A Health Caring Powys: a Strategy for 2017-2027

The document ‘Healthy Caring Powys’ promotes a more holistic way of supporting people by working together more effectively, through multiple levels of integration. For example NHS and social care, physical and mental health and via secondary and primary care.  

Powys ACP Project Group

An Advance Care Planning/Future Care Planning mapping exercise took place this year.

A Powys ACP project group has been formed with aim of:1. Development of ACP document2. Involvement and engagement of key stakeholders3. Development of education/guidelines/communication skills training

There are GP EOL facilitators and Macmillan lead nurses for EOL planning, all with a role to support ACP/FCP.

Current Work: 1. Appointment of 2 Macmillan GP EOL facilitators for 2 sessions a week each. They have been doing some ACP education sessions within Primary Care2. Appointment of 2 Macmillan Lead nurses for EOL care planning who will start in September. They will lead on education to support ACP across the HB3. ACP Workshop held in June for key professionals , facilitated by Dr Ros Johnson. The afternoon looked at what we need to do to take forward ACP in Powys and an action plan is in development.4. Marion Baker has held a workshop looking at end of life delivery and pulling together multiple professionals working in all areas to share knowledge/ideas and set standards of care . From this there plan to be working groups looking at a POWYS templates to distribute for ACP/advance decisions to all teams5. ACP has been included in the recent palliative care degree module delivered in Powys in 2018.6. Palliative care link nurses have had a session on ACP7. We are partnered with Byw Nawr and have held public awareness events each year8. The palliative CNS team support monthly palliative MDTs with GP practices for all patients on the palliative care register where elements of ACP are discussed and actioned9. The palliative CNS team have been working closely with other chronic conditions CNSs to support them to incorporate ACP conversations into their practice.10. The ACP section of CaNISC is completed for all patients on the specialist palliative care caseload and can be accessed by WAST11. Patients at EOL are flagged to Shropdoc and ACP plans are shared.

Future plans:1. Develop an all Powys document2. Develop an education plan to support roll out of ACP document3. Explore the development of treatment escalation plans in Powys4. Further public awareness events throughout the year5. Delivery of the 6 steps education programme in Powys care homes which will include support with ACP