How to develop and maintain a role in palliative and end of life care

The GPwER PEoLC should be able to demonstrate evidence of: 

• a CCT or equivalent in general practice 
• current GMC registration and licence to practise  
• continued practice in primary care on a performers list  
• active engagement in appraisal 

Practitioners are expected to demonstrate that they have completed recognised training, which may include acknowledgement of prior learning and experience. This can be acquired in different ways, many of which are complementary and are not mutually exclusive.

Formal training

• Relevant, current or recent experience (within the last five years) working in a palliative care setting (hospital advisory team, hospice or inpatient unit, community palliative care team, day hospice)
• Independent self-directed learning, including reading, maintenance of personal portfolio, audit, quality improvement and research projects, reading journals, listening to relevant Podcasts and achieving personal goals
• Palliative care directed e-learning.

Profession specific learning paths:

• The End of Life and Palliative Care Toolkit provides a collection of tools, knowledge, and current guidance for healthcare professionals to support patients nearing the end of life to live well until they die. The resources include information for patients and those close to them. 
• Learning Path for General Practitioners with a Special Interest in Palliative and End of Life Care
• Learning Path for General Practitioners
• Attendance at recognised teaching events including face to face or virtual teaching sessions on topics relevant to palliative care (see section 10 for examples) 
• Case presentations  
• Grand rounds or clinical meetings 
• Critical appraisal, including journal clubs 
• Advanced communication skills training  
• Participation in relevant community of practice events to support life-long learning, for example via Project ECHO 

Higher study focused on palliative care

Higher study to a minimum of Certificate level is strongly encouraged (see section 10 for resources).

Continuing Professional Development (CPD)

GPs are expected to undertake CPD and demonstrate where this has led to important changes and developments as part of the annual appraisal and revalidation process. For GPs developing their portfolio to demonstrate competence as a GPwER, CPD activity should include palliative care alongside relevant activities for GP.

Once established as a GPwER PEoLC, practitioners should undertake annually some CPD specific to palliative care, alongside quality improvement work relevant to their palliative care practice, to maintain capability.

A. Knowing yourself and relating to others

• Demonstrates excellent communication across settings 
• Demonstrates compassionate leadership 
• Demonstrates ability to work as part of a team  
• Demonstrates the importance of team-working and leadership skills including coaching, mentoring, influencing, negotiating 
• Able to lead complex decision-making, following clear ethical and legal frameworks 
• Demonstrates collaboration and partnership working 
• Able to drive performance 
• Performance management 
• Is a motivating and inspiring clinician

B. Applying clinical knowledge and skill 

• Demonstrates commitment to developing and maintaining own Continuing Professional Development (CPD) 
• Able to critically appraise literature or research to inform evidence-based teaching and practice 
• Delivers effective teaching and training to medical students, doctors in training and other health care professionals 
• Able to effectively plan a teaching session and define relevant learning outcomes 
• Able to utilise a variety of appropriate teaching techniques or methods across a range of different learning settings 
• Able to participate in organising a course 
• Able to provide effective feedback to learners 
• Able to reflect on or evaluate teaching and respond to feedback

C. Managing complex and long-term care (in relation to palliative and end of life care)

• Identifies people with limited reversibility in their underlying medical condition, including recognising flags or triggers that indicate a pattern of deterioration, for example unplanned hospital admissions; worsening physical or cognitive function; delirium 
• Identifies when people are starting to die 
• Demonstrates active, holistic management for people with frailty syndromes and advanced dementia, including managing the interface between active and palliative management  
• Demonstrates advanced diagnostic and communication skills; ability to develop a problem list; appropriately select, manage and interpret investigations (including when investigation is not appropriate) and formulate an individualised management plan, considering patient preferences  
• Effective management of medical emergencies across all frailty and palliative care settings, including determining when intervention is inappropriate and how to manage this in the individual’s own residence of appropriate   
• Performs a structured medication review; able to optimise and manage medicines in patients living with long-term conditions and frailty  
• Able to effectively assess decision-specific mental capacity and coordinate best interests decision-making in those lacking capacity for specific decisions 
• Able to offer and support ‘what matters most’ and advance care planning discussions with patients with capacity  
• Able to offer and support those close to patients to develop a plan for care for urgent or new problems, where the individual does not have capacity for advance care planning discussions; including use of national processes, for example ReSPECT, Gold Standards Framework or electronic care coordination systems 
• Ability to support patients and those close to them to identify meaning in their lives, enhance wellbeing and where appropriate, support people to focus towards realistic hope  and goals  
• Demonstrates ability to:
  1. focus on the positive goals for patients and their families, to make the most of time remaining  
  2. manage complex and challenging situations with patients, those close to them and colleagues  
  3. anticipate and manage disease-specific symptoms, problems and palliative care emergencies 
  4. facilitate effective communication of complex issues and information as patients transfer across settings  
  5. identify obstacles to communication and skills in overcoming these

D. Working in organisations and systems 

• Liaise with and provide support for other GPwER PEoLC in the local area 
• Able to supervise less experienced doctors in training in their clinical assessment and management of patients  
• Able to provide support and advice to local primary care colleagues to enable these other clinicians to develop, maintain and improve their level of clinical capability in PEoLC 
• Demonstrates effective liaison with local primary care palliative and end of life care leads in terms of education strategy, for example GP Macmillan facilitators 
• Provision of support and training to GPs and members of the primary healthcare team in the management of patients with palliative and end of life care needs 
• Demonstrates knowledge of key education themes for generalists for example, Advance Care Planning, discussion around CPR decision-making, Communication Skills Training, Palliative and End of Life Care symptom management, ethical and legal issues 
• Demonstrates ability to work with colleagues to support the development of newer roles, for example advanced practitioners and physician associates, to support the delivery of sustainable primary and PEoLC services across all settings

E. Caring for people and communities. 

• Demonstrates good awareness of the breadth of community and specialist services to provide appropriate support to the individual and those close to them 
• Demonstrates awareness of the opportunities for community engagement, development and health promotion to improve a range of health and social care outcomes at the end of life 
• Community initiatives such as compassionate communities and integrated care networks will be important in delivering sustainable services in the future and in addressing current inequalities in access to services

GPwER in palliative and end of life care - core capabilities Venn diagrams (PDF file, 319 KB)

The GPwER PEoLC builds on the leadership abilities of the 'standard' GP role (see RCGP Leadership Capabilities Framework)

The GPwER PEoLC may work across one or a mix of care settings (hospital, community – including a person’s own home or care home and hospice).

Demonstrating personal qualities

• Demonstrates ability to synthesise clinical and psychosocial information leading to patient-centred decision-making across care settings
• Demonstrates ability to provide a clinical opinion in situations where there is clinical uncertainty or conflict with patients, those close to them, or both
• Supports clear communication to facilitate patient care across settings
• Demonstrates ability to work as an autonomous practitioner, utilising their expert generalist skills

Working with others

• Demonstrates ability to coordinate care across settings in collaboration with hospital and community providers, to optimise patient-centred care and use of resources, for example attending Gold Standards Framework (GSF) and other relevant multidisciplinary team meetings
• Demonstrates ability to bridge gap between ‘specialist’ services for complex patients and ‘non-specialist’ palliative care for patients with less complex needs
• Demonstrates ability to collate information from all members of the multidisciplinary team
• Demonstrates ability to support, educate, influence and develop members of the wider multi-professional team to deliver high quality palliative care across all care settings

Managing services 

• Engagement with local health organisations and PEoLC research, audit and quality improvement to inform service development and evaluation across settings

Improving services

• Demonstrates awareness of the needs of local populations when developing and delivering PEoLC services
• Demonstrates effective leadership, negotiation and management skills
• Demonstrates collaboration with other members of the local health community (including primary care, pharmacy and palliative care), develops and implements clinical guidelines for the management of palliative care patients in and out of hours
• Engagement with PEoLC research, audit and quality improvement to inform service development and evaluation across settings

Setting direction

• Demonstrates understanding of the structures that support effective leadership and management in NHS and third sector organisations, including the role of volunteers, fundraising teams and trustees
• Works with patients, the public and service providers to support an integrated, patient-centred approach to commissioning services 

The GPwER PEoLC will develop advanced knowledge and skills to support the palliative care of patients that are in the last phase of life and those with frailty, dementia and long-term conditions, building on their generalist knowledge and skills. GPs working as a GPwER PEoLC should ensure that they are aware of the work led by other GPwERs in the area, particularly those working in frailty or complex care, to ensure that service provision is coordinated.

When supporting clinical practice, the GPwER PEoLC will need to be confident in clinical assessments, tailored to the needs and setting of the patient, informing individualised management plans. Across all settings, the GPwER will need to demonstrate expert communication with patients, those close to them and colleagues.

GPs with an interest in PEoLC may have had opportunities to gain knowledge, skills and experience during their career, from Foundation Training or Integrated GP training posts in palliative care and other relevant Fellowships or taster sessions. There are opportunities within General Practice for interested doctors to take on additional roles, for example practice or network end of life lead, Macmillan GP facilitator. Interested doctors can take on sessions in local palliative care services to develop their knowledge and skills further. Arranging taster or shadowing sessions and undertaking joint assessments with local palliative care services in different settings can also be useful.

GPs are expert medical generalists and, as such, do not need formal accreditation in enhanced roles for which they have been trained. Formal accreditation is not required for GPwER PEoLC; services should ensure that practitioners are working to the level outlined in the framework.

As for all doctors, GPs are required by the GMC to recognise and work within the limits of their competence and should refer to the GMC's Good medical practice for a description of what it means to be a good doctor.

Employers and service commissioners may have specific requirements relating to the provision of a GPwER service. 

The evidence that a GPwER is keeping their requisite knowledge and skills up to date and maintaining their competencies should be reviewed through the GPwER's annual whole scope of practice appraisal. This should form part of the discussion of all external roles and include quality improvement activity such as case analysis and audit. This has replaced any need for periodic re-accreditation.

The RCGP would expect that, for a GP to describe themselves as a GPwER, at least some ‘core’ general practice should be maintained. This is because as a GP they bring important additional skills in practising holistically and dealing with complexity and uncertainty to their GPwER role. However, we acknowledge that some frailty doctors (those who have trained as GPs) may have stopped general practice altogether. For such doctors, appraisals may be delivered through the acute trust.

Where there is a need for a GPwER to demonstrate at their annual appraisal that they remain safe, competent and up to date in their core general practice role, they may wish to utilise the Academy of Medical Royal Colleges' factors for consideration template (PDF file, 77 KB).