Summary
The Midhurst Macmillan Community Specialist Palliative Care service was set up in 2006 when the King Edward VII Hospital’s inpatient palliative care unit closed. In the Midhurst service a consultant-led multi-disciplinary team provides ‘hands on’ care and advice at home, in community hospitals and in nursing or residential homes seven days a week. This service provides specialist clinical interventions in the community such as blood/blood product transfusions, parenteral treatments, IV antibiotics, IV biphosphates, fluids, paracentesis, ultrasound and intrathecal analgesia.
Challenge
The Midhurst Service was set up in 2006. It uses a modified version of the Swedish Motala Model for advanced home care, with a consultant-led multi-disciplinary team providing ‘hands on’ care and advice at home, in community hospitals and nursing or residential homes, seven days a week.
Almost three quarters of people with cancer would prefer to die at home, but less than a third do so. More than half of carers said their relative did not have complete pain relief throughout their last three months.
Nationally, between 48% and 58% of people die in their preferred place of death. The service aimed to address this by offering person-centred care, including clinical interventions at home.
Objectives
The Midhurst service was set up to with a number of objectives. These included ensuring people in the area had access to high quality specialist palliative care, maximising patient choice by providing treatment and support at home and in community settings, and reducing acute hospital interventions and inpatient stays
The team also aimed to ensure close working between the NHS, voluntary, charitable and private sectors in order to deliver high quality patient care, and to engage volunteers in supporting people to receive holistic care at home.
Further objectives included providing support for carers, including bereavement support, and making sure that the service was sustainable and affordable.
Solution
The Midhurst Service provides active specialist palliative care through a range of interventions undertaken either at home or in the community including blood/blood product transfusions, parenteral treatments, IV antibiotics, IV biphosphates, fluids, paracentesis, ultrasound and intrathecal analgesia.
The service has a consultant-led, multidisciplinary community-based team. Its comprehensive nature means the team can respond to a wide range of needs.
Working within a given patch, the CNSs hold overall responsibility for organising and coordinating care, while other team members retain responsibility for their aspect of the service.
Flexibility is a key offering of the Midhurst Service. There is a lack of emphasis on hierarchy in relationships within the team, and whoever is in the home provides what is needed, within their sphere of competence.
The Midhurst service is managed by the Sussex Community NHS Trust and commissioned by three local Clinical Commissioning Groups. It covers Surrey, Hampshire and West Sussex.
Results
Since 2007 the service has supported over 2,800 patients, seeing 400 new patients and families last year. Outcomes include enabling 53 per cent of its patients to die at home in 2013/14, and 83 per cent to die in their preferred place.
The breadth of services delivered in patients’ homes and the earlier referral allowed trust to develop between the patient, carers, and team.
Partnership working is integral. The team works with 19 GP practices and a range of groups, and services, including seventy volunteers. Bereavement support is coordinated by the bereavement coordinator and counsellor.
Midhurst patients spend less time in hospital than those within traditional service models, and have fewer A&E attendances than any other group of patients.
Learnings
The key learning was that Swedish Motala Model could be adapted to deliver high quality community-based care for a UK population. Delivering clinical interventions in the home proved safe, while improving patient choice and experience.
Having a rapid-response team reduced the likelihood of emergency hospital admissions, contributing to the higher percentages of people dying in their preferred place. Early referral allowed patients to decide their preferences, which could be fulfilled by their care team.
Links with other NHS services, social care services and community organisations were crucial. Continued community and volunteer engagement were essential.
If the Midhurst service was replicated elsewhere, the total cost of care in the last year of life could be reduced by 20%.
Evaluation
In 2012/13 the service was a case study in The King’s Fund programme ‘Coordinated Care for People with Complex Conditions’. It has also been endorsed by NHS England as one of its eight High Impact Interventions to help commissioners meet future demand through commissioning cost-effective, high quality services.
The team is now helping others replicate their success through the Macmillan Specialist Care at Home programme. This means six other centres are working together to spread the good practice the Midhurst Macmillan Community Specialist Palliative Care service started. The Midhurst model will be tested in six different demographics, including urban, suburban and rural areas. Evaluation of this programme of work will be available in March 2016.
