“I write this update as we (the team in North West Wales) prepare for our first MDT and our first clinic. We are the new adopters! Our team consists of a palliative care consultant, cardiology consultant, hospital palliative clinical nurse specialist and a small team of heart failure nurses. Together we share an enthusiasm and willingness to make this project work.”Dr Gemma Lewis-William
The Supportive Care Pathway for people in their later stages of heart failure is now being adopted in North Wales. The new adoption site team in North Wales are introducing this service current staff and most of the team are hospital-based with links with community colleagues both within heart failure and specialist palliative care. The service will be adopting a new approach to more collaborative working between the two services with earlier identification of patients felt to be in their last year or so of life and working together to not only to optimise their heart failure but also other symptoms prevalent in this population. Coupled with this, the collaborative service will allow earlier and more open conversations around advance care planning and ‘thinking ahead’.
As part of this project, it is hoped that the service will help support community services (notably primary care/GPs and district nurses) to support patients at their preferred place of care and death. Broader stakeholder involvement may involve the voluntary sector as we are privileged to have a hospice day therapy on the Ysbyty Gwynedd site. This is currently closed (due to Covid-19 and now due to renovations) but may prove a beneficial link to support the patients with additional services (social worker, physiotherapy, counselling etc).
Achieving geographical coverage
North West Wales in itself is split into four separate counties. Ysbyty Gwynedd is situated in North West Wales which covers a significant rural geography across the counties of Anglesey, Gwynedd, Dwyfor and Meirionnydd. Our geography is vast and rural. For this project to work we felt we needed to start small, assess what works and review what doesn’t. Our geography is beautiful but it may pose some challenges.
Where we are now and next steps (updated June 2021)
Our patients will be identified by the heart failure clinical nurse specialists and listed for MDT. We plan to meet monthly for this. We have agreed to limit patients within two counties (Arfon and Mon) and to also limit to those known to the consultant cardiologist linking into the project. Depending on numbers and resource we may be able to expand this. We have largely kept to the original referral criteria from the original site but have adapted slightly.
The clinic will be a new endeavour and initial plans are to offer a joint consultant and nurse clinic, whilst managing the demands of covering the hospital palliative care service. The initial funding from Bevan will help support the release of the clinical nurse specialist to perform this new role.
We have the availability of a day hospice on the main hospital site in Ysbyty Gwynedd and it is hoped that this venue will be able to offer consulting space as well as the potential for patients to be referred for additional assessments by other allied health care professionals. We are keen to measure the number of added referrals the new project brings as well as the outcome measures listed by the original site.