Janette BarrieIt is fascinating to note that it is anticipated that the population of Scotland will rise to 5.7 million by 2039, and that the population will age significantly, with the number of people aged 65 and over increasing by 53% between 2014 and 2039.

There are many positives for us to appreciate in being able to live longer lives. However, we are also aware that the likelihood of having long-term, multiple chronic or complex conditions increases with age. So we need to be able to support our changing population and an essential part of that is having models of care that are designed to meet the many needs of individuals.

Anticipatory Care Planning (ACP) is part of that support – it’s about encouraging people to think ahead, know how to use services better and to help them make choices about their future care.

Each Anticipatory Care Plan is tailored to the stage of the individual’s condition and each ACP discussion is completely voluntary and considers the anticipated deterioration in the condition.  ACP is not legally binding and the caveat exists that any individual has the right to change their mind at any time.

Following my own experience of developing ACP in NHS Lanarkshire, we had identified a wide range of different ACP plans being used across Scotland’s health and social care sector. Consequently I was delighted to be invited to join the Healthcare Improvement Scotland team to drive forward a national standard and resource for ACP in Scotland.

So in 2016, as part of Healthcare Improvement Scotland’s Improvement Hub (ihub), we started to bring together best practice from across the country. We knew a national approach to ACP could have a huge influence on person-centred care, where and how a person could be cared for, and for ensuring a patient’s wishes were met at every stage of their journey.

We developed and promoted a standardised national ACP template, guidance for health and care professionals, guidance for individuals and a dedicated web presence myacp.scot. To date, the web presence has been viewed nearly 11,000 times with the supporting documents downloaded over 2,000 times since it was launched.

One of our key indicators of success was the availability by staff to view an individual’s ACP electronically after patient admission. Since the start of the project we have seen over 5.3% of the population’s Anticipatory Care Plans are now available (up from 4.5%). That’s an increase of over 46,000 from last year. This will support improvements in the quality of care people receive and support and enable people to achieve their own personal goals and outcomes.

The intention now is to get to a stage where it is common practice to offer every individual with a long-term condition a care plan. The plan can range from a self-management plan, through to an end-of-life care plan (when appropriate). We know this will empower individuals and carers to identify early, any circumstances that may have a negative or detrimental impact on their health and wellbeing, and on their long-term condition.

There is still much to do, but following the early success of the standardised national template for ACP, we are also now working in partnership with Children’s Hospice Association of Scotland (CHAS) to develop a children’s version of the successful ACP planning guide and hope to have this available in 2018.


Janette Barrie is National Clinical Lead for Anticipatory Care Planning.

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