Background The Palliative and End of Life Care (PEoLC) Clinical Development Group in Shropshire, Telford, and Wrekin (STW) found the number of patients on Primary Care PEoLC registers, and the uptake of advance care plans (ACP) was low across the region. Identifying patients predicted to be in the last year of life reduces unnecessary admissions to hospitals; improves patients’ and families’ access to support; and improves confidence in healthcare professionals’ ACP conversations.

Primary Aim To increase the number of adults on a Primary Care PEoLC Register in 20% of Practices in STW by 10% by March 2023.

Methods The group used the Model for Improvement with Plan, Do, Study, Act cycles. Standard wording and system codes were added to letters sent to a patient’s Primary Care Provider.

Results The number of patients on the PEoLC register was monitored monthly between September 2022 to April 2023. By April, the number on the register had increased by >10% in 20% of practices (2 s.d.) and the number of patients with an ACP on the register had increased by >10% in 30% of practices (2 s.d.). April’s data was included because of the delay between sending the letter and addition to the register. There was an overall decrease in the number on the register because of the mortality rate over winter.

Conclusion Adding a recommendation to add a patient to PEoLC registers, on letters sent to primary care providers, leads to an increase in the patients identified to be in the last year of life. This project identified the importance of working together as a multi-disciplinary team. This is an ongoing project, and the team are engaging with specialist services to expand the study. A toolkit is in development to identify people who may be in the last year of life.