Humber & North Yorkshire Partnership ICS

Summary

End-of-life care is about understanding and being able to act on the wishes and preferences of people at the most difficult point in their lives. Those who are at the end-of-life are looked after by many health and care professionals in different settings, including their GP, hospital team, hospice, community nursing team, as well as social care, out-of-hours providers and emergency services. However, many of these organisations use different software, with sharing between the different systems very difficult. So, the question faced was: how do we share the latest wishes of a person between these different health and care settings in a safe, up-to-date and patient-focused way?

Humber and North Yorkshire Partnership (HNYP) have used EPaCCS (Electronic Palliative Care Coordination System) to provide a solution to these challenges. EPaCCS enables the recording and sharing of a patient’s care preferences and key details about their care at the end-of-life, including their preferred place of care and death, the circumstances under which they’d want to be admitted to hospital, whether they would want CPR to be attempted, and details about their medications.

EPaCCS was initially rolled out in Vale of York, Scarborough & Ryedale and North Lincolnshire and, after the successful pilot, EPaCCS has been extended across HNYP. The EPaCCS solution has been instrumental in supporting the coordination of care during the COVID-19 pandemic, when there has been a major focus on Advanced Care Planning for vulnerable patients. EPaCCS has provided a solution to share patients’ end-of-life care preferences and plans in real-time between the different health/care providers looking after them.

To date, over 8,000 EPaCCS records have been created and the solution is enabling collaborative working to support end-of-life patients, reducing duplication and ensuring that the most up-to-date view of a patients’ preferences and status are visible and updatable across different health and care settings.

The innovative introduction of this digital solution has been recognised as best practice and has been published as a national NHS Blueprint that shares the experience and approach with other parts of the country.

Requirement and Challenge

Health and Care professionals in Humber and North Yorkshire Partnership (HNYP) were not able to access existing end-of-life care plans for their patients, nor the wishes and agreements already established with other professions involved in their care. This had resulted in difficult and repeated conversations with patients, and their families and carers, to establish the agreed wishes of the patient. It also resulted in unwanted trips to A&E when patients preferred to spend their final days at home, with their families and those that cared for them.

In some instances, families and carers were not always fully aware of the details of the End-of-Life Care Plan, so emergency services were faced with a series of phone calls to try to establish their patients’ wishes, which may on occasion have been different to those of their families and carers.

It was clear that a more integrated digital solution which enabled end-of-life plans to be shared amongst paramedics, GP, Mental Health, community and A&E professionals would be required.

Approach and Solution: Project and Supplier Management, Business Change, and Training

Ideal Health’s consultants, already embedded with Humber and North Yorkshire Partnership working on their Shared Care Record programme, knew the regional digital architecture well and understood the local clinical and operational priorities. A collaborative approach to resolving the issue was established, working together with the ICS Digital team and the supplier of the EPaCCS solution Black Pear, to craft a digital approach to sharing end-of-life information and data across ICS partners.

The programme collaborative included local GPs, Yorkshire Ambulance Service (YAS), and the acute, community and mental health providers, all of whom needed access to end-of-life care plans which, by their very nature, are unique to each individual’s condition and wishes.

The innovative digital solution that was implemented prompted considerable business and operational changes across ICS partners, including within YAS to ensure paramedics were aware that end-of-life care plans were now accessible and to be used on emergency calls.

Outcome and Benefits

• A change in how information is provided to enable care providers to respond to patients wishes at the point of care, and to support paramedics in their care and conveyance decisions
• A clear record of End-of-Life Care Plans that can be accessed by all those involved in care, and a record of who in each family is aware of their relative’s end of life wishes
• The EPaCCS solution has made often difficult and emotional conversations possible, with the individual at the centre of their own care, and has changed operationally how paramedics manage end-of-life situations
• A seamless view of end-of-life care plans within HNYP and local clinical leads who work with GP practices to embed EPaCCS in their ways of working
• A strategic and operational digital EPaCCS blueprint for NHSE is now being shared with other regions to support the development of similar end-of-life digital pathway solutions
• During the pandemic, the EPaCCS solution was developed to be even more integrated with local EPRs, as part of the overall drive for a real-time holistic view of patient data