Facilitating good process in primary palliative care: does the Gold Standards Framework enable quality performance?

Background: Palliative care is an important, complex aspect of primary care, requiring a multidisciplinary approach. The Gold Standards Framework (GSF), a programme used by over 3000 UK practices, aims to facilitate high-quality palliative care through the introduction of systematic clinical and organizational processes. Quality payments for palliative care are available to UK practices which maintain registers and hold multidisciplinary meetings. Objectives. To explore the effectiveness and sustainability of the implementation of GSF at practice level. Methods. The study followed a qualitative comparative case study design using in-depth interviews and observational data with 15 practices participating in GSF, from three areas differing in socio-geography. Semi-structured interviews (total 45) with GPs, community nurses and practice managers were supplemented by observation of practice meetings and systems, to provide contextual insights. Transcribed interviews were analysed using a thematic matrix approach and comparisons were made within and between practices. Practices were identified on a continuum of performance (high, medium and minimal) according to the evidence of functioning in palliative care-related activity. Results: Considerable variation existed between practices in both the extent of palliative care-related processes and the effectiveness of inter-professional communication. High-performing practices displayed a clear-shared purpose for palliative care with effective communication, whereas minimal performing practices demonstrated little utilization of basic GSF processes and deficiencies in inter-professional communication. Conclusion. Effective palliative care requires good team relationships and robust processes. While GSF can enable such improvements, quality measures focusing on processes alone are inadequate to distinguish good practice, questioning the effectiveness of current quality measures in UK general practice.