Our end of life care projects

The problem

A lack of coordination in care meant people who were dying were spending longer in hospital than was wanted or needed. 

The impact a social outcomes contract enabled

A care coordination hub was set up to ensure people and their carers could be supported outside hospital where possible. 

From Apr 2020 to Mar 2022, 73% of patients accepted into the hub who died, were able to reduce their hospital activity in their last year of life.

The problem

People in Somerset did not all have the same access to advance care planning – a process where you discuss and record what sort of care you would like in future. It can help ensure people get the treatment they would prefer for serious illness and at the end of their lives.

The impact a social outcomes contract enabled

Specially trained volunteers helped patients to make an advance care plan (ACP) and signposted them on to GPs or other services when needed. 

After one year the service had 860 referrals and completed 55 ACPs. 

The problem

Care home residents were going to A&E more than was necessary when staff were unable to get the medical support they needed for residents in other ways.

The impact a social outcomes contract enabled

A telemedicine support service was provided for care home staff to ensure high quality, safe and personalised care that promotes dignity and choice for all residents. 

This led to a 28.7% reduction in emergency admissions from care homes across the project, which started in December 2018.

The problem

People in Hillingdon were not able to die in their preferred places due to a lack of community-based support.

The impact a social outcomes contract enabled

A rapid response service was created to assess patients’ needs and trigger services to support them within two hours of referral – in the community where possible.

This model of care supported 2,275 patients in the community, of which 90% have been able to die in their usual place of residence.

The service has been sustained in Hillingdon since the end of our period of social investment in August 2021.

The problem

Residents in Waltham Forest were spending more time in hospital, and more people were dying in hospital rather than at home due to limited community-based support.

The impact a social outcomes contract enabled

A programme was set up to bring together local services and organisations working in end of life care. This was done through developing an education strategy, a system-wide dashboard, a steering group and increased use of advance care plans.

This successfully and sustainably unified end of life care in Waltham Forest, leading to a reduction in unplanned hospital activity from care homes – in 2020 this was 11.2% lower than in the previous 12 months.

The problem

People in nursing homes in Haringey were more likely to have emergency admissions to hospital in their last year of life.

The impact a social outcomes contract enabled

The Facilitator aimed to proactively identify residents in two nursing homes in Haringey who were approaching the end of their life, have discussions and document their wishes about their future. 

Emergency admissions into hospitals were reduced by 14%. And 94% of people who were admitted with an advance care plan were admitted in line with their wishes. 

The problem

People living in inner city Bradford were experiencing health inequalities at the end of life. Services needed to be more visible and accessible to some groups.

The impact a social outcomes contract enabled

An emergency assessment community team was created to enable more equal access.

Firstly, a specialist palliative care presence was created in A&E to help identify end of life patients and influence how their care was managed, avoiding hospital where possible.

Secondly, a rapid response community service was created to receive patients discharged from A&E and provide care for up to 72 hours until mainstream services can be mobilised.

As of the end of September 2022, of 103 referrals into A&E, 66 people were discharged into the community without needing to be admitted. 

The problem

The impact a social outcomes contract enabled

The RIPEL programme aims to address this by providing enhanced care and support for people at end of life through four interrelated services:

• Home Hospice to support people at home in the last two weeks of life
• Community Rapid Response to provide immediate crisis support in the community
• Hospital Rapid Response to assist early supported discharge for those dying in hospital
• Enhanced Palliative Care Hub to provide out-of-hours advice, support and coordination. 

We’ve supported over 500 people in the first year to achieve a better end of life through Home Hospice and Hospital Rapid Response. The Hub’s telephone support line (9am-5pm) for all, launched in July this year and the final stage is the Palliative Care Crisis Team to support people in crisis at home.

The problem

People were not able to die in the place and setting of their choice due to gaps in community services in the Highlands. 

The impact

An enhanced Palliative Care Helpline has created a simplified and single point of access both for individuals and professionals. The service provides access to advice and coordination of care for people in their last year of life in North Highlands. Since launch in May 2023, there has been significant demand for in hours support but also an increase in engagement with the helpline out of hours.

A Palliative Care Response Service launched in January 2023 in Inverness. It provides supported discharge from hospital and access to care at home for people in their last year of life. Of 74 referrals from January to June 2023, 87% went on to have a care visit. 39 service users were supported to die at home, with only three referred onto acute settings.

The programme is delivered through the End of Life Care Together partnership.