Standard 2: Early identification

The General Practice commits to:

To meet this Standard the practice commits to:


Practice Guidance

2.1 Early identification of patients 



2.1a Understand how to identify people who may be approaching the end of life
  • An agreed protocol for identifying people who may be approaching the end of life – with potential Advanced Serious Illness and EOLC needs.
  • Include seamless transition of practice supportive care registers, such as thosefor: dementia, frailty, disease specific long-term conditions, recurrent admissions, care homes, palliative care.
  • Demonstrate active use and timely, regular reviews of people on the register.
  • As far as it is possible, aim to maximise the number of people on your Advanced Serious Illness and EOLC 'supportive care' register.
  • Agree how all members of the practice team can highlight people who may benefit by being on the supportive care register
  • Agree flagging mechanism on practice computer and what this means for the patient
  • Understand different disease trajectories
  • For example, BMJ: Palliative Care from Diagnosis to Death video and article
  • Understand your practice population and varying cultural, psychological and access needs taking into account; long term health conditions, disabilities (including learning disabilities), BME, deprivation, elderly, care home residents, homelessness, prisons etc.
  • Understand how this fits your local population and who you may expect to be on a supportive care/ EOLC register using the End of Life Care profiles 
  • Evidence use of clinical judgement, risk stratification and use of prompts such as Supportive and Palliative Indicators Tool (SPICT) or GSF (PIG) to identify people at risk of deteriorating or dying and Electronic Frailty Index (eFI)

2.2 Practice Advanced Serious Illness and EOLC register


2.2a Have a robust system in place to record and review patients requiring EOLC

  • An easily accessible register.
  • Staff aware of how to access and code on the register.
  • System to flag patients to all staff to enable quick, effective decision-making and access.
  • The practice list represents an expected proportion of people in the practice (typically at least 1%) with Advanced Serious Illness and EOLC needs or reasons recorded why this does not align with the local population.
  • Demonstrate continuous improvement each year to identify people in your practice affected by Advanced Serious Illness, and EOLC – at least identifying your practice's '1%' for those thought to be in the last year of life.
  • Evidence use of active practice 'Supportive Care' register for patients and carers with Advanced Serious Illness, and EOLC needs.
 2.2a Have a robust system in place to record and review patients requiring EOLC
  • Patients have a named GP.
  • Patients have capacity assessed and recorded.
  • Patients have legal documentation recorded, for example, ADRT, LPA, DNACPR.
  • Age of patients recorded.
  • Diagnosis recorded: highlighting cancer/ non-cancer.
  • Inequality group recorded.
  • Communication and information needs, for example, any sensory loss or disability (including learning disability).
  • Patients' care and support holistic needs and preferences are recorded
  • Consider inequalities within CQC   thematic review (relevant to all countries)
  • Consider differences between expected and unexpected deaths.
  • When patients have a diagnosis that is likely to lead to a loss of capacity in the future, it is important to timely raise this with the patient and to offer appropriate information, support and the opportunity to understand legal documentation available to support their care and wellbeing preferences.
  • Capacity is decision - and time - specific; it should be clear that this recording of overall capacity relates to documenting 1: whether there is an impairment of/disturbance in the functioning of someone's mind/brain; and 2: whether this may affect the person's capacity to make a particular decision. If yes, the documentation can then include details of how/when capacity for specific decisions should be assessed, and who should be involved in this. 
  • CQC The Mental Capacity Act 2005: guidance for providers.

Next: Standard 3: Carer Support - before and after death >

QI 2: Continuous Improvement

  1. Monthly recording of percentage of patients on practice list that is on Supportive Care Register. Displayed on a line graph, considering a number (or %) that is aligned with their population. Defined practice population (or %) = number of deaths in the last 12 months/total practice population.

  2. Monthly recording of percentage of carers for patients on Supportive Care Register. Displayed on a line graph with an increasing objective to reach around 60-90% of Supportive Care Register patients, or a % t that is aligned with their population.

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