Shipman scapegoats ordeal ends
Why quality pay is only way forward
With the quality and outcomes framework review now in full swing, this new series provides a platform for GPs to make the case for inclusion of new targets this week, Dr Nicholas Brown argues for greater prominence for palliative care
this week, Dr Nicholas Brown argues for greater prominence for palliative care
Most GPs agree that care of terminally-ill patients is a fundamental and rewarding part of primary care. But as the primary care team grows and the GP delegates more and more responsibilities, the issue of how well placed GPs are to fulfil such a personal and responsive role is now being questioned.
In addition, most practices now only retain direct clinical responsibility for less than one-third of the total 168 hours in the week.
There are currently10 points in the quality and outcomes framework (QOF) linked with palliative care.
These include points for having systems in place that ensure relevant team members are informed of deaths, that alert the out-of-hours provider that a patient is dying at home, and that identify a carer.
A further six points can be earned for having a cancer register and for carrying out a six-month review of patients on it.
Initiatives are already set up on how to improve care, most notably the NICE guidance on cancer services 'Improving Supportive and Palliative Care for Adults with Cancer' (March 2004) and the gold standard framework. But there is a current reluctance of GPs to engage in yet another new initiative.
And their preoccupation with QOF and their release from the obligatory 30 hours' PGEA requirement has left even well-sponsored educational events poorly attended.
There is plenty of evidence showing the benefit of good palliative care (see box). NICE has been convinced by the evidence and made these proposals into recommendations. Now GMS2 should do the same.
PCTs with deficits can't find the cash for such initiatives and so QOF is the only way forward.
Nicholas Brown is a GP in Chippenham and primary care cancer lead for Kennet and North Wiltshire PCT
Evidence on how we can improve palliative care
As a starter for 10, here are just some of the evidence-based things we should be including in the next QOF:
· A register of all patients with complex palliative and supportive care needs (not just cancer).
· For the practice to demonstrate it has a system of multidisciplinary primary health care team communication to proactively plan care of patients with complex
needs with a co-ordinator
responsible for the day-to-day implementation of this process. Addington-Hall et a · 1 and Raftery et a · 2 showed this resulted in fewer home visits and fewer hospital admissions, and that relatives were less likely to feel angry when they thought of the patient's death.
· An integrated terminal care pathway that involves the practice such as the Liverpool Care Pathway for symptom control and advanced planning of care3.
· The practice has a strategy for the bereaved. Stewart et a · 4 showed this had a significant effect on support satisfaction rates and on diminishing support need.
1 Addington-Hall JM et al. Randomised controlled trial of effects of co-ordinating care for terminally-ill cancer patients. BMJ 1992;305:1317-22
2 Raftery et al. A randomised controlled trial of the cost-effectiveness of a district co-ordinating service for terminally-ill cancer patients. Palliative medicine 1996;10:151-61
3 Ellershaw JE et al (2001). Care of the dying, setting standards for symptom
control in the Last 48 hours of life. J. Pain Symptom Manage 21(1),7-12
4 Stewart M et al. Promoting positive effect and diminishing loneliness of widowed seniors through a support intervention. Public Health Nursing 2001;18:54-63