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Working together for End of Life Care

Over the last year, the three CCGs within the Frimley Health and Care Integrated Care System (ICS) have been working closely together to align End of Life Care (EOLC) across the area.

Last year at a regional NHS England EOLC event, Frimley Health and Care colleagues began conversations that naturally concluded that it would be a good time to create a single EOLC strategy, one that would be designed and implemented across all of the Frimley Health and Care organisations.

North East Hampshire and Farnham CCG’s lead for EOLC, Rosie Fowler said: “It’s taken us a bit of time to get there; we had a lot to do. We originally started looking at each other’s strategies and soon found that we were facing the same challenges, and that we all wanted to achieve the same things…so it was all systems go from that moment on.”

The EOLC team held events to speak to carers’ and gain their insight into what it’s like to care for someone who is approaching the end of their life, in the local area.

Frimley Health and Care EOLC teams were keen to listen to the carers’ experiences of the local services; the good and the bad, and to learn if there were any gaps in those services, and then to work out how things should change for services to be improved.

This process was invaluable and has been instrumental in helping create the new strategy and how services should change.

The next developmental step was to appoint clinical and managerial chairs for the new ICS steering group.

Camberley MacMillan GP and Clinical Lead for Cancer, EoLC and Frailty at Surrey Heath CCG, Dr Emma Whitehouse, was appointed as the clinical chair of the ICS End of Life Care Steering Group. Jo Greengrass, Associate Director of Quality and Nursing at East Berkshire CCG was appointed as the managerial chair.

Following these key appointments, the team underwent a self-assessment programme, based on the National Ambitions for Palliative and End of Life Care, the national framework which health and care organisations should aim to achieve.

Areas for improvement included the requirement to unify and digitalise processes across organisations, such as DNACPR (Do not resuscitate notice) and Advance Care Plans.
Currently, there are multiple different paper versions of these documents across the system. The Self-Assessment also highlighted a need for a consistent training offer.

Following a successful launch event earlier this year, more than 25 local healthcare professionals gathered to provide their input into the design of the ICS End of Life Care work plan for 19/20. After detailed discussions, a vote was held, and agreement reached for the following key areas to be the ICS’s EOLC priorities for the next six months:

The top 5 priorities for Frimley Health and Care End of Life Steering Group:

  • The development of a ‘Patient Passport’ – Clear information and expectations about local palliative and end of life care services – a way for patients to navigate and understand the system.
  • A training and education strategy – (including advanced communications; 5 priorities of care; paid carers and nursing homes), based on an understanding of existing accessibility to training and education.
  • Access to 24/7 specialist symptom control and advice for patients/carers, and rapid response nursing in Frimley South – learning from Frimley North Rapid Response model for EOLC.
  • Development of a Frimley ICS Directory of Services and creation of an online presence.
  • Development of a single, electronic Advance Care Plan


This early success generated by the EOLC steering group has resulted in end of life care having greater visibility across Frimley Health and Care organisations; and provides a single point of contact, where professionals can liaise and collaborate with each other.  A place where colleagues can link together and work towards a single agreed approach for this very important area of work.

Rosie added: “This approach means we will be consistent in what we do. We won’t have different areas working in different ways.  We will now begin to align End of Life Care across the ICS, and that’s great news for patients.”

Emma and Jo are ably supported by each of the CCG EoLC leads. This includes Cyane Sullivan from Surrey Heath CCG, Rosie Fowler from North East Hampshire and Farnham CCG, and Surinder Jassal from East Berkshire CCG.

Surinder has recently been welcomed to the team, taking over from Jenna Gilkes. This tight knit team works together to foster the relationships with partners and drives the agenda forward to improve care and support for people, at end of life, their families and carers within our ICS population.

Frimley Health and Care