The NICE Guideline on palliative care (2004) emphasises the importance of coordinated planning and care between all agencies. This is reiterated in requirement 9 of the NSF for long-term conditions, which states:

Professionals working within neurology, rehabilitation and palliative care need to work closely with primary care staff and care providers, including non-NHS care staff (social care, domiciliary and home care staff), combining their expertise to support people in the advanced stages of long-term neurological conditions.

How can good teamwork be achieved?

The NSF will not be fully implemented until 2015, so access to specialist palliative care can be inconsistent in different areas of the UK. Despite this, government and specialist palliative care providers are committed to offering services to those who need them.

The good examples of teamwork below illustrate innovation and burgeoning services that are being established nationwide. 

Specialist palliative care teams working alongside specialist neurology and neuro-rehabilitation teams (for example in joint clinics) promoting more consistent shared practice

St Richards Hospice in Worcester has recently appointed a nurse specialist whose remit is to develop specialist palliative care services for people with non-malignant conditions. The hospice itself has received an increase in the number of referrals for day hospice care, especially from those with MS. The post holder hopes to develop the service to provide homecare support in the community. There is strong commitment to developing collaborative working practices with local neurology teams and MS nurse specialist. The post has been funded 50% by the hospice and 50% by the MS Society until 2009.

University Hospital North Staffordshire Multiple Sclerosis Nurses working in collaboration with their local palliative day care team at the Douglas McMillan Hospice offer a palliative day care service for people with advanced MS.

Two groups of 18 people meet on alternative weeks. The aim of joint working was to improve identification, assessment and treatment of physical, social and psychosocial complex problems. The day care programme includes various complementary therapies, art therapy, networking, support and socialisation as well as spiritual care and respite for carers. Whilst many benefits have included improved symptom management, well-being, quality of life, self-esteem, confidence and empowerment, the project will be researched to assess ongoing benefits with the aim of promoting the work as best practice. 

Training in palliative care skills for staff providing care in people’s own homes, hospitals and care homes

Brambles works closely with the local hospice, St Catherine's, to meet the needs of people with complex needs. Eleven staff from the hospice recently completed an exchange programme with 11 staff from Brambles. The two-day experience offered one day for training and one for practical application. The programme was extremely well received by staff, raising awareness of the skills implicit in each other’s jobs. The exchange also enhanced communication and two-way advice. Brambles staff were particularly interested in the lymphoedema, respiratory and counselling services offered through the hospice. Since then, advice and assessment of lymphoedema from the hospice has been a direct benefit to Brambles guests.  

Forums for information exchange

The North West Regional Link Group was established in 2003 with the aim of influencing care and knowledge of MS among health care professionals who see people with MS on a regular basis. The group is informal and acts as an opportunity for multidisciplinary networking. Membership consists of nurses, rehabilitation therapists, palliative care specialists and primary care teams. Among other topics discussed by the group, a session was run on palliative care management.

The Greenwich and Bexley Cottage Hospice runs a group called the Cakewalk Café from 10am to 3pm twice a month. The group is open to anyone living with a life-threatening illness, carers and those who have been bereaved. Membership includes people living with cancer, MND, MS and HIV. The hospice counselling team offers practical help and support, lunch is provided, and alternative therapies such as massage and reflexology are offered. The Cakewalk Café has an attendance of about 65 people and has been a springboard from which other support groups have developed.

The Community MS Team (CMST) Regional Neurological Rehabilitation Centre, Newcastle, was set up in 1995 as a joint venture between health, social services and the local branch of the MS Society. Based in the community, it provides physiotherapy, occupational therapy, counselling and psychology and is linked to MS specialist nurses and neurologists at the acute trusts to ensure joined-up services for people with MS. The team is also a member of a regional partnership forum for the North of England, an MS society initiative to improve services for people with MS, which brings together charities, health and social care providers.

Members of the CMST have found they interface with palliative care on an increasingly regular basis as more clients with very advanced MS are being maintained at home. They and their colleagues in specialist palliative care felt they needed to increase their skills and knowledge to meet the needs of this client group. In 2005 a small working party was set up with representatives from neuro-rehabilitation, specialist palliative care and a person with MS. Their starting point has been a well-attended joint study day, with further sessions planned for the future. The working party plans to look at issues around continuing care as well as practical matters such as the provision of, and training for, specialist equipment like a suction machine.

Other examples of joined-up working in Newcastle include the CMST 'sister' service, the Regional Disability Team, which has a long association with the local Leonard Cheshire Home and has been working on an education programme for staff covering the later stages of MS.