Standard 5: Care is based on the assessed unique needs of the patient carer and family - Example GP Practice Team EOLC group exercise

Record: Those attended, apologies, and date of meeting.

The aim

  • For the practice to consider how best to manage care planning.
  • To routinely offer/enable timely and accessible conversations to facilitate holistic, personalised care and support planning1,2,3 for people with advanced serious illness and end of life care needs, and where relevant to those important to them.

This includes:

  • Treatment escalation plan.
  • Advance Care Plan.
  • Links to support within the community: map who is available to support the patient and family/carer in a crisis and also to support living well – considering anxiety, depression, loneliness and social isolation.


Marie Curie Daffodil Standards Reflective Practice Standard 5 Principles


Personalised care and support plans (PSCP) aim to promote patient-centred, informed care and a structure to enable compassionate discussions about medical and non-medical goals of care, empowering choice with the right to consent to or refuse treatment and care offered. It is sensible for plans to consider possible future emergencies, incorporating if they are unable to make or express choices. Where relevant, discussions should involve family, carers and those important to the patient.

Ideally, personalised care and support planning discussions occur when a patient’s condition is stable, in anticipation of crisis, deterioration and dying. However, there may also be an opportunity to start the process of Personalised Care and Support Planning following an episode of deterioration or carer struggling to cope resulting in a hospital admission. Once a person has settled into a new care home, planning discussions can be effective.

Advance Care Planning for people with advanced serious illness and end of life care needs is associated with improved patient experience and reduced hospital admissions. Compassionate and honest communication is fundamental to helping people to make decisions about end of life care through these planning discussions. This process should include a consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users, carers and parents with a disability, impairment or sensory loss.4

Discussions should ideally be fluid and progress over time, at a person’s pace, rather than as a single event. It may be that some patient’s do not want to have these discussions and this should not be forced. Patients may change their mind, so offering patients the opportunity to review and continue discussions about their goals of care is beneficial.


Think about a specific patient who has died and who was or could have been identified prior to death. that is, had a known advanced serious illness and ‘expected death’. Did they have a care plan with these discussions coded and documented? Components to consider:

  • Treatment escalation plan
  • Advance Care Plan
  • Mapping who is available to support the patient and family/carer in a crisis

See examples above + Example Your Health and Wellbeing code mapping

Discuss the following questions as a group (and someone take notes on the key points)

  1. Look for a patient that did not have any components of a care plan (TEP, ACP, Support Map), what opportunities were there to offer and have these care planning discussions?
  • What could have been the benefits to the patient (+/- relevant family/carers), the practice, the wider system?
  • What gaps were there?
  • What would the practice do differently in future?
  • How will the practice monitor improvement?
  1. Look for a patient that did have a care plan with some or all components documented:
  • Who was involved in these discussions?
  • When was the patient identified to have an advanced serious illness? How long after this did the care planning start? How long after care planning discussions did the patient die? Were there opportunities to improve the timeliness of the process?
  • Were details of people important to them recorded, e.g. family, carer, neighbour?
  • Was it documented that the patient did or did not have any specific communication needs, e.g.cognitive impairments, hearing or sensory loss, English not their first language?
  • What was the quality and impact of conversations recorded?
  • Was the patient flagged as identified on ‘Supportive Care Register’?
  • If recorded, did the care the patient received align with their wishes? If not, why was their variation?
  • Was the patient offered a copy of their care plan?
  • Was the care plan information available to key professionals in and out of hours?
  • What was done well and how could the care planning have been improved?
  • How will lessons learned improve future practice? Is there an action plan?
  1. Consider the processes involved in creating a personalised care and support plan?
  • Clarify tasks undertaken by different members of the team when care planning (from diagnosis of an advanced serious illness to after death)
  • Do all members of the team understand what information is to be included in personalised care and support plans?
  • Does the practice have a robust, reliable template dataset to collect information about a person’s care planning discussions?
  • Is this template dataset shared between other local practices/ CCG?
  • Is the patient routinely offered a copy of their care plan?
  • If relevant to your locality, do patients have online access to their care plans?
  • Is the care plan information available to key professionals in and out of hours? e.g. via EPaCCS or hand held record
  • How does the practice monitor improvement? How will lessons learned improve future practice? Is there an action plan?
  1. Create a process map of PCSP5
  • Start point of process map is identify patient.
  • End point is patient having copy of plan.
  • Use different coloured post- its, one for a step in the process, one for an area of improvement.
  • Each stage needs to be broken down. The more detailed the better.
  • The steps are placed sequentially horizontally.
  • If one step can be done in several ways this is added vertically.
  • Complete the process before adding the areas for improvement. These post-its are placed next or over the relevant step in the process.
  • Once this is done participants may identify solutions and add it to the map using a different coloured post-it note.

Informing part of the evidence on Standard 5

  • Objectives of PCSP agreed by practice team.
  • Coding, Recording and Coordination system agreed by practice team.
  • Personalised care and support plan available.
  • Process map of PCSP.

Next: Standard 6: Quality care during the last days of life >

QI 5: Continuous Improvement

The practice has identified areas for improvement from their process map (see 5.1b). They then use the three questions from the Model for Improvement, which are:

  1. What are we trying to accomplish?
  2. How will we know if a change has made an improvement?
  3. What changes can we make that will result in an improvement? One of these changes at a time are taken into a Plan-Do-Study-Act cycle. Guidance on Model for Improvement and PDSA cycles can be found on the Quality Improvement section of our website. 


  1. Mullick A. Martin K. Sallnow L. An introduction to advance care planning in practice BMJ 2013; 347:f6064
  2. Personalised care and support planning handbook
    • NHS England: The journey to person-centred care
    • Core Information NHS England, Long Term Conditions, Older People & End of Life Care
  1. Dementia Good Care Planning guide - NHS England
  2. Accessible Information Standard: Making Health and Social Care Information Accessible
  3. Quality Improvement for General Practice

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