Anticipatory Care Planning: A Call For Action


The Anticipatory Care Planning: A Call for Action event took place on 9th June at the COSLA building in Edinburgh with participants from across the Scottish (and Welsh) health and social care sector.

This is the first of three interactive workshops in which delegates will learn about the emerging examples of good practice and help influence the future development of Anticipatory Care Planning (ACP) across Scotland.

It was a busy day (perhaps too busy…) comprising four plenaries, and four breakout sessions, with a focus on whole-system pathways, effective use of technology and information sharing, improving the interfaces between services and person-centred care and carers support.

Dr Gregor Smith, Deputy Chief Medical Officer from the Scottish Government opened the day with a welcome, highlighting the importance of ACP in achieving the 2020 vision, and reminding everyone to get their picture taken in the Selfie room with an ‘A Call For Action’ message (which he gamely obliged).


Plenary Session 1: To Anticipatory Care Planning . . . And Beyond!

Dr Stuart Cumming, National Clinical Lead for ACP
Janette Barrie, National Clinical Lead for ACP

With an ageing population there is a need to refocus the model of care. Stuart and Janette ran through a brief history of anticipatory care development in Scotland, the national action plan for ACP and the challenges ahead. They spoke on the work Living Well in Communities are doing in this area.

ACP is person-centred, and crosses the whole health and care system. They highlighted the need to raise awareness of this and to have a consistent, sustainable approach to it. NHS Lanarkshire have run a successful public awareness campaign on ACP and power of attorney.

They talked about the importance of the Key Information Summary (KIS) in reducing the risk of hospital admission and suggested more focus is needed on:

  • Carers
  • Technology
  • Early intervention to end of life care
  • Workforce and cultural change
  • Value of Collaboration

The take home message:

See change? Think ACP.

Plenary Session 2: Don’t Worry be Appy!

Idong Usoro, Technical Director, University of the West of Scotland

Idong presented on eHealth and telemedicine. He discussed the barriers to using technology in healthcare, such as the lack of interoperability of systems and high start-up costs but emphasised the significant impact it could have on patients, offering person focused care and self management of long term / chronic illnesses. The key benefits highlighted:

  • patient focussed
  • easy transfer of records between services
  • personal management of chronic / long term conditions
  • improved delivery of complex social care services

A number of good eHealth examples were highlighted:

  • SCET and NHS NSS made the National Palliative Care guidelines accessible from a mobile app and website. This is now widely used across the country.
  • The Florence healthcare app. Patients submit health data readings, such as blood pressure, medication, temperature from their phone, which their clinicians can monitor via the web.

Breakout Session 1: Alice’s Story

Sheila Steel, Associate Improvement Advisor for ACP

Sheila introduced Alice’s story, a video which illustrates problems in care experienced by Alice and her family. Delegates were asked to consider how to improve care for people like Alice.

From the following discussion:

What are the challenges for delivering person-centred care?

Need to help the workforce to understand that it can be rewarding to work in community settings.

What works well just now?

Carer-friendly communities, in which facilities such as libraries are supporting people with a caring role.

What can we put in place to deliver better care?

District nurse: service can be very task-orientated, it’s difficult to find time in the working day to have good conversations.

What 3 things could make a real difference?

Making time, changing process where it doesn’t enable and not waiting for permission or someone else to change the system.

What can we change locally or within the wider system….?

If info is shared appropriately people could receive care at home and hospital admission could be avoided in some cases.

Breakout Session 1: • ACP Technology – Testing your Appyness

Idong Usoro, Technical Director, University of the West of Scotland
Prof. Thomas Connelly, University of the West of Scotland

Idong and Thomas introduced the anticipatory care planning app, currently in development. The app will allow people to better organise their care, medication and appointments. The group were asked for their input around features and functionality.

The main points made were that it can’t sit in isolation and should link with other platforms, such as GP records and e-KIS. The app and the information on it should also link with local support, particularly social work but also third sector organisations involved in the persons care.

Breakout Session 2: Palliative & End of Life Care

Sandra Campbell, Macmillan Nurse Consultant in Cancer and Palliative Care
Dr Paul Baughan, Forth Valley GP Lead for Cancer and Palliative Care

Sandra and Paul presented on anticipatory care planning in relation to palliative and end of life care. Sandra gave a strategic overview of palliative and end of life care. The vision is that by 2021 everyone who needs palliative or end of life care can access it.

ACPs need to be not only person-centred but person-owned.

Paul introduced research on Key Information Summaries (KIS) and the quality of information contained within them. The Strathcarron hospice study found that 82% of palliative patients had a KIS, but only 56% had information on any future problems that might occur.

Following this, delegates discussed what matters to people as they approach the end of life, and how communication could be improved. The themes from these discussions:

  • finances
  • trust in professionals
  • access to KIS
  • integration
  • information flow.

Breakout Session 3: Carers Support Plans & Carers Bill 

Moira Oliphant, Carers Policy Unit, Scottish Government

Moira discussed carers support plans, the carers act and why supporting carers matters.

The adult carer support plan will help identify personal outcomes, support carer involvement in a persons care, encourage collaboration in care and importantly be person centred. Supporting carers is important so that more people can be cared for at home.

There is a need to remember that Anticipatory Care Planning is for all ages, not just for the frail and elderly.

Plenary Session 3 & 4: Tests of Change

Dr Thomas Monaghan, Improvement Advisor at Healthcare Improvement Scotland, introduced the afternoon. This was an opportunity for delegates to hear about the tests of change and good practices which are being carried out across the country.

Moira Flett, MS and Neurology Advisor from NHS Orkney was unable to attend on the day but recorded her presentation on the Anticipatory Care Planning form (a work in progress), which is part of NHS Orkney’s health and care pilot study.


Dr Trudy Foster, a GP in NHS Forth Valley discussed the confusing landscape in anticipatory care planning, highlighting is a need for consistency and education. ACP needs to work for everyone (in both paper and electronic versions) to reflect people’s preferences.

Maria Elliot a Community Nurse in Glasgow North spoke about her project with district nurses on power of attorney.

Elizabeth Ferguson, Project Manager for ACP in Glasgow South talked on the Glasgow model of anticipatory care and the importance of conversation from the beginning. Anticipatory care should be embedded into day to day practise, not just as and end of life process. It was a recurring theme today  – signposting communication across all involved in anticipatory care planning hugely important. The key message:

A good conversation underpins a quality anticipatory care plan.

Michelle Howorth, Engagement & Involvement Manager for The Advocacy Project spoke on advocacy support and anticipatory care planning in Glasgow and Lanarkshire. The Advocacy Project is supporting people to complete ACPs. There was discussion around how the non-medical / third sector fit into anticipatory care planning and the types of conversations non-clinicians would have with people about ACP.

From the discussion: ACP needs to be broader, incorporate community assets and everyone involved in a persons health and social care.

Patricia Brooks-Young, Lead Nurse & Clinical Researcher from NHS Lothian presents on how they have embedded person-centred anticipatory care plan into the acute care setting. They’ve take a whole systems approach, focusing on information reconciliation.

She also touched on working with occupation therapists and speech and language therapists to pick up on any deterioration in people’s condition.

Closing Remarks

Dr Anne Hendry, Clinical Lead for Integrated Care at the International Foundation for Integrated Care, summed up the day, celebrating progress in implementing anticipatory care planning to date and looking at future challenges. The 5% of the population now with ACPs should be considered a tipping point and the work should really kick off from this. She finished with the question:

Going forward how do we create time and space for good quality conversations and care management?


Participants had the opportunity to set down their commitments to anticipatory care planning and at future workshops, will have the opportunity to discuss their progress and how this has benefited their organisation. Some examples below:

This slideshow requires JavaScript.





One thought on “Anticipatory Care Planning: A Call For Action

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s