In 2025, the project completed a substantial program of foundational research, national data assessment, and stakeholder engagement to address gaps in how palliative care needs are identified and coordinated in general practice. This work directly informed the development and implementation of GenPal, a structured needs assessment and decision-support process designed for use in primary care.
A comprehensive scoping review was conducted to examine how palliative care screening tools are implemented in primary care, and what enables or limits their routine use. The review found that while screening tools have the potential to support earlier identification of palliative care needs, their implementation is often inconsistent and highly dependent on local context.
Key insights from this work showed that screening tools are most effective when they:
This research highlighted the importance of moving beyond stand-alone tools toward integrated, practice-ready approaches that are feasible in everyday general practice.
NPCC undertook stakeholder consultations with GPs, practice nurses, and people with lived experience of serious illness. These consultations consistently emphasised that palliative care screening works best when it is embedded within collaborative, patient-centred care processes.
Patients and carers highlighted the importance of:
This feedback informed the design of GenPal as a supportive, longitudinal process rather than a one-time screening event.
A secondary analysis of national PCOC data was conducted to better understand referral pathways from general practitioners (GPs) into specialist palliative care. These analyses demonstrated that general practitioners currently play critical role in initiating referrals, and that many patients referred by GPs enter specialist palliative care late in their illness trajectory.
These findings reinforced the need for earlier, needs-based identification approaches within general practice to improve equity and timeliness of care.
To complement primary care perspectives, NPCC conducted a national survey of specialist palliative care services examining referral criteria, processes, and barriers to acceptance. This work demonstrated considerable variation in referral practices across Australia, reflecting system-level constraints and inconsistent application of criteria.
The findings identified referral acceptance as a key triage point influencing equity, timeliness, and coordination between primary and specialist care, and highlighted the importance of shared referral frameworks and improved referral quality.
Designed for scale and sustainability
Timely identification and coordination of palliative care needs in primary care remain inconsistent across Australia. NPCC addresses this gap by embedding structured, practice-ready approaches that enable earlier recognition of patient needs, support proactive care planning, and strengthen coordination with specialist palliative care services. These priorities align with the National Palliative Care Strategy 2018, focusing on early identification, person-centred care, equitable access, and integrated service delivery.
NPCC is a nationally scalable model, integrating seamlessly into existing workflows and electronic medical records. The crucial difference with NPCC is that it comes with a full implementation package, providing structured support for practices to adopt and embed palliative care needs assessment, setting it apart from previous attempts in this area. Key enablers include:
This combination of practical tools, local support, and systematic evaluation ensures NPCC is ready for national rollout, supporting consistent, sustainable, and equitable palliative care across Australian general practice.
Together, this foundational work has identified clear priorities for improving palliative care coordination in Australia:
In response, NPCC implemented GenPal in collaboration with Primary Health Networks and selected general practices across diverse regions. This work has strengthened the role of general practice in recognising and responding to palliative care needs and is generating evidence on feasibility, acceptability, and impact.
Findings from the project will inform strategies for sustainable and scalable national integration of palliative care needs assessment within Australian general practice.