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Living and Dying Well: A national action plan for palliative and end of life care in Scotland



Scottish Partnership for Palliative Care

Extract from Palliative and end of life care in Scotland: the case for a cohesive approach, May 2007


Recommendation 1
NHS Boards and CHPs should encourage adoption of the principles, approach and documentation of the GSFS by the remaining 28% of general practices in Scotland not yet involved.

Recommendation 2
SEHD, NHS Boards, CHPs and palliative care networks should support application of the core principles of the GSFS in all care settings across Scotland.

Recommendation 3
SEHD, NHS Boards, CHPs and palliative care networks should support the ongoing extension of the principles, approach and documentation of the GSFS to patients with life-threatening and long-term conditions and to frail elderly patients with multiple co-morbidities.

Recommendation 4
SEHD, NHS Boards, CHPs and palliative care networks should commit to supporting the ongoing education and facilitation required to allow mainstreaming of the GSFS to be sustainable in all primary care settings.

Recommendation 5
CHPs and palliative care networks should encourage GP practices to make full use of the upgraded IT systems that will become available from summer 2007. This should include GPs using their upgraded existing IT system to record patients' palliative care needs, plan review dates and assist multi-disciplinary team meetings, and sharing summary information with OOH services and NHS 24.

Recommendation 6
SEHD, NHS Boards and palliative care networks should support and facilitate flexible use of the LCP in all care settings.

Recommendation 7
Dedicated resources should be made available by CHPs and NHS Boards to introduce, embed and mainstream use of the LCP across Scotland. This should take into account the need for localisation of LCP documentation to support clinical need, and for appropriate education and training to ensure staff have the necessary understanding to use the LCP successfully and appropriately.

Recommendation 8
All NHS Boards should ensure that systems are in place which allow timely and easy 24-hour access to medication for patients with palliative care needs.

Recommendation 9
Further guidance should be provided to patients and professionals, clarifying when and for what purposes it is appropriate to contact NHS 24, and what information they will be required to provide.

Recommendation 10
Ongoing efforts should be made at a local level to work with NHS 24 to learn from recent experiences to improve services within a local context.

Recommendation 11
All NHS Boards should work towards early implementation of a 24-hour community nursing service to support existing medical OOH arrangements.

Recommendation 12
SEHD should ensure that changes in out of hours provision do not adversely affect the provision or quality of palliative care to patients in the community.

Recommendation 13
The Scottish Executive should conduct an investigation into the implementation of NHSMEL (1996) 22, with a view to clarifying the joint Health Board and Local Authority responsibility for funding palliative and end of life care.

Recommendation 14
NHS Boards, Local Authorities and CHPs should consider adopting/adapting the principles of the NHS Borders model when developing their own approach to joint working and joint care management.

Recommendation 15
The DNAR policy and associated documentation developed by NHS Lothian should be adopted by all NHS Boards, along with education to support the effective and appropriate application of the documentation and procedures.

Recommendation 16
SEHD, NHS Boards and CHPs should make available additional resources to enable appropriate education and training, and to enable dedicated support to facilitate the introduction and sustainability of the improvements outlined in this report.