1. 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

2. “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.

3. 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.

4. 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.

5. 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.

6. 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

7. 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.

8. 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

9. 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

10. 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.

11. 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

12. 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

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

14. “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”

15. 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

16. 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:
“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

17. 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

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

19. 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.

20. SCR1 Form

21. SCR2 Form

22. 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

23. 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.

24. 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.

25. The National Council For Palliative Care: http://www.ncpc.org.uk
GSF In Primary Care-More Information
Gold Standards Framework Central Team Site:
The National Council For Palliative Care:
My GP Facilitator Blog Site!
Elizabeth or I