Future care planning

Future care planning means talking about what matters most to you when making plans for your health and care in the future. You can talk with people who are close to you about having a future care plan and with your doctor, nurse or care worker. People looking after you want to hear about what’s important when they’re planning your treatment and care with you, now and in the future.

Making plans and knowing how to get the right help means there’s less to think about if you become unwell. It’s better to start thinking ahead and making some plans for your life, health and care while you are well.

If you’re a carer, you can make plans to support the person you care for if your own health changes.

You can start future care planning yourself by finding out about it and talking with your family and friends.

Everyone is different and can have their own plan. Future 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
• decisions about CPR
• recommendations for other treatments or hospital admissions

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. Future care planning 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 now and in future
• 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 future care plan makes this easier for them.

Who can have a future care plan?

Anyone of any age can start future care planning and plan ahead. Having a future care plan in your healthcare record is free of charge. Future care plans help improve shared decision making but are not legal documents.

Future care planning is particularly important and helpful if you:

• have one or more long-term health conditions
• 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 serious health condition or disabilities that will get worse

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 that means you need more help and support

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 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 do not want
• agreeing your plan with you and when it will be reviewed and updated

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)

Future 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
• community pharmacies

The KIS has information that NHS staff should know if you need urgent or emergency treatment and care. Anyone can ask their GP if they have a KIS or ask for one to be started.

Other health records

ReSPECT plans are used for future care planning in several health boards in Scotland. A ReSPECT plan has information about what matters to the person. It also has clinical recommendations to help health and care staff with decisions about treatment and care. ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment.

In some health boards in Scotland, medical and nursing staff use a Treatment Escalation Plan (TEP) to record information about a person’s care.

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 future care plan can be updated at any time. You can ask for this to happen. Your GP, nurse, or another healthcare professional or care worker may suggest reviewing your plan.

Further information about planning ahead

Changes in your health can affect all aspects of your life. Some people choose to get 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