Aim To describe the development and implementation of an Integrated Care Pathway (ICP) for those with life-limiting illness in one locality utilising continuous quality improvement (CQI) and chronic disease management (CDM) principles; commissioned by and centred in primary care.

Background There is a need to develop an evidence-based, effective, sustainable primary care-centred model for those with life-limiting illness which starts well in advance of the terminal phase, links together other key providers of care and identifies and addresses patient care preferences.

Method Following an NHS Improvement Foundation course a palliative care steering group was formed in West Northumberland involving all key organisations to plan the pathway. New commissioning powers were used to develop local enhanced services and the principles of CDM and CQI to identify and manage patients and promote change. Quantitative data was collected about important pathway processes and outcomes using Miquest software and an annual locality death audit.

Results A locality partnership group oversaw three phases of commissioning and implementation: 1) The development of Palliative Care registers and data recording 2) Home care and community palliative care beds 3) Detailed pathway interventions. Improvements resulted in many clinical process and outcomes measures including an increase in registrations, the identification of patient preferences, use of ‘just in case’ drugs and Liverpool Care Pathway and a reduction in hospital deaths. However the use of advance care plans was suboptimal. Wide variations exist between practices.

Conclusions It is feasible to commission and deliver an ICP centred in primary care to a defined population for those with life-limiting illness linking key providers of care. The use of CDM and CQI processes has enhanced this implementation. The authors need to increase the use of effective pathway interventions earlier to more patients and reduce variations between practices. Further research and work on cost-effectiveness is being planned.