Our ACP team. Left to right: Dr Stuart Cumming, Janette Barrie, Sheila Steel

Work is now underway on the Living Well in Communities Anticipatory Care Planning (ACP) work stream. This article introduces the new team who are delivering this work, gives some background information on ACP and recent work in Lanarkshire, and the work that we are doing in this area on the Living Well in Communities portfolio of improvement programmes.

What is Anticipatory Care Planning?

Anticipatory Care Planning involves health professionals and/or care providers working together with individuals and their carers to discuss their goals and wishes, and recording these decisions so that in the event of a gradual or sudden decline,  those providing care have clear guidance on what that person and his or her carer would wish to happen. It facilitates a whole-systems approach for people living with long-term conditions, ensuring that person-centred care and personal outcomes are achieved.

The Living Well in Communities ACP team

Our ACP team is made up of Sheila Steel, our Associate Improvement Advisor, from NHS Lanarkshire and our National Clinical Leads, Janette Barrie from NHS Lanarkshire and Dr Stuart Cumming from NHS Forth Valley.

Recent work in Lanarkshire: raising public awareness of Anticipatory Care Planning and Power of Attorney

For the last two years Lanarkshire’s health and social care partnerships have teamed up with Glasgow City Council and NHS Greater Glasgow and Clyde Health Board to raise public awareness of Power of Attorney (POA).  However, Lanarkshire saw the opportunity to incorporate anticipatory care planning into this campaign to raise the profile of both ACP and POA.

From the number of direct enquiries from members of the public regarding the anticipatory care planning process and how to initiate this, it was clear further information was required, building upon the TV and online campaigns.

Campaign activities included TV advertising, radio advertising, website information, social media updates via Twitter, Facebook, patient opinion and a public poster campaign.  Posters were distributed in key public areas within Lanarkshire, including the general hospitals, community hospitals, GP surgeries, leisure centres, on local buses and using street lamp posts.  The posters were supplemented with leaflets and radio adverts.

From the TV adverts and campaign activity there was a 34% increase in POA registrations.  The TV advert reached 56% of the available TV audience, with 25% watching the advert more than three times, with a total of 1.1 million viewers. Numerous website enquiries were received, with some from as far away as the United States.

From the response in terms of campaign coverage, activity and impact, there has been increased interest in ACP and POA from professional groups and the public.

The work on Anticipatory Care Planning as part of the Living Well in Communities portfolio

Our ACP team will be developing a national approach to anticipatory care planning which will support people with long-term conditions to live in the community and avoid hospital admission. This will include documentation, guidance, learning materials and a promotional campaign. An important part of the work will be influencing the national eHealth strategy to improve the electronic information summary system used to access individuals’ anticipatory care plans across the health and social care system.

Tests of change to inform future spread are currently underway in Lanarkshire, Forth Valley, Greater Glasgow and Clyde and Orkney. Living Well in Communities will work with health and social care partnerships to implement elements of the Anticipatory Care Planning action plan, which aims to:

• Embed ACP as a model to deliver proactive, intensive, collaborative case management in every locality
• Work with hospital and emergency services to increase access to the Key Information Summary
• Work with national carer organisations to ensure appropriate carer support and involvement with ACP.

Focus groups in Lanarkshire

The ACP team recently held two anticipatory care planning focus groups in Lanarkshire. There were lively and informative discussions with regard to ACP and the beneficial outcomes for individuals, carers and care providers. Participants shared real-life stories on patient and carer experiences and the positive impact of planning ahead and having ACP discussions at the right time.

Participants were also encouraged to provide comments and feedback on how to improve on areas within the ACP process to embed successfully within future culture and practice, and on sustainable measures. Feedback from the events was very positive: participants really enjoyed having the opportunity to contribute to the sessions.

Find out more

You can access resources related to anticipatory care planning from the ACP toolkit on the Living Well in Communities community site. There is also more information on Living Well in Communities and related programmes on the ihub website.