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"A Gold Standard of care for all people in the last years of life, supporting them to live well until they die."

What is GSF?

GSF is a practical systematic, evidence-based approach that enables generalist frontline care providers better care for all people in their final phase of life.

 

The aim is to enable a ‘gold standard’ of care to help people live well before they die, and to die well in the place and the manner of their choosing. This includes;

  • All people

  • With any condition

  • In any setting

  • Given by any care provider

  • At any time in their last years of life

 

It is driven by an aspiration of quality care for all and operates through;

  • quality improvement with training

  • quality assurance with standards of care

  • quality recognition with recognised accreditation

 Aims of GSF. GSF aims to improve the quality of care for people, communication and  coordination  and outcomes both for people and health systems.(see right). 

It achieves this by providing:

  • Training- tailored to specific settings

  • Tools - a toolkit of resources

  • Measures- intrinsic before and after evaluations and 

  • Support, review and customised consultancy.

GSF helps identify people earlier in the last phase of life in order to assess their physical and personal needs earlier , offer them advance care planning discussions and then     plan coordinated care in line with their preferences.  

GSF also helps in wider communities develop integrated whole-system cross-boundary care, as part of population-based end of life care planning.

 

What do we hope to achieve with GSF?

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1. Better Quality of Care - experienced by all people nearing the end of their life

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2. Better Communication & Coordination between Care Systems and Teams

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3. Better Outcomes

  • for People - Living and dying well, where they choose

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  • for Health Care Systems - Better use of limited resources, reducing over-hospitalisation​

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"GSF is ...                          a common vocabulary"

"a clear, step-by-step way to achieve your goals"

"seeing the bigger picture"

See what people are saying about GSF

Sharon Burton from the UK's General Medical Council describes the benefits of GSF.

The 1-3-5-7 summary of GSF

The GSF Process can be simply summarised in a one, three, five, seven structure as described in the video below.

Change Culture in EOLC
"Death is not failure but a bad death is"

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Reactive to Proactive Care


An example of how moving from reactive to proactive care can benefit individuals, families and healthcare services.

Mr Brown 
Aged 82 with COPD and moderate frailty 

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Reactive Care

  • Living at home alone with domiciliary care support,   just coping ,independent , seems OK, 'doesn't want a fuss'

  • Repeated admissions to hospital over the last year unnoticed – 'revolving door’

  • No proactive thinking

  • Not recognised gradual decline, slower recovery and reduced  reserve  

  • Not on GP's GSF register , no MDT discussion, planning crisis care in case,   

  • No advance care planning (ACP) , no listening to needs or concerns ,

  • Crisis - breathlessness worsens at weekend, out of hours doctor called 

  • Readmitted  to hospital, rapidly deteriorates

  • Family unaware of seriousness of decline 

  • Poor final days of life, dies on ward alone

  • Family in shock,  anger, guilt  and blame 

  • GP and carers feel they let family down

  • 'He was 82 - what do you expect?' 

  • Poor bereavement , family distress, no  time to say goodbye, little support in grief

  • No reflection - no improvements made 

  • 'It happens to someone every night in A&E' 

Proactive Care

  • Gradual decline and vulnerability recognised

  • Frailty + COPD assessed and monitored 

  • Repeated admissions noted 

  • Identify him for GSF register, discussed at MDT

  • Anticipatory proactive planning and crisis prevention discussed with out of hours 

  • Worsening condition recognised earlier

  • Assess clinical and personal needs

  • Proactive care in line with needs- based coding

  • Advance care planning discussion + DNACPR recorded and communicated – space to listen

  • Preferred to be at home, no 'heroic treatments'

  • Plan – Discharged home with rapid discharge

  • Community care , crisis prevention , GPs, community team  and domiciliary carers

  • Care coordinated, out of hours, social care 

  • Crisis – discussion with family,  ACP respected 

  • Hospital admission averted 

  • High quality care provided-dies at home

  • Bereavement care for family 

  • Team reflection+ further improvements discussed 

  • Better outcome for patient, family, teams, staff

  • Most cost effective + best use of resources

Developments of GSF

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Gold Patients

Some teams developed the concept of ‘Gold Patients’. 

 

Patients with priority needs are given "Gold" status which grants them a special card, access to a Gold helpline, special GP appointments, listing on a register as well as their information being shared with out-of-hours services about their needs.  

 

The focus is on encouraging personalised care at every stage, driven by the important ‘advance care planning' conversations asking not ‘what is the matter with you’ but the question ‘what matters to you?’ and then ensuring this is central to all future plans and decisions.

To see more information and experience of others on the benefits of being a Gold Patient, Click here

For more information, see Frontrunners and other published papers in the Evidence section of website.

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