Title: Quality improvement priorities for safer out-of-hours palliative care: lessons from a mixed methods analysis of a national incident reporting database
Funder: Marie Curie

Abstract: Improving the patient experience and quality of palliative care is a priority for healthcare systems across the United Kingdom (UK) with the development of policy documents outlining which domains which should be addressed to facilitate this. Quality standards do exist by the National Institute for Health and Care Excellence to guide this work. The RCGP, Marie Curie and others have developed excellent resources to upskill primary care professionals in the necessary skills for high quality palliative care delivery. However, there is a dearth of research identifying the system level issues responsible for on-going deficits in care in this patient group. This mirrors the lack of high quality evidence of harm in primary care in general – a gap the PISA team was established to help close. Following on from the World Health Organisation (WHO) safer primary care initiative and priority setting exercise, The team have been working over the last two and a half years to identify the types of patient safety incidents occurring in primary care in England and Wales. The National Reporting and Learning System (NRLS) has provided rich data to facilitate this initiative. These data has allowed the PISA team to postulate why an incident has occurred and propose interventions for improvement. The early analysis of 1,200 incidents involving patients receiving palliative care suggests that there is a significant lack of confidence amongst professionals working in the ‘out of hours’ primary care services around assessment, management and support needed by patients and families of patients receiving palliative care. One in five incidents in our sample describe issues happening in the OOH setting. These range from difficulties with accessing equipment, patients unable to access symptom relief when required, staff being unsure how to set up and manage syringe drivers, a lack of communication about resuscitation wishes and errors in drug dosing at the end of life. These findings echo existing findings which acknowledge that out of hours’ professionals’ struggle to meet the needs of palliative patients and that palliative care should be a focus of greater research. Current work around palliative care needs in primary care has focused on information sharing and ensuring advanced care needs have been shared with OOH services and NHS improvement teams being encouraged to invest in these systems. The coding and analysis work is soon to be completed and full analysis of the type previously described by our team will produce a set of areas for improvement, and possible interventions identified via scoping review of existing literature using a well-established method. This combination of incident report analysis and scoping review will highlight as yet unidentified deficits in the safety of palliative care delivery in the OOH primary care setting. Co-production approaches, where patients and front-line professionals work together to develop services based on local priorities is viewed as a way of implementing sustainable and prudent changes to services. The local improvement programme to be co-produced based on a combination of these findings during a stakeholder event should support buy-in from local providers of palliative care OOH and patients and families. Evaluation of how and in which contexts changes in practice are successful during this improvement project will support dissemination of the concepts and ideas others can emulate through academic outputs and feed into the RCGP palliative care toolkit in the form of a “How to Guide”. A driver diagram will be used to summarise and spread findings.


Research activity codes: 7.2 END OF LIFE CARE;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE