In total, 1837 practices expressed interest in participation, of which 1455 (79.2%) registered for participation. Of these, 1305 (89.7%) completed a baseline questionnaire. Practices were located across all regions of England and Northern Ireland, and had a registered population of almost 10 million people (ie, about 15% of the total population). shows the characteristics of the 1305 practices that participated and the subgroup of 955 (73.2%) that submitted at least one follow-up questionnaire. For the latter, the period between completion of the baseline and final follow-up questionnaire was a mean (SD) of 12.8 (2.8) months (median 13 months).
Characteristics of the participating practices
Of the 955 practices that provided follow-up data, the non-response rate to individual process questions varied from 0.4% to 6.0% at baseline, and 0.4% to 4.2% at follow-up; for individual rating questions it varied from 1.4% to 2.7% and 1.2% to 2.2% respectively. The cumulative impact of non-response to individual questions resulted in only 505 (52.9%) practices providing responses to all process questions and only 449 (47.0%) responding to all process and rating questions together with complete demographic information in both questionnaires. However, the practice characteristics and pattern of responses from the 505 and 449 practice datasets were very similar to those of all 955 practices: two-sample t tests showed no significant differences between the 449, 505 and 955 datasets in total process scores at baseline and final, or in the degree of change. Mann–Whitney tests showed no significant difference between the three datasets in the ratings of quality at baseline and final.
Change in process and rating scores
shows the level of implementation of processes related to palliative care that practices reported at baseline and follow-up. The mean (SD) for the total number of processes implemented (maximum possible
35) increased by 9.6 (95% CI 9.0 to 10.2; p<0.001), from 15.7 (6.4) at baseline to 25.2 (5.2) at follow-up. Change was largest for practices with low baseline scores (total score <13 points); these achieved a mean change of 14.8 points (95% CI 13.9 to 15.7; interquartile range 11–19 points). Those with medium scores at baseline (13–24 points) had a mean change of 8.2 points (95% CI 7.7 to 8.8; interquartile range 5–11), while high-scoring practices (>25 points) achieved a mean change of only 1.2 points (95% CI –0.4 to 2.9; interquartile range 0–4.8). illustrates the pattern of change relative to baseline process score.
Responses to process questions at baseline and follow-up
Degree of change relative to baseline process score.
The aspects of practice that showed the greatest level of change were related to coordination and communication, both being processes for which there was considerable scope for improvement at baseline. For example, at follow-up, 90.2% of practices described having a register of patients in need of palliative care compared with 23.4% at baseline, 78.9% (27.0% at baseline) regularly discussed palliative cancer patients at team meetings, 70.6% (23.4% at baseline) recorded advance care planning with the PHCT, and 72.8% (25.4% at baseline) recorded palliative care patients’ preferred place of death (p<0.001 for all comparisons). For some processes the gain was relatively modest. For example, at follow-up only a minority of practices reported the use of a physical symptom assessment tool or holding practice-based educational events on cancer/palliative care.
Practices generally rated the quality of their palliative care as being at least “good” on each of the six dimensions at baseline (with the exception of “quality of support offered to carers” which had a median rating of “average”), and across all dimensions self-ratings improved in the 12 months following GSF implementation (for each item p<0.001) (). The degree of change was highest for ratings of the “quality of palliative care for cancer patients” and “confidence in assessing, recording and addressing the physical and psychosocial areas of patient care”, and least for “quality of support to staff” and “quality of teamwork in practice”. However, as indicated by the ranges shown in , there were some practices for which change occurred in a negative direction.
Responses to rating questions at baseline and follow-up* and the difference between scores
Predictors of baseline and follow-up process and quality rating scores
For the 449 practices that completed all parts of the questionnaire and included in the generalised linear model, no significant associations were identified between practice characteristics or GSF phase and total process scores. Responses to three of the rating questions at baseline (“confidence in assessing, recording and addressing the physical and psychosocial areas of patient care”; “quality of support offered to carers”; and “quality of palliative care for cancer patients”) were associated with total baseline process score (p<0.001 for each measure). For example, for practices that rated the quality of palliative care they provided as “average”, the adjusted mean of the total process score at baseline was 14.2 (95% CI 12.9 to 15.4), compared with 17.2 (95% CI 16.0 to 19.4) for those that rated their care as “very good”.
The extent of change that occurred in process scores was directly associated with the rating of the quality of palliative care at follow-up and inversely with the rating of support to carers at baseline (p<0.001). For example, practices that rated their quality of palliative care at follow-up as “very good” had an adjusted mean change of 11.6 (95% CI 10.8 to 12.4), while for those that rated their care as ‘average’ it was only 4.3 (95% CI 2.9 to 5.6). On the other hand, for practices that rated the support they offered to carers at baseline as “poor”, the adjusted mean change was 10.3 (95% CI 8.9 to 11.6), while for practices that rated it as “very good”, it was 6.9 (95% CI 5.1 to 8.6). This suggests that the extent to which practices are dissatisfied with their provision of support to carers affects the motivation to improve palliative care processes.
Three variables emerged as being strongly associated with final total process score. These were baseline total process score, and final responses to the rating questions about “confidence in assessing, recording and addressing the physical and psychosocial areas of patient care” and “quality of palliative care for cancer patients” (p<0.001 for each item). The more positive the response to each of these rating questions, the higher the adjusted mean final total score. For example, practices rating their confidence as “very good” had an adjusted mean final total score of 26.6 (95% CI 25.4 to 27.7), whereas those that rated it as “poor” had an adjusted mean of 15.1 (95% CI 11.5 to 18.7).