Dr David Plume MBBS DRCOG MRCGP Palliative Care Initiatives in Primary Care The Gold Standards Framework. Dr David Plume MBBS DRCOG MRCGP Macmillan GP Facilitator for Central Norfolk

“Systematic approach” “Framework” “Optimisation” The Gold Standards Framework (GSF) “Systematic approach” “Framework” “Optimisation” “Gold Standard” care for those nearing the end of life in the community. Quality not quantity Any end stage disease process. Grass roots initiative from Primary care (Dr Kerri Thomas), in 2001, to improve generalist palliative care and collaboration with specialists.

1 Chance to get this right 3 Processes. GSF in Primary Care 1, 3, 5, 7 1 Chance to get this right 3 Processes. IDENTIFY those in need of palliative care input/support ASSESS their needs, symptoms, preferences/issues PLAN the care of these patients, with these patients.

5 Goals Patients symptoms are controlled GSF in Primary Care 5 Goals Patients symptoms are controlled Preferred place of care and death established Security and support Better advance care planning Information Less fear Fewer admissions Carers supported, informed, involved and empowered. Staff confidence, communication and co-working improved.

7 Tasks C1 Communication C2 Co-ordination C3 Control of symptoms GSF in Primary Care 7 Tasks C1 Communication C2 Co-ordination C3 Control of symptoms C4 Continuity including OOH C5 Continued learning C6 Carer support C7 Care in dying phase.

Prevents role blurring Critical incidents C1- Communication Multi-professional discussion around difficult issues e.g. preferred priorities of care, child bereavement, informal carer support. Prevents role blurring Critical incidents Avoidance of crisis intervention

Nominated co-ordinator Organise PHCT meetings C2-Co-ordination Nominated co-ordinator Organise PHCT meetings Supportive care register. Documentation is complete and up to date Also co-ordination of MDT.

To ensure each patient has their symptoms, problems and concerns: C3-Control of Symptoms To ensure each patient has their symptoms, problems and concerns: Assessed Recorded holistically Discussed Action plan

Anticipation of care, equipment and drug needs to prevent: C4-Continuity of Care – Out of Hours OOH provider aware of the patient, their diagnosis, current management and particular problems, concerns and wishes. Anticipation of care, equipment and drug needs to prevent: Crisis situations Inappropriate/avoidable admissions to hospital

C5-Continued Learning The primary healthcare team is committed to staying up to date with skills and information relevant to end of life care of their patients.

Emotional Practical Bereavement Staff support C6-Carer Support Emotional Practical Bereavement Staff support Carer breakdown is the key factor in prompting institutional care for dying patients

Recognising their value and importance Involving them Informing them Main Needs of Carers Recognising their value and importance Involving them Informing them Training them Supporting them Helping them to adopt coping strategies – internal/external Watching for personal health problems

C7-Care of the Dying – Terminal Phase Patients on the last days of their life are cared for appropriately using the Liverpool Care Pathway

“not worth the time/cost” “we are doing well already” GSF in Primary Care “complicated” “time consuming” “not worth the time/cost” “we are doing well already” “more time spent in meetings” “we haven’t had any complaints”

GSF In Primary Care “care for people near the end of life is a vitally important area of health and social care, a litmus test for other areas and a humanitarian and economic imperative.” GSF Programme Position Summary Paper for NHS EOLC Programme Nov 07 The college is pleased to support the Gold Standards Framework, which is having a huge impact on the quality of care at the end of patients' lives. The values expressed in this framework are central to the College ethos of Knowledge with Compassion.”Dr Graham Archard, Vice Chairman Royal College of General Practitioners, March '05

GSF In Primary Care I fully support the further rollout of GSF within primary care. I have also been impressed by the adaptation of GSF for use in care homes, and the benefits that this can bring to patient care. Professor Mike Richards National Cancer Director and Chair of the Advisory Board on End of Life Care Oct 17th 07 Implementing the framework enabled processes of communication associated with high quality palliative care in general practice, but there was variation how this worked in individual teams. Interpersonal relationships and communication in primary palliative care. Kashifa Mahmood-Yousef etc al. BJGP 2008;58:256-263 “this was probably the best thing we have done as a practice as long as I can remember, and certainly the thing that has had the greatest impact on the care we deliver” Dr G. Norwich

End of life care developments. GSF in Primary Care-Where will I come upon it? 3 Threads GSF in Primary Care The focus of today GSF in Care Homes Does what it says on the tin! Push to get CH managers into GSF meetings Phase two studies showed reduced crisis admissions by 12% and deaths in hospital by 8% End of life care developments. Advance care planning After Death Audit analysis tools

GSF In Primary Care-When? LCP GSF- 1 yr PPoC-Never to early

The reality when setting up can be very simple! GSF in Primary Care The reality when setting up can be very simple! 1 designated admin lead 1 meeting, ideally once a month, the duration of which will depend on the practice. 2 Forms, one of which even doubles up as the OOH handover form! Try to invite a MDT-DN/CSPCN/OT/Physio/SW, and Care Home Manager if appropriate.

SCR1 Form

SCR2 Form

For more info speak to Dr Nick Morton The Forms Changes are afoot! Norwich PBC Consortium working on new versions of OOH Forms, DNAR Forms etc. For more info speak to Dr Nick Morton

Registration with the Central GSF team GSF In Primary Care-Central Team Registration with the Central GSF team Not obligatory to get QOF monies Dedicated electronic support Access to PDA tools Accreditation when available Source for PCT/SHA when looking at uptake.

Quality Outcomes Framework GSF in Primary Care Quality Outcomes Framework PC1 Register of those in need of palliative care/support. PC2 Regular MDT case review meetings where all the patients on the palliative care register are discussed. Beyond QOF As of 2007 50% of practices are registered with the Central Team 2/3 of practices claim to be using GSF 90% of practices are claiming palliative care QOF points Push now is not for coverage but depth and consolidation. Accreditation for practices, quality assurance.

The National Council For Palliative Care: http://www.ncpc.org.uk GSF In Primary Care-More Information Gold Standards Framework Central Team Site: http://www.goldstandardsframework.nhs.uk The National Council For Palliative Care: http://www.ncpc.org.uk My GP Facilitator Blog Site! http://www.syringedriver.co.uk E-Mail Elizabeth or I Elizabeth.Stallwood@norfolk-pct.nhs.uk dplume@nhs.net