Advance Care Planning in Primary Care: A Quality Improvement Project Through an Equity Lens

Introduction

Advance Care Planning (ACP) enables patients to express preferences for end-of-life care, supporting dignity and reducing uncertainty for next of kin. In primary care, ACP documentation is often inconsistent, particularly among ethnic minority patients, with barriers including language discordance, cultural beliefs around discussing death, and limited awareness of end-of-life options. This quality improvement project aimed to increase ACP documentation among eligible patients in a diverse general practice in England, whilst assessing equity of uptake by ethnicity.

Methods

The plan–do–study–act (PDSA) framework was used. Eligible patients were identified using the EARLY clinical search tool, which flags patients at increased risk of deterioration within 12 months using coded markers (e.g. frailty, cancer, multimorbidity). Ethnicity from electronic records was grouped as White versus ethnic minority (Asian, Black, Mixed, Other). Baseline data were collected in May 2024, measuring the proportion of eligible patients with ACP documentation.

The project lead delivered teaching to GP clinicians, sharing baseline results and communication tips, including culturally sensitive approaches. Clinician feedback and baseline findings led to the introduction of electronic prompts to flag eligible patients, supporting opportunistic ACP discussions during routine consultations. Repeat measurement was completed in May 2025.

Results

Overall ACP documentation improved from 28% (22/78) to 43% (31/72). Among White patients, uptake increased from 30.4% (21/69) to 47.5% (29/61). Among ethnic minority patients, documentation increased modestly from 11.1% (1/9) to 18.2% (2/11), with small subgroup numbers limiting precision.

Conclusion

Teaching reinforced by electronic prompts successfully improved overall ACP documentation but did not achieve equitable improvement. Further cycles are planned to incorporate minority community input, increase interpreter access, provide culturally adapted multilingual resources, and embed ACP training within induction to sustain practice with rotating clinicians. Addressing these disparities is essential to achieving equitable end-of-life care for all patients.