Bromley Care Coordination (BCC) was commissioned by Bromley CCG in December 2013, to enable patients with advanced illness or frailty, thought to be in the last year of life, to receive timely and coordinated care. The need for the service was identified through working closely with GPs and commissioners to address inequalities in dying, these patients might not have previously met the referral criteria for Specialist Palliative Care. The service aims to help people die with dignity in a place of their choice and reduce unnecessary hospital admissions.

Its design acknowledges the changing shape of the Bromley population, notably its ageing population. The number of people aged 65 years plus is set to grow by 14% by 2021. In 2012 only 19.3% of Bromley residents died at home.

Patients are given a high quality assessment at home of their health and social care needs and discussion about advance care planning and resuscitation if appropriate. An appropriate ‘key worker’ is identified and referrals are made to other services in the borough as necessary. Those under the care of BCC and their families have access to 24 h telephone advice. If the patient’s needs increase and become more complex they can easily be transferred to the St Christopher’s specialist palliative care community service. Otherwise they are monitored and followed up by the skilled team within BCC, who will help provide care at home when someone is dying as necessary.

In the last year there have been 391 referrals with 176 deaths, of which 86% were at home. 87% of patients had a non-malignant diagnosis or frailty. Early data from the local hospital confirms a much reduced level of readmission to hospital for BCC. Informal and formal feedback from users indicates high level satisfaction with care and the opportunity to remain at home.