Anticipatory Care Planning: Time to Make it Happen

acpdocThe latest Anticipatory Care Planning: Time To Make It Happen event took place on 16th November at the Royal College of Surgeons with participants from across the health and social care sector.

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

It was another busy day comprising three plenaries, three breakout sessions, and four updates from the tests of change highlighted at the first meeting.

Welcome and Opening Remarks 

Diane Murray (Associate Chief Nursing Officer, Scottish Government)
Dr Stuart Cumming (National Clinical Lead, Anticipatory Care Planning)

Janette Barrie (National Clinical Lead, Anticipatory Care Planning)
Sheila Steel (Associate Improvement Advisor, Anticipatory Care Planning)

Diane started proceedings with a personal story on the power of why, and the ways ACP matters to her. Stuart and Janette introduced the work so far, what’s progressed and looked to the future. All three providing a reminder that:

Anticipatory care is about people of all ages. Anticipatory care is everyone’s business.

This was followed by a short, (thematically appropriate) ice-breaker music quiz with Sheila and her wheels of Steel.

Realistic Ageing

Dr Martin Wilson (Consultant Geriatrician, NHS Highland)

Martin was his usual informative, entertaining and restless self, speaking on realistic ageing and planning for the end of life (in a presentation that manage to reference Abba and Beyonce).

He talked about the need to plan ahead with elder care. It will be a medical reason why you go to hospital, but it’s likely a social one that stops you getting back home. So thinking in advance about housing, transport, support in older life is essential.

It was a theme that recurred during the day, with Martin highlighting the importance of Power Of Attorney, a written will, and Key Information Summaries – no matter your age.

At what point does it start to become an unwise move to avoid a peaceful death?

What are the most valuable assets when you need care at the end of life?

  • Unpaid carers
  • Paid carers
  • Nursing home beds
  • A human being who can explain what is going on

Early Intervention using the Lifecurve

Dr Sarah Mitchell (Programme Manager, Allied Health Professionals National Delivery Plan)

Anticipatory Care is one of the Active and Independent Living Improvement Programme priorities for 2016-2018, aiming to:

  • create pathways to facilitate anticipatory care planning
  • support AHP workforce to have ‘good conversations’
  • undertake pilot projects to test anticipatory care approaches
  • drive contribution to transformation change plans in primary care

The long term impact of this work?

  • people will have knowledge, resources and confidence to plan their future health and well-being
  • AHP workforce will be confident in having outcomes focused conversations which help people plan for their future

Sarah spoke on early intervention, looking at the Lifecurve developed by the Institute for Ageing at Newcastle University. She questioned if care staff were working at the wrong end of the lifecurve, with resources concentrated towards the end of a person’s life, and asked if earlier preventative measures might improve outcomes.

Early intervention is key to improving people’s lives.

Children and Young Adults

Fiona Reid (Diana Children’s Nurse, CHAS)
Evelyn Rodger (Diana Children’s Nurse, CHAS)
Katrina Marshall (Palliative Care Nurse, NHS Lothian)

Fiona, Evelyn and Katrina talked through the work CHAS are doing supporting Anticipatory Care Planning for babies, children and young people. They each discussed three case studies and identified where ACP had helped in their care.

It was clear from the room that training on having difficult conversations about death and dying is essential. It’s important to realise that different conversations are required around anticipatory care for adults and children.

This prompted a discussion more generally on how anticipatory care planning should work with children and young adults, particularly around the transition to adult services.

Multidisciplinary ACP: Model to Support Integration

Kathleen McGuire (Strategic Lead, NHS Ayrshire & Arran)

Kathleen presented on Ayrshire & Arran’s multidisciplinary anticipatory care planning model, supporting integration.

What matters in the South Ayrshire ACP model?

People, relationships, culture, processes

Their model aims to ensure all patients:

  • consent, can participate and are involved in developing the ACP
  • develop a self-management plan, where appropriate
  • are assessed by the multidisciplinary team and have clear triggers and reassessment timescales
  • have their ACP shared with out of hours, acute, and other members of the team
  • will have ACP available in their own home if they so choose

Tests of Change Updates

We had updates on the tests of change following on from the previous ACP event, A Call for Action.

Adam Ovington (The Advocacy Project)

Adam spoke about their pilots in Glasgow and South Lanarkshire:

  • providing information to residents at sheltered housing complexes
  • providing follow up one to one surgeries for residents to have discussions and input information into their anticipatory care plans
  • liasing with relevant health professionals, family members and others with residents if needed in relation to inputting information into the ACP
Power of Attorney
Maria Elliott (Community Nurse – Glasgow North)

Maria spoke about her continuing work on the documentation, communication and facilitation of power of attorney by district nurses.

Looking to the future she would like to see:

  • consent and capacity training for registered practitioners
  • consent and capacity training for undergraduate nursing students
  • specific POA NHS support role for patients and practitioners
ACP Nursing Team
Fiona Drysdale (ACP Team Lead – NHS Forth Valley)

Fiona provided an update on NHS Forth Valley’s anticipatory care planning nurse team. Their outcomes assessments don’t focus on the services available but on what the individual wants to achieve. Personal outcomes should first and foremost be understood as what matters to the person and why.

To the nursing team ACP assessment = good conversation.

Let’s TALK – not TICK!

ACP Technology
Idong Usoro (Technical Director, University of the West of Scotland)

Idong was on hand to demonstrate the new ACP mobile app and collect feedback on the beta test. We hope to launch it in the next few months.

Seven Songs For A Long Life

Dr Amy Hardie (Director and Documentary Filmmaker)

The afternoon saw the 206th official viewing of Amy Hardie’s documentary Seven Songs For A Long Life documentary on Strathcarron Hospice. There were boxes of hankies on the tables for a reason…

It’s a beautiful film, as much about living as it is about dying. If you get the chance, see it.

After the film Amy facilitated a workshop – What Matters In The End. Participants were encouraged to think about, and discuss, what would matter to them towards the end of their lives.


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The Take Home Message

Anticipatory care is: the right information, the right action, at the right time, in the right place, with the right person.

Check back for details of our next event around May 2017.


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