Bedfordshire Palliative Care Service

Based at Sue Ryder in Bedford is a first point of contact for patients, families, carers and health and social care professionals requiring 24hr advice, care and support for palliative care.

Qualified clinicians skilled in specialist palliative care will triage calls to identify the most appropriate local provider to respond to the caller's needs.

The service has been designed to improve the overall experience and continuity of care for patients in the last 12 months of life, their families and carers.  It also supports generalist health and social care professionals involved in caring for patients at end of life.

The goal of the specialist palliative care is to ensure the best quality of life for Adults and Older Adults with life limiting conditions and their families both throughout the direct care of those complex needs by links with specialist services / teams and the indirect care of those with palliative care needs through expert advice, support, education and training and governance.

The role of the Palliative Clinical Nurse Specialist is to work in partnership with the primary care team and hold a caseload of those patients with complex specialist palliative care needs. Each patient with a life threatening condition will be assessed holistically using an agreed tool at the beginning of their palliative diagnosis and at appropriate points of the care pathway. Referral is made to other services and agencies as appropriate and the team will work with the relevant key worker at any given time.

The team also work in partnership with other agencies to provide specialist services

Service is based within localities across Bedfordshire, working in neighbourhoods with community nursing and aligned GP Practices.

Monday - Friday 9am - 5pm 

On call at weekends for specialist assessment and advice.

24 hour cover to support patients in their homes through assessment for care visits, nursing, symptom control  and provision of equipment

Please see table for further information on how to make referrals:

Palliative Care in Community Info for GPs in Bedfordshire

 

 

 

Team

Provides:

How to Refer:

Palliative Care Hub

24hr/7 day week palliative care and co-ordination service for people with life limiting condition.

To be offered to all patients thought to be in last year of life irrespective of diagnosis.

Telephone support, advice and signposting.

Register of patients thought to be in last year of life.

 

Electronic referral on Systmone

Provide patient with information leaflet and contact no.

 

 

Hands on care for crisis support for 72hrs

Contact Hub by phone

 

Night sits - prioritized on daily basis

Complete Night Sit referral form before 2p.m. on day required. Please phone Hub as well.

Need to be requested each day night sit required.

 

CHC FastTrack

Complete FastTrack paperwork and export to CHC

District Nursing & Unplanned Care Provided by ELFT

24 hr / 7 day week community nursing service

GP aligned

Regular assessment and monitoring of patients

and carers needs, condition and symptoms:

 

Ongoing holistic assessment and support

Assessment for palliative patients rapidly deteriorating, needing care, equipment and regular monitoring.

Nursing assessment of aids and adaptations to promote independence, comfort and quality of life.

Assessment for care package

 

Timely introduction /discussion of end of life care planning using care planning tools.

Phone referral via SPoA

Telephone Nos.

Palliative Care Hub 01767 641349

ELFT  SPoA  0345 602 4064

 

Patients who are:

  • Registered permanently or temporarily with a Bedfordshire GP
  • Aged 18 years and over
  • Identified to be in the final 12 months of life

Patients who meet the above criteria will be asked to sign their consent to be included on the Register to enable their information to be shared across local providers/organisations that will enable the seamless delivery of care.

Please note: when seeking/receiving advice in regard to patient care and making referrals, NHS Connecting for Health Information Governance standards and policies must be adhered to.

Patients who are:

  • Not registered permanently or temporarily with a Bedfordshire GP
  • Under 18 years of age

Not identified to be in the final 12 months of life.



Last updated: 12/08/2019

Update due: 12/08/2020