The four steps to the right Anticipatory Care Plan – Paul Baughan

We’ve launched a new section of our ihub website with information, tools and resources to support Anticipatory Care Planning (ACP), a crucial process which ensures that the right things are done in the future for each person, should their health change. Dr Paul Baughan, clinical lead with our Primary Care team explains why this ACP is so important and the various stages to enable the right outcome for patients.

The longer I work in general practice, the more I realise that there are many different ways to treat people who have exactly the same medical condition. Priorities for care vary considerably between individuals, and if we do not stop to ask “What matters to you?” then we can actually cause harm – even when following the latest evidence-based guideline.

Spending time with someone to explore treatment and care options that are right for them – in the context of their current state of health, their social situation, and the various priorities in their life – is critically important. It can ensure that the right things are done in the future for that person, should their health change. Things such as the type of medicines to use during an exacerbation or sudden deterioration, the people who should be contacted to help with decision making, and how the person would like to receive care if staying at home is becoming more difficult. These preferences can be written down, kept with the person, documented in their clinical notes, and shared with other people who need to know. Many people call this approach ‘Anticipatory Care Planning’.  

There are four crucial steps to a successful ACP, which forms the basis of the new Healthcare Improvement Scotland ACP toolkit. Each of these steps is important to ensure that we do the right thing for the person we are caring for. We know that harm can be caused if we jump straight in at Step 3 (documenting a care plan), without the important preparation and planning, or having first engaged in meaningful conversations with the right people.

As a GP, as well as the Clinical Lead for Primary Care with Healthcare Improvement Scotland, let me explain how I’ve been using the four stages and how they help me to ensure that the right care plan is created for everyone.

Step 1: Preparation and Planning

The first step, Preparation and Planning, involves identifying who you will be having an ACP discussion with, then preparing yourself and the person for that conversation. 

I do this by finding out as much as I can about the person before meeting with them. I ask myself the following questions: What is their current state of health? What have other professionals and specialists said or written in their notes? Is there anyone who normally supports this person with decision-making? What is their social situation? What realistic options are there for future treatment and care?   

It is also important that I prepare the person with whom I will be speaking, check that they are happy to have this type of conversation, and ask whether there is anyone else who should be involved in these discussions (For example, a family member or power of attorney).  

Step 2: Meaningful Conversations

The conversation between the health or care professional and the individual, as well as those important to them, is at the heart of ACP.

I find the REDMAP framework, developed by Dr Kirsty Boyd, Reader in Palliative Care at University of Edinburgh, a helpful structure to follow.

It’s important to allow appropriate time for these discussions, and this can be a challenge in general practice. I will often hold these important conversations over a number of different appointments over several weeks. This allows the person and their family time to think about things before we agree an action plan that is right for them. 

Step 3: Documentation and Sharing

Once a plan has been made, it is important that it is shared with all those who need to know. After all, it might be needed in the middle of the night when the practice is closed. The best way that we have to share this information between health professionals is through the Key Information Summary (KIS). However, information can only be added to KIS through GP practice clinical systems. For those unable to access this, there is now a web-based Essential ACP Online Tool to document aspects of the ACP. This can be securely shared with the individual or the GP practice. Work is progressing with a digital version of ReSPECT, and ultimately I look forward to a time when we have a single citizen-held electronic health and care record. One within which my patients can enter their own information about ‘What matters to me’, and that can be supplemented with information from all the health or social care staff who are involved in providing care.

Step 4: Regular Review

People may change their mind about their priorities for care as their health or social situation changes. What matters to someone in six months’ time may be very different from now. That is why it’s important that ACP information is regularly reviewed and kept up to date. 

33% of the Scottish population have something entered within their KIS.  Not all of these will incorporate an anticipatory care plan, however it does present me and my primary care colleagues with a logistical challenge to keep them up to date. Healthcare Improvement Scotland with RCGP and Scottish Government has recently published pragmatic guidance and top tips for reviewing and updating KIS. An important aspect of this guidance is exploring the resources (people and time) that are available and ensuring that the extended multidisciplinary team is involved in these reviews. This requires preparation and planning, which of course brings us back to Step 1.

So whether, like me, you are working in general practice, or are based in another part of our health and social care system, anticipatory care planning is important. It is not a one-off activity to be ticked-off and completed, but instead is a process that requires preparation and planning, meaningful conversations, documentation and sharing and regular review.

Paul Baughan is a GP and the Clinical lead with Healthcare Improvement Scotland’s Primary Care Team.

More information

Visit http://ihub.scot/acp for all the resources mentioned here and share with us your learning about ACP by emailing: his.pcpteam@nhs.scot.