To ensure that community provision of end of life care could continue to operate responsively and effectively during the COVID-19 pandemic whilst maintaining high standards of care.

The key objectives were;

• Adoption of a single format of Treatment Escalation Plan (TEP) across Kent and Medway.
• Agreement of joint COVID-19 palliative care prescribing guidance.
• Prescribing agreements established regarding just in case medication, carer administration of sub-cutaneous medications and repurposing of medicines.
• EoLC resource pack incorporating COVID palliative care prescribing guidance developed and accessible for clinical staff including primary care teams.
• Development of shared core EoLC education, initially via e-learning and later delivered via Zoom, available to all staff across Kent and Medway to maximise resource. Local adoption of evolving national guidance (remote verification of expected death), supported by provision of education to equip staff with skills and knowledge required.
• Provision of consistent training to care home staff.

Kent Community Health NHS Foundation Trust (KCHFT) provides out-of-hospital, community-based NHS healthcare services for more than 1.5 million people living in Kent. The Kent and Medway region covers a wide geographical area with four integrated care partnerships (ICPs) bringing the provider organisations together to work as one. The region has an aging population with the number of over 65 year olds forecast to increase by 50% between 2018 and 2038 and almost one in three of the population currently living with longer term conditions. There are significant inequalities across Kent and Medway with pockets of both affluence and deprivation. In 2019, the healthy life expectancy for men differed by 7 to 8 years between the most and least deprived areas.

Health providers in Kent and Medway comprise four acute providers, an NHS community provider, two non-NHS community providers serving Medway and parts of north Kent, a large mental health provider, 4 hospices and 200 GP practices. In April 2020, the eight CCGs merged to become a single CCG across Kent and Medway.

At the beginning of March 2020 it was clear that the UK was likely to face a significant outbreak of COVID-19. Due to the risk of acute hospitals becoming overwhelmed, there was a focus on the increasing appropriate home management of end of life.

This was anticipated to create significant challenges to the delivery of services by community providers particularly with regard to symptom management and provision of anticipatory medicines for End of Life Care. The need for clear care planning supported by treatment escalation plans was also identified as a key priority.

It was quickly acknowledged within Kent Community Health NHS Foundation Trust (KCHFT) that system wide action within Kent and Medway would be required to provide an effective response to meet these demands.

Challenges were apparent due to varied practice and training within the Kent and Medway area but we felt this could be addressed by increased collaboration, networking and sharing of knowledge and resources.

In order to work at pace and at scale, the initial focus was for KCHFT to provide a catalyst for the formation of a Kent and Medway EoLC COVID19 Response Group. This group included key local stakeholders for EoLC to drive collaborative working and ensure an effective, unified response to the healthcare challenge and support staff to deliver effective patient care.

The group identified COVID end of life care prescribing guidance as a priority, taking best practice nationally and advice locally from acute, community and CCG pharmacy leads. This has enabled staff to have appropriate information to manage COVID-19 EoLC symptoms and address the presentation of EoLC symptoms for dying patients ensuring patient support.

Prescribing agreements regarding just in case medication, carer administration of sub-cutaneous medications and repurposing of medicines were agreed. This included provision of out of hours pharmacist access. Establishment of these policies and agreements has enabled a responsive approach to symptom management medication with the aim of reducing delay in addressing patient needs.

An EoLC resource pack incorporating the COVID palliative care prescribing guidance was developed and adopted across Kent and Medway. This has ensured that staff working in all areas have access to the most appropriate and current information.

The need for training resources and an education programme to support the treatment escalation plan (TEP) work that had already been commenced in local areas was also addressed.

Verification of Expected Death (VoED) flowcharts were provided to support remote verification in specific situations developed from national guidelines and agreed locally. This has been followed by innovative development of VoED remote training for Health Care Support Workers to assist GPs with remote verification of expected death.  Additionally, training for VoED for Registered Nurses has reviewed and updated in response to the rapidly developing national guidelines and is currently being provided collaboratively. This was part of work to develop of a suite of learning material now available across Kent and Medway and including DNACPR, VoED, Syringe Pump management, Advance Care Planning and Recognition/Care of the Dying Patient.

Having established the initial training, work evolved further to provide a collaborative agreement to deliver Kent and Medway EoLC core skills training between August and October 2020. This work was predominately by the led by the Ellenor Hospice Team providing online training sessions. The success of this work led to the formation of EoLC Kent and Medway Education Collaborative to scope medium and longer term delivery of core EoLC skills for all staff in Kent and Medway.

We were able to obtain administrative support from Kent and Medway STP to facilitate meetings during the development of this work. Existing CCG IT resource has also been used to provide a platform for digital resource sharing. This included the sharing of resources with primary care and care home staff as well as hospice and community providers.

Key Findings

Local work was already in place to develop treatment escalation plans. The impact of this has been a clearer management of patients, avoiding unwanted hospital transfer and ensuring EoLC priorities are aligned to patient wishes. However for community services and the ambulance service, this required familiarity with variable forms and processes.

The EoLC COVID-19 response group was able to provide an arena for discussion and support the implementation of consistent training for staff and an agreed system for sharing TEPs with the ambulance service. One benefit was the clear understanding of barriers to sharing of TEPS on existing digital systems which enabled quick pragmatic solutions to be achieved. The group also took best practice nationally and pharmacy advice locally to develop a COVID-19 prescribing guide. This has enabled our staff to have appropriate information to manage COVID-19 EoLC symptoms and address the presentation of EoLC symptoms for dying patients ensuring patient support.

The importance of accessible information was addressed via collaborative work on a COVID end of life care resource pack. This incorporated the prescribing guidance, NICE COVID rapid guidance and training resources to ensure that all staff have access to the most appropriate and current information. Adaptation to a digital model of communication and training was transformational and enabled previous geographical and time constraints to be removed.

The use of existing IT resources was key to rapid dissemination of the pack which was available on the CCG digital platform ahead of the anticipated peak of the pandemic. Equally without the rapid agreement of shared resources the project would not have progressed at a sufficient pace.

This work has highlighted the need for collaborative working across systems and stimulated further work to develop a pilot for enhanced out of hours End of Life Care and Frailty support.

Innovative use of the existing resources (for example the use of the Referral Support Tool (hosted by the Clinical Commissioning Group) as a platform for access to EoLC resources by community, primary care and care home staff across Kent and Medway) can enable rapid implementation of new systems and resources.

Use of digital resources can enable wide dissemination of shared education and resources. The collaborative approach detailed above has resulted on wider accessibility of EoLC training for staff and the development of COVID-19 specific EoLC information to meet patient needs. This information included symptom management and education but also focused on how to deliver compassionate care and communication skills with the challenges of COVID-19 restrictions. It has been of particular value for staff working across integrated care systems to have access to a single source of information and training whilst a collaborative approach enabled progress at pace. Between May and October 2020, 95 staff have accessed 233 of these training sessions online within KCHFT alone.

The need for resources to address staff need for self-care and provides links to support available were also recognised and form part of ongoing COVID-10 response work.