Medway and Swale CCG jointly lead the development and implementation a revised end of life care for adults strategy across the whole system for our localities. The National End of Life Care Strategy indicates that the majority of people would prefer to die at home. Yet in 2016, there were 2142 deaths in Medway, with 47.6% (1020) of these occurring in hospital, 24.7% (529) at home and 10.4% (222) in care homes. This highlights the need for change and why locally we need to focus on identifying opportunities for health and social care systems to work together to provide coordinated care and support, opportunities for patients to discuss their personal needs, choice of where to be cared for and to die, with appropriate advice and support for carers at every stage.

 

Support 

Primary Care

General Practitioners (GPs) provide generalist support for end of life patients according to their needs through the dying process in line with the Gold Standards Framework, including pain management, emotional support and coordination of care dependent on the patient and carers needs.

Community Nursing Service

The Community Nursing Service, provided by Medway Community Health Care, delivers 24/7 nursing services to patients registered with a Medway GP, over the age of 18 years and are either permanently or temporarily housebound. The Service functions as part of an integrated health and social care model and works collaboratively with stakeholders to deliver high quality patient care. Community nursing provides the majority of the palliative and end-of-life patients care for patients living in their own homes or residential care.

https://www.medwaycommunityhealthcare.nhs.uk/our-services/community-nursing/

Wisdom Hospice (Specialist Palliative Care Service (SPCS))

The SPCS, provided by Medway Community Health Care provides support alongside community nursing for palliative patients over the age of 18 years, who have complex care needs that are difficult to manage such as pain, nausea, vomiting, dyspnoea, constipation, anxiety, and agitation. The service also supports patients, their families and carers who have complex psychological needs including concerns about children, vulnerable individuals, spiritual or religious concerns.

https://www.medwaycommunityhealthcare.nhs.uk/our-services/palliative-care/

Cruse Bereavement care

Provides comprehensive bereavement support to anyone bereaved by providing advice and counselling. The service is available to Medway residents and their immediate family, as well as the extended family and friends at whatever stage following bereavement.

https://www.cruse.org.uk/Maidstone-and-Medway-area

Medway On Call Care (MedOCC): Palliative Care helpline & Medway’s electronic palliative care co-ordination system (EPaCCS)

The palliative care helpline provides access to 24/7 crisis support for end of life patients, their family and / or carers. GPs and nurses are able to provide telephone advice, visit patients, and as appropriate refer to other community and specialist teams. Call 01634 792098.

EPaCCS, known locally as  ‘My Wishes’ ensures that patients are able to record electronically (via their health care worker) their wishes and advance care decision which can then be accessed, respected and acted upon by health and social care professionals. MedOCC also facilitates 24/7 access to South East Coast Ambulance NHS Foundation Trust (SECAmb) crews to ‘My Wishes’ to support decisions relating to care of palliative / end of life patients.

https://www.medwaycommunityhealthcare.nhs.uk/see-a-gp/medway-on-call-care-medocc/

Specialist Assessments and Placements Team (SAPT)

SAPT are responsible for ensuring the delivery of NHS Continuing Healthcare for the local population on behalf of the Clinical Commissioning Group. 

Many people in England have on-going care needs as a result of disability, illness or accident, the vast majority get help and support which they have to pay something towards – either through social service charges or because they are assessed as having the financial means to buy the care themselves. However for some people the need for nursing and or healthcare support is of such a level/or type that they qualify for all their assessed needs to be met by the NHS, including those personal and social care needs which might otherwise be met by social services or funded by the individual themselves.

To qualify for NHS Continuing Healthcare an individual has to be assessed as having ‘Primary Health Need’. Eligibility is not assessed on a particular illness or disability, but whether the individuals ‘day to day’ nursing/healthcare needs are, when taken as a whole, beyond the local authority (social services) power to meet.

Referrals to SAPT can be made by health and social care practitioners completing the Department of Health ‘Checklist Tool’ which will indicate if the individual meets the threshold for further assessment of their needs; or, in the case of individuals who have a rapidly deteriorating condition, with limited life expectancy and an increasing level of dependency, health practitioners can refer to SAPT using the ‘Fast Track Tool’.

The nurses in SAPT will assess eligibility for NHS Continuing Healthcare and if the individual is eligible will arrange/commission such services to meet the assessed needs. Eligibility is reviewed within three months and then at least annually. If individuals needs change so might their eligibility for NHS Continuing Healthcare.

Click here for Specialist Assessments and Placements Team information.