AS WE near the end of our lives, having choice over our care is crucial. When Elaine, 51, was diagnosed with lung cancer and brain mets, the care she received from a new ‘joined-up’ team – which brings together healthcare professionals and colleagues in social care – meant her last days could be spent in the comfort of her home, with care that was wrapped around her.

“Elaine was diagnosed with lung cancer and very quickly it became apparent that the cancerous cells had spread. We knew that we had to plan for the worst,” explains senior social worker, Christine Jobling.

Because of the seriousness of her health needs, we needed to find a solution quickly, that would ensure that Elaine’s health and social needs would be fully supported. We knew that what was needed was an overall view, that would not only look at pain management, but that would ensure that the things that mattered to Elaine were taken care of – her desire to stay at home, and to be with her pet dog for example. The care needed to look at the whole picture.

The way in which the care is delivered in the city is changing. ‘All Together Better’ is a brand new way of ‘joining up’ care for people who have some of the most complex health needs. It brings together health and social care teams, allowing them to work from one base, in partnership, to create care and support that meets the medical needs of the person, but that also takes into account their social needs. The result is healthcare that really cares.

“Elaine’s condition was unpredictable, and because of how quickly her condition deteriorated, she found it very hard to come to terms with, and talk about her end of life plans. She did, however, make it very clear that she would like to pass in the comfort of her home, something many people would want.

“Because of the coming together of our teams, we could deliver that dying wish for Elaine, knowing that her health care was not being compromised as a result. Elaine was very frightened of being alone in the night in case she died alone, so we ensured that she had care throughout the small hours of the day to keep her calm and settled. Every part of Elaine’s care programme was geared towards not only her needs, but her wants – the things that matter when your life is coming to an end.”

Through All Together Better, health professionals like community nurses, work hand in hand with colleagues in social care to agree care plans that help ensure the frailest in society are given the best possible support. The new way of working is part of a national pilot that aims to deliver care at home to those with the most complex health and social needs.

“Without All Together Better, Elaine would have had to move to a hospital or hospice, away from home, and from the pet dog she loved so much.

“With the care programme we delivered, we ensured that Elaine’s last days were spent with her beloved dog, and in the comfort of the home she loved, with a team around her that helped ensure she saw out the final days of her life in comfort and peace – and there can be no greater gift than that.”

Find out more about our work