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“To think about patients as a whole...

...a whole geography level"


Julie Barker GP in Newark & Macmillan GP Nottingham ICS

Population - Based Integrated Cross Boundary Care

GSF can be used in 2 main ways

  • Either as a whole system response, introducing GSF to all sectors, as in the Integrated Cross Boundary care sites

  • Or as training for those in one particular setting eg primary care, hospitals, domiciliary care, care homes or other settings.

In the 10 GSF integrated cross boundary care sites GSF is used to enhance a 'common vocabulary’ improving communication between GPs, hospitals, care homes and others with better use of digital records / EPaCCS, reducing hospital admissions and enabling more to live and die well at home. 


Key EOLC metrics have been developed. Many areas have developed GSF registered ‘Gold’ patients, providing additional benefits for them, such as Airedale’s Gold Line​.

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Population-based, Person-centred End of Life Care ' Thomas K Gray M

We developed some key metrics to assess progress of population- based end of life care, as piloted in several of our GSF Cross Boundary Care Sites.

Hear what people say about using GSF principles across boundaries.

Integrated whole island care in Jersey 

A great example of use of GSF across all systems  to develop integrated care was demonstrated in the GSF Jersey work– see right and download  the EAPC 2019 Jersey poster here .

Further details and full evaluation are available

Benefits of being Gold or GSF patients  


To see more information about the benefits of being a Gold Patient, click here

Further details  are available

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GSF helped increase identification of patients in last year of life to 30%.

“The GSF and Gold Line provides me with the added reassurance that my patients and their family  have a plan, and the added resources in place as they move from secondary care to the community.”

Dr RM, Consultant Geriatrician at Airedale

Further Reading

To find out more about Improved coordination in GSF Cross Boundary Care Sites, Click here

To read the Population Based Editorial BJGP Thomas, Gray, Click here

To read more about Cross Boundary Care, Click here

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