GPs are identifying patients for anticipatory and palliative care more equitably across the different disease trajectories and earlier in the disease process than they were previously identifying patients specifically for palliative care. However, many patients still lack care planning, particularly those dying with organ failure.

BackgroundEffective communication of anticipatory care planning (ACP) discussions between patients and general practitioners across different healthcare settings is vital. In Scotland, the Key Information Summary (KIS) is a new piece of software that allows clinical data for selected patients to be shared electronically across the wider National Health Service from the primary care record. This can include details of ACP discussions and decisions. The KIS is now routinely accessible in secondary care and is available through the hospital electronic record in two formats (abbreviated and full versions).AimThe primary aim of this project was to significantly improve clinician access to the full KIS record within secondary care.MethodsFour Plan Do Study Act (PDSA) cycles were undertaken in total to improve access to the full KIS between October 2014 and March 2016 in the Medical Admissions Unit of a Scottish hospital.ResultsBaseline data showed poor awareness and use of available KIS information by clinicians for patients admitted to hospital. Most were unaware the KIS was available and only 19% had seen the KIS for their patient. Where a KIS existed for a patient, clinicians felt the information contained within it was useful in 75% of cases, and one in every five KIS could alter clinical management. Data collection following the first 3 PDSA cycles revealed a significant increase in access to the full KIS after 5 months (from 4% to 45%). However 1 year on after after a fourth PDSA cycle to implement sustainable interventions this level of access was not maintained.ConclusionsReasons for these results are discussed, as well as limitations to certain interventions. Access to the full KIS at the point of hospital admission can be significantly improved using a quality improvement approach. Improved access to this information may influence the clinical management of selected patients. However sustainable, system-wide strategies are needed to maintain these changes in the longer term.

IntroductionElectronic Key Information Summaries (KIS) are shared electronic patient records widely used throughout Scotland.1 These allow selected parts of the GP patient record to be routinely shared with healthcare professionals across settings. The KIS may contain vital information to support out of hours palliative care decision-making, such as patient preferences for place of care, DNAPCR status and anticipatory medicines.AimTo identify when different information pertinent to out of hours palliative care decision-making was serially recorded within the KIS for patients who died with cancer, organ failure or frailty and/or dementia.MethodA retrospective review of the primary care notes of deceased patients across nine general practices in Lothian was conducted in 2014. Sudden and unexpected deaths were excluded. Data were collected on the type and timing (number of weeks before death) of information recorded in the KIS.ResultsWe analysed 605 patient notes. A KIS was shared for patients with organ failure 22 weeks before death (Mdn = 22, IQR = 10–31), and for those with frailty and/or dementia, 20 weeks before death (Mdn = 20, IQR = 8–34). For patients with cancer, KIS’s were commenced later (Mdn = 14, IQR = 6–27). Most patients with a KIS had information on anticipatory care, preferred place of care and DNACPR shared during the last month of life. Information on anticipatory medicines was shared two weeks before death (Mdn = 2, IQR = 1–6).ConclusionElectronic key information summaries facilitate the timely documentation and sharing of patient information that is vital to support out of hours decision-making and prevent inappropriate hospital admissions.ReferenceTapsfield J, Hall C, Lunan C, McCutheon H, McLoughlin P, Rhee J, Rus A, Spiller J, Finucane A, Murray SA. Many people in Scotland now benefit from anticipatory care before they die: an after death analysis and interviews with general practitioners. BMJ Supportive and Palliative Care 2016. doi:10.1136/bmjspcare-2015-001014

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The RCGP conference, like other annual healthcare conferences offers a protected space for reflection on ethical aspects of practice. This paper presents a summary and discussion of a fringe session led by the RCGP Committee On Medical Ethics at the 2017 RCGP annual conference in Liverpool. Well thought-out rules offer a potential solution to the burden of responsibility for making every single decision from first principles. But guidelines can be difficult to follow, too numerous to know, may conflict with each-other and may not be appropriate in all circumstances. Delegates at this meeting discussed barriers to good guideline development and implementation, perceptions of medicolegal risk in non-adherence, aspects of benefit, harm and justice in guideline use and ethical guidelines. Delegates found it easier in the meeting to critique clinical rather than ethical guidelines. There was broad agreement that understanding how to practice in relation to guidelines represented a learning need in general practice education.

Background and Aims The ‘inverse care law’, first described in 1971, results from a mismatch of healthcare need and healthcare supply in deprived areas. GPs in such areas struggle to cope with the high levels of demand resulting in shorter consultations and poorer patient outcomes. We compare recent national GP and patient satisfaction data to investigate the ongoing existence of this disparity in Scotland. Methods and Results Secondary analysis of cross-sectional national surveys (2017/2018) on upper and lower deprivation quintiles. GP measures; job satisfaction, job stressors, positive and negative job attributes. Patient measures; percentage positive responses per practice on survey questions on access and consultation quality. GPs in high deprivation areas reported lower job satisfaction and positive job attributes, and higher job stressors and negative job attributes compared with GPs in low deprivation areas. Patients living in high deprivation areas reported lower satisfaction with access and consultation quality than patients in low deprivation areas. These differences in GP and patient satisfaction persisted after adjusting for confounding variables. Conclusions Lower GP work satisfaction in deprived areas was mirrored by lower patient satisfaction. These findings add to the evidence that the inverse care law persists in Scotland, over 50 years after it was first described.