Palliative care is rarely delivered by one provider; for most patients their care will be managed by community and one or more hospital teams at the least. This can be problematic for patients, their family and friends, and health professionals. Evidence suggests that, in general, providers work in isolation from each other. Although formal processes are in place for transfer of information between the sectors on discharge between acute and community sectors, there is a de facto lack of communication and therefore a lack of appreciation of the working practices within each environment. This resulting lack of collaboration between teams can lead to disruptive care that detracts from the holistic philosophy purported to be the basis of supportive and palliative care (National Institute for Health and Clinical Excellence (NICE) 2004; Department of Health (DH) 2000). In October 2005, 20% of a clinical nurse specialist's (CNS) full-time post was dedicated to working between the palliative care teams of Central Manchester and Manchester Children's NHS Trust (CMMC) and Central Manchester PCT (CMPCT). The aim was to improve communication and dialogue to promote more effective integrated working between the two sites and develop effective interprofessional working. This article will evaluate the impact of this new post, after 18 months, on collaboration between the teams, their practices and their patients. Finally, it will offer recommendations for future development.

Aims and methodWith increasing numbers of students and falling numbers of individuals receiving electroconvulsive therapy (ECT) it has been difficult to timetable all students to witness ECT, and it has been suggested that this experience may be dispensed with. However, we wondered how the experience of witnessing ECT might enhance students' knowledge and, just as importantly, challenge negative perceptions of ECT. We surveyed students' attitudes and knowledge at the beginning and the end of their 8-week attachment in psychiatry.ResultsThere appears to be a clear benefit in terms of knowledge and positive attitudinal change for students who both witness ECT and receive a lecture on the subject.Clinical implicationsDirect observation of ECT can challenge and affect attitudes in ways a lecture may not. Any changes to the provision of ECT teaching for medical students, including replacing witnessing ECT, needs to be carefully developed and assessed.

Nurse independent prescribing (NIP) within adult community palliative care has been implemented in many areas ito improve the quality of care for these patients by providing a more flexible and streamlined service. In order to evaluate whether NIP does benefit community palliative patients, a small case study was carried out comparing how long it took for patients to receive their medication following assessment or review by the palliative care clinical nurse specialist (CNS), both before and after implementation of NIP. The results suggest that NIP resulted in more timely access to medication for these patients.

Independent non-medical prescribing has been a safe, effective and economical initiative for St Teresa's nurse-led hospice, as indicated by yearly audits of prescribing charts and incident reports. However, there are several challenges involved, some shared with other palliative care organisations and some unique to this hospice. These include accessing consistent evidence, especially in light of high volumes of off-licence or unlicensed prescribing with limited stock of medication, and pro-actively pursuing tailored Continuous Professional Development. These challenges, though sometimes complex, are not insurmountable for the experienced non-medical prescribers in this non-conventional setting.

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