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POPULATION BASED
PALLIATIVE CARE NEEDS ASSESSMENT
AN ALL WALES SUMMARY
OF ASSESSMENTS FOR
NORTH WALES, SOUTH EAST WALES &
SOUTH WEST WALES CANCER NETWORKS
Peter Tebbit
Palliative Care Development Adviser
October 2005
1
INTRODUCTION
Population-based palliative care needs assessments have been completed for the three
Cancer Networks in Wales. The final reports were delivered to each of the Networks
in August 2005 and are provided as supplementary documents to this report.
This report provides an all Wales summary of the principal conclusions contained in
the three Network reports. It is anticipated that it will provide a useful context for
consideration of national palliative care policy and service development over the next
few years.
Methodology
The assessments have been undertaken in general accordance with the guidance set
out in Population-based Needs Assessment fro Palliative Care – A Manual for Cancer
Networks published jointly by the National Council for Palliative Care and the Cancer
Action Team for the NHS in England in 2004. Some modification has been necessary
to the advice contained in the Manual in order to take account of the difference in
context between the NHS in Wales and England.
The approach taken in the guidance and in the Cancer Network assessments has been
to employ a methodology that uses the minimum required data/information collection
and analysis. It has concentrated on the key factors. If further work is considered
necessary on particular aspects then work could be put in hand to do that at either
Network or national level.
It is important to recognise that needs assessment is not an exact science. The
techniques currently available do not lead to absolute measurements of palliative care
need in populations. They do however provide analyses of the principal factors that
influence need. Consequently, they can provide data that enables the needs of the
different LHB populations within Networks to be compared one with another i.e.
measurements of comparative need. Such an approach can also provide estimates of
comparative need as between the three Networks in Wales and more generally with
the Networks in England.
Such a benchmarking approach enables an assessment to be made for each Network
of the volumes of each core service that may be required to meet the differential needs
of the populations within Networks. It also enables an assessment to be made of
whether the current distribution of palliative care resources and access to them reflects
the differential needs of the LHB populations within each Network.
Key Factors that Influence Need
The published guidance referred to above identifies two principal factors that affect
the need for palliative care resources in any given population. They are the annual
incidence of deaths as a ratio to population and relative economic and social
deprivation of populations.
2
Annual Incidence of Deaths
The annual incidence of deaths is regarded as the single most important indicator of
palliative care need in a population since most palliative care needs arise during the
last year of life. The annual incidence of deaths is also regarded as a good proxy
indicator for palliative care need that may arise earlier than the last year of life.
Economic and Social Deprivation
There is probably a consensus of professional opinion that caring for people in the
most deprived areas does require more resources than in the most affluent areas.
There is also some evidence to suggest that the level of resources required to support
people in the most deprived areas may be up to twice the level needed in the most
affluent areas. In consequence it is considered that deprivation is the second most
important factor affecting the need for palliative care resources in a population.
Other Factors
It is recognised in the assessments undertaken for the three Networks that there may
be other factors that may influence at the margins the level of need derived from the
analysis of incidence of deaths and deprivation. Accordingly, analysis of the
following has also been made:





Place of death
Age structure of populations
Numbers of males and females
Ethnic composition and religion
Single person and pensioner households
Scope of the Assessments
The assessments consist of four parts:
Part 1 – An assessment of the palliative care needs of the population
Part 2 – An assessment of the core service components required to meet assessed
needs
Part 3 – A mapping of the services currently available to meet those needs
Part 4 – A comparison of what services are needed with what are already available in
order to identify service gaps
Data Sources
The data provided in this report has been taken from the individual Network
assessments. The sources for that data are detailed in those assessments. Much of the
data has been obtained via the individual Networks. Their ability to provide that has
been variable in respect of the periods to which the data relates e.g. service mapping
data, incidence of deaths. However, such differences are minor and are not therefore
considered to be such as to invalidate any summary conclusions for Wales as a whole.
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ALL WALES SUMMARY OF NETWORK NEED
DEFINING THE POPULATIONS TO BE ASSESSED
The LHB populations included in each Network are as follows:
North
South East
South West
Anglesey
Conwy
Denbighshire
Flintshire
Gwynedd
Wrexham
Blaenau Gwent
Bridgend
Caerphilly
Cardiff
Merthyr Tydfil
Monmouthshire
Newport
Rhondda Cynon Taff
Torfaen
Vale of Glamorgan
Carmarthen
Ceredigion
Neath Port Talbot
Pembroke
Powys
Swansea
The populations of each Network have been derived from primary care resident
populations based on GP lists in ADS 2003 and reconciled to 2001 Census based mid
2002 Local Authority estimates. They are:
North Wales
South East Wales
South West Wales
667,683
1,396,675
851,198
Total
2,915,556
Note: When the assessment commenced it was understood that the population of
Bridgend LHB was to be included in the South West Cancer Network. However,
somewhat later, it became clear that Bridgend should be included in the South East
Cancer Network. As far as the individual Network assessments are concerned
Bridgend has been included in both South West and South East. However, in this all
Wales summary, all data in respect of Bridgend has been included only in South East.
4
ANNUAL INCIDENCE OF DEATHS
Table 1 – Presented at Network Level
Network
North
South East
South West
All Deaths
8070
15123
10304
Cancer
Deaths
2048
3883
2513
Cancer
deaths as
% of all
deaths
25.4%
25.7%
24.4%
Ratio of all
deaths to
100,000
population
Ratio of
cancer
deaths to
100,000
population
1209
1083
1210
307
278
295
Table 2 – Presented at LHB Level
LHB
Population
All Deaths
Cancer
Deaths
Cancer
deaths as
% of all
deaths
Ratio of all
deaths to
100,000
population
Ratio of
cancer
deaths to
100,000
population
Blaenau
Gwent
Bridgend
Caerphilly
Cardiff
Carmarthen
Ceredigion
Conwy
Denbighshire
Flintshire
Gwynedd
Isle of
Anglesey
Merthyr
Tydfil
Monmouth
Neath Port
Talbot
Newport
Pembroke
Powys
Rhondda
Cynon Taff
Swansea
Torfaen
Vale of
Glamorgan
Wrexham
69,305
909
232
25.5%
1312
335
128,245
170,178
308,263
174,746
77,010
110,483
94,228
149,153
117,197
67,406
1473
1818
2952
2272
758
1688
1261
1461
1398
809
376
472
774
526
190
414
306
384
367
217
25.5%
26.0%
26.2%
23.2%
25.1%
24.5%
24.3%
26.3%
26.3%
26.8%
1149
1068
958
1300
984
1528
1338
980
1193
1200
293
277
251
301
247
375
325
257
313
322
55,842
671
165
24.6%
1202
295
84,786
134,593
922
1753
243
428
26.4%
24.4%
1087
1302
287
318
138,814
114,349
127,131
230,927
1433
1379
1488
2662
379
342
369
649
26.4%
24.8%
24.8%
24.4%
1032
1206
1170
1153
273
299
290
281
223,349
90,866
119,449
2654
965
1318
658
273
320
24.8%
28.3%
24.3%
1188
1062
1103
295
300
268
129,236
1453
360
24.8%
1124
279
5
Key Points from Tables 1 and 2






The annual incidence of all deaths per 100,000 is about the same for the North
and South West Networks but is about 12% higher in those Networks than in
the South East.
The annual incidence of cancer deaths per 100,000 in the North is 4% higher
than in South West and 10% higher than in South East.
The variations in incidence of deaths are much greater for LHB populations
than for Networks
For all deaths Conwy has the highest incidence at 1528 per 100,000
population and Cardiff the lowest at 958. That is a 59% difference.
For cancer deaths Conwy has the highest incidence at 375 per 100,000
population and Ceredigion the lowest at 247. That is a 52% difference.
These differences have an important effect on the palliative care resource
needs per head of population for both LHBs and Networks.
Table 3 – Presented at national levels
Wales
England
All Deaths
Cancer
Deaths
Cancer
deaths as
% of all
deaths
Ratio of all
deaths to
100,000
population
33,724
500,003
8,476
128,631
25.1%
25.7%
1161
1018
Ratio of
cancer
deaths to
100,000
population
292
262
Key points from Table 3




For all deaths the incidence per 100,000 is 14% higher in Wales than in
England
For cancer deaths the incidence per 100,000 is around 11% higher in Wales
than in England
These differences would suggest that Wales has a need for palliative care
resources per head of population that is higher than the need in England.
Some of the deaths due to causes other than cancer will be preceded by short
or no identifiable terminal periods. Some will be sudden deaths but many will
be preceded by a recognised period of predominantly palliative care need. It is
estimated that such deaths amount to about two thirds of non-cancer deaths i.e.
for Wales around 17,000 deaths annually. Together with cancer deaths
(8,476) there will therefore be around 25,000 people annually in the last year
of life who would benefit from palliative care, general and/or specialist.
PREVALENCE OF PROBLEMS/SYMPTOMS
By making use of some research findings about the prevalence of problems/symptoms
of people in the last year of life, it has been possible to estimate the prevalence for
people with cancer and other diagnoses for both individual LHBs and Networks. The
Table below provides such estimates at Network level.
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Table 4
Prevalence of Problems/Symptoms
Estimated numbers of patients in each Network population
Problem
Symptom
Pain
Trouble
with
breathing
Vomiting or
feeling sick
Sleeplessness
Mental
confusion
Depression
Loss of
appetite
Constipation
Bedsores
Loss of
bladder
control
Loss of
bowel
control
Unpleasant
smell
North
South East
People
with
cancer
People
with noncancer
People
with
cancer
People
with noncancer
South
West
People
with
cancer
1720
962
2690
1968
3261
1825
5021
3671
2112
1180
3481
2546
1045
1084
1980
2022
1281
1401
1045
677
1444
1526
1980
1281
2696
2847
1281
830
1870
1974
777
1455
1444
1526
1475
2758
2696
2847
955
1784
1870
1974
962
575
757
1285
562
1325
1825
1087
1436
2398
1049
2471
1180
703
930
1662
727
1714
513
883
969
1647
630
1142
389
521
737
974
477
675
People
with noncancer
Key points from Table 4




Each year over 18,000 are estimated to experience pain in the last year of life
Around 12,000 will have trouble with breathing
Over 9,000 will suffer from depression
There is no indication as to what proportion of these people will need care
from specialist palliative care services as opposed to receiving palliative care
from their usual professional carers.
7
PLACE OF DEATH
The Table below compares people’s preferences for place of death (according to
research findings) with actual place of occurrence of death.
Table 5
Preferred place of death compared with actual place of death
Place of
occurrence
Psychiatric
hospitals
Hospices
NHS hospitals
Non NHS
hospitals
Other
communal
establishments
Home
Elsewhere
Preferred
place of
death
)
)
)
)
)
Actual
place of
death –
North
Wales
Actual
place of
death –
South East
Wales
0.4%
0.6%
Actual
place of
death –
South
West
Wales
1.2%
Actual
place of
death –
England
&
Wales
0.5%
24%
11%
2.9%
59.9%
10.2%
2.6%
63.8%
8.0%
0.3%
59.0%
9.1%
4.3%
57.1%
10.3%
4%
8.1%
4.8%
7.1%
7.3%
56%
5%
16.3%
2.2%
18.2%
2.0%
20.9%
2.4%
18.3%
2.2%
Key points from Table 5






Non NHS hospitals includes hospitals and communal establishments for the
care of the sick e.g. nursing homes
All of the data about actual place of death has been taken from ONS Table 19
Deaths: area of usual residence and sex, by place of occurrence for 2002
The proportion of deaths occurring in hospices is significantly less than the
England & Wales average of 4.3%. However the Wales figures for hospices
do not include deaths occurring in NHS managed specialist palliative care
units e.g. Ty Olwen
The proportion of deaths occurring in NHS hospitals is higher than average
particularly in South East
The proportion of deaths occurring at home is low in North Wales when
compared with the average
Preferences for place of death are not being met for large proportions of
people across Wales
8
PROPORTION OF PEOPLE AGED 60 AND OVER
For palliative care a key factor is likely to be the numbers of older people in the
population and how that might vary across LHB and Network populations.
Table 6 – Proportion of people aged 60 and over
North
24.2%
South East
21.0%
South West
24.7%
Wales
22.8%
England
20.9%
Key points from Table 6


The proportion of people aged 60 and over in Wales is about 10% greater than
in England. This accounts for most of the differences in the annual incidence
of deaths per 100,000 population i.e. 14% higher in Wales
The proportion of people aged 60 and over in North and South West Wales
compared with South East Wales i.e. 16/17% greater, appears to account for
the higher incidence of deaths which is about 12% higher.
At LHB level Conwy has the highest proportion of those aged 60 and over (29.4%)
and Cardiff the lowest (18.3%). This variation largely accounts for the huge
difference in incidence of deaths between these two LHBs referred to above.
ETHNIC COMPOSITION AND RELIGION OF THE POPULATION
Analysis of 2001 Census data has been undertaken in order to establish whether there
are any numerically significant minority populations within the Networks. If there
were then there may have been implications for the level of palliative care resource
needed. The outcome of the analysis is as follows:



North Wales – There are no numerically significant ethnic or religious
minority groups
South East Wales – There are numerically significant Asian Groups in Cardiff
(4%) and Newport (2.6%) and a Black Group in Cardiff (1.3%). However, it
is not considered that any palliative care resource implications arise.
South West Wales – There is a numerically significant Asian Group in
Swansea (1%) but it is not considered that any palliative care resource
implications arise.
LIVING IN HOUSEHOLDS
Analysis of 2001 Census data has been undertaken in order to establish whether the
proportions of single pensioner and other pensioner households reflect the variation
in data about incidence of deaths and the age structure of LHB and Network
populations. The outcome is that the variations found in the proportions of pensioner
households is generally reflective of the other data. For example the highest
proportion of pensioner households is to be found in Conwy and the lowest in Cardiff.
There are therefore no palliative care resource implications arising that may be
additional to those that may arise from the variations in annual incidence of deaths.
9
ECONOMIC AND SOCIAL DEPRIVATION
Reference is made in the introduction to this report to the significant effect of
economic and social deprivation on the palliative care resource needs in different
populations. In the individual Network assessments, use has been made of the Welsh
Index of Multiple Deprivation for measuring the relative deprivation between the
LHB populations in each Network. The methodology for using the Index as a
modifier to an Index derived from annual incidence of deaths from cancer and other
causes is described in detail in the reports for the individual Networks. Similar
methodology has been employed to compare the palliative care resource need for each
of the three Wales Networks one with another. The results of that are set out in the
Tables below.
Table 7
Index of Comparative Need for Network Populations – for people with cancer
Network
Cancer
deaths per
100,000
Index
value
Deprivation
modifier
Modified
Index
Value
Network
need index
value
Effect on
resource
need
North
307
278
295
100
90.6
96.3
1.32
1.44
1.39
132
130.4
133.8
101
100
103
+1%
+0%
+3%
South East
South
West
Key points from Table 7



The Network deprivation modifier is derived by population weighting the
average of Electoral Division (EDiv) scores for all the LHBs within each
Network. The average of EDiv scores are taken from the Welsh Index of
Multiple Deprivation
There is very little difference in the palliative care resource needs per head of
population for each Network. At most there is a 3% difference between South
West and South East
Within the Networks there are very large differences in resource need per head
of population between LHB populations. In the North, Anglesey and Conwy
have a 53% greater need than Flintshire. In the South East, Blaenau Gwent
has a 121% greater need than Monmouth. In the South West, Neath Port
Talbot has a 76% greater need than Ceredigion.
10
Table 8
Index of Comparative Need for Network Populations – for people with diagnoses
other than cancer
Network
2/3 non
cancer
deaths
Deaths per
100,000
Index
Value
Deprivation
Modifier
Modified
Index
Value
Network
Need
Index
Value
Effect on
Resource
Need
North
4015
7492
5194
601
536
610
98.5
87.9
100
1.32
1.44
1.39
130.0
126.6
139
103
100
110
+3%
+0%
+10%
South East
South
West
Key points from Table 8



There is little difference in resource need per head of population as between
the North and South East Networks.
The South West Network has a 10% greater resource need per head of
population than South East and 7% greater than North.
Within the Networks there are very large differences in resource need per head
of population between LHBs. In the North, Conwy has a 68% greater need
than Flintshire. In the South East, Blaenau Gwent has a 132% greater need
than Monmouth. In the South West, Neath Port Talbot has a 82% greater need
than Ceredigion.
It is also considered useful to benchmark palliative care need at Network level with
the 34 Cancer Networks in England. One important reason for doing that is that the
assessment of the volumes of core service components is dependent at least in part on
comparisons with current average provision across England.
Comparison with the Cancer Networks in England does present problems in that the
Welsh Index of Multiple Deprivation differs in important respects from the Index
used in England i.e. IMD 2000 and more recently IMD 2004. However, despite that,
it is possible to make a broad assessment of whether deprivation levels in Wales are
on average greater or lesser than in England. In Wales 23% of LHBs have average
scores, according to the Welsh IMD, that are above the mid-point of all LHB scores.
In England the proportion of Primary Care Trusts that have IMD 2004 scores above
the mid-point of all PCT scores, is 17%. This would suggest that, on average,
deprivation is greater in Wales than in England.
After taking that into account together with the generally higher incidence of deaths
than in England, it is possible to draw some conclusions about the level of resource
need in the Wales Networks as compared with the average Cancer Network in
England.
North Wales Cancer Network
The annual incidence of deaths from all causes is about 19% above the England
average and from cancer it is about 17% above. This factor alone would suggest that
11
palliative care resource need for this Network would be some 15/20% higher than for
the average Network in England. Deprivation levels in North Wales are lower than in
Wales as a whole. Taking all that into account it would appear reasonable to conclude
that palliative care resource need per head of population would be at least 15% above
the England average.
South East Wales Cancer Network
The annual incidence of deaths from all causes and from cancer alone is about 6%
above the England average. This factor alone would suggest that palliative care
resource need for this Network would be about 6% higher than the average Network
in England. Deprivation levels in South East Wales are higher than in Wales as a
whole. Taking all that into account it would appear reasonable to conclude that the
palliative care resource need would be about 10% above the England average.
South West Wales Cancer Network
The annual incidence of deaths from all causes is about 18% above average and from
cancer it is about 12% above average. This factor alone would suggest that palliative
care resource need for this Network would be about 15% higher than the average
Network in England. Deprivation levels in South West Wales are about average for
Wales as a whole. Taking all that into account it would appear reasonable to conclude
that the palliative care resource need for cancer would be about 15% above the
England average and for other diagnoses about 20% above.
These conclusions about comparative resource need have been employed in the
calculation of the estimated volumes of each service component that may be required
to meet assessed need.
12
ALL WALES SUMMARY OF RESOURCES NEEDED
COMPARED WITH RESOURCES AVAILABLE
SPECIALIST PALLIATIVE CARE BEDS
Numbers of Beds
The Table below shows the numbers of specialist beds assessed to be required for
each Network compared with the number of beds available.
Table 9 – Specialist palliative care beds needed and available
Network
North
South East
South West
TOTALS
Cancer
Beds Needed
38
77
49
164
Beds
Available
33.75
57
41
131.75
Non-cancer
Beds Needed
19
38
25
82
Beds
Available
1
1
2
4
Key points from Table 9





There is an apparent deficit of around 32 beds for people with cancer
There is an apparent deficit of around 78 beds for people with other diagnoses.
However it should be noted that the estimate of need for 82 beds is a tentative
assessment.
In the North 18 of the beds currently available do not meet the criteria for
specialist beds.
In the South East there is some flexibility in the numbers of beds available
over and above the 57 available in that some beds at Velindre are used for
specialist palliative care.
In the South West many of the beds available do not currently meet the criteria
for specialist beds.
Access to Beds
Access to beds does not in general reflect the differential needs of the LHB
populations within the Networks. The following points are made in respect of each
Network.
North Wales Cancer Network
Anglesey and Gwynedd have poor access to available beds compared with the other
LHB populations.
South East Cancer Network
Blaenau Gwent, Caerphilly and Monmouth have very poor access to available beds.
In contrast Bridgend, Cardiff and Vale of Glamorgan enjoy high levels of access. It is
13
no coincidence that the largest in-patient units with over half of the Network beds lie
in or close to these areas.
South West Cancer Network
Detailed analysis of access has not been possible for this Network. However it is
clear that the populations of Ceredigion and Powys have very poor access to specialist
palliative care beds.
Staffing of Beds
There at least 5 units with no input from consultants in palliative medicine.
The ratios of nursing staff to beds varies from 1.2 in Ty Olwen up to 3.42 in St.
David’s Hospice in North Wales.
In respect of staffing other than medical and nursing there are gaps more or less
everywhere against the recommendations of the NICE Guidance on Supportive and
Palliative Care. The gaps appear particularly widespread in the South West.
Use of Beds
There are large variations in the way in which beds are used. Some of these
variations may be justified but others may not be. The most significant variations are
as follows:



Average length of stay varies from 9 days up to 19.6 days i.e. more than 100%
difference. Nationally average length of stay is 12.7days.
Bed occupancy varies from 51% up to 96%. Most observers would expect 80
to 85% to be achievable. Only one third of the units in Wales manage to do
that.
Nationally, the ratio of deaths to other discharges is 1.09 i.e. there are slightly
more deaths than other discharges. Across the units in Wales the ratios vary
from 0.52 to 2.38
14
SPECIALIST PALLIATIVE COMMUNITY CARE
Numbers of staff required
The Table below details the estimates of medical, nursing and other staff required for
specialist palliative care community teams across Wales.
Table 10
Staff requirements for specialist palliative community care
Network
Consultant
in
palliative
medicine
CNS in
palliative
care
Social
Worker
Physiotherapist
Occupational
therapist
Pharmacist
Dietician
Chaplain
North
1.6
3.1
19
37
0.6
1.2
0.6
1.2
0.6
1.2
0.6
1.2
0.6
1.2
0.5
0.9
2.0
24.5
0.8
0.8
0.8
0.8
0.8
0.7
6.7
80.5
2.6
2.6
2.6
2.6
2.6
2.1
South
East
South
West
TOTALS
Key points from Table 10






Comparison of available numbers of consultants with the estimated
requirements is dealt with below in the section on medical staff for all service
components
The North has 12.1 CNSs available and therefore has a deficit of 9 CNSs.
The South East has 47.1 CNSs available and consequently has an apparent
excess of 10 CNSs. The Network has been recommended to give
consideration as to whether these additional numbers can be justified.
The South West has 16/17 CNSs available and therefore has a deficit of 8/9
CNSs
For Wales as a whole there is a net deficit of 7/8 CNSs but for the North and
the South West there is a combined deficit of 17/18 CNSs.
It did not prove possible to obtain precise data from all teams on the WTE
currently available for the other professions. However, information has been
collected on whether there is any input into each team from the other
professions. The conclusion from that is that most teams cannot yet be
described as full multi-professional teams as recommended by the NICE
Guidance.
The estimated staff requirements do not take any account of either the implementation
of Agenda for Change nor the new arrangements for provision of out of hours general
practitioner services. It is considered that the effects of the implementation of these
initiatives cannot yet be firmly assessed. It will however be necessary to do that at
some future point.
15
Access to Specialist Palliative Community Care
In general access to the specialist community teams does not reflect the differential
needs of the LHB populations within each Network.
North Wales Cancer Network
Denbighshire has relatively poor access compared with assessed need. On the other
hand it has relatively high access to specialist beds. There may well be a trade-off
between volumes of beds and community services i.e. high availability of beds may
mean less need for community services and vice-versa.
South East Wales Cancer Network
Monmouth has very high access to specialist palliative community care i.e. 137%
more than that required to reflect differential LHB need. Torfaen also has more
access than the needs assessment would suggest. However, as in the case of
Denbighshire referred to above, both Monmouth and Torfaen have poor access to
beds.
South West Wales Cancer Network
It has not been possible to undertake the same kind of analysis of access to services as
in the other two Networks but it is clear from the current distribution of CNSs that it
is most unlikely that current access does reflect the differential needs of the LHB
populations. For example, it is assessed that the Swansea/Neath Port Talbot part of
the Network has a deficit of 8 community-based CNSs.
Team availability
There is considerable variability in the extent to which teams currently provide
services out of hours. There are few teams that can provide direct assessment and
care from 9 to 5 at weekends. There is greater provision of 24 hour telephone advice
but there are still large gaps particularly in the South West Network.
There appear to be two main problems in extending out of hours services:


There are too few consultants in palliative medicine to provide adequate
coverage for all parts of Wales.
Most teams are not of a threshold size that would enable the CNS members of
the team to provide an out of hours service. The small numbers in each time
cannot cover 24 hours seven days per week.
There may however be some ways in which the second of these problems can be at
least partly addressed. In the South West there are 7 individual community services,
in South East there are 7 and in the North only three. In the latter case the three teams
provide services, as one element of a total specialist palliative care service, to paired
LHB populations. There would appear to be much scope for similar action in the
other two Networks and specific suggestions in that regard have been made to the
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South West Network. The combining or merging of teams to serve two or more LHB
populations would create larger teams and thus make it less difficult to provide out of
hour services. It may also improve integration of local services and thus enhance
continuity of care.
In some areas of the South West and the South East there do not appear to be clearly
defined catchment areas with different teams providing services to the same LHB
populations. The introduction of the concept of a single integrated specialist
palliative care service for two or more LHB populations would eliminate such
practice.
PALLIATIVE CARE DAY THERAPY
The Table below shows the number of day care places assessed to be needed
compared with the number currently available.
Table 11 – Day care places needed and available
Network
North
South East
South West
TOTALS
Places needed per
year
10,000
20,000
13,000
43,000
Places needed per
week
200
400
260
860
Places available
per week
204
350 to 400
175
729 to 779
Key points from Table 11


The number of places available in the North and South East match the
assessed need.
The number of places available in the South West is about two thirds of the
number assessed to be needed.
Access to Day Care
North Wales Cancer Network
Current access does not reflect the differential needs of the LHB populations.
Gwynedd has very poor access whereas Conwy and Denbighshire enjoy much greater
access than is suggested by the needs assessment.
South East Wales Cancer Network
The analysis could not be completed due to a lack of data from one provider.
However, it is unlikely that access does reflect the differential needs of the LHB
populations.
South West Wales Cancer Network
Insufficient data has been collected to enable any substantive analysis to be
undertaken.
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Models of Day Care
There is much evidence form the current make-up of day care staffing to suggest that
there may be several different models of day care currently being offered. For
example medical input is available in some services but not in others. Similarly, there
are some services that do not have any nursing staff at CNS level. The availability of
other professional staff is also patchy.
The advice given to each Network is that it will be essential for the Network to
consider and agree what the objectives of local service provision should be and what
types of intervention should be offered. This would be necessary in order to ensure
equitable access to day care across the Network.
Current Use of Day Care Places
There is much variation in the extent to which day care places are used.


The percentage take-up of available day care places varies from only 34% up
to 94%. In general take-up is poor and constitutes an inefficient use of
resources, both staffing and physical.
The total number of new patients gaining access to day care is around 1,300
which is about 15% of annual cancer deaths in Wales. It does therefore play a
comparatively minor role in supporting people with cancer.
SPECIALIST PALLIATIVE CARE HOSPITAL SUPPORT TEAMS
Numbers of Staff Required
An assessment has been made for each Network which is based on the number and
size of acute hospitals in each Network. The Table below shows the numbers of
medical, nursing and other professional staff required for each Network. It also
shows the numbers of CNSs currently available.
Table 12 – Hospital Support Team staffing requirements
North
South East
South West
TOTALS
CNS at G & H
CNS available
9
5.6
20
15.5
17
8/9
46
29/30
Consultants
Other Medical
Social Worker
Physiotherapist
Occupational
Therapist
Pharmacist
Dietician
Chaplain
2.5
2
2
1
1
5.5
4.5
4.5
2.25
2.25
4.5
4.0
4.0
2
2
12.5
10.5
10.5
5.25
5.25
0.45
1
0.45
1
2.25
1
0.85
2
0.85
2.3
5.25
2.3
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Key points to note from Table 12


There is a deficit of around 16/17 clinical nurse specialists in palliative care.
Insufficient data was provided to enable any conclusions to be drawn as to
whether input from professional staff other than nursing and medical was
adequate. Information has however been collected about whether there is any
input into individual teams from other professions. This shows that there are
few teams that approach compliance with the NICE recommendations about
professional composition of teams.
Team availability
There is no provision for direct patient assessment and care at weekends in hospitals
in the North and South West Cancer Networks. In the South East there is provision at
3 of the Network’s nine hospitals.
24 hour advice is generally available on a doctor/doctor basis across the South East
but is not generally available in the South West or the North.
The suggestions made above (in the section on community care) about the potential
benefits of combining community and hospital teams are also relevant to solution of
the problems in providing out of hours cover by hospital support teams.
NETWORK MEDICAL STAFF
An assessment has been made of the medical staff requirements for each of the
Networks. This has been built up from the requirements of each of the four core
service components. The Table below provides a summary of those requirements. It
also shows the current availability of medical staff.
Table 13 – Medical staff required and available
Network
North
Required
Consultants
6.1
South East
12.7
South West
TOTALS
9.1
27.9
Available
Other medical Consultants
6.8
2.0 + 1
vacancy
14.2
6.2 + 1
vacancy
9.1
4.0
30.1
12.2 + 2
vacancies
Other medical
6.4
12.4
5.0
23.8
Key points from Table 13


There is an apparent deficit of 13/14 consultants in palliative medicine. The
number currently in post is less than 50% of the estimated requirement.
There is an apparent deficit of around 6 WTE other medical staff
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GENERAL PALLIATIVE CARE SERVICES
It is acknowledged in each of the three Network assessments that most palliative care
is and should be provided by all health and social care professionals as a routine,
integrated part of their normal professional practice. There are therefore no separately
identifiable ‘core service components’ for general palliative care services. The
availability of these services is not in consequence dependent on the assessed level of
need as set out earlier in this report. Quite simply all health and social care
professionals who contribute to the assessment, treatment and care of all those with
advanced disease (not just cancer) should be able to:



Assess the palliative care needs of each patient and their family across the
domains of physical, psychological, social, spiritual and information needs
Meet those needs within the limits of their palliative care knowledge, skills
and competence
Know when and how to seek advice from or refer to specialist palliative care
services
The task for the Cancer Networks and the NHS generally is to take actions that will
enhance the ability of health and social care professionals to do that. The NICE
Guidance recommends the introduction of specific mechanisms that will tend to
facilitate that.
Each primary care team should have:

Introduced the Gold Standards Framework into the team’s practice or
introduced an alternative mechanism that can produce similar benefits for
patients and families
In addition each primary care team and hospital team (in all specialties) should have:

Introduced the Integrated Care Pathway for the Dying Patient into the team’s
practice or introduced an alternative mechanism that can produce similar
benefits for patients and families
In addition to GSF and ICP services may also wish to consider the introduction of the
tool for ensuring Preferred Place of Care that has been developed in the Lancashire
and South Cumbria Cancer Network.
SERVICES FOR PEOPLE WITH DIAGNOSES OTHER THAN CANCER
Each Network has been provided with estimates of the prevalence of problems in
patients with progressive non-malignant disease. The estimated number of people
with each problem ranges from about the same number as people with cancer to well
over twice as many. Yet nationally only about 5% of all access to specialist palliative
care services is by people with non-malignant disease. It is therefore probable that
any expansion of services to provide increased access would be justified. On the
other hand it would be grossly simplistic to argue that the current core services should
be doubled in size to allow access for the non-cancer group at a level comparable with
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that for cancer. There is currently little agreement, let alone evidence, about what
models of service would be appropriate for the other principal disease groups.
In consequence the advice given to the Networks is along the following lines:



At least maintain current levels of access to services by people with nonmalignant disease
Develop ways of enhancing the palliative care knowledge and skills of the
general health and social care workforce e.g. as described in the section above
on general palliative care services.
Develop any discrete services incrementally in collaboration with other
specialties e.g. cardiology, respiratory medicine
OTHER OBSERVATIONS
Services for Mid-Wales
In the vast geographical areas of Ceredigion and Powys there is currently no palliative
care service that meets the definition of a specialist level service. Solutions to this
problem remain elusive. It may be that services need to be co-ordinated and
supplemented from centres that lie outside the area – from South Wales, from North
Wales and from England. It was suggested in the report for South Wales that a
workshop needed to be set up with participants from all the interested parties to
explore potential solutions. The South West Network has picked up that suggestion
and has organised workshops for both Ceredigion and Powys. These are to take place
in October and December.
Data Recording and Collection
Some services have experienced difficulties in providing the service mapping data
that was required for the needs assessment process. It is suggested that each Cancer
Network should consider what action needs to be taken in order to ensure that the data
required for this exercise can be readily available in the future. The availability of
data on a routine basis would not only enable service development and activity to be
monitored by the Networks on a continuing basis but also facilitate the updating of the
needs assessments as and when required.
October 2005
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