| Summary: | Many people in Scotland who could benefit from palliative care do not receive it. The Scottish Government’s Strategic Framework for Action on Palliative and End of Life Care (SFA) states that by 2021 everyone in Scotland who needs palliative support will have access to it. Early identification offers increased opportunities for support. The project aimed to redesign the delivery of community-based palliative care, for all conditions, through the integration of supportive and palliative care approaches into mainstream primary and community care service provision. The team used the Model for Improvement methodology and public and professional consultations in the form of an open space event and climate surveys, to develop a consistent response for people with early palliative care needs, their families and their carers. Using the Model for Improvement allowed the project team to test ideas and confidently change direction when the evidence indicated this was required. Using this investigative and learning approach which was supported by key stake holders (heads of health and social care services, local authority, funders, local hospices, other third sector services and a General Practitioner representative) allowed for the creation of a community model for palliative care that aids identification, and streams people to the appropriate arm of support based on whether their needs are stable or changing. The model is based on a traffic light where green is stable, amber is changing and red is rapidly changing. Individuals identified as green are linked into a social prescribing model supporting self-management, amber a newly created community multidisciplinary meeting and red mobilisation of community health and social care services for people who may be deteriorating towards death. The amber meetings called WISeR (Weekly Integrated System Response) facilitate the coordination of care and appropriate allocation of resources, complement existing Gold Standards meetings and link informal carers with the carers centre. While the intention was to provide more seamless, person-centred service provision, the collaborative working has also resulted in improved professional relationships and understanding of roles. While the first 4 years of the project were partnered with Macmillan Cancer Support, interest in the outputs led to Healthcare Improvement Scotland inviting the project to become one of 6 sites in Scotland that are testing and implementing improvements to help identify people who would benefit from early palliative support and the coordination of their care in order to met one of the Scottish Governments commitments stated in SFA. In the autumn of 2018 the project will be scaling up the traffic light model and WISeR meetings to additional general practice surgeries in Renfrewshire. Instead of being condition specific, the model is based on recognised points of need including each stream from the traffic light model. These points follow an individual from diagnosis to bereavement adopting a person centred approach and offering a holistic needs assessment. While a person’s needs can change unexpectedly, these points are recognised as key times when people, their families and carers need information and support.
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