This site is intended for health professionals only

How we increased the number of patients on our end-of-life register by 600%

The problem

We were concerned that our end of life care was too focussed on patients with cancer, while our relationship with our local care homes was not strong enough. This was particularly a problem as there is a high proportion of elderly patients amongst the 13,400 on our list at Ilkley Moor Medical Practice, including residents in the 11 care homes we look after. Therefore, we were very keen when NHS Airedale Wharfedale & Craven CCG offered us the chance to complete a programme aimed at identifying and providing for patients at the end of their life – the Gold Standards Framework (GSF) ‘Going for Gold’ programme.

What we did

The first step of the programme is identification. The GP, nurse or even receptionist seeing the patient asks themselves: would it be a surprise if this patient died within the next year? If the answer is no, they are suitable for the programme. We also use the frailty index score.

Secondly, the GP or community matron discusses the patient’s health face-to-face and explains that we are hoping to plan their care in an individualised patient-centred way. The third step is constantly assessing the patient’s condition. All patients on the GSF register are coded according to the traffic light system for expected prognosis – green for months, yellow weeks and red for days. Every time we see the patient we assess if the category has changed.

To implement this system, we held monthly, hour-long educational meetings for the whole practice. It was hard for clinical staff to make the time available for these meetings, so we incorporated it into our practice meetings and brought in a palliative care consultant to advise.


Increasing the number of patients on our GSF register does create time constraints. We previously had 27 patients on the GSF register, all cancer patients. Now we have 236 on the register, 70% of whom are non-cancer patients. That does create more work, but we have got funding from the CCG, £60,000 over 12 months, for two GP sessions per week and our close work with the community matron.

It can be difficult to engage in conversations about dying, but we’ve learned that developing a good rapport with the patient, choosing an appropriate time and slowly introducing the idea works best. It’s important to communicate that this is about ensuring better quality care rather than there is nothing more that can be done.


We’ve increased the number of patients on the GSF register almost sixfold. Of those on the register, we’ve had advance care planning discussions with over two thirds. This has enabled us to support more than 50% of patients to die in their preferred place – their home. We have also reduced hospital admissions by 20-30% because of fewer emergency crisis events.

But for me, the greatest results have been qualitative. The administrative staff have gained the confidence to identify patients they think are approaching the end of life – they often see subtle changes in patients sooner than doctors.

For the patients, they feel a much greater sense of reassurance and are more empowered to get in touch at any time. The Goldline, a dedicated phone line set up by our local palliative care team, has been a massive asset and helped to complement the work we’ve been doing. We’ve received lots of positive feedback from relatives, and found people wanting to register at our practice because of our comprehensive end of life care system.

We’re also working much more closely with care homes and with the district nurses. In a nursing home pilot we have worked alongside our community matrons to ensure all of the residents have care plans in place. We now go to the care homes once a week and do a ward round. Because of this pilot we were finalists for the GP Team of the Year Award at the General Practice Awards.

Dr Helena Rolfe is a GP partner in Ilkley, Yorkshire


Visit Pulse Reference for details on 140 symptoms, including easily searchable symptoms and categories, offering you a free platform to check symptoms and receive potential diagnoses during consultations.