Older people with social care needs and multiple long-term conditions

Establishing the role

The Midhurst Macmillan Service was set up in 2006 in response to the closure of a local hospital with a Macmillan Cancer Support Palliative Care Unit. The closure prompted a consultation among local stakeholders to find an alternative, and their choice was to set up a community-based service. It has access to palliative care consultants based in the community who are able to provide specialist interventions at the patient's home.

Roles and responsibilities

There are 3 types of staff in the Midhurst team: medical, clinical and non-clinical. The medical professionals focus on care management, liaising with GPs, district and community nurses, specialists and other relevant medical staff to arrange or change treatment for patients. Care coordination is carried out as part of the district nurse role. They act as the single point of contact for the patient and families. They ensure that information about patients is shared at regular multidisciplinary meetings and logged on the internal IT system. The care coordinator updates relevant team members about a patient's status and liaises with GPs and community health teams. As part of their role, they deliver end of life care training to care agencies, including on care coordination.

Requirements of the role

Good communication skills are critical in this role, for identifying a person's needs and wishes and keeping everyone informed. Understanding family dynamics and knowing how community based services work is also important. In some cases the care coordination role needs to be passed on to a different professional for the patient's best interest, in which case the care coordinator needs to be flexible and willing to share responsibility. Good training skills are also required in order to pass on their knowledge to other care agencies.

Allocating a care coordinator

The care coordinators are split across 19 GP practices: care coordinators are linked with GP practices and allocated according to the patient's GP.

Care network

The care coordinator works alongside a multidisciplinary team consisting of palliative care consultants, specialist nurses, healthcare support workers, allied health professionals and a large group of volunteers. They also liaise with family members, GPs, continuing care teams and a range of other health and social care services.

Health and social care context

The Midhurst Macmillan Service is hosted in a community NHS trust. The service and its staff are located at a community hospital, and the funding comes jointly from the NHS and Macmillan Cancer Support.

Making a difference

Data from the service for 2011/12 shows that it achieved its target of enabling people to die in their place of choice: 185 of the 348 patients treated in that year died at home, and for 183 (99%) this was the place of their choice. Interviews with staff, commissioners and external care providers have revealed the positive impact of the service. Good clinical outcomes of the service overall can be seen in less frequent A&E attendances and reduced hospital stays.

Financial benefits

Unfortunately, they can only provide results of an overall economic review of the service, so not specific to the care coordinator role. The review demonstrated significant savings, mainly through earlier access to community based specialist palliative care before an inpatient stay occurs. If a service such as Midhurst was replicated elsewhere, the total cost of care in the last year of life could be reduced by 20%.

Impact on family members

The service lead believes the role of the care coordinator has a huge impact on family members – having 1 person who can build up a rapport with them and who knows what is going on is seen by family members as extremely beneficial. An evaluation of the service in 2012 showed that: 'patients, carers and staff themselves report that a key aspect of the Midhurst Service is the flexibility of roles of the team members'.

Impact on people living alone

The service leads report that those living on their own without family support find the care coordinator role invaluable. Having someone to coordinate their care with professionals is even more important for those without family to hand. In these instances, the care coordinator will have volunteers to work with individuals to ensure they are not lonely and to help with their shopping, general needs and so on.

Learning points