Community nurses (CNs) now have a golden opportunity to work closely with GP colleagues in reviewing and improving end-of-life (EoL) care. The new NHS England (2019a) GP contract has attached substantial financial rewards to implementing a locally led EoL quality-improvement project before the end of March 2020. This reflects the aspirations of the NHS long term plan (NHS England, 2019b) to ‘personalise care to improve end-of-life care’. GP contract holders must review recent EoL care provision for patients and implement a tailored project to improve each of the following domains:
As CNs are key to delivering and coordinating EoL care at home (Mitchell et al, 2016), they have an important role to play in this work. The GP contract expects practice teams to work closely with community colleagues in tailoring and delivering the project (NHS England, 2019a). GP practices will retrospectively audit EoL care provision and identify areas for improvement. CNs, as GPs' trusted ‘eyes and ears', are perfectly placed to identify aspects of palliative care that could be improved (Walshe et al, 2008).
Personalised care can be viewed in several ways. The recently released ‘Da?odil Standards' (Royal College of General Practitioners and Marie Curie, 2019) provide GP practice-level EoL self-assessment criteria, suggested standards of care provision and quality improvement indicators. Areas for review include anticipatory care and carer support before and after death. Teams already delivering integrated EoL care have an opportunity to build upon past successes. Practices could identify how patients with a multitude of life-limiting illnesses can access the level of support traditionally received only by those with terminal cancer.
With less than a year, the timeframe for the innovation project is short. This is a big ask for already busy clinicians and requires careful planning and coordination. With any quality-improvement initiatives, there is a risk of ‘gaming’, where individual measurements of care are improved without fundamental shifts in practitioners' ways of working (Alderwick et al, 2017). Personalised EoL care is much more than documenting a decision to no longer attempt cardiopulmonary resuscitation or a patient's preferred place of death. Care must reflect patients' unique situations, wishes and changing needs. Locally led change projects focusing on improving integrated EoL care can have lasting legacies (Bowers et al, 2010). If CNs take up this opportunity to work closely with GPs to improve care, personalised and well-coordinated EoL care could noticeably advance.