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ZV57C [V]Palliative care
8H7g. Referral to palliative care service
8BAP. Specialist palliative care
8BAT. Specialist palliative care treatment - outpatient
8H6A. Refer to terminal care consult
8CM1. On gold standards palliative care framework
8HH7. Referred to community specialist palliative care team
8BJ1. Palliative treatment
8BA2. Terminal care
8H7L. Refer for terminal care
8BAS. Specialist palliative care treatment - daycare
9EB5. DS 1500 Disability living allowance (terminal care) completed
1Z01. Terminal illness - late stage
8BAe. Anticipatory palliative care (v16)
2JE.. Last days of life (v17)
8CM10 GSF supportive care stage 1 - advancing disease
(v17)
8CM11 GSF supportive care stage 2 - increasing decline (v17)
8CM12 GSF supportv care stge 3 - last days: cat C - wks prognosis (v17)
8CM13 GSF supportv care stge 3 - last days: cat D - days prognosis (v17)
8CM14 Gold standards framework supportive care stage 3 - last days: category
B - months prognosis (v18)
8CME : Has end of life advanced care plan (v17)
9Ng7 : On end of life care register (v17)
Palliative care is the active total care of patients with life-limiting disease and their families by a multi-professional team. The first National End of Life Care (EOLC) Strategy was published in July 2008. It builds on work such as the NHS cancer plan 2000, NICE guidance 2004, NHS EOLC programme 2005 and was informed by the consultation including primary care in the Darzi end of life workstream.
In Scotland, “Living and Dying Well, a national action plan for palliative and end of life care in Scotland” 2008 places great emphasis on the role of primary care in providing palliative care for all patients with such needs, regardless of diagnosis. The action plan uses the concepts of planning and delivery of care, and of communication and information sharing as a framework to support a person centred approach to delivering consistent palliative and end of life care in Scotland.
www.scotland.gov.uk/Publications/2008/10/01091608/0
The way primary care teams provide palliative care in the last months of life has changed and developed extensively in recent years with:
The National EOLC Strategy and “Living and Dying Well” suggest that all practices should adopt a systematic approach to end of life care and work to develop measures and markers of good care. They recommend the Gold Standards Framework (GSF) and the associated After Death Analysis (ADA) as examples of good practice. Evidence suggests that over 60% of practices across the UK now use GSF to some degree to improve provision of palliative care by their primary care team.
The introduction of Gold Standard Framework (GSF) to primary care and its associated audit tool, the ADA are associated with a considerable degree of research and evaluation. GSF provides ideas and tools that help practices to focus on implementing high quality patient centred care.
www.goldstandardsframework.nhs.uk
About 1% of the population in the UK die each year (over half a million), an average of 20 deaths per GP per year. A quarter of all deaths are due to cancer, a third from organ failure, a third from frailty or dementia, and only one twelfth of patients have a sudden death. It should be possible therefore to predict the majority of deaths, however, this is difficult, with errors occurring, 30 per cent of the time. Two thirds of errors are based on over optimism and one third on over pessimism. However the considerable benefits of identifying these patients include providing the best health and social care to both patients and families and avoiding crises, by prioritising them and anticipating need.
Identifying patients in need of palliative care, assessing their needs and preferences and proactively planning their care, are the key steps in the provision of high quality care at the end of life in general practice. Therefore this QOF indicator set is focused on the maintenance of a register, (identifying the patients) and on regular multidisciplinary meetings where the team can ensure that all aspects of a patient’s care have been assessed and future care can be co-ordinated and planned proactively.
A patient should be included on the register if any of the following apply:
1. their death in the next 12 months can be reasonably predicted (rather than trying to predict, clinicians often find it easier to ask themselves ‘the surprise question’ – ‘Would I be surprised if this patient were still alive in 12 months?’).
2. they have advanced or irreversible disease and clinical indicators of progressive deterioration and thereby a need for palliative care e.g. they have 1 core and 1 disease specific indicator in accordance with the GSF Prognostic Indicators Guidance (see QOF section of GSF website. www.goldstandardsframework.nhs.uk)
3. they are entitled to a DS 1500 form. (The DS 1500 form is designed to speed up the payment of financial benefits and can be issued when a patient is considered to be approaching the terminal stage of their illness. For these purposes, a patient is considered as terminally ill if they are suffering from a progressive disease and are not expected to live longer than six months.)
The register applies to all patients fulfilling the criteria regardless of age or diagnosis. The creation of a register will not in itself improve care but it enables the wider practice team to provide more appropriate and patient focussed care.
The practice reports the number of patients on its palliative care register.
Verification – in the rare case of a nil register at year end, if a practice can demonstrate that it had a register in year then it will be eligible for payment.
The practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed.
The QOF monitors occurrence of the multi-disciplinary meetings but it is up to the practice to ensure the meetings are effective. The aims of the meetings are to:
Many practices find use of a checklist during the meeting to ensure all aspects of care are covered is useful e.g. SCR1 and 2 templates and assessment tools on the GSF website.
Scottish practices participating in the Palliative Care DES will have access to a reporting template which can be used and adapted for this purpose and available at annex D: www.sehd.scot.nhs.uk/pca/PCA2008(M)12.pdf
The practice should submit written evidence to the PCO describing the system for initiating and recording meetings.
Prepared By Jean Keenan