Sue Ryder South East - referral guidance

Working across Berkshire West and South Oxfordshire, Sue Ryder South East offers specialist, holistic support for people with complex palliative care needs, as well as those close to them.

Our specialist palliative and end-of-life care services include:

• 24/7 clinical advice line for patients, carers and healthcare professionals
• community specialist palliative care team
• at-home care for patients approaching the end of life
• inpatient care at Sue Ryder Duchess of Kent Hospice and Wallingford Community Hospital
• specialist physiotherapy and occupational therapy
• lymphoedema service (Berkshire West only)
• wellbeing and emotional support, with access to Sue Ryder bereavement services
• patient support groups.

For many people who have life-limiting condtions or who are nearing the end of life, their care needs can be met by their primary care team – such as their GP, district nurses, or nursing home staff.

However, some people may need specialist support from Sue Ryder. For example, when symptoms can no longer be managed by first-line treatments, or when there’s a risk of crisis, unplanned hospital admission, or carer strain. We accept referrals based on need rather than condition or phase of illness.

If you’re unsure whether your patient is currently eligible for referral, please call our team on 0118 950 5276.

We accept referrals for adults (aged 18+) who meet the following:

• Active progressive, incurable or life-limiting illness
• Complex, escalating or multi-faceted needs that cannot be readily managed by primary or generalist care, including complex physical symptoms and psychological, emotional or spiritual distress related to their illness.
• Registered with a GP within Berkshire West or South Oxfordshire.

Some of our services have specific referral criteria, which you can read below.

We are a specialist palliative care service with a high demand for our support. We are commissioned to provide care for patients who have severe or multifaceted needs, that cannot be managed by generalist care alone.

We are unable to accept referrals for the following:

• Patients with chronic but stable conditions, or where symptoms are currently controlled by first-line treatments.
• Patients under 18 years of age.
• Patients who decline referral.
• Support with advance care planning, without other complex palliative care needs.
• Prescription of just in case medication, without other complex palliative care needs.

We accept referrals from GPs, consultants, clinical nurse specialists, district nurses and other healthcare professionals. We cannot accept referrals directly from patients or carers.

Patients must be aware of the referral, and their GP should be informed also.

Should you have a patient meeting the above criteria please:

• complete the Sue Ryder referral form with detailed clinical information to support triage
• email the completed form and accompanying documents to sryc.seregion@nhs.net
• OR complete a referral via EMIS (for patients in South Oxfordshire only).

To discuss a referral or our referral criteria, please call our team on 0118 950 5276.

We aim to review all referrals within 24 hours. Referrals are reviewed using the Nexus RUN-PC evidence-based triage tool.

Care options include:

• at-home assessment or telephone-based support from the community specialist palliative care team, which includes clinical nurse specialists and doctors
• outpatient or at-home support from a physiotherapist or occupational therapist
• Hospice at Home care
• referral to patient support group
• inpatient admission.

Should a patient’s condition improve or become stable and specialist care is no longer needed, they may:

• be referred to an alternative Sue Ryder service
• be discharged back to their GP or lead healthcare professional.

When a patient is discharged from Sue Ryder’s inpatient care or our specialist community team, a letter will be sent to the referring clinician to advise of the outcome.