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The early identification of patients who may benefit from a palliative approach remains challenging in primary care. The Gold Standards Framework (GSF) provides a structured approach to identify patients who may be approaching the end of life; however, its implementation in primary care settings outside the United Kingdom remains poorly understood. To explore general practitioners’ experiences of using the GSF prognostic indicator guidance to identify patients with palliative care needs in primary care in Brunei.
Methods
This qualitative study was part of a broader mixed-methods project that evaluated the use of the GSF in primary care. Focus group discussions and small-group interviews were conducted with general practitioners who had applied the GSF in routine clinical practice following a structured training workshop. Data were audio-recorded, transcribed verbatim, and thematically analyzed using an inductive approach.
Results
Ten general practitioners participated in this study. Four overarching themes were identified: (1) adapting the GSF to primary care practice, (2) structural constraints within primary care, (3) prognostic uncertainty and role discomfort, and (4) system enablers for integrating a palliative approach. While the GSF was perceived as a useful framework, its application required contextual adaptation and was influenced by both clinician- and system-level factors.
Conclusion
The GSF can support the identification of patients with palliative care needs in primary care settings. However, effective implementation requires alignment with local workflows, improved continuity of care, and system-level support, including clear referral pathways and integrated care planning.
Brunei is a country in Southeast Asia undergoing a rapid demographic transition characterized by an aging population and an increasing burden of noncommunicable diseases [1,2]. These conditions account for the majority of deaths and are associated with prolonged illness trajectories, resulting in a growing need for palliative care across the healthcare system. Early identification of patients who may benefit from a palliative approach is essential to improve quality of life, support advance care planning, and reduce unnecessary hospital utilization [3].
Primary care is well positioned to play a central role in delivering a palliative approach, given its emphasis on continuity, holistic care, and long-term patient relationships [4]. In Brunei, primary care is predominantly government-funded and delivered through a network of health centers and clinics. Patients may be seen by different physicians at different visits, whereas individuals with advanced or complex illnesses are commonly managed by specialist outpatient services or hospitals. Community palliative care services are limited, and palliative care is largely coordinated by specialist teams in hospitals. Consequently, care for patients with advanced illnesses is largely centered in tertiary services, with primary care often limited to the episodic management of acute or stable conditions [5]. This model may delay the recognition of palliative care needs and limit opportunities for anticipatory care planning in the community.
The Gold Standards Framework (GSF) prognostic indicator guidance provides a structured approach to identifying patients who may be approaching the end of life, incorporating clinical indicators and the ‘Surprise Question’ [6]. The GSF was developed and has been widely implemented in the United Kingdom and has been associated with improved coordination of care and earlier identification of patients requiring a palliative approach [7]. However, its application in healthcare systems with different structures and care pathways remains poorly understood [8].
In Brunei, the GSF was previously used to identify the proportion of patients in primary care who may benefit from a palliative approach [9]. However, the practical challenges associated with its implementation and the contextual factors that influence its use in routine clinical practice remain unclear. This study aimed to explore general practitioners’ (GPs’) experiences of using the GSF in primary care in Brunei, with a focus on identifying barriers and enablers to its implementation.
Methods
Ethical considerations
This study was conducted and reported in accordance with the Consolidated Criteria for Reporting on Qualitative Research guidelines [10]. Ethical approval was obtained from the joint Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah Institute of Health Sciences Research Ethics Committee, Universiti Brunei Darussalam, and the Medical Health Research and Ethics Committee, Ministry of Health, Brunei Darussalam (No. UBD/IHS/B3/8). Participation was voluntary, and written informed consent was obtained prior to the interviews. Confidentiality and anonymity were maintained throughout the study.
Study design
This qualitative study was part of a broader mixed-methods project that evaluated the use of the GSF in primary care. Findings from the quantitative phase, which estimated the prevalence of patients requiring a palliative approach, have been reported separately [9]. The present study focused on exploring clinicians’ experiences of implementing the GSF in routine practice.
Setting and participants
This study was conducted at selected primary healthcare centers in Brunei Darussalam. GPs who had participated in the initial GSF training and applied the tool during routine clinical practice were invited to participate in focus group discussions.
Participants were purposively recruited to capture diverse clinical experiences across primary care settings. Inclusion criteria were registered medical doctors working at participating health centers who had prior exposure to the GSF during the study. Invitations were distributed through the participating health centers after the completion of the implementation phase. Recruitment continued until thematic saturation was achieved.
Data collection
Data were collected through focus group discussions and small-group interviews (triads) conducted after completion of the GSF implementation phase. Group-based interviews were chosen to facilitate interaction and allow participants to reflect on their shared experiences of using the tool in practice.
A semi-structured topic guide was used to explore the participants’ perceptions of the GSF, their experiences applying the framework in clinical settings, and perceived barriers and facilitators to implementation. Interviews were conducted in English by members of the research team trained in qualitative methods (J.X.C. and A.H.) and lasted approximately 30 to 45 minutes. The sessions were audio-recorded with participants’ consent. Data collection continued until thematic saturation was reached and no new themes emerged from subsequent interviews.
Data analysis
The audio recordings were transcribed verbatim and analyzed using thematic analysis. An inductive approach was adopted to allow themes to emerge from the data without imposing predefined categories. The transcripts were read repeatedly for familiarization. Initial codes were generated and iteratively refined through constant comparison across transcripts. The codes were then grouped into categories and subsequently developed into overarching themes that captured patterns in participants’ experiences.
This analysis was conducted collaboratively by multiple researchers to enhance credibility. Differences in interpretation were discussed and resolved by consensus. An audit trail was maintained throughout the analytical process to support transparency and rigor. The research team included clinicians and academics with experience in primary and palliative care, who interpreted the data, and regular discussions were used to minimize individual bias.
Results
Ten GPs from seven primary healthcare clinics participated in the focus group discussions. The participants varied in age, years of clinical experience, training background, and primary care practice setting, reflecting a range of perspectives across different clinical environments. All participants had completed GSF training and had experience applying the framework in routine clinical practice. The participant characteristics are shown in Table 1.
Four overarching themes were identified: (1) adapting the GSF to primary care practice, (2) structural constraints within primary care, (3) prognostic uncertainty and role discomfort, and (4) system enablers for integrating a palliative care approach. These themes reflect the interaction between clinician-level experiences and broader health system factors that influence the implementation of a palliative approach in primary care.
Theme 1: adapting the GSF to primary care practice
The participants described the need to adapt the use of the GSF within the context of primary care. For many, this represented their first formal exposure to a structured prognostic tool for identifying patients requiring palliative care. Initial impressions varied, with some participants perceiving the tool as detailed and not fully aligned with the types of patients commonly encountered in primary care settings.
“The ones relevant to us and the sort of cases we normally see are COPD, asthma, frailty, and multiple comorbidities. These conditions would be more relevant.” (FG2P2)
This perceived mismatch prompted participants to suggest that the GSF would benefit from contextual adaptation to better reflect the local patient population and disease burden. In particular, they highlighted the importance of incorporating conditions more commonly encountered in Brunei, especially poorly controlled chronic conditions.
“We see patients with poorly controlled diabetes, and sometimes they end up with complications, for example, amputations… In the long run, they are quite suitable for the pathway as well.” (FG2P4)
The level of detail within the GSF was viewed as a potential barrier, particularly during its initial use and in busy clinical settings where time for familiarization was limited.
“The criteria are very specific… you have to go through it first before you can use it properly.” (FG2P3)
However, with increasing familiarity, participants found the GSF more intuitive and efficient to use, often serving as a checklist to support clinical judgment.
“It was easy to use, and the tool is easy to understand. At the end of the clinic, you tick the boxes on the form. It takes less than a minute, because when you see a patient, you know which category they fall into.” (FG3P2)
Theme 2: structural constraints within primary care
Participants described the structural features of the healthcare system that limited GSF implementation in primary care. In particular, the organization of care, with a strong emphasis on specialist-led management in tertiary settings, reduced the role of primary care in longitudinal and end-of-life care planning. As a result, primary care was often limited to episodic management of acute or stable conditions, resulting in a lack of continuity of care.
Patients were frequently seen by different GPs at each visit, limiting opportunities to develop a longitudinal understanding of their disease trajectories. This fragmented approach reduced clinicians’ ability to identify gradual decline and patients who may benefit from a palliative approach.
“We only see the patients for one or two visits… we cannot really follow their progress.” (FG1P2)
Another barrier was the limitation of short consultation times, which participants considered insufficient to address complex patient needs or initiate discussions about prognosis and palliative care.
“We are short of time… for one patient, we have ten minutes, fifteen minutes at the most.” (FG1P1)
In addition, participants highlighted the increasing complexity of patient presentations, particularly among older adults with multiple comorbidities. Even when presenting with minor complaints, patients often had underlying health and social issues often requiring comprehensive assessment.
“Older adults come regularly and are using our services more often. They come for a simple cough and cold… but usually there’s more behind it.” (FG3P2)
Theme 3: prognostic uncertainty and role discomfort
Beyond the structural challenges, participants described uncertainty and discomfort when applying the GSF to make prognostic judgements. Many participants were reluctant to assess patients’ likelihood of deterioration or death, particularly during brief consultations and when they had limited prior knowledge of the patients.
“I am not comfortable making a prognosis and telling a patient that they might be dying in six months or one year… especially when they come for minor illnesses like a cough.” (FG1P2)
Uncertainty was heightened by the unpredictable trajectories of chronic illnesses, where patients could remain stable for prolonged periods or rapidly deteriorate.
“There are many factors that can prolong their life… the environment, social situation, laboratory results… with just one visit, you cannot easily tell.” (FG2P1)
Participants also described uncertainty regarding their role in identifying and managing patients with palliative care needs. In a healthcare system where advanced illness is primarily managed in tertiary settings, some GPs felt that prognostication and palliative care decision-making should be led by specialists.
“We would be more comfortable if the specialist has already indicated the patient is at that stage.” (FG1P2)
This perceived boundary between primary and specialist care contributed to hesitation in using the GSF proactively and limited the early identification of patients who may benefit from a palliative approach.
Theme 4: system enablers for integrating a palliative approach
Despite the identified challenges, participants highlighted several system-level factors that could enable the integration of a palliative approach into primary care. Exposure to the GSF and its associated training increased awareness of unmet palliative care needs and prompted reflection on the role of primary care in addressing these needs.
“I am not familiar with what palliative care services we have in Brunei… this was quite an eye-opener.” (FG1P1)
Participants emphasized the importance of clear referral pathways to guide clinical decision-making and improve confidence in identifying patients who were appropriate for palliative care.
“If we have clear criteria… we would be more confident to refer them.” (FG1P1)
In addition, participants highlighted the need for ongoing support from specialist services, including access to advice and shared care plans, to enable primary care clinicians to manage patients’ palliative care needs more confidently within the community.
“I don’t think I am confident to manage palliative patients unless they have a proper care plan by the palliative team about what to do if they have issues. I will need to refer or ask their advice before starting treatment.” (FG2P2)
The development of a palliative care registry was identified as a potential enabler for improving prioritization, coordination, and continuity of care across settings.
“A registry would be helpful for tracking these patients. If I know a palliative patient came to the health center, we can identify and prioritize them to be seen earlier.” (FG2P1)
The integration of the GSF into existing electronic health record systems, such as Bru-HIMS, has also been identified as a practical strategy to support implementation. Digital integration was perceived to facilitate real-time communication between primary and tertiary care providers and to enable shared care planning.
“If it is integrated into the system… it can be forwarded directly, and people know the patient needs palliative care… just like when we notify infectious diseases, it automatically goes to public health.” (FG3P1)
Discussion
This study explored GPs’ experiences of implementing the GSF to identify patients who may benefit from a palliative approach in primary care in Brunei. Although the GSF was perceived as a useful and structured tool, its implementation was influenced by a combination of clinician-level and system-level factors. Four key themes were identified: the need to adapt the GSF to primary care practice; structural constraints within primary care; prognostic uncertainty and role discomfort; and the importance of system-level enablers in supporting integration.
While this study identified barriers and facilitators similar to those reported in previous GSF implementation studies, the findings provide important contextual insights into a Southeast Asian healthcare system in which palliative care remains predominantly specialist-led. In contrast to primary care settings in the United Kingdom, participants described limited continuity of care, episodic consultations, and uncertainty regarding the role of primary care in prognostication and palliative care planning. This suggests that the successful implementation of prognostic tools depends not only on tool adaptation and clinician training but also on the extent to which healthcare systems support longitudinal primary care involvement in the management of advanced illness. This context influenced clinicians’ confidence, decision-making, and perceived responsibilities in identifying and managing patients with palliative care needs, highlighting the importance of strengthening primary care integration when introducing a palliative approach in healthcare systems where specialist services remain the dominant model of care.
Participants highlighted that, while the GSF provided a comprehensive framework, it did not always align with the case mix commonly encountered in primary care. Similar findings have been reported, showing that palliative care tools developed in specific healthcare contexts require adaptation to remain relevant and usable in different settings [6,11,12]. The suggestion to incorporate locally prevalent chronic conditions reflects the need for contextual adaptation of prognostic tools to ensure clinical applicability.
At the same time, familiarity played an important role in usability. Initial perceptions of complexity were mitigated by repeated use, suggesting that training and exposure are key to successful implementation. This supports the existing literature, which indicates that clinician engagement and experiential learning are critical for embedding palliative care tools into routine practice [13,14].
A major barrier identified in this study was related to the structural features of the healthcare system. The organization of care in Brunei, with a strong emphasis on specialist-led management in tertiary settings, limited the role of primary care in longitudinal care and end-of-life planning. Primary care encounters, which were often episodic and characterized by limited continuity, reduced opportunities for GPs to develop a longitudinal understanding of patients’ illness trajectories, which is essential for identifying gradual decline and initiating a palliative approach. Similar challenges have been reported in other healthcare systems where continuity of care is limited, highlighting the importance of system design in enabling early identification of palliative care needs [15,16].
Time constraints in primary care consultations further exacerbated these issues. Short consultation durations restricted opportunities for holistic assessment and discussions about prognosis, reinforcing the need for system-level adjustments rather than relying solely on individual clinicians’ efforts.
Beyond structural constraints, clinicians expressed discomfort regarding prognostication, particularly in brief episodic encounters. The unpredictability of chronic illness trajectories contributed to uncertainty when applying the GSF, especially when patients presented with stable or minor complaints. In addition, participants described uncertainty regarding their role in identifying and managing patients with palliative care needs. In a system in which advanced illness is predominantly managed in tertiary care, GPs often deferred prognostic decision-making to specialists. This perceived boundary between primary and specialist care limited proactive identification and reflected the broader issue of role delineation within the healthcare system. These findings are consistent with existing literature, which identifies prognostic uncertainty and lack of confidence as key barriers to early palliative care integration in primary care settings [17-19].
Despite these challenges, participants identified several enablers that could support the integration of a palliative approach into primary care. Exposure to the GSF increased awareness of unmet palliative care needs and prompted reflection on the role of primary care in addressing these needs. This suggests that structured tools can act as catalysts for changing clinical perspectives. Participants emphasized the importance of clear referral pathways to guide decision-making and improve confidence in identifying appropriate patients. The absence of such pathways has been recognized in other settings as a barrier to timely palliative care referral [20]. The development of a palliative care registry and integration of tools such as the GSF into electronic health record systems have also been highlighted as key strategies for enhancing coordination and continuity of care [21]. These system-level interventions may facilitate communication between primary and tertiary care providers and support shared care planning [22,23].
Implications for practice and policy
Although tools such as the GSF can support identification, their effectiveness depends on alignment with local clinical workflows and healthcare system structures. Key priorities include strengthening continuity of care, developing clear referral pathways, and enhancing collaboration between primary and specialist services. Digital integration and the establishment of a palliative care registry may further support coordinated care delivery.
Strengths and limitations
This study provides insights into the implementation of a structured prognostic tool in primary care within a Southeast Asian context, where limited qualitative evidence currently exists. Focus group discussions enabled the exploration of shared experiences and generated rich data reflecting clinicians’ perspectives.
This study has some limitations. It involved 10 GPs from selected primary care centers. Although thematic saturation was achieved, these findings may not represent the full range of perspectives across all primary care settings in Brunei. Participants were recruited from centers involved in the GSF implementation project and had prior exposure to GSF training, which may have influenced their perceptions. Nevertheless, the inclusion of clinicians with varied levels of experience and training backgrounds across multiple health centers enhances the transferability of the findings to similar healthcare systems where palliative care remains largely specialist-led. Similar to other qualitative studies, these findings should be interpreted within the scope of an exploratory implementation study.
Conclusion
The GSF has the potential to support the identification of patients who may benefit from a palliative approach in primary care. However, its implementation is shaped by clinician-level factors and, more importantly, by the structural features of the healthcare system. Addressing these barriers through system-level interventions, including improved continuity of care, clear referral pathways, and digital integration, is essential for embedding a palliative approach in primary care in Brunei and similar settings.
Notes
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Funding
None.
Data availability
The datasets generated and/or analyzed for the study are not publicly available due to confidentiality considerations but are available from the corresponding author on reasonable request.
Author contribution
Conceptualization: all authors. Methodology: all authors. Investigation: JXC, AH. Data curation: JXC. Formal analysis: all authors. Supervision: SPT, MRV. Writing–original draft: JXC. Writing–review & editing: SPT, AH, MRV. Final approval of the manuscript:
all authors.
Table 1.
General characteristics of participants
No.
Age (y)
Sex
Nationality
Duration in practice (y)
Qualifications achieved
GP with special interest
1
36–45
Female
Philippine
>10
MRCGP
No
2
46–55
Female
Myanmar
>10
MRCGP
No
3
46–55
Female
Myanmar
>10
MBBS
Yes (psychiatry)
4
26–35
Male
Brunei
5–10
MD
No
5
26–35
Female
Brunei
<5
BM
No
6
26–35
Female
Brunei
5–10
MBBS, MSc PHC
No
7
36–45
Female
Brunei
5–10
MSc PHC
No
8
26–35
Female
Brunei
>10
-
Yes (diabetes)
9
26–35
Male
Brunei
5–10
MBChB, MSc PHC
No
10
36–45
Female
Pakistan
5–10
MBBS, DTCD, MRCGP
No
GP, general practitioner; MRCGP, Membership of the Royal College of General Practitioners; MBBS, Bachelor of Medicine, Bachelor of Surgery; MBChB, Bachelor of Medicine, Bachelor of Surgery; MD, Doctor of Medicine; BM, Bachelor of Medicine; MSc PHC, Master of Science in Primary Healthcare; DTCD, Diploma in Tuberculosis and Chest Diseases.
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2. Teo SP, Lei JY, Han MB, Tarif SM, Kassim N, Ali NB, et al. Community-based dementia screening initiative in Brunei: final results. J Gerontol Geriatr 2026;74:8.
3. Yen YF, Lee YL, Hu HY, Lai YJ, Sun WJ, Ko MC, et al. An interventional study for the early identification of patients with palliative care needs and the promotion of advance care planning and advance directives. J Pain Symptom Manage 2020;59:974-82.
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5. Shaharudin MY, Mohamad Z, Husaini A. The impact of COVID-19 on palliative care services in a tertiary hospital in Brunei Darussalam. Southeast Asia Multidiscip J 2021;21:65-82.
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9. Chong JX, Teo SP, Husaini A, Venkatasalu MR. Gold Standards Framework can identify primary care patients who would benefit from a palliative approach. J Am Med Dir Assoc 2020;21:1353-4.
10. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349-57.
11. Ernst A, Schade F, Stiel S, van Baal K, Herbst FA. The implementation of guidelines in palliative care: a scoping review. BMC Palliat Care 2025;24:102.
12. Van Campe F, Chambaere K, Pivodic L, Gilissen J, Pesut B, Duggleby W, et al. Systematic adaptation of public health palliative care interventions across settings using ADAPT guidance: methodological learnings from the EU NAVIGATE project. Palliat Med 2025;39:460-72.
13. Thomas K, Armstrong-Wilson J, Clifford C. The Gold Standards Framework Hospital programme: implementation and progress. Int J Palliat Nurs 2022;28:172-7.
14. Mahmood-Yousuf K, Munday D, King N, Dale J. Interprofessional relationships and communication in primary palliative care: impact of the Gold Standards Framework. Br J Gen Pract 2008;58:256-63.
15. den Herder-van der Eerden M, Hasselaar J, Payne S, Varey S, Schwabe S, Radbruch L, et al. How continuity of care is experienced within the context of integrated palliative care: a qualitative study with patients and family caregivers in five European countries. Palliat Med 2017;31:946-55.
16. Couchman E, Ejegi-Memeh S, Mitchell S, Gardiner C. Facilitators of and barriers to continuity with GPs in primary palliative cancer care: a mixed-methods systematic review. Prog Palliat Care 2023;31:18-36.
18. Schoenborn NL, Bowman TL, Cayea D, Pollack CE, Feeser S, Boyd C. Primary care practitioners’ views on incorporating long-term prognosis in the care of older adults. JAMA Intern Med 2016;176:671-8.
20. Pigni A, Alfieri S, Caraceni AT, Zecca E, Fusetti V, Tallarita A, et al. Development of the palliative care referral system: proposal of a tool for the referral of cancer patients to specialized palliative care. BMC Palliat Care 2022;21:209.
21. Rogers M, Meier DE, Heitner R, Aldridge M, Hill Spragens L, Kelley A, et al. The National Palliative Care Registry: a decade of supporting growth and sustainability of palliative care programs. J Palliat Med 2019;22:1026-31.
22. Walshe C, Caress A, Chew-Graham C, Todd C. Implementation and impact of the Gold Standards Framework in community palliative care: a qualitative study of three primary care trusts. Palliat Med 2008;22:736-43.
23. King N, Thomas K, Martin N, Bell D, Farrell S. ‘Now nobody falls through the net’: practitioners’ perspectives on the Gold Standards Framework for community palliative care. Palliat Med 2005;19:619-27.
Gold Standards Framework to identify palliative care needs in primary care: a qualitative study of implementation in Brunei Darussalam
Graphical abstract
Graphical abstract
Gold Standards Framework to identify palliative care needs in primary care: a qualitative study of implementation in Brunei Darussalam
No.
Age (y)
Sex
Nationality
Duration in practice (y)
Qualifications achieved
GP with special interest
1
36–45
Female
Philippine
>10
MRCGP
No
2
46–55
Female
Myanmar
>10
MRCGP
No
3
46–55
Female
Myanmar
>10
MBBS
Yes (psychiatry)
4
26–35
Male
Brunei
5–10
MD
No
5
26–35
Female
Brunei
<5
BM
No
6
26–35
Female
Brunei
5–10
MBBS, MSc PHC
No
7
36–45
Female
Brunei
5–10
MSc PHC
No
8
26–35
Female
Brunei
>10
-
Yes (diabetes)
9
26–35
Male
Brunei
5–10
MBChB, MSc PHC
No
10
36–45
Female
Pakistan
5–10
MBBS, DTCD, MRCGP
No
Table 1. General characteristics of participants
GP, general practitioner; MRCGP, Membership of the Royal College of General Practitioners; MBBS, Bachelor of Medicine, Bachelor of Surgery; MBChB, Bachelor of Medicine, Bachelor of Surgery; MD, Doctor of Medicine; BM, Bachelor of Medicine; MSc PHC, Master of Science in Primary Healthcare; DTCD, Diploma in Tuberculosis and Chest Diseases.
