to support this.
There are numerous examples of documents which are being used
for recording advance care plans across Wales, and consideration
has been given to the need to standardise the documentation.
However, the priority is to promote the use of advance care
planning in all health and social care settings and to ensure that all
professionals are aware of the key components and decisions that
should be included in conversations relating to advance care
planning, regardless of the type of documentation used.
Advance Care Planning should be initiated or explored when it is
recognised that the patient has a life limiting illness. Advance care
planning should be appropriately commenced in the patient’s setting
– this could be in primary care, tertiary care, wherever the patient
is.
Agreed and documented advance care plans need to be
disseminated appropriately.
The opportunity to document an
advance care plan during an unplanned secondary care admission
needs to be recognised and exploited to avoid further unwanted
admissions and facilitate preferred place of care / death.
The challenge is to ensure that there is appropriate communication
of the plan and there needs to be an acknowledgement that
advance care planning is a dynamic process rather than a one off
discussion, especially as patients’ wishes may change over time.
Page 20 of 42
WHAT HAS ALREADY BEEN ACHIEVED?
Considerable work has been undertaken across the health board to
promote the importance of Advance Care Planning (ACP).

Currently, the main aspects of advance care planning
(documentation of preferred place of death, recording of
DNACPR orders) are carried out by a variety of professionals.
The information is recorded using different documentation by
individual organisations.
Hospice of the Valleys and St
David’s Hospice Care both have their own ACP documentation.
ABUHB has produced an ACP summary and communications
document. Further ACP documents are available on the All
Wales Palliative Care website along with guidance on their
use.

ACP has been introduced to Nursing Homes through education
provided by Hospice of the Valleys, St David’s Hospice Care,
ABUHB Complex Care and Palliative Care Services.

ACP issues are routinely discussed at primary care teams’
palliative care meetings.

Currently the main method of communicating an advanced
care plan is via the use of special notes to Out of Hours. There
is no standardised method of dissemination of ACP documents
or decisions between primary care, secondary care and
community services.

CANISC has a dedicated ACP section but this is only accessible
to specialist palliative care. General Practitioners have been
supplied with read-coding guides and templates for recording
ACP information.
VISION FOR THE FUTURE
 All patients approaching End of Life are offered the
opportunity and support to discuss and document ACP by the
multidisciplinary team (MDT). The MDT will have the skills and
confidence to support patients through the ACP process.

There is a consistent approach to the delivery of ACP across
Gwent and all organisations.

ACP wishes are recorded using appropriate documentation
that is suitable for the individual’s needs.

A clear mechanism is developed to facilitate the sharing of
information with all relevant parties.
Page 21 of 42


The information is easily accessible to all relevant
professionals regardless of the IT systems used.
There are mechanisms in place to highlight the existence of
the ACP and to review / update whenever there is contact
made with the patient.
Key Deliverables

Performance Measures
Identify named leads in both
Primary Care, Secondary Care
and Specialist Palliative Care to
promote Advance Care planning.

Audit of CANISC data.

Audit of OOH data.

Evaluate / review of primary
care QP data and GP survey
results to obtain GP specific
data regarding ACP.

Establish current level of ACP
recording
through
audit
of
CANISC across all providers.

Compare and evaluate existing
training and education initiatives
regarding ACP.

Evaluate / review education
programmes
/
activity
regarding ACP.

Agree
training
strategy

Review of ACP usage and
processes in Care Homes.

Agree methods of documentation
and
mechanism
for
sharing
information.

Promote the philosophy of ACP to
all relevant professionals across
all settings.

Investigate
strategies
and
solutions for communicating and
sharing ACP
/
education
Page 22 of 42
STRATEGIC AIM 3
To promote well-organised and co-ordinated care:
Facilitating an integrated, seamless service across
boundaries and settings.
The NICE ‘Quality Standard for end of life care for adults’ (2011)
states that care for people approaching the end of life must be
consistent and co-ordinated across all relevant settings and services
at any time of day or night, and delivered by practitioners who are
aware of the person’s current medical condition, care plan and
preferences.
It is therefore crucial that there are robust
mechanisms for documenting and sharing this information across
the patient’s care pathway, so that the person’s care plan does not
breakdown due to lack of communication.
WHAT HAS ALREADY BEEN ACHIEVED?










Generic services and specialist palliative care services are
available 7 days a week, with access to specialist advice on a
24-hour basis, to ensure responsiveness to the patient’s
needs in adult services. However services within paediatrics
are more limited.
Each organisation has information packs with appropriate
information and contact numbers.
Processes in place for hospital specialist palliative care team
to access equipment such as hospital beds for use in a
patient’s home 7 days a week. This is variable in the
community
Fast track discharge process in place
Provision of Just in case boxes to maximise access to
symptom control and facilitate death in preferred place of care
are accessible in most but not all areas. No access in Blaenau
Gwent from Brynmawr South.
Well established, responsive hospice at home service. Further
hospice at home provision being introduced in Blaenau Gwent.
Special notes for Out of Hours services – variable usage /
access
Regular palliative care MDT’s are held both in primary and
secondary care to promote communication and joint decision
making re patients’ care plans.
Canisc information system providing a shared system for
specialist palliative care team. This information system is not
accessible to the generic workforce.
Palliative medicine consultant support for hospital and
community palliative care teams
Page 23 of 42


Community Resource Teams support by expediting discharge
and preventing admission – variable models and referral
criteria across the boroughs
Established partnership working between Third Sector
community specialist palliative care and statutory services.
VISION FOR THE FUTURE
 Clarity on process of referral to Frailty services in each area to
promote equitable, seamless care across all settings
 To expand access to Canisc for primary and secondary care
 To have access to IT systems that facilitate the sharing of
communication promoting seamless care
 Increase the use of and sharing of palliative care special notes
to GP OOHs with reciprocal systems to feedback to specialist
palliative care services.
 To improve transition from paediatric services to adult
services
 To ensure continuity of service provision around the clock in
all boroughs.
 Develop IT systems that support secure remote access to
patient information for community services.
Key Deliverables




Performance Measures
Engage with Community
Resource Teams to clarify
role with palliative care
patients across Gwent
exploring ways to promote
equity and seamless care
Engage with paediatric
services to explore the
development of a
transition pathway
Identify any variances in
service provision across
Gwent
To explore the expansion
of Canisc with the IT leads
from PCIG








Page 24 of 42
Audit of use of special
notes
Audit of the use of the just
in case boxes
Recording of palliative care
MDTs on Canisc
Hospice at home outcomes
An agreed pathway for
transition of care
Data on 7/7 working
Data on fast track process
Review of any incidents /
complaints related to
communication leading to a
breakdown in seamless
care
STRATEGIC AIM 4
To support the family and carers of those who are
receiving palliative care, who are dying or have recently
died, throughout the end of life care process and in to
bereavement
The experience of family, friends and carers closely connected with
a person who is approaching the end of their life, and in
bereavement can be emotional, stressful and physically and
mentally exhausting.
Although carers may not view their crucial role as burdensome, it
often gives rise to psychological, social and practical support needs
which can go unacknowledged and unmet. These needs will differ
between individuals and at different points along the patient
pathway.
Such needs may include:
 Information – e.g. about the patient’s condition, treatment,
likely symptoms to expect as the illness progresses, what the
carer can do to help; contact list of key healthcare
professionals; directory of available support services
 Practical support – e.g. with transport, home help,
equipment,financial matters
 Respite provision
 Emotional support –e.g. counselling or support groups
 Bereavement support – e.g. bereavement counselling for
those who need extra support in dealing with their grief
Health and social care services have a duty to support those who
are caring for loved ones as they approach the end of their life. All
carers are entitled to an holistic assessment of their support needs,
and access to appropriate support and / or advice. Under the
Carers Strategies (Wales) Measure 2010, the Health Board with its
local authority partners has a duty to develop and implement an
Information Strategy for Carers.
NICE guidelines recommend the following should be offered to
families and carers:

Family members and carers should be offered stand alone /
separate assessments of their support and information needs
ie separate from the patient’s assessment, particularly at
stages in the patient pathway acknowledged as especially
demanding and when extra help might be needed. Cultural
Page 25 of 42





preferences regarding family involvement should be taken
into account.
Whenever possible and appropriate, family members and
carers should be invited to accompany patients during clinical
encounters and should be involved in discussions about
treatment and care, in accordance with the patient’s wishes.
Family members and carers should be made aware of, and
have easy access to, sources of local information, advice and
support designed to meet their own needs.
Family members and carers who are bereaved should, in the
first instance, be encouraged to use existing support systems.
Where these prove insufficient, or it is predicted that those
involved are likely to experience difficult grief reactions, there
should be access to additional help and support.
Providers of specialist bereavement support should work
closely with other care providers (both statutory and
voluntary) to ensure carers and family members can access
services when needed.
Carers should be given the opportunity to feedback on
services they have encountered.
WHAT HAS ALREADY BEEN ACHIEVED?

Each hospice has a range of services to address the needs of
the family and carers whose loved one are receiving palliative
care

Access to social work and welfare benefits advice is available
in the community and in the in-patient unit

Giving of information and sign posting is part of the overall
assessment of the carer

Carers have access to various groups throughout ABUHB in
the main provided by Hospice of the Valleys and St David’s
Hospice Care

Day hospice care is in place providing regular day respite for
carers if needed

Fast track process to expedite an increase in care packages

St Davids Hospice Care provides a specialist children and
young people support service for those facing the death of a
parent, guardian or other close relative. The service provides
both pre and post bereavement support. The service will
accept referrals from the whole of ABUHB and also accepts
Page 26 of 42
referrals for children who have been affected by a sudden
death such as suicide.

Macmillan pharmacists have developed an e-learning
education programme to support pharmacists in supporting
patients and their carers
Vision for the Future
For all carers to be supported whilst caring for a palliative care
relative/friend, ensuring equality of access and to receive timely,
high quality bereavement support.
Key Deliverables





Performance Measures
Explore and scope provision
of carer support to ensure
equality across ABUHB.
Explore and scope provision
of bereavement support to
ensure equality of provision
across ABUHB – particularly
within the acute sector.
Ensure patients, relatives
and carers access entitled
benefits in a timely manner –
avoiding duplication of effort.
Map the current services for
respite care and identify gaps
in service provision.
Ensure patients are receiving
appropriate benefits
 Standardised reporting
mechanism across ABUHB.
Recording the number of
carers assessments using
standardised documentation.
 Reporting numbers of deaths
where a NOK is recorded
against the numbers of
bereavement services access.
 Collate inappropriate
admissions to acute setting
and explore reasons for
admission, identifying
specifically if it was due to
carer fatigue.
 Audit the number of patients
in receipt of benefits under
special rules at the time of
death.
 Review of feedback /
evaluation such as “I Want
Great Care.”
Page 27 of 42
STRATEGIC AIM 5
To ensure an adequately trained workforce who are
educated to deliver excellence, who continuously improve
patient / service user experience and demonstrate effective
leadership.
Education and enhancing the awareness and skills of staff in
addressing people’s palliative and end of life care needs is viewed
as an important and integral component of the specialist palliative
care service. The belief is that education, training and support can
empower staff to provide high standard of care promoting value,
ownership and motivation.
The aim is to provide education that empowers the generic staff
through increasing their knowledge and confidence in palliative
care.
This will have a positive outcome for their personal
development but also improve and enhance patients’ and carers’
experiences.
The education delivered needs to be both formal and informal.
There are national and UK strategies (End of Life Care Strategy,
DoH, 2008 & Together for Health – Delivering End of Life Care, WG,
2013) that make clear the requirement for an educated work force
in the area of palliative care and specifically in caring for dying
patients and their families.
They offer a curriculum that is
competency based for health and social care workers working with
palliative care adults.
‘It is necessary to avoid the consequences of isolated courses
without links to available resources which will lead to the failure
of palliative care development, representing a poor result in
comparison to the amount of effort. It is far better to find a way
to support the acquisition of knowledge and skills within a
programme of palliative care education which is well structured,
co-ordinated, focused and efficient.’ (EAPC 2004)
The recent report from the Welsh Palliative Care Implementation
Board (2011) identifies communication particularly at the end of
life, as a key area of education within the generic workforce.
Competencies offer a way to monitor if the knowledge and skills
gained are transferred to the practical setting. Becker (2007)
identified that palliative care is also about attitudes and holistic
care.
Page 28 of 42
WHAT HAS ALREADY BEEN ACHIEVED?
 Well evaluated courses and study days provided by individual
organisations.
 Targeted education for nursing staff, plus e-learning module
for pharmacy staff with limited ad hoc CPD sessions for GPs
VISION FOR THE FUTURE
 Needs analysis on workforce educational needs
 An agreed multi disciplinary All Gwent Education programme
reflecting competencies where all organisations contribute
equally
 The development of an agreed educational strategy to drive
the vision forward
 Mechanisms to measure performance.
Page 29 of 42
Key Deliverables





Performance Measures
Explore and scope provision of
current workforce across
Gwent.
Scope the training needs of the
workforce in Gwent
Scope current provision of
training and education
Develop an education group to
include representation from all
organisations to develop a
structured competency based
educational
curriculum/
programme.
To
ensure
all
available
information on education and
training including the strategy
and curriculum is accessible to
all via the intranet / internet.
Page 30 of 42



Completion of an
agreed structured
competency based
educational
programme
Evaluations of
education provided
Achievement of
competencies with
follow up needs
analysis undertaken
STRATEGIC AIM 6
To promote patient choice and facilitate Preferred Place of
Care (PPC) / Preferred place of death (PPD)
Facilitation of Preferred place of care / death is a measurable
outcome outlined in the Welsh Government End of Life delivery Plan
(Together for Health: Delivering End of Life care, 2013) and the
Aneurin Bevan University Health Board (ABUHB) Delivering End of
Life Care 2013-2016 Local Action Plan.
Dying in a preferred place of death (hospital, hospice or home) is a
topical issue. Most people have a preference to be cared for and die
at home (over 50% in most studies, range 31-87%) (Gomes et al.,
2013) and direct contact with a specialist palliative care team has
been found to be directly associated with increased likelihood of
congruence between preferred and actual place of death (Tang and
Mccorkle, 2003).
At face value death in a preferred place seems to be a straight
forward marker to record and measure: a patient’s expressed wish
of where they wish to die is recorded and compared with their
actual place of death. On closer scrutiny recent research has shown
that this is a complex area, particularly where figures of death in
the preferred place are represented purely as statistics.
The issues are explored well in a recent systematic review of this
subject area (Gomes et al., 2013). For example, it is now known
that a significant proportion of patients will change their preferred
place of death in the period of weeks to months leading up to their
death. On average around 20% of patients change their preference
for place of death, however the range is 2-80% between different
studies and patients may change their preference more than once
(Gomes et al., 2013). The direction of change varies, but most
commonly it is from home to hospice, from hospital to home and
from home to hospital (Gomes et al., 2013). This therefore makes
it more difficult to capture accurate data relating to preferred place
of death.
There is also a distinction to be made between preferred place of
care and preferred place of death, as they are not necessarily the
same. A patient may, for example, wish to remain at home for as
long as possible, but wish to die in a hospice or specialist palliative
care inpatient unit. Furthermore, some patients do not wish to
have such explicit discussions about their preferred place of death,
and this should always be respected. Only around half of people
had expressed a preference for place of death to their relatives and
/or healthcare professional in the VOICES study (See DoH VOICES
study 2012, a survey of 22,292 bereaved relatives).
Page 31 of 42
When preferred place of death is viewed in isolation, patients may
give a particular preference which, when taken in the context of
other preferences or priorities, becomes less clear. For example, a
young male patient with advanced cancer expressed a general wish
to die at home. However, on further discussion he expressed a
desire not to die at home. This was because he did not want his
young children to be afraid of being in his bedroom because that
was the place that their father had died, and therefore on balance
he wanted to be admitted to the local hospice in the last days of his
illness. Taken at face value he did not die in his preferred place of
death, but dying in a hospice was not necessarily a bad outcome
from his point of view or that of his family. The issues are therefore
complex.
In summary, dying in a preferred place of death is an important
aspect of end of life care. For most, but not all, patients this will be
home. Capturing and measuring death in preferred place of care is
difficult and complex, but as an overall concept we should be
striving to achieve it.
WHAT HAS ALREADY BEEN ACHIEVED?

Within ABUHB, all specialist palliative care services use the
same electronic patient record, Canisc: Cancer Network
Information
System
Cymru
(Palliative
Care
Cymru
Implementation Board, 2011). As well as a clinical record
tool, it is also possible to derive reports for individual
palliative care teams from the Canisc system. However, at
present the reporting functionality does not support the use of
reporting on place of death and preferred place of death as an
outcome measure.

As already noted in the work completed on Advanced Care
Planning, there is no standardised method of communication
of ACP documents or decisions (including preferred place of
death) between primary/secondary and community services

Good community resources are available to achieve a death at
home in ABUHB, however, much resource is invested in acute
healthcare settings, with relatively little in other healthcare
settings e.g. hospices, nursing homes, community hospitals.

There are currently a range of services offering support to
enable patient choice;
o 3 DGH’s with specialist palliative care teams
o 1 specialist palliative care unit - 10 beds
Page 32 of 42
o 2 community specialist palliative care services (Hospice
of the Valleys and St Davids Hospice Care)
o 1 non-specialist palliative care service (Marie Curie)
o a range of primary care services, including, GPs,
Community Nurses, Pharmacies, Social Services,
Continuing Healthcare, Community Resource Teams
but issues relating to funding streams and availability of
resources can restrict or delay delivery.

Currently within ABUHB, the ability to respond to change in
preference although variable, has greatly improved with the
developments of Fast Track and Continuing Healthcare
Funding (CHC). However, the availability of inpatient hospice
care is disproportionately low (10 beds for 639,000
population). The voluntary sector partners have responded to
this disparity by providing increased availability for hospice at
home care and this has been recognised by PCIG funding.
Therefore, whilst access to palliative care services is not in
question, the ability to deliver choice of preferred place of
care at the end of life may be limited.
VISION FOR THE FUTURE

Appropriate, effective and consistent methods of recording
and communicating preferred place of death and changing
preference

Identified alternatives to dying at home or in a Local General
Hospital which will enable honest choice of PPC/PPD and the
ability to respond to changing preference

Improved provision of in-patient specialist palliative care with
appropriate number of beds for the population with access to
other appropriate specialist services as required

Clearly identified, dedicated non-specialist in-patient palliative
care beds, with appropriate funding and palliative care trained
staff in a range of settings (DGH, nursing homes, community
hospitals)
Page 33 of 42
Key Deliverables
Performance Measures
 Agree definition and use of
 Achievement of
terms, “preferred place of care”
recorded preferred
and “preferred place of death”
place of care/preferred
place of death
 Undertake scoping exercise to
 Bed occupancy rates
establish the appropriate
for specialist palliative
number of specialist palliative
care in-patient beds
care in-patient beds for
and demographics –
population
showing equity of
access
 Undertake scoping exercise to
establish the appropriate
 Bed occupancy rates
number of non- specialist
for non-specialist
palliative care in-patient beds
palliative care infor population and accurately
patient beds and
identify current level of
demographics –
provision
showing equity of
 Working across all partner
access
organisations, identify and
implement best service model
 Data from fast track
for specialist and non-specialist
in-patient provision (including,
 Qualitative data on
funding, education, R&D,
reasons for nonequity and access)
compliance with
preferred place of
 Identify, develop and
care/preferred place of
implement IT solution for
death
tracking changes in preference
and collecting validated
 Family/care feedback
outcomes (including qualitative
(including I want Great
data relating to failure to
Care)
achieve PPC/PPD)
Page 34 of 42
STRATEGIC AIM 7
To demonstrate a high quality service through measurable
outcomes and compliance with quality standards.
The Specialist Palliative Care providers as a whole, aims to deliver
safe and compassionate care focussed on the needs of individuals.
We acknowledge that to ensure high quality and safe care we need
to continually build on the strong foundations in place.
The Francis Report (Report of the Mid Staffordshire NHS Foundation
Trust Public Inquiry, 2013)) which detailed results of an
investigation into the failings of the Mid Staffordshire NHS
Foundation Trust was welcomed and subsequent recommendations
are encouraging everybody within our service to view our actions
‘through the lens of Francis.’
The principal question that should be repeatedly asked is ‘Is the
individual person, and their safety, central to all we do?’
To deliver patient-centred care we must ensure we listen. This
includes listening to patients, their carers and staff and then, most
importantly, acting upon what is heard. It is worthwhile noting that
in addition to using palliative care quality markers to define our
desired outcomes we have also employed generic quality
frameworks to set standards;
1. Welsh Quality Markers for End of Life Care (May 2012)
 17 quality markers developed by the Palliative Care
Implementation Board to inform the Peer review and
support the delivery of quality care at the end of life.
2. Together for Health – Delivering End of Life Care: A
delivery plan up to 2016 for NHS Wales and its Partners
(April2013)
 A framework for action by Local Health Boards, NHS
Trusts and Third Sector partners, setting out the
Welsh Government’s expectations of the NHS in
Wales in delivering high quality end of life care,
regardless of diagnosis, circumstance or place of
residence in Wales.
3. Achieving Excellence- the Quality Delivery Plan in Wales
(2012-2016)
 11
Action
points
ensuring
the
continuous
improvement in the Welsh NHS (dual goals of quality
improvement and quality assurance)
4. Doing well, Doing Better (April 2010)
Page 35 of 42

26 standards (replacing Healthcare standards for
Wales (2005))
5. Safe care, compassionate care (January 2013)
 National governance framework to enable high
quality care in Wales
6. Delivering safe care, Compassionate Care: Learning for
Wales from The Report of the Mid Staffordshire NHS
Foundation Trust Public Inquiry (July 2013)
 NHS Wales and the Welsh Government’s response to
the Robert Francis Report.
WHAT HAVE WE ALREADY ACHIEVED?
 A multi-agency workshop has been held to review all key aims
of the End of Life Delivery Plan and the themes and aims of
the strategy;
 In principle agreements have been given by partner
organisations to share performance information once a set of
measures have been agreed and approved by the strategy
group.
VISION FOR THE FUTURE
 Agreed terminology and definitions for measurement and a
single performance framework to support consistent
measurement and enable benchmarking across the services in
Gwent;
 Agreed targets for improvement, aligned to key national and
local strategic drivers, including the End of Life Plan which
comprise;
o Measures of quality from the perspective of service
users;
o Measures of service quality, safety and effectiveness
(e.g.
adherence
to
policies,
procedures
and
national/local guidance and best practice;
o Measures of service efficiency.
Page 36 of 42
Key Deliverables








Performance Measures
To
agree
definitions
for
performance measures;
To agree a set of common
performance
measures
and
receive formal ratification from
each organisation of the ability to
share performance measures;
To trial performance recording
and reporting via the strategy
development group;
Agree an ongoing performance
reporting
mechanism
and
monitoring group whose terms of
reference include responsibility
for
review
of
performance
measures and what action will be
taken where performance is
deemed to require support for
improvement.
To
agree
definitions
for
performance measures;
To agree a set of common
performance
measures
and
receive formal ratification from
each organisation of the ability to
share performance measures;
To trial performance recording
and reporting via the strategy
development group;
Agree an ongoing performance
reporting
mechanism
and
monitoring group whose terms of
reference include responsibility
for
review
of
performance
measures and what action will be
taken where performance is
deemed to require support for
improvement.
Page 37 of 42
To be agreed but likely to
include as outlined in
Quality Improvement
Plan:
 Peer Review
 Participation in
national audit and
service evaluation
o e.g minimum
data set, ICP
variances, I
want great care





Use of patient
outcome scores
Fast track data
Annual report 7/7
working
Data re preferred
place of care
Review of
incidents/complaints
STRATEGIC AIM 8
To engage in the research agenda and to develop the skills
and competencies to generate as well as implement evidence
in practice.
Historically Research and Development has been viewed as an add
on with the focus on clinical service and outcomes and as such has
not been given priority. It has been lacking in a breadth of
expertise and activity and there is a culture of protecting palliative
care patients from involvement in clinical research. Added to this,
there has been a lack of infrastructure to support fledgling
researchers and teams / units to recruit to approved trials.
Whilst good research is undertaken, it is sporadic and focused
amongst a few individuals, and more likely to be undertaken by
those with protected time to do it such as the clinical academic.
WHAT HAVE WE ALREADY ACHIEVED?
 Nursing and medical involvement with Masters level research
 CNSs undertaking masters course
 Several consultants with MSc in Palliative Medicine and 2
consultants with Doctorates
 Established expertise to supervise Masters and Doctorate level
research: several consultants with MSc and MD qualifications
have already successfully supervised multi professional
candidates
 Presence of Senior Clinical Research Academic
 Significant grant income circa £4million past 5 years
 Established publication output
 Member of NISCHR faculty
VISION FOR THE FUTURE







Undertaking and evaluating service development and
enhancement.
Supporting the conduct of high quality research projects
Supporting the development, conduct and dissemination of
primary research
Facilitating patient participation in research and development.
Providing a quality palliative care service throughout Gwent,
which is supported by current evidence.
All staff appreciate their role in supporting meaningful
research / service development within the specialty
All staff support the undertaking of peer review within their
Page 38 of 42


respective workplace
All staff are able to support the conduct and recruitment to
clinical trials
Those with sufficient interest should be supported to
undertake service improvements / research
Key Deliverables
Performance measures

Clarify current level of palliative Programme of research produced
care research being undertaken
within Gwent and identify extent
of expertise

Establish R and D lead for each Named
R&D
lead
from
provider
organization.
Attendance
at
Research
Development Strategy Group
each
and

Establish All Gwent Palliative Membership
Care Research and Development Development of 5 year R&D plan
Group who meet quarterly

Increase
awareness
and Number of staff attending study days
understanding of importance of
Research and Development in
Palliative Care



To work collaboratively with the
Research and Development
department within ABUHB
Number of grant applications
To identify and collaborate with Collaborations made with:
support mechanisms available
 Clinical Academic
 Marie Curie Palliative Care
Research Unit
 Cardiff
University
Palliative
Care / Medicine MSc course
 University of South Wales
Masters Course
Publications in peer reviewed journals
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
To establish growing expertise
/ Abstracts at National / International
meetings
Successful
completion
of
 To secure funds to support staff postgraduate research MSc/MD/PhD
to
undertake
supervised
research programs eg MSc
Number of staff completed training
 To provide Good Clinical Practice
Training throughout provider
settings
Number of sites recruited
 To establish recruitment sites for
ongoing
NISCHR
portfolio
studies
Number of patients recruited
 To have an active programme of
recruit to NISCHR portfolio
studies
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Knowing we are successful
Feedback from patients, families and carers
We will need to develop clear and simple ways of gaining feedback
from users of our services to ensure that what we develop is
meeting the needs.
Feedback from staff and other organisations interacting with
us
Our staff are a vital and much valued resource. We will need to
ensure that we are enabling staff to comment on what is going well
and what is not going quite so well, to ensure that changes can be
made appropriately.
Monitoring and Reporting Mechanism
The strategy implementation group will meet bi monthly to feed
back on the work streams sub groups which are aligned to each
strategic aim.
Performance measures and data will be collated from all the partner
organisations to inform formal progress and also to update on
Aneurin Bevan University Health Board Delivery Plan for End of Life
Care.
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Making it happen
The implementation of the strategy will be led by a Macmillan
Service Improvement Lead manager lead using a partnership
approach with the service providers from across Gwent.
A
programme management approach will be adopted with a Strategy
Group overseeing the work of the eight work streams which are
aligned to the eight aims of the Strategy.
The Strategy will be formally launched with all partners by
September 2015. The launch will highlight the eight identified work
streams and ensure engagement with all stakeholders involved its
delivery.
Each work stream will develop their own SMART objectives to
enable achievement of the key deliverables within current available
resources.
Three work streams have been identified as a priority for 2015 –
2016. These are:



Aim 2 To support living and dying well: Facilitation of effective
advance care planning throughout the patients’ illness with a
focus on end of life
Aim 5 To ensure an adequately trained workforce who are
educated to deliver excellence, who continuously improve
patient/service user experience and demonstrate effective
leadership
Aim 6 To promote choice and facilitate Preferred Place of Care
(PPC) / Preferred Place of Death (PPD)
Progress reports will be carried out annually and shared via the
Community Services Division’s Transformation Board and ABUHB’s
End of Life Board.
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