The NW London CSPC Model of Care Working Group

The new model of care working group was asked to develop and co-design a new model of care for community-based specialist palliative care, based on best practice and evidence, to help us develop high quality community-based specialist palliative care that is delivered equitably and sustainably across NW London. 

The new model of care aims to make sure people have a choice, get the right care, at the right time, by the right team and in the right place, alongside their wishes and preference. Through it, all residents, no matter their circumstances, will be able to access the services they need.

Co-design is the method of involving users (people), stakeholders (decision makers) and practitioners (front line staff) in the process of design. Whenever we are designing new services and patient pathways, it is important that anyone who would like to contribute has the opportunity to input into the process.

Who were the members of the NW London community-based specialist palliative care new model of care working group?

Membership of the NW London community-based specialist palliative care new model of care working group consisted of local residents and carers with lived experience of palliative and end-of-life care services, practitioners and other palliative and end-of-life care stakeholders. It included:

  • NW London NHS community specialist palliative care and NW London Hospice providers 
  • Twelve patients and carer representatives
  • Primary care representatives
  • Acute hospital specialist palliative care representatives
  • Acute hospital discharge representatives
  • NW London care homes lead
  • London Ambulance Service
  • Community nursing representatives
  • Continuing Health Care (CHC) representatives

We also invited additional topic or other programme related stakeholders when needed.

This helped ensure that the new model of care supports integrated care as it is developed with all appropriate interdependent programmes and considers the patient journey through the whole pathway.

What was the new model of care working group’s remit?

The NW London community-based specialist palliative care new model of care working group was asked to:

  • Develop a new model of care that will help us decide what type of services we need and what the common core offer that every patient in NW London should have access to.
  • Develop a set of good practice and evidence-based core service standards, requirements and service definitions. These will demonstrate what we believe good community-based specialist palliative care looks like for all our residents.
  • Develop a set of co-designed principles that will help us to successfully design and deliver the new patient-centred model of care across NW London.
  • Support the development of a long list of options for delivery of the new model of care.

The model of care working group also looked at the future need of the NW London population over the next five plus years. In particular:

  • The future requirements for in-patient bedded services and what they could look like.
  • The principles by which we will decide the size and shape of future palliative in-patient services and the number of beds required
  • The future requirements for other community-based services (hospice at home, community-based specialist palliative care teams, psychological and bereavement support, 24/7 specialist palliative care advice line, out-patients, day hospice services).
  • The principles by which we will decide the size and shape of these community-based services for the future.
  • They have also put forward recommendations as to what supporting services activity (for example, improving uptake of the London Urgent Care Plan (UCP) and having a workforce recruitment and retention plan) are needed to deliver good community-based specialist care services and the mechanisms for developing these programme enablers.

The model of care is being designed to support local flexibility and equity of access. This means that the local Borough Based Partnerships will have the ability to develop additional services beyond the NW London core service offer if they wish to, based on their local priorities and local population needs.

What happened in the model of care working group?

The model of care working group met 38 times over the course of twelve months or so and we thank them for their hard work and determination in helping us deliver excellent community-based specialist palliative care services for NW London residents.  During the meetings they were provided with detailed background evidence and information and discussed what good community-based specialist care services should look like and what future capacity and demand for these services will be.

The background evidence and information they were provided with included:

Many local residents have been kind enough to share their stories to illustrate both the good experiences and the challenges that people face when using community-based specialist palliative care services. We need to learn from their experiences and the feedback was used in the model of care working group meetings so it could directly influence the discussions taking place on a topic-by-topic basis.

The work of the review programme and the new model of working group to date

The minutes for the model of care working group’s meetings can be found here.

A summary of the review programme’s work is provided in the table below.


Considered by the new model of care working group?

Further detail

Defining what the core elements of care and service delivery are


The national service specification for palliative and end-of-life care and the starting point for this work.


The working group are further defining these based on our resident and population needs.

Defining how much of these key elements we need


This isn’t covered in the national specification, but is critical if we are to make sure we are able to introduce a model of care across NW London. Note that ‘How much’ includes hours, staffing, capacity etc.

Defining how services should be delivered


For example, we may want to define elements such as access (including geographical availability) but not how services are integrated at a local borough level.

Defining where services are to be delivered


The new Model of care working group will put forward some recommendations that will be included in the long-list of service change options that will be developed further following more engagement with the public and other stakeholders. These options will go through an appraisal process and be subject to public consultation if deemed necessary

Who delivers elements


Future programme work once model of care and option have been agreed.

How much it costs


Not considered at this stage.



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