Bridging palliative and primary care from the perspective of stakeholders: a systematic review and meta-synthesis

Integrating palliative care into primary healthcare is essential for improving equitable access to person-centred care. Primary palliative care (PPC)—palliative care delivered by primary care providers as part of routine primary care—remains poorly defined and inconsistently implemented across contexts. This systematic review and meta-synthesis synthesised qualitative evidence on the barriers, facilitators, and stakeholder experiences influencing PPC integration. It also examined convergence and divergence across stakeholder perspectives and generated a conceptual framework to explain why integration remains difficult despite decades of evidence. A systematic review and meta-synthesis of qualitative studies was conducted following PRISMA 2020 and ENTREQ guidelines. Six electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Scopus) and Google Scholar were searched from inception to May 2026. Eligibility was determined using the SPIDER framework and a clear operational definition of PPC. Methodological quality was assessed using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist. Data were synthesised using Thomas and Harden’s thematic synthesis approach. Confidence in review findings was evaluated using GRADE-CERQual. A conceptual framework was developed inductively during the final stages of synthesis. Forty-five qualitative studies were included, conducted across diverse geographical and healthcare settings with stakeholder groups comprising primary care providers, specialist palliative care providers, patients, family caregivers, and policymakers. Four analytical themes were generated. First, PPC is structurally marginalised: policy frameworks exclude primary care providers, financing models do not support time-intensive palliative work, and care transitions systematically sever the GP–patient relationship. Second, the long-term primary care relationship is both PPC’s most distinctive therapeutic resource and its most persistently threatened one — undermined by fragmented teamwork and poor primary–specialist collaboration. Third, primary care providers enter PPC practice underprepared and emotionally unsupported, with training deficits spanning undergraduate through to GP vocational level and moral distress that goes largely unrecognised. Fourth, realistic integration pathways exist within current primary care infrastructure: proactive advance care planning, community health worker integration, and reframing PPC language can unlock capacity without requiring new specialist services. Three cross-cutting concepts explain why integration stalls despite decades of evidence: the peripheral status of PPC within health systems; the invisible relational and emotional labour it demands; and the persistent gap between primary care’s potential and its actual capacity. Convergence across stakeholder groups was strongest around structural barriers; divergence emerged around the role of specialist involvement. GRADE-CERQual confidence was moderate for Themes 1, 2, and 4, and low for Theme 3. PPC integration is a complex, whole-system process requiring coordinated action across policy, health systems, workforce development, and clinical practice. The findings suggest that integration is constrained not by a lack of evidence about barriers and facilitators, but by the peripheral status of PPC within health systems, the emotional and relational labour required of primary care providers, and the gap between primary care’s potential and its actual capacity. Strengthening governance, sustainable financing, education, interprofessional collaboration, community engagement, and integrated care pathways is essential. Reframing palliative care as a prevention and management strategy for serious health-related suffering may make integration more acceptable within the dominant curative orientation of primary care. The proposed conceptual framework offers a heuristic to guide future policy, practice, and research.