Last Phase of Life Programme

With a projected increase in the number of deaths in England per year and a growing proportion of the population living longer with multiple co-morbidities, there is a clear need to make provisions for an increased demand for last phase of life care. Information gathered for the Sustainability and Transformation Partnership across Barnet and its neighbouring boroughs highlighted significant inequalities in provisions for care in the last phase of life. Data suggests that Barnet care home residents make up the largest proportion of emergency department attendances and non-elective admissions in the North London area, with only 1 in 6 Barnet residents aged over 75 dying in their usual place of care.

Barnet Community Education Provider Network’s (CEPN) Last Phase of Life Programme acknowledged the need for local action and recognised that one resource to shift the balance of care from the hospital back to the community might be a single multi-agency advanced care plan document to be available across primary, secondary and community care sectors. In order to successfully implement such a record and write meaningful, patient-centred care plans, staff would need to be competent in identifying when a care plan is necessary and possess the skills to approach this topic with patients and their loved ones compassionately.

Short term aims were to increase the knowledge and confidence of Barnet’s social, health and voluntary workforce when engaging in last phase of life discussions with longer-term outcomes being to improve the quality and quantity of documented advanced care plans, ultimately increasing the number of patients dying in their preferred place of care.

Achievements of the programme include:

  • Delivery of two workshops repeated in nine multi-professional collaborative learning groups (MCLGs) with a total of 220 training places filled by attendees from primary and secondary care, community services and care homes.
  • Organisation of The Pan-Barnet Managing Patients in the Last Phase of Life Event with over 160 attendees from the health, social and voluntary care sector. During this event, Coordinate my Care (CMC) was well received across the workforce as a platform to provide a multi-professional digital advanced care plan in which to record a patient’s wishes for their last phase of life.
  • Development of The Barnet Last Phase of Life Steering Group to identify and implement key priorities for last phase of life care in Barnet and comprised of over 30 organisations including patient representatives.
  • Imminent delivery of ten Advanced Care Planning reflective teaching sessions to be delivered across two care homes empowering staff to participate in end of life conversations with patients and their loved ones.

If you would like more information about this project please contact Dr Asha Dalsania  asha.dalsania@nhs.net