How Compton Care worked in partnership with a local GP practice to improve wrap-around care for people on the palliative and end of life care register.
Compton Care has been working in partnership with a local GP practice to improve care for patients who are on the palliative and end of life care (PEoLC) register. The hospice placed two specialist professionals in the practice on a part-time basis for a year: one clinical nurse specialist (CNS) and one paramedic practitioner.
The hospice identified that people with PEoLC needs were not always being included on the practice’s PEoLC register. The GP practice did not have a risk stratification tool to help identify these patients. With permission from the GP and the Integrated Care Board (ICB), they installed a new tool that analyses all the practice’s supportive care registers and identifies people with PEoLC needs.
Although the GP practice was already involving patients in advance care planning (ACP), the partnership enabled hospice staff to continuously promote the importance of ACP and share best practice. This support from specialist staff improved the quality of the information held within the ACP documents. Practice staff had greater understanding of the longer term implications of not recording people’s wishes correctly.
The hospice team discovered that referrals to other services often got delayed because the primary care staff weren’t able to get through to the right person first time. They worked with the practice staff to facilitate onward referrals. They helped the practice build connections with secondary care, social care and other vital services.
Outcomes
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The partnership has been positive for everyone involved.
There is now an increased number of people on the GP practice’s palliative and end of life care register.
Staff at the GP practice have greater confidence about having discussions with patients who have PEoLC needs. More patients have an advance care plan, and the quality of information in the plan has improved.
The Multi-disciplinary team (MDT) has increased in value because staff have better relationships. Practitioners have an improved understanding of each other’s role and appreciate the importance of holistic care for people with PEoLC needs. More carers are being invited for assessment and support.
The MDT has taken on responsibility for identifying learning from after-death audits. This means that learning can be shared with all practice staff, not just clinicians.
The partnership achieved ‘Highly Commended’ in Marie Curie’s Daffodil Standard Awards in 2024. It gained 100% in an evaluation using the ICB’s self-assessment Primary Care Framework.
Facilitators, challenges and advice
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Key facilitators
Wolverhampton’s Integrated Care Board (ICB) was implementing a new Primary Care Framework replacing the old QOF+ model. Primary Care Networks were asked to evidence improvement in certain areas, with palliative care being one of the key themes.
A local GP recognised Compton Care’s expertise and asked the hospice to work in partnership to improve palliative care. The GP practice received some funding from the ICB for this work, which was passed on to the hospice to help backfill the two embedded posts.
Challenges
While developing the new risk stratification tool, it became clear that the GP practice’s supportive care registers required updating. The hospice staff supported the practice to update the registers and raise awareness of why this was important.
Embedding specialist professionals in general practice is a steep learning curve for everyone. It takes time to get used to different ways of working. However, as the project progressed, staff reported that it was really helpful to be able to build relationships. They particularly valued the opportunity to have in-person conversations with each other about patients’ specific needs.
Tips and advice
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When care isn’t co-ordinated, everyone suffers. Take time to learn about the challenges primary care teams experience and work together to find solutions.
Utilise different viewpoints and skillsets. Embedding both a paramedic practitioner and a clinical nurse specialist in the GP practice gave an extra dimension to the partnership.
When you’re selecting staff to embed in a new environment, make sure they approach it as an opportunity to learn and build positive relationships.
Future development
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The partnership have submitted their model to the ICB as an example of best practice. This is an excellent first step in evidencing what can be achieved.
Compton Care is approaching other Primary Care Networks to see if the model can be replicated.
