Abstract

The challenge for Lincolnshire reflects that of most of the NHS. In spite of our best efforts our current model does not always deliver the highest quality safe services. Demand for services are increasing, associated with an increasingly aged population with multiple comorbidities and associated complexities. There is a national shortage of appropriately trained and skilled staff, compounded in Lincolnshire with increased challenges in recruitment. We need to look at a way of delivering services that is less reliant on secondary care. We need to stop duplication of services and move away from the traditional reactive model of care the NHS was designed to deliver, to a service model that recognises the biopsychosocial determinants of health and is therefore a more holistic proactive model. Delivered seamlessly by a multi- agency, multidisciplinary team working together to achieve person centred outcomes.

Lincolnshire has adopted a Neighbourhood Team (NHT) model of working that reflects the proactive model of care described by NHS England’s House of Care policy – A framework for long term conditions. One of the priorities has been to look at the provision of very end of life care in the last 12 weeks of life. To enable improved use of resources and coordination between services, to deliver care that is truly person-centred. At the end of life, time is precious. Loved ones’ feedback is that services often feel uncoordinated, and the numbers of seemingly duplicated visits by different services can be overwhelming.

One Neighbourhood Team has chosen to audit and review the delivery and coordination of end of life services in the last 12 weeks of life, with a view that this will also positively influence closer collaboration and improved outcomes for all people. The poster presentation outlines our work and achievements.