Anticipatory Care Planning (ACP)

Anticipatory Care Planning (ACP) is where you talk about what matters most when making plans for your care in the future. You can talk about this with those close to you, and your doctor, nurse or care worker. Your care team want to know what's important when they're planning treatment and care with you.

Making plans in advance means there's less to think about if you become unwell. It's never too soon to think about what you'd like to happen if you get ill, or your health condition gets worse.

If you're a carer, you can make plans for supporting the person you care for if your own health changes.

You can start Anticipatory Care Planning (ACP) yourself by finding out more about it and talking with your family and friends.

Everyone is different and has their own plan. Anticipatory care plans may include:

• personal information about what matters to you and your family
• where and how you can be cared for
• a carer information and support plan
• an emergency treatment and care plan
• decisions about CPR

Why plan ahead?

Thinking ahead and making plans for changes in your health gives you more say over what happens. You may already have thought about what you would like. Anticipatory Care Planning (ACP) is the way to do this in Scotland.

Talking about your health and what matters to you can help you:

• manage changes in your health and wellbeing, or family situation
• have a plan for what to do if you (or your carer) get ill or need help in an emergency
• tell people what you would like to be able to do
• record anything you do not want to happen

If you're unwell, your family or friends may need to help make decisions about your treatment and care. Having a care plan makes this easier for them.

Who can have an anticipatory care plan?

Anyone of any age can start Anticipatory Care Planning (ACP) and plan ahead. Having an anticipatory care plan in your healthcare record is free of charge.

ACP is particularly important and helpful if you:

• have a long-term health condition
• have disabilities
• have many health and support needs
• are an older person and you need regular help and support
• are a young person or the parent or carer of a child or young person with a life-limiting health condition

How do I start planning ahead?

You can begin planning at any time. People often start to think ahead and talk with friends and family when life events happen such as:

• a new diagnosis
• a hospital admission
• moving into a care home
• a decline in health

Your GP, nurse or care worker might suggest a meeting to start talking about your health, care and support. You can bring a family member or friend, or carer with you if you wish.

Conversations about ACP can cover:

• how planning ahead can help you
• what you know about your health and how it might change
• medical information about your health, treatment and care
• what matters to you and your family
• what treatment and care options you have and how they can help you
• treatments that would not work for you
• treatments you would not want
• agreeing your plan with you and when it will be reviewed

You can also talk about any other questions, worries, or problems you may have.

How health plans are recorded, shared and updated

Key Information Summary (KIS)

Anticipatory care plans are usually added to a person’s Key Information Summary (KIS). The KIS is an electronic health record. It is held in your GP practice health record and shared securely with other health services and teams including:

• hospitals
• NHS 24
• the ambulance service
• out of hours healthcare services

The KIS has information that NHS staff should know if you need urgent or emergency treatment and care. Anyone can ask their GP for a KIS to be started for them. Your doctor, nurse or care worker may ask if you wish to have one.

Other health records

Some health boards in Scotland use other health records for anticipatory care plans. These plans may be added to a person's hospital records and/or their KIS. They include:

• Treatment Escalation Plans (TEPs)
• Recommended Summary Plan for Emergency Care and Treatment (ReSPECT process)

People with disabilities may have a hospital or healthcare passport. Ask your care or support worker for further information.

Over time your health and situation may change. Your anticipatory care plan can be updated at any time. You can ask for this to happen. Your GP, nurse, or another professional may suggest reviewing your plan.

Further information about planning ahead

Changes in your health can affect all aspects of your life. Some people will need advice about legal and financial planning from a lawyer or advice centre.

Read further information about:

• Making a will
• Power of Attorney
• Adults with incapacity
• Advance directives
• Organ donation in Scotland