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Introduction Patients with MND are usually referred to palliative care services late in their disease progression. Reasons for this appear to centre on patients being so distressed at the prospect of palliative care services involvement, that they delay referral for as long as possible. Having identifi ed this as a problem, the hospice embarked on a joint venture with the Motor Neurone Disease Association. The premise of such joint working was to develop an outreach project for local patients with early stage MND. A grant was successfully secured from the DH (project 64 grant). Aims The aims of the project were to introduce this cohort of patients/carers to palliative care services at a much earlier stage in their illness and to decrease levels of distress/anxiety associated with a referral. It was also to give the opportunity for patients/carers to meet others in a similar situation and to provide them with information about common problems. Methods Two programmes were devised, each of 10 sessions, with a different theme per session. Each programme was devised to support 10 new patients/carers, with sessions taking place in the day hospice (hence the title 'a foot in the door'). Results During the fi rst and fi nal sessions of each programme, patients/carers were asked to anonymously score a series of statements concerning their confi dence in (and experience in accessing) care, their concerns for the future and feelings about hospice services. Results show that a positive change in all domains occurred. Conclusion This outreach project had a positive impact on MND patients/carers. The project format can be replicated by other palliative care providers. A DVD further detailing the project is being made in order to help other palliative care providers develop similar work.

Improving access to palliative care for all patients with life limiting illness has resulted in a significant increase in referrals to specialist palliative care services. Expanding services to keep pace with increasing demand and ensure that all referred patients have access to specialist advice and clinical assessment in a rapid and timely manner has posed a challenge and placed greater emphasis on the importance of prioritising referrals according to need.Extending services to cope with growing numbers of referrals has required innovative thinking and enhanced systems. Our service has seen a 24% increase in referrals over the last 3 years. As referrals have risen in number it has become increasingly necessary to look at referrals management and review our processing of them. Our key aim being to ensure that referrals are prioritised according to need and dealt with as quickly as possible.We reviewed our management of referrals in a number of stages using a variety of methods including process mapping, audit and focus group work. Methods were chosen based on the size, needs and processes within each department. The review exposed a number of gaps, bottlenecks and inequities.Finding solutions to our bottlenecks and to better manage referrals has been well supported by our use a standardised holistic assessment tool across the organisation. We use an organisationally adapted version of the Support Team Assessment Schedule -STAS (Higginson, 1989) to structure our assessment of patients against 30 factors across all required domains.We are now working creatively to expand our use of the tool to prioritise referrals and manage departmental waiting lists. Evaluation has shown that using STAS within clinical departments has enabled us to enhance our method of processing and prioritising referrals according to need and ensure that we are better placed to meet demand.

significant improvements to their quality of life. All of which have been captured through robust quantitative and qualitative outcome measures.

In 2008 a new Consultant in Internal Medicine was appointed to a busy cancer centre in Pakistan. He found himself providing predominantly palliative care, alongside a skilled but small palliative nurse team. This was recognised. He was made Consultant Lead for Palliative Care, and supported to enrol on a UK Diploma course and to do a 6 week locum registrar spell in a UK hospice for professional development.The relationships forged led him to request continued connecting with the hospice Consultant, through SKYPE, for 1 h per month once back in Pakistan. This to allow reflection on complex cases, as he had no Consultant to do this with.We started connecting 2 years ago, achieving 10 × 1 h sessions annually, discussing 1–2 cases each time. The palliative care team in Pakistan contributed, and an educationalist/Nurse joined the Consultant in the UK hospice.For Pakistan it has been so useful to discuss difficult symptom control and emotional challenges with an experienced physician, with, over time, real gains in patient, family and staff support. Sharing of working policies has been invaluable. Our connection has helped powerful lobbying to politicians regarding controlled drugs access, and armoury for Consultant and team to pursue initiatives like the Liverpool Care Pathway.For the UK we have seen our Pakistan colleagues overcoming huge practical challenges, particularly in support of people at home, often involving intense family support in care delivery. We have been impressed by the willingness of the wider hospital team to work together, quickly, towards best comfort care. These things have enhanced our UK care: we are more including of families, and understand more those we care for with international connections. We recommend this as an affordable, manageable and rewarding way to support international palliative care development and build educational and supportive links across services.