Standard 4: Seamless well planned coordinated use

The General Practice commits to:

To meet this standard the practice commits to:


Practice Guidance

4.1 Multi-disciplinary team meetings 












4.1a Understand the role and optimum outcomes of the MDT meeting in Advanced Serious Illness and EOLC
  • Practice agreement for MDT meetings, for example, how often, who attends, goals etc
  • Objectives of MDT agreed by practice team and recorded.
  • Assess effectiveness of meetings by obtaining feedback by attendees.
  • Consider peer discussion to agree roles and responsibilities for each team member.
  • Consider peer discussion to agree objectives of MDT.
  • Consider peer discussion / reflective reading on what makes an effective MDT.
  • Consider process for: new patients, dying, deteriorating and stable.
  • Consider who and how to involve for specialist advice, for example, Specialist Palliative Care, Geriatrics, Paediatrics etc.
  • Consider elements such as frequency of review to cover patients, quality of symptom control, quality of documentation, safeguarding issues, patient and carer involvement etc.
  • Consider visiting another practice, hospital or hospice MDT or invite external peer review.
  • Agree practice agreement for MDT meetings, including clinical governance arrangements.
  • Consider how to work with non-NHS bodies, for example, social services, housing, voluntary sector
  • Consider how you may involve PPG
  • Consider asking the practice team what makes a good meeting and how you may record these factors in each meeting, for example, construct a simple template with these factors and fill in after a meeting.
 4.1b Hold regular Advanced Serious Illness, and EOLC MDT meetings
  • Evidence of holding regular practice MDT for people with ASI + EOLC needs.
  • The meetings include an effective mechanism to review patients and carers on register in a timely manner.
    Record date of review and any change/outcome and also include in patients notes.
Not all patients and carers on the register can be reviewed at each meeting but a mechanism needs to ensure those of highest priority are discussed but that no one is ignored over a significant period.
4.1c Have input from interface teams, for example, hospice, community nursing, social prescribing etc.

Minutes/notes of MDT meetings showing:

  • Community nursing attending MDT regularly.
  • Evidence liaisons and partnerships built with other services to attend MDTs and/or provide multidisciplinary and cross-sectoral care, for example, SPC/hospice, geriatricians, mental health, social care, local voluntary sector services, social prescribing, paeds
  • Established route for advice /referrals to senior clinicians in SPC/hospice, geriatrician, psychiatrists, paeds etc.
  • Consider the most effective ways to have input and communicate with MDT members in and outside MDTs to achieve well-planned, safe care.
  • Consider use of technology and virtual MDT working.
  • Consider if there are benefits from multi-practice MDTs
Consider how to make the most effective use of people’s time and maximise different professionals’ strengths in order to contribute to meeting the needs of patients and carers.

4.2 Coordination of care across all care settings

4.2a Communicate across care settings
  • System in place and recorded to coordinate care across all care settings.

For example, EPaCCS or hand-held notes.

  • Case examples showing evidence of active use, regular and timely reviews and updating
  • Agree the system to be used within the practice.
  • Consider how the practice primary record communicates with the system.
  • Consider the risks/benefits of the system.
  • Consider how the system communicates within your locality/ wider system

For example, Out of Hours, Ambulance Services, hospices, community nursing etc

  • Consider how to make sure records are contemporaneous with the practice primary record and how to enable a relevant copy to the patient.
  • EPaCCS = Electronic Palliative Care Coordination Systems.

4.3 Data Collection

4.3a Achieve consistent data collection
  • Agree and have recorded standardised coding list for ASI + EOLC within the practice.
  • Understand, agree and use best-practice, standardised coding within the practice for Advanced Serious Illness and EOLC, for example, diagnostic information, urgent access flags etc.
  • Follow best-practice ASI + EOLC coding list.
  • Ensure quality and safe care is supported through access to reliable, timely clinical information and data.

4.4 Data Sharing






4.4a Have a system for data sharing
  • System in place and recorded for sharing clinical information and PCSPs for people on the register – available to OOH and Emergency Services.
  • System in place and recorded for sharing clinical information and PCSPs for people on the register available to cross-sector integrated services, for example, EPACCS.
  • Agree the system to be used within the practice.

4.5 Monitor the quality of care provided to people who died over the year

4.5a In practice annual retrospective death review

 Audit criteria to include:

Number of patients identified vs total number of deaths, expected or unexpected death, age, diagnosis, date identified on register (if expected), date and place of death, cause of death, on ASI + EOLC register, PCSP in place and recorded, date of MR and those from practice involved, any recorded decision- making for care and death preferences, DNACPR, Care Details, discussion of sensitive conversations with patients and carers, anticipatory medication prescribed, grief and bereavement assessment, number of hospital admissions in last year of life.

  • Presentation of audit and share learning outcomes at MDT.
  • Share learning outcomes with wider stakeholders, as necessary.  For example, CCG, acute providers and community providers
  • Annual audit of people who died on the register = Retrospective death audit.
  • Mortality review template can be used.
  • Items discussed to ensure high-quality, safe, effective and caring reviews within MDT process.
  • Understand your local public health practice profiles, JSNA etc.
  • Consider equity of care for the ‘hard to reach and vulnerable groups’ such as: Elderly, Dementia, LGBT, LD/Autism, BAME, Diagnosis-specific groups, children, people with disabilities, homeless, prisons.
  • Compare people who were identified and died on the register and those who were not
  • Consider how the practice shares practice learning on standards with other practices, federations and interface teams such as Out-of-Hours, Hospitals, Hospices/ specialist palliative care teams, care homes, paediatricians, geriatricians. 

4.6 Specialist Palliative Care (SPC) – acute, community and hospice teams

4.6a Have access to SPC/ hospice team(s)
  • Guidance available to practice team on how to access specialist palliative care services 24/7 for both adults and children, for example, for advice; referral criteria and process
  • Consider how practice and SPC/ hospice team(s) coproduce on issues such as teaching, shared resources, and MDTs.
  • Understand when and how to access specialist palliative care services 24/7.
  • Give consideration to early involvement of specialist palliative care services based on assessed need to improve quality of life, potentially improve survival and reduce distress for patients, their carers and families.
  • Ensure that shared care advice and arrangements where necessary are fostered between specialist palliative care providers, across entire practice ASI and EOLC register.

Next: Standard 5: Care is based on the assessed unique needs >

QI 4: Continuous Improvement

Incorporate the use of the Supportive Care Register Template  to support better and consistent decision making and discussions at MDTs for patients and carers/those important to them. 
Use the same template to consider all deaths and any learning (for people identified on the Supportive Care Register and people who died but were not identified). 

If reflected on regularly at each MDT (e.g. monthly), this naturally helps the practice a) plan care and support for those identified and b) learn from deaths. In addition, the template forms the basis of a regular (e.g. annually) practice Retrospective Death Audit  (to cover an agreed time) and action taken where outcomes achieved do not meet the practice accepted standards. 

Consider continuous monitoring of template criteria e.g. preferred place of death achieved, which are plotted on a line graph monthly. Consider National Information Standard for minimum EOLC dataset.

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