Supporting the NHS using intense transformational change in a charitable specialist palliative care provider

Editor – We share learning from our intense transformational change experienced during lockdown.

Following the 16 March 2020 announcement, we began urgent preparations to play our part to meet the needs of patients approaching the end of their lives with both COVID-19 and non-COVID-19 terminal illness. Our aims were to protect the NHS and remain true to our charitable mission of caring compassionately for adults with terminal illness.

We responded with pace by redistributing the workforce within our three service areas (inpatient unit, living well and care at home; see supplementary material S2).

On our inpatient unit, we adapted our referral scoring system to favour admissions from hospitals to release acute beds, however our local integrated care system designated our ward as a ‘cold site’, due to the layout and its impact on infection control. By redeploying staff from other areas, we safely opened previously closed beds. Isolation rooms were created, with an adjacent personal proctective equipment gowning room.

We drastically reduced visiting hours for all but the imminently dying, so families were connected by daily calls from the multiprofessional team. We also used creative ways to connect patients and families, emotionally and spiritually, by shared objects including decorated pebbles, carved crosses and candles, as well as using video messaging.

The patient and carer group sessions, which our living well service would normally provide, were adapted to video calls. The data in Table 1 shows a dramatic change from traditional face-to-face contacts during the pre-COVID-19 era, to telephone support and video conferencing during lockdown.

The crisis required an expansion of our care at home service to support patients at home and in nursing homes. The advice and referral team increased its hours of operation from 8am–6pm to 8am–10pm. The capacity for weekend specialist advice and care was enhanced with consultant weekend domiciliary visiting to support clinical decision making and end-of-life prescribing. Our hands-on nursing team (hospice care at home) launched a night visiting service. The care at home data for face-to-face dropped during the first month of lockdown, but bounced back in May, reflecting these additional service developments (Table 1).

The patient and family support team offered practical support through the care after death processes, emotional support via counsellor and a virtual funeral recorded by our chaplains.

The education team developed several free e-training modules on COVID-19, advance care planning and identification of frailty to support colleagues in discussing ceilings of care, do not attempt cardiopulmonary resuscitation and end-of-life care planning. These were taken up well by nursing homes.

Investments in leadership and team working, made over the preceding 2 years, paid dividends in being able to deliver change rapidly. With the government's £200 million support to hospices nationwide and using our reserves, together with generous contributions from our supporters, some of whom funded specific responses to COVID-19, we have been able to meet the additional costs of service development. We were also indebted to our staff for their positive ‘can do’ attitude.

Learning and refining as we go has been a theme. The changes we made opened our eyes to new ways of working. Teleconferenced meetings and video calls to patients have been exceptionally well received. We have worked hard in the past to break down staff silos, and these melted away as staff found themselves working in new areas.

Having faced and overcome the issues at the peak of the pandemic, we are certainly not complacent as we consider preparations for a possible second wave this coming winter.

• © Royal College of Physicians 2020. All rights reserved.