Working together with primary and community care

Challenge: Within every ICB population, there are thousands of people who do not get the care they need, and who could benefit from earlier, more personalised support.

In particular, older people and those living in deprived communities are less likely to access specialist palliative and end-of-life care. Without targeted intervention, inequalities in access may worsen.

Response: We are currently working with partners to embed specialist Sue Ryder Nurses alongside primary care networks and integrated neighbourhood teams.

These Sue Ryder Nurses will help identify and coordinate care for people with palliative care needs who are most at risk of missing out on timely interventions.

Expected impact:

• Earlier access to palliative and end-of-life care
• More people supported at home and in their community
• Fewer avoidable crises and emergency hospital admissions
• Reduced pressure on local health and care services

Challenge: People living with advanced illness can experience severe breathlessness, which has a considerable impact on quality of life. However, they are often unable to take part in traditional pulmonary rehabilitation courses, due to being unwell, not meeting the eligibility criteria or access issues.

Response: Our specialist breathlessness service in Gloucestershire provides a tailored rehabilitation programme through outpatient clinics, home visits, telephone support and Take a Breath group sessions.

Support is delivered through GP clinics, community venues and Sue Ryder facilities, while specialist physiotherapy and occupational therapy home visits are available for people unable to attend.

Patients receive exercises, rehabilitation and practical education on managing breathlessness, fatigue and advance care planning, and carers can also attend to learn how to provide support.

Results:

• 34 clinics have run, with 94 patient contacts since creation of the breathlessness rehab clinic in June 2024.
• Improved symptom management and confidence among patients and carers.
• Reduction in distress and improvement in wellbeing.
• Greater independence and support to remain in the preferred place of care.

In practice:

• “I am more hopeful for the future. I was going downhill, but this group has totally changed that. I am more confident going out and socialising.”
• “My goal for coming to the group was to be able to get back into the kitchen. I baked a cake on Saturday!”