title: Improving primary palliative care in Scotland: lessons from a mixed methods study.
abstract: BACKGROUND
  Since 2012, all GP practices across Scotland have been supported to take a systematic approach to end-of-life care, by helping them to identify more patients for palliative care through a Palliative Care Directed Enhanced Service (DES). We aimed to understand the impact of this initiative.
  
  
  METHODS
  Routine quantitative data from the 2012/13, and 2013/14 DES were collected from regional health boards, analysed and discussed. Qualitative data were collected from a sample of 2012/13 DES returns and analysed using Thematic Analysis.
  
  
  RESULTS
  Data were received from 512 practices in nine Scottish Health boards for the 2012-13 DES and 638 practices in 11 Health boards for 2013-14. A sample of 90 of the returns for 2012-13 was selected for qualitative analysis. In 2012-13, 72 % of patients who died of cancer were listed on the palliative care register (PCR) before death while 27 % of patients who died as a result of non-malignant conditions were listed on the PCR. In 2013-14, cancer identification remained the same but identification of people dying with other long-term conditions had improved to 32.5 %. We identified several key issues needed to improve palliative care in the community. The need for training to identify patients with palliative care needs (particularly non-cancer); communication skills training; improvements in sharing information across the NHS; under-resource of and lack of coordination with district nurses; improvements in information technology; and tools for working with enlarged palliative care registers.
  
  
  CONCLUSIONS
  The DES helped more patients with long-term conditions (LTC) receive generalist palliative care. Approaching generalist palliative care as anticipatory care could facilitate communication between GPs and patients/families and remove some barriers to early identification of palliative care needs. Improvement of information technology and use of identification tools like the SPICT™ may improve professionals' communication with each other and help may make identification and management of patients easier.
authors.affiliation: The University of Edinburgh, Centre for Population Health Sciences, The Usher Institute of Population Health Sciences and Informatics, Primary Palliative Care Research Group, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK. Bruce.Mason@ed.ac.uk.
authors.forename: Bruce
authors.initials: B
authors.lastname: Mason
authors.affiliation: The University of Edinburgh, Centre for Population Health Sciences, The Usher Institute of Population Health Sciences and Informatics, Primary Palliative Care Research Group, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK. Susan.Buckingham@ed.ac.uk.
authors.forename: Susan
authors.initials: S
authors.lastname: Buckingham
authors.affiliation: Marie Curie Hospice Edinburgh, Edinburgh, UK. Anne.Finucane@mariecurie.org.uk.
authors.forename: Anne
authors.initials: A
authors.lastname: Finucane
authors.affiliation: NHS Dumfries and Galloway, Dumfries, Scotland. peter.hutchison@nhs.net.
authors.forename: Peter
authors.initials: P
authors.lastname: Hutchison
authors.affiliation: The University of Edinburgh, Centre for Population Health Sciences, The Usher Institute of Population Health Sciences and Informatics, Primary Palliative Care Research Group, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK. Marilyn.Kendall@ed.ac.uk.
authors.forename: Marilyn
authors.initials: M
authors.lastname: Kendall
authors.affiliation: NHS Lothian, Edinburgh, UK. HazelMcCutcheon@nhs.net.
authors.forename: Hazel
authors.initials: H
authors.lastname: McCutcheon
authors.affiliation: NHS Lothian, Edinburgh, UK. Lorna.Porteous@nhslothian.scot.nhs.uk.
authors.forename: Lorna
authors.initials: L
authors.lastname: Porteous
authors.affiliation: The University of Edinburgh, Centre for Population Health Sciences, The Usher Institute of Population Health Sciences and Informatics, Primary Palliative Care Research Group, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK. Scott.Murray@ed.ac.uk.
authors.forename: Scott A
authors.initials: SA
authors.lastname: Murray
mesh_terms: D001291:Attitude of Health Personnel; D005260:Female; D006801:Humans; D008297:Male; D010166:Palliative Care / Q000592:standards* / Q000639:trends; D011320:Primary Health Care / Q000592:standards* / Q000639:trends; D036301:Qualitative Research; D058996:Quality Improvement / Q000458:organization & administration*; D012189:Retrospective Studies; D012606:Scotland; D013222:State Medicine / Q000592:standards