Case study:

10 March 2009

Integrated Palliative Care at Home Service in Knowsley

Key points

For the past four years Knowsley’s Integrated Palliative Care at Home Service has provided a holistic and seamless care pathway for adult patients suffering from cancer and other life-limiting conditions.

The service, for patients deemed to be in the last six months of life, encompasses health, social, domiciliary and personal care. The model of integrated health and social care reduces duplication across the sectors and provides a person-centred approach to providing supportive and palliative care.

So far 350 patients have been referred to the service, which aims to support carers, reduce the potential for carer breakdown and help people die in their preferred place of care.

The feedback from service users has been positive. Patients and carers referred to the service said their identified needs were met. In the last year 68% of patients died at home.

The initial driver for change came from personal experience. One of the staff’s relatives experienced uncoordinated care when they were dying. An assessment of the population of Knowsley suggested there were around 450 people dying of cancer and 850 dying from other causes each year. All of these people might require supportive and palliative care services.

The plan was to develop a new worker who could address all the patient’s needs , whether health, social or personal care – in one intervention. A multi-agency strategic steering group was set up and patients and carers then undertook a mapping exercise of existing services. This process identified the key requirements for supporting patients to die at home, if this was their preferred place of death.

The service began as a pilot in May 2005 funded through the New Opportunities Fund. Originally it consisted of four Health and Social Care Workers, a Registered Nurse, a Project Co-ordinator and part time administrative support. At the end of the three year project the model was reviewed and mainstreamed to integrate with District Nursing teams who are co-located with Social Workers. The service operates every day of the week with flexible working hours reflecting patient and carer need. It is supplemented by an in-house night sitting service which provides overnight respite breaks for carers.

The service is now managed by the District Nursing Team Managers. Referrals into the service are accepted from health, social care, primary, secondary care and third sector. In managing the transition from a project to a mainstream service the nursing auxiliaries have embraced modernisation of provision and are now working to the new role of Health and Social Care Worker. This has resulted in increased capacity and continuity in the delivery of Integrated Palliative Care. This supports local strategies to increase the use of quality tools at end of life.