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How we improved end-of-life care in our practice

Dr Laura Pugh explains why her practice decided to undertake a Gold Standards Framework training programme, how they applied this learning and the results they achieved.

Our practice, Cape Hill Medical Centre in Smethwich in the West Midlands, is a diverse, inner-city practice with 11,830 patients. The team includes five partners, five part-time salaried GPs, advanced nurse practitioners, nurse practitioners, practice nurses and health care assistants.

While the practice was providing good quality care for people in their final months, we knew there were a number of important areas for improvement. Crucially, we knew that we could be a lot better at identifying patients approaching the end of life and reaching all of the diverse communities we care for.

What is the Gold Standards Framework?

Having committed to undertaking the Gold Standards Framework (GSF) Going for Gold training programme, we decided that it was critical that the whole team was involved. That meant the admin staff, as well as the clinical team, were included in the sessions which we held approximately every six weeks.

In terms of the sessions themselves, we would work through the course materials, including useful tools and resources, and watch the relevant section of the DVD that accompanied the programme.

We like to take our time here at Cape Hill and so rather than rush the training we found it best to embed what we were learning as we went along.

The sessions on advance care planning were the best example of this. We didn’t feel confident in this area so we really took our time going through the course materials and assessing the tools, establishing what worked best for us. Having set learning outcomes for each of the six sessions was really helpful.

The training helped us realise that these conversations with our patients were about getting to the heart of what people really want as they approach the end of their lives.

Now we view these discussions as very rewarding as they provide the framework for delivering care to patients and, where possible, giving them what they want and deserve. Because we struggled with it and invested a lot of time in trying to get it right, we ended up getting to good place.

What results have we achieved?

While a big part of end-of-life care is about wanting to do it well, what GSF has given us is the structure and tools to deliver better, more coordinated care, not just well intentioned care.

We’re more skilled at symptom management and, while delivering better end-of-life care can take more time, the rewards are great.

We work in an inner-city area with high deprivation and wide diversity and there are challenges associated with this, but the training has helped us to reach marginalised groups as well as those who find it easy to access services.

The numbers speak for themselves. Before we started the training there were 41 patients on the palliative care register. We’ve more than trebled that number to 125. And the vast majority of those (110) have had advance care planning discussions and 118 have had their clinical symptoms assessed.

One of the best demonstrations of positive change to have come out of the training is the number of people whose wishes we are now fulfilling. More than two thirds of the patients on the list die in their preferred place now and that figure rises to 88% for those that have expressed a preference, compared with just over half (56%) prior to the training.  

Either the patient’s named doctor or one of the advanced nurses now initiate advance care planning discussions and these help underpin this significant improvement in our overall level of care.

How we have achieved this improvement

We’ve managed to achieve this by putting this patient cohort much more to the front of our thoughts, whether that’s at our weekly practice meetings, the dedicated monthly meetings where we discuss their changing needs or the quarterly meetings that involve a much wider group, including the hospice at home team. Discussing what went well as well as areas for improvement in each and every death has been a further lever for positive changes.

One simple way of highlighting the importance of these patients is by calling them gold patients and giving them access to fast-track appointments for a period during the morning and evening.

Prior to undertaking this training we were providing good care but now we are making sure we are all doing it the same way, dictated by a set of GSF guidelines that we’ve devised. The ‘gold patient’ white board in reception ensures that the whole team knows who is approaching the end of life and helps us work much better across the whole team and we’ve also published four information leaflets for patients.

It’s certainly been labour intensive, but by putting in the work ‘up-front’ we have all noticed a significant decrease in the number of crises and hospital admissions.

End-of-life care shouldn’t be about a perceived extra workload but making sure patients are looked after appropriately. Patients are now getting a better deal because they are being given the chance at the earliest possible opportunity to share their wishes and preferences with clinicians.

The whole practice team has been completely engaged in the process and the clinicians feel happier and more confident because they have learned a new set of skills.

  • Dr Pugh is a GP at Cape Hill Medical Centre in Smethwick, West Midlands

Further details

For more information about the GSF Going for Gold Training Programme click here or call 01743 291891.

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