|Palliative Care: Clinical Indicators|
|Register of all patients in need of palliative care/support||Register||3|
|Regular practice multidisciplinary case review meetings (at least three-monthly) where all patients on the register are discussed||Meeting||3|
- There are two indicators in this disease area. The first indicator is for setting up a register of patients in need of palliative care and the second is for conducting at least three-monthly multidisciplinary case review meetings of all patients who are on the palliative care register.
- According to the guidance, the average GP can expect 20 deaths a year, of which five will be from cancer, seven from organ failure, one to two, sudden death, and six to seven, dementia, frailty and multiple co-morbidity.
- QoF data for palliative care for 2006/7 shows national prevalence rates for palliative care of 0.08 per cent in England and 0.09 per cent in Northern Ireland.
- The guidance says there is a growing impetus to improve end of life care for patients both with cancer and non-cancer diagnoses. It says the indicator set is designed to deliver three key steps in providing good end of life/primary palliative care. They are:
- Identifying patients in the advanced stage of illness in need of palliative/supportive care.
- Assessing their needs and preferences.
- Proactively planning their care.
Step 1: Setting up the register
- The register should consist of all patients aged 18 and over who are in need of palliative care support. It is prospective from April 2006.
- The framework guidance specifies the criteria practices should use to decide who should go on the register on the basis of prognosis and need. It says a patient should be included if:
- Their death in the next 12 months can be reasonably predicted and/or
- They have clinical indicators of need for palliative care that are prognostic clinical indicators of advanced or irreversible disease and include one core and one disease specific indicator in line with the gold standard framework (GSF) and/or
- They are the subject of a DS 1500 form (designed to speed up payment of benefits).
- The GSF, a widely implemented programme for palliative care patients, includes guidance on setting up a palliative care register. It has developed a series of clinical prognostic indicators which attempt to estimate when patients have advanced disease or are in the last year or so of life. There is one general indicator set plus sets for each of the major disease areas.
- In addition to the prognostic indicators, the GSF suggests practices consider two other approaches when compiling the register. One is the ‘surprise question’: ‘Would you be surprised if this patient were to die in the next six to 12 months?’ and the other is to consider patients with advanced disease who have made a choice for comfort care only, or are in special need of supportive/palliative care.
- The GSF suggests practices who have not had a palliative care register before may find it easier to begin with cancer patients, then add non-cancer patients to the register at a later stage. The disease register compiled for the cancer indicator set should be a useful starting point.
- The whole practice team should be able to contribute to building an accurate disease register for palliative care.
- Note that if there is nobody on the register at the end of the year, the practice will still be eligible for payment if it can demonstrate that it had a register in-year.
Step 2: From now onwards
- The second indicator requires practices to hold multidisciplinary case review meetings to discuss all patients on the palliative care register, at least three-monthly.
- Once the register is set up, decide how often meetings will be held, who will organise them and who will attend. Points can be earned for three-monthly meetings, although the GSF recommends monthly meetings.
- The GSF suggests it is a good idea to appoint a co-ordinator, usually a district nurse, practice nurse or manager, to arrange meetings and keep the register up to date.
- The guidance says the aims of the review meetings are to:
- Improve the flow of information.
- Ensure each patient has a management plan and decisions are acted on by the most appropriate member of the team.
- Ensure the management plan includes preference for place of care.
- Ensure carers' support needs are discussed and addressed where reasonably possible.
- Note that to qualify for the points, practices need to submit written evidence to their PCO describing the system for initiating and recording meetings.
- The meetings can help to ensure the register stays up to date throughout the year and new patients are added as appropriate.
Useful Resources for Palliative Care
1. Gold Standards Framework - QOF resources
2. National Cancer Research Institute Strategic Review
3. World Health Organisation Europe:
- Palliative Care: The Solid Facts
- Better Palliative Care for Older People