If hospital patients are to have access to specialist palliative care, specialist palliative medicine must operate successfully in a busy hospital setting. This paper evaluates prospective data from 3,523 patients referred to a hospital specialist palliative care service over eight years (1999–2006). The number, age and frailty (determined by the palliative performance scale) of referred patients increased every year. The median time from referral to death was 27 days. Referrals specifically for symptom control doubled (80% versus 40%). The service responded by providing a shorter, more intensive service: more joint (nurse/ doctor) consultations, a 300% increase in medical consultations and more discharges back to the referring team. Co-management between palliative medicine and other consultants has increased, and attention is focused on the management of difficult symptoms. For some patients the referring specialist will lead management, while for others with predominantly palliative care needs, management will be led by palliative medicine specialists. For patients with the most complex needs, intensive symptom control and palliative care may be most effectively delivered in a dedicated hospital unit.
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