Our developing model of care

A core and common offering will be created across all other community-services to make sure all populations have access to a consistent level of high quality care, reducing inequality and unwanted variation.

In addition to the core service offering, individual boroughs will be able to develop additional services in order to meet local needs, and better safeguard against service inequity.

We are committed to making changes to community services that will meet the needs of NW London residents. Co-design (and integration) the different types of bedded care that are available will ensure maximal utility is achieved from repurposed resource.

We will retain the current hospice inpatient service capacity and the resource needed to deliver it. This will make sure we are able to respond to fluctuations in demand and meet the projected increase in need.

We need to make sure we use the budget allocated to community-based specialist palliative care as efficiently as possible so that we are providing the maximum amount of high quality care services that we can.  This could include investing in the other community-based specialist palliative care core services including:

  • Different types of bedded care such as enhanced care home beds
  • Community-based specialist palliative care team
  • 24/7 specialist palliative care advice
  • Hospice@home
  • Hospice outpatient clinics and wellbeing services
  • Psychological support
  • Bereavement support

The NW London CSPC Model of Care Working Group is continuing to finalise these service models (including the types of beds being suggested). These will be made available when this work is completed.

We will make sure community-based specialist palliative care services have the flexibility to increase service provision against the projected growth in need for the next five years and beyond.

We will develop sustainable services that recognise current and projected service demand and take into account our current workforce and the limited availability of specialist palliative care professionals including consultants. Whilst recommendations have been set out by national bodies such as the Association for Palliative Medicine APM), there are limitations in how these can be applied to NW London services.

We will continue to focus on developing existing services and reaching out to communities and groups who are not currently using community-based specialist palliative care services.

Supporting services and activity

In order to deliver the new model of care, we will need to make sure our providers have access to an extensive range of support services such as IT infrastructure or a workforce with the right knowledge and skills that is able to deliver high quality compassionate care.

It also builds on much of the feedback we obtained through our engagement about what the need to make sure we reach and take into account the different cultural and faith needs of our NW London population. This includes:

  • Digital & data (e.g. Urgent Care Plan (UCP), remote working, information sharing tools)
  • Governance (e.g. how to ensure accountability for service improvement and safeguard high standards of care)
  • Workforce support (e.g. exploring ways to improve our workforce skills, tools and abilities to deliver high quality care, e.g. training offer/programmes)
  • Organisational development (e.g. exploring ways to drive workforce recruitment, retention, deployment and development)
  • Developing culturally competent services (e.g. making sure that our services have the skills and knowledge to take into account the diverse needs of our population)
  • Community outreach (e.g. developing a community outreach programme to explain the importance of CSPC and how to access it)
  • These are crucial support functions which will allow us to achieve improvements in the quality of care we are able to deliver.

These do not directly affect the delivery of patient care but are important in their own right as they provide the support mechanisms by which the workforce and their organisations deliver care.

These supporting services and activity are needed to make sure we can deliver our future model of care. They are not options which require long listing, short listing or consultation, but rather consistently underpin all elements of future working arrangements.

Our future bedded care needs

Our definition of the new Model of Care for community-based specialist palliative care services will continue to iterate as we continue to engage - the description below is our current position to inform the committee of current thinking.   We need to develop bedded care that allows us to care and support patients with a range of specialist palliative and end of life care needs. This could be in a number of locations including a hospice inpatient unit, a care home or a patient’s own home with community support.

Patients with complex needs who require intensive support and are unable to or do not wish to stay at home

We need to be able to care for people with unresolved very complex needs that cannot be met by the capability of the community teams e.g. district nursing, specialist palliative care nursing and primary care and need more intensive specialist palliative care intervention. These needs may be physical with management of complex symptom or rehabilitation required; psychological, social and/or spiritual where we need to take into account family situations and ethical dilemmas regarding treatment and other decisions.

Mr X has a brain tumour and has only a few weeks to live. He has recurrent seizures and nausea which is difficult to manage and needs constant medical support to control his symptoms.  The best place for Mr X to receive his care could be a hospice inpatient unit where he will have support of a specialist consultant palliative care consultant and specialist palliative care nurses.

Mrs D has metastatic cancer that has spread to different parts of the body.  She has severe pain which is distressing for her and her family and they are struggling to cope with managing her care at home. The best place for Mrs D to receive her care could be the hospice inpatient unit where she will have support of a specialist consultant palliative care consultant and specialist palliative care nurses. If her pain becomes stable she may be able to return home and continue to be supported by community services in the home.

Patients with less complex needs and are unable to or do not wish to stay in their own home but are also not appropriate for hospice inpatient unit admission

We need to be able to care for people with a progressive life-limiting illness, with or without comorbidities, where the focus of care is on quality of life, including complex symptom control.


Example: Ms B lives on her own, without nearby family, and has a life-limiting illness. Her condition has gradually progressed and although she is not in crisis the community-based specialist palliative care services, general health and social care services are now unable to meet her care needs. Ms B and her family are worried that she is not coping well in her last months of life.  The best place for Ms B to receive her care could be in a care home where they can provide enhanced support and care for her symptoms 24-hours a day.

Mr S has deteriorating dementia. Whilst he has a life limiting illness he is physically still quite strong but his family is struggling to cope. The best place for Mr S to receive support is a care home where they can provide enhanced support and care for his symptoms 24-hours a day.


Patients with less complex needs who wish to stay in their own home and with the right level of support are able to do so

We need to be able to care for patients with less complex needs who, in their final weeks of life, wish to and, are able to stay at home using general community services (e.g. District Nursing, GP, Continuing Health Care Fast Track) alongside a range of specialist community palliative care services (e.g. the Community Specialist Palliative Care Team who are able to provide specialist advice and input and Hospice@home who are able to provide time limited support for increased in care).  However, should these patients’ needs exceed the capability of the community services available, a change in place of care (i.e. hospice inpatient unit/ hospital/ care home) may be necessary.

Mr J has COPD and is in the last few weeks of life.  He wants to die at home and his family wish to support him to do so.  A range of services have been put in place to allow him to do so including oxygen, pain management and bereavement support for the family available from community services, both general and specialist. Mr J deteriorates rapidly and passes away at home.

Mrs G has rapidly deteriorating lung cancer.  She and her family wish her to stay and die at home, she has increased care needs with less complex symptoms. Hospice@home, which provides time-limited but intensive support, has been able put in the support to allow that to happen in her final weeks.

Mrs K has metastatic breast cancer. The family wished Mrs K to stay at home and with support from a variety of community services, including hospice at home and community based specialist palliative care team this had been achieved for some time. Sadly, as Mrs K continues a gradually deteriorates her family and community services are no longer able to cope with her care needs. Mrs K’s needs could be best met at a care home where she is able to get 24-hour enhanced support for her on-going care.

Patients only needing generalised palliative care and no specialist input who wish to, and with the right care and support, to stay in their own home in the last few weeks of their life


Mrs X has stable but non-curable Myeloma. She has end of life care needs that does not require input from the community-SPC team. She and her family wish for her to stay at home for her care and death. With the support of their GP they have developed an Urgent Care Plan that sets out what they want to happen if Mrs G symptoms deteriorate and they are no longer able to cope. Community Nursing, Continuing Health Care and the patient’s GP could enable this to happen

Accessibility tools

Return to header