Table 5 Key points for improving services
Problem identified | System change recommendation |
|---|---|
Burden on client and family from multiple professional contacts | Link worker as a single point of contact to help navigate between services. Will provide advice, training, support and referral routes |
Lack of early identification of palliative need and poor understanding of client reluctance and lifestyle | Community of Practice between services |
Divergence of values and philosophies between services | Key performance indicators based on client needs, not service function |
Extensive routes to palliative care | Clear pathways options, supported by link workers and community of practice |
Limited community options for care and place of death preference not available | Hostel and housing provision to support those in palliative care; bespoke hostel/care accommodation |
Fragmented services and poor inter-agency communication | longer-term service commissioning to establish lasting care pathways and networks. Integrated Care Systems to include voluntary sector organisations, with shared information and joint working |