Should GPs be paid to talk about end of life care?

Categories: Care.

The advanced end of life care planning scheme, known locally as the ‘Yellow Folder’ system (indicating where the care plan contents are held), was originally launched in July 2011.

GPs in east Suffolk adopted the end of life care scheme, which began as a three month pilot as part of the Marie Curie Delivering Choice Programme.

The Yellow Folder scheme was then rolled out to all GP practices in Ipswich and east Suffolk in September 2012 and is now in general use.

Media debate

The controversy began when it was revealed in a Daily Mail article in October that GPs were in fact being reimbursed for completing the end of life care plans at a rate of £50 per patient.

The newspaper’s Sunday edition, the Mail on Sunday, reported that the “key objective” of the scheme was “reducing healthcare costs” and that “every death outside of hospital saves the NHS almost £1,000.”

Dr Gillian Craig, a retired geriatrician, also spoke out against the scheme in the press and questioned “why GPs were being offered an extra payment for having a difficult conversation.”

But Ipswich and East Suffolk Clinical Commissioning Group (IESCCG) stated that the care plans are “carried out compassionately with patients to give them a dignified death in the place of their choice.”

Speaking to ehospice, IESCCG said that they no longer reimburse surgeries for administration costs as the reimbursement is included within a wider initiative which sees GPs working more closely with care homes.

A spokesperson for the CCG  said:

“The pilot offered a £50 reimbursement to GPs in the Ipswich and East Suffolk area to recognise the administration time it takes to fill them in and to raise the profile of end of life care.

“Between 1 April 2013 – when the CCG took over commissioning – and 1 October 2013 – when the scheme stopped – there have been 377 payments to 41 surgeries, a total of £18,850.

“Before that, the PCT paid out a total of £64,900 for 1,298 Yellow Folders for patients in care homes, from July 2011 to March 2013, out of a yearly £900 million budget.

“Surgeries were not reimbursed for those Yellow Folders for people living at home – a further 130 people.”

Hospices drive success

According to the CCG the programme has been a success in allowing people to make decisions about where they would like to be cared for at the end of their life.

They told ehospice that “more than 52% of our patients now die in their choice of place. In London some 30% of people die in their choice of place.”

St Elizabeth Hospice, in Suffolk, led the Suffolk Advance Care Planning (ACP) project on behalf of NHS Suffolk. The hospice does not receive any financial payments for the completion of the care plans. 

The project promoted the introduction of the Yellow Folder system across Suffolk and is also viewed as a success by the hospice.

Annette Villis, of St Elizabeth Hospice, who is the Lead Facilitator on the Advanced Care Planning Project, explains: 

“The yellow folder system was introduced alongside the ACP Project, the two successfully ‘merging’. The ACP team has worked with all health and social care staff groups to provide free education and training sessions on Advance Care Planning and how to fill in the Do Not Attempt Cardio Pulmonary Resuscitation form.

“Both hospices in Suffolk, St Nicholas Hospice Care and St Elizabeth Hospice, are supporting and implementing the ‘yellow folders’, as are both local hospitals.

“All care homes have received education and training on how to use the yellow folders and are working with residents and their families to fill in the forms where appropriate.”

Annette told ehospice that the folder is a set of advance planning documents which contain:

  • a Gold Standards Framework “Thinking Ahead” care plan
  • a directory of key contacts
  • a Gold Standards Framework “Passport” sheet which clearly identifies which documents are ‘live’ 
  • and the East of England Regional Do Not Attempt Cardio Pulmonary Resuscitation form, where this has been completed.


Cancer and End of Life Care Programme Manager, Maggie Parsons, is developing the Yellow Folder scheme within the Great Yarmouth and Waveney Clinical Commissioning Group in Norfolk, following its successful implementation in neighbouring county, Suffolk.

Maggie said the rest of Norfolk has also started to implement the system with the aim of getting both counties on board in their entirety.

“We’re also hoping that we can agree across Norfolk and Suffolk what the core components of the pack are, so there is more consistency for patients and carers,” she said.

Maggie has set up a regular meeting for commissioners across the two counties who are involved in commissioning end of life care.

“Through that group we’ve been trying to work collaboratively on the Yellow Folder scheme,” said Maggie. “The next step on from that is to implement an electronic palliative care record, which will be like an electronic version of the Yellow Folder.”

“Suffolk is a little ahead of us on that,” she added. “They are the trail blazers!”.

‘Putting the patient in charge’

As well as being a care commissioner, Maggie is also the project lead for Norfolk and Suffolk Palliative Care Academy, which recently introduced a website that raises awareness of the issues associated with death and dying called ‘Be ready for it’.

The website is working towards having much of the Yellow Folder contents available to download, so the public can easily access the information.

“If families and patients want to do their advance care planning themselves they can, and they can print them off and take them round to their GPs and share them with them.

“It’s about doing the forward planning, so that patients and their families can be involved in their decisions, and about having those conversations up-front.

“It’s about putting the patient in charge and helping them have the choice that they want.”

You can download information about the Yellow Folder and its contents on the IESCCG website.

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