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Planning for Care

These guidance notes refer to different parts of the ACP Summary on Clinical Portal.

Consent

We do not require explicit consent to share the information contained within the ACP. Therefore the ACP Summary no longer records if someone has given consent to have an ACP.

An ACP is a document brings many pieces of information together into a shareable format. Therefore by engaging in an ACP conversation, the individual (or legal guardian) is agreeing to share this information.

Article 6(1)(e) of the UKGDPR in conjunction with the Intra NHS Scotland Sharing Accord allow the information contained within this document to be shared with Primary Care and other NHS Boards including NHS 24 and Scottish Ambulance, without the need for explicit consent. We are sharing this information for routine patient care as part of our Board’s duty to provide healthcare to our patients. It is best practice for staff to make sure the individual and/or their legal proxy is aware this information will be shared when conducting ACP conversations. If the patient would like further information about how the Board uses their data it can be found in our Privacy Notice here – https://www.nhsggc.org.uk/patients-and-visitors/faqs/data-protection-privacy/#

Recording whether someone would like to share information via ACP

Although we no longer record consent on the ACP Summary, the summary does include a question about whether or not an individual (or their legal guardian) wishes to have an ACP.

By asking this question we hope to enable staff to evidence when a conversation takes place, but the offer of an ACP is declined. We will monitor this data.

If an ACP is refused, staff have the opportunity to record the reason for this. We would ask all staff to complete this in order to provide context to their colleagues who may wish to revisit the conversation at a later date.

Clinical Frailty Score (Rockwood)

We would encourage all staff to consider carrying out a Rockwood Frailty Assessment and select the appropriate score in the ACP Summary.

If a frailty assessment is not applicable please select “0 – Not Applicable”.

Frailty Score Guidance (you can also download an app – Clinical Frailty Scale (CFS) – to help with the assessment – download for apple or android).

Diagram of Clinical Frailty Scale
Special Notes / What is important to the individual?

Overview of person including family circumstances, accommodation information, health goals, what matters to them, emergency planning information etc. If person is a carer, or has informal carers please state too.

If person lacks capacity ensure this is recorded alongside who has been present during any discussions.

If a person declines an ACP, staff are encouraged to ask permission to record this decision on the ACP Summary so that other services are aware that an ACP has been offered. It is also best practice to indicate whether the person may be willing to revisit these conversations at a later date. Please record this in the appropriate question.

Current Health Problems / Significant Diagnoses

Overview of health issues and diagnoses. Baseline functional and clinical status to help clinician identify deterioration – e.g. baseline O2%, 6-CIT score, level of mobility, current or planned treatments.

It is good practice to indicate if there are any treatments or interventions that the person would not wish. If they have an Advanced Directive this can be indicated.

My preferred place of care

Depending on the person’s own circumstance and health journey, this may include preference about:

  • long term care (e.g. nursing or residential care)
  • place of treatment. This could include short or long term treatment.
  • place of death

This section may also include the current level of care being provided by informal carers and/or any discussions which have occurred regarding on going and future care they may be able to provide.

My views about hospital admission / views about treatments and interventions / family agreement

It is best practice to give as much information as possible regarding views about hospital admission and explore with people what might happen in different scenarios. For example people may be willing to be admitted for a short period for symptom management, however would be unwilling to be admitted if it was likely they would be in hospital for long periods.

For people who are frail, in residential/nursing homes or approaching the end of their lives, it may be useful to discuss the 3 following scenarios:

  1. If you had a sudden illness (such as a stroke or a heart condition), how do you think you would like
    to be cared for?
  2. If you had a serious infection that was not improving with treatments we can give in the community like antibiotic tablets or syrup, how do you think you would like to be cared for?
  3. If you were not eating or drinking because you were now very unwell, how do you think you would like to be cared for?

Current Events

Monthly Death Cafes (Virtual)

Let’s break the taboo, and talk about Death! This event is an informal space to talk with others about something which affects us all…so boil the kettle, raid the biscuit tin and come and join the conversation!

Please note that this is a discussion group rather than a grief support or counselling session.

These events are open to staff and members of the public.

Currently these events happen on MS Teams so places are limited. However, if you are a curious about what a Death Café might be like, we’d encourage you to come along and say hello! Whether you’d like to dip your toe in the water, or keen to become a regular, you can register for any of our cafes by selecting a date below:

Monday 22nd August 2022 7-8pm

Monday 19th September 2022 7-8pm

Monday 24th October 2022 7-8pm

Monday 21st November 2022 7-8pm

Monday 19th December 2022 7-8pm

Lunch & Learn Sessions

Lunch & Learn Sessions are informal events for staff to highlight new ways of working and give people an opportunity to ask questions. They usually last around 30 minutes. Check out our current themes and dates of sessions below.

Lunch & Learn Session: New ACP Summary

In June, the ACP Summary was updated. Come along to hear about some of the key changes that have been made as well as how to create and update the document. These sessions are open to all staff across health and social care.

You can register for any of these session by clicking on your preferred date.

Dates of Sessions:

Monday 22nd August 2022 – 1.00-1.30pm

Thursday 25th August 2022 – 12.30-1.00pm

Thursday 1st August 2022 – 1.00-1.30pm

Lunch & Learn Session: Recording ACP Journeys via EMIS

Come along to learn which codes should be used as well as a demonstration of how coding works on the EMIS system. These sessions are open to all staff across health and social care who use the EMIS platform.

You can register for any of these session by clicking on your preferred date.

Dates of Sessions:

Tuesday 23rd August 2022 – 12.30-1.00pm

Friday 26th August 2022 – 1.00-1.30pm

Monday 29th August 2022 – 12.30-1.00pm

You can read about past events below. We have also recorded some of our events so that you can watch them in your own time – the videos are available under each event description.

Past Events
Demystifying Death Week 2022

2nd – 6th May 2022

Demystifying death week is about shining a light on death, dying and bereavement in Scotland. Events throughout the week will give people knowledge, skills and opportunities to plan and support each other through death, dying, loss and care.

This year NHSGGC ran 13 events across the week. Some events were recorded and you can watch them below.

You can read our Summary Report for the week.

Additional Resources:

Demystifying Death Week 2022 – Resource List

Demystifying Death Week 2022 – Carers Resource List

Demystifying Death Week 2022 Events

Taking Care of Yourself When Looking After Someone

Supporting other people can take its toll, and whilst it may be the last thing on our minds, taking time for ourselves is really important. Come along for an informal chat about some ways to help recharge and promote self-care.

This session was not recorded.

Death Cafe

Let’s break the taboo, and talk about Death! This event is an informal space to talk with others about something which affects us all…so boil the kettle, raid the biscuit tin and come and join the conversation!

Please note that this is a discussion group rather than a grief support or counselling session.

This session was not recorded.

Having Conversations That Matter

This is an experiential workshop to give participants an easy way to start thinking about what’s important to them and those around them. This event is open to any member of staff working in Health and Social Care across the Greater Glasgow and Clyde Health Board Area. 

This session was not recorded.

Anticipatory Care Planning – An Introduction for Staff

Anticipatory Care Planning has benefits for everyone. It empowers people to tell us what really matters; it gives friends and family an opportunity to talk open and honestly; and it helps professionals to work with everyone to create the best care and treatment plans possible. During the session we will be looking at tools and resources we use across NHSGGC to help promote future planning, and how our systems work together to share information. ACP is everyone’s business, so make sure you know your role in the conversation.

You can watch the recording here:

Planning for The Future

When it comes to planning for the future, do you even know where to start? During this informal information session we will give you some ideas of things to think about and tools to help you plan, as well as telling you how this information can be shared with others so that everyone is in the know.

You can watch the recording here:

Preparing for Hospital – What You Need to Know

No one wants to go into hospital, but sometimes it is unavoidable. However there are some simple things we can do now, to try and make the experience less stressful for everyone.

Come along to learn about making “grab bags”, what paperwork to bring along and what the discharge process might look like. This event might be particularly useful for anyone supporting someone else and worried about what the future might look like.

You can watch the recording here:

What is Palliative Care?

When you think about palliative care, what is the first thing that comes to mind? “Terminal illness”? “End of life”? “Comfort Care”? Whilst all these things are true, palliative care is so much more than this. It is about improving the quality of life of anyone facing a life-limiting condition and can be beneficial at lots points during someone’s health journey. During this session, we will be busting some myths when it comes to Palliative Care and also exploring the support that the NHSGGC Specialist Palliative Care Team can provide both colleagues and patients.

Recording will be available shortly.

Power of Attorney / Making a Will

The legal parts of future planning can often be confusing, with lots of people not quite sure where to start. This session will explore how to get started with Power or Attorney and making a Will, and why both of these things are so important. There will also be an opportunity to put any questions you have to an expert. 

You can watch the part of the session about Power of Attorney here:

You can watch the part of the session about Wills here:

Anticipatory Care Planning Communication Skills Training

This is part of our usual training programme. The session helps staff reflect on the best way to incorporate ACP conversations into their everyday practice.

This session was not recorded.

For future dates please visit our ACP Training Hub

Anticipatory Care Planning and Treatment Escalation Plans

How can we help our on-call teams to do the right thing in the middle of the night – when faced with a deteriorating patient that they have never met? Sometimes intervening may be of no benefit or could cause distress but making that judgement can be very difficult. It is possible that there is a plan but accessing it may be a challenge. We will discuss the plans that may be available, how to find them, how to improve them and how to initiate them and have the conversation. Please note, this is a recording on a session which took place as part of NHSGGC’s Realistic Medicine Week in March 2022.

Recording will be available shortly.

What Happens When Someone is Dying

Dying is a normal process, but these days the process is often surrounded in mystery. Come along to learn more about what actually happens as someone approaches the end of their life and have an opportunity to talk to some experts.

This session was not recorded.

Seasons of Change – Spring Session 2022

An opportunity for staff to reflect on loss, grief and bereavement

Loss, grief, and bereavement are universal emotions.  Whilst death and dying is a natural part of life, during the past two years it is likely that many more people have been touched by experiences which may have triggered feelings associated with loss and change. 

To give staff an opportunity to reflect on both our collective and individual experiences, a new informal online event was created.  The intention was to create a space for staff to reflect and recharge.  There was no active participation necessary, rather staff are encouraged to listen and reflect on the various contemplative pieces (sessions will also have subtitles).   

Staff from across all parts of health and social care were encouraged to attend, including our colleagues in Care Homes, Primary Care and Third Sector.  

Sessions ran on MS Teams everyday during lunchtime of the week 16th-20th May 2022.

You can read our Summary Report for the session.

You can now watch the session in your own time.

Additional Resources:

Seasons of Change – Spring 2022 – Resource List

Carers Week 2022

Carers Week is an annual campaign to raise awareness of caring, highlight the challenges unpaid carers face and recognise the contribution they make to families and communities throughout the UK. It also helps people who don’t think of themselves as having caring responsibilities to identify as carers and access much-needed support.

The campaign is brought to life by thousands of individuals and organisations who come together to provide support for carers, run activities, highlight the vital role carers play in our communities and draw attention to just how important caring is.

This year NHSGGC hosted 5 events as part of Carers Week 2022. We will also be highlighting how staff can help support carers and work with them as equal partners in care. Please follow @NHSGGCCarers on Twitter for all the latest updates.

You can read our Summary Report for the week.

Additional Resources:

Carers Week 2022 – Resource List

Taking Care of Yourself When Looking After Someone

Supporting other people can take its toll, and whilst it may be the last thing on our minds, taking time for ourselves is really important. Come along for an informal chat about some ways to help recharge and promote self-care.

This session was not recorded.

Death Cafe

Let’s break the taboo, and talk about Death! This event is an informal space to talk with others about something which affects us all…so boil the kettle, raid the biscuit tin and come and join the conversation!

Please note that this is a discussion group rather than a grief support or counselling session.

This session was not recorded.

Having Conversations That Matter

This is an experiential workshop to give participants an easy way to start thinking about what’s important to them and those around them. This event is open to any member of staff working in Health and Social Care across the Greater Glasgow and Clyde Health Board Area. 

This session was not recorded.

Planning for The Future

When it comes to planning for the future, do you even know where to start? During this informal information session we will give you some ideas of things to think about and tools to help you plan, as well as telling you how this information can be shared with others so that everyone is in the know.

This was a repeat of the session run during Demystifying Death Week. You can watch it here:

Preparing for Hospital – What You Need to Know

No one wants to go into hospital, but sometimes it is unavoidable. However there are some simple things we can do now, to try and make the experience less stressful for everyone.

Come along to learn about making “grab bags”, what paperwork to bring along and what the discharge process might look like. This event might be particularly useful for anyone supporting someone else and worried about what the future might look like.

This was a repeat of the session run during Demystifying Death Week. You can watch it here:

You can keep up to date with all the latest news via our Twitter account @NHSGGC_ACP

Please get in touch if you need any further information or to report any broken links on these pages. You can email ACPSupport@ggc.scot.nhs.uk.

Here you will find links to various documents and websites which we hope will be useful.

Resources have been grouped into themes. To view resources and hyperlinks please click on them.

The ACP Summary was updated in July 2022. All guidance documents have now been updated to reflect these changes.

We have been experiencing some technical issues with links not opening the appropriate document. We have now resolved this issue. If you are still having problems opening documents, please clear all cookies and cache history from your browser before trying again.

Anticipatory Care Planning (ACP) Standing Operating Procedure
DISCUSS Guides
Preparation Guides For The Public
Preparation Guides For Staff
ACP Documents (Person-Held Booklets)
ACP Summary Guides
Winter Planning Toolkits For Staff and Services

By ensuring we know what people’s wishes and preferences are, we can make the right decisions if emergency situations arise. This includes whether or not they would wish to be admitted to hospital or prefer to receive treatment elsewhere if possible.

ACP and Winter Planning – Information for Staff and Services – PDF

We know that many staff have been identified as a close contact by the Test and Protect process and as a result are now required to isolate. Whilst this means many services are under extreme pressure to continue to provide face to face support, there is now extra capacity in the system for staff to carry out tasks which can be completed remotely e.g. beginning to engage with people and their families about future planning.

Having ACP Telephone Conversations – Information for Staff – PDF

Library of Good Practice (Example ACP Summaries)

Click on the names to read their ACP:

Alan Fulton – An older man who cares for his wife.

Monica Hill – A lady with breast cancer receiving support from a local hospice. 

Elizabeth MacDonald – An older lady with COPD.

Ali Malik – A young adult transitioning between child and adult palliative care services. You can also view an example of a Child and Young People Acute Deterioration Management (CYPADM) form

Charles Menzies – An older widow who is living independently with no known conditions.

Duncan Moore – A middle-aged man with a new diagnosis of Diabetes Type 2.

Jacqueline Morrow – A parent carer with a daughter on the autistic spectrum.

Sophie Morrow – A young woman with autism.

Margaret Quinn – An older lady living with dementia.

Sarah Rosenshine – An older lady living with osteoporosis.

Cathy Steel – An older frail lady receiving Palliative Care.

Paul West – A middle-aged man recovering from cancer.

Tom Williams – A Care Home Resident.

Other Resources

We would love to hear about your experience of Anticipatory Care Planning. Whether you have had a fantastic future planning conversation, or been able to use an ACP to help create bespoke treatment plans that are tailored to individuals, we want to hear about it! 

You can either tell us about the event using our online case study collection portal, or download our ACP Case Study Template word document and send it to ACPSupport@ggc.scot.nhs.uk 

Please ensure you have permission from all the people involved in this case before you share this story.
Please also remember to anonymise all patient identifiable information.

If you have any questions or concerns about whether or not you can share this story please speak with your line manager or email ACPSupport@ggc.scot.nhs.uk

Emotional Support

Having these conversations can bring up lots of different emotions. It is just as important to look after your mental wellbeing as well as your physical health. There are lots of resources available which have information and advice for you and your friends and family. For instance, NHS Inform talks about the 5 Steps to Mental Wellbeing.

Grief and loss can be experienced at lots of different times. We can experience these emotions even before someone has died. This is natural. You might find it useful to talk to someone about this – maybe a friend or relative. There are also organisations which have advice and can offer advice.

If you are supporting someone at the end of life you can find more information on our webpages.

If you are supporting someone who is experiencing a bereavement then you can find information on the Headsup webages.

If someone has died, you can find information and advice about what you need to do next.

Useful Websites and Organisations

There are lots of organisations and services who can help you and the people that matter to you get the information you need. Some organisations and services can also help you fill out the documentation.

You can also speak with any health care professional involved in your care. They might not be able to help you with everything (e.g. making a Will or making a Power of Attorney), but they will be able to signpost you to more information if necessary. They can help answer any questions you might have about anticipatory care planning and make sure that the important information is stored on the system.

Find information about other useful websites and organisations below.

Useful Websites

Here is a list of websites which provide lots of information about future planning. They also provide some resources you may find useful. If you need to speak to someone, or need support to use the planning tools then you can contact one of the useful organisations below.

Useful Organisations

Anticipatory care planning (ACP) helps people make informed choices about how and where they want to be treated and supported in the future. Health and care practitioners work with people and the people that matter to them to ensure the right thing is done at the right time by the right person to achieve the best outcome.

ACP puts people at the centre of the decision-making process about their health and care needs. It encourages people to have conversations about what matters to them and can be started at any stage of a person’s care. This can be after life events such as a hospital admission or a decline in health.

What is an ACP?

An ACP is a record of someone wishes. It should be created over time and reflects conversations between a resident, the people that matter to them and the health care professionals that work with them. 

What information is in an ACP?

The plan should include:

  • a summary of the “thinking ahead” discussions
  • a record of the preferred actions, treatments and responses that care providers should make following a decline in health

Some ACPs include information about care at the end of life including where residents would like to be cared for and their wishes about different treatments including resuscitation. All these discussions should be had sensitively and with consideration and should include the people who the resident wishes to be there. 

How can we help everyone prepare for these conversation?

Some people will not have considered these topics before. It is important that you give them time and space to reflect before having these conversations.

To start with, have a conversation with everyone to explain what ACP. You can give them some information to read through and think about. Let them know you would like to talk more about this in the future.

Information Leaflets

Information for Residents – (PDF)

Information for Relatives and Friends – (PDF)

DISCUSS – A Guide For People Thinking About Their Future – PDF

DISCUSS – A Guide For People Thinking About Their Future – PDF (Black & White Version)

DISCUSS – A Guide For Friends, Family and Carers – PDF

DISCUSS – A Guide For Friends, Family and Carers – PDF (Black & White Version)

DISCUSS – A Guide For Staff – PDF

DISCUSS – A Guide For Staff – PDF (Black & White Version)

It is important to involve everyone in these discussions, however if a resident does not have capacity to make these decisions, then it may not be appropriate to give them this information. In these cases we should make every attempt to involve friends, family and carers in order to agree what would be best for the resident and respect their wishes. 

You may feel like you don’t know enough about some topics to give advice to others. For example you might not feel able to answer some questions about DNRCPR, or you might be unsure of the level of support home care can give. If someone asks a question that you don’t know the answer to, be honest about this. Tell them you aren’t sure right now but you will find the information and get back to them. Talk to your colleagues to try and find out the necessary information or you can email ACPSupport@ggc.scot.nhs.uk.

How do you complete an ACP?

During the Covid-19 pandemic it is as important as ever to have an ACP in place and to know what is important to residents if they become seriously unwell with Covid-19 or other serious illnesses.  

There are different ways of recording ACPs and each care home may differ. However it’s important to share this information with health and social care partners so that treatment plans reflect people’s wishes.  The easiest way to do this, is to link with the GP who can update the Key Information Summary (KIS). This is an electronic record which NHS24, the Scottish Ambulance Service and hospitals can access.

To help transfer this information quickly and easily, all HSCPs in Greater Glasgow and Clyde use a ACP Summary to record ACP decisions. This mirrors the information on the KIS so GPs can if they wish quickly copy information to the KIS. It can be accessed either on Clinical Portal (specific ACP tab), or services can use an interactive PDF.

If you have access to Clinical Portal you can fill out the summary directly on there. Clinical Portal will automatically send the ACP to the GP and they can if they wish transfer the information to the KIS. 

If you do not have access to Clinical Portal you can fill out this interactive PDF and email or post a copy to the GP as the GP is not making regular visits at the moment. 

Remember, if any changes are made at the ACP review this information needs to be sent to the GP so they can update the KIS.  

Guide to updating ACPs on Clinical Portal (PDF)

Guide to updating ACPs on Clinical Portal (Video)

Guide for GPs Updating eKIS from ACP Summary (PDF)

How can you use an ACP to make care and treatment plans?

People’s wishes and the wishes of those that matter to them, must always be taken into account when deciding on treatment plans. By doing this you will make a plan specific to this individual and based on what is important for them.  

Many residents who live in a care home may choose to remain there if they become unwell. Their main priority might be comfort, and being in their own room, looked after by staff who know them well. However there will be some residents who may benefit from admission to hospital and would want to be transferred. If they do go into hospital it is important to send with them a copy of any previous discussions. If someone has a DNACPR form please send a copy with them.

What happens if someone changes their mind?

Anyone can change their mind, and as circumstances change, what is important to people might also change. This is why we think the most important part of the ACP process is the ongoing conversations with residents and the people that matter to them.  

Final plans do not need to be made but recording the content of these discussions means these plans can be built on. We would expect that ACPs would be reviewed perhaps every 6 months at the time of the resident’s reviews.  

ACP Care Home Projects

There are currently many projects happening in Care Homes across NHSGGC to help improve the use of ACPs. These include projects focused on:

  • content of an ACP
  • identifying and recording frailty
  • ensuring key information is easily identifiable in residents files
  • ensuring ACP information is uploaded to KIS

If you work in a care home and are interested in participating in a project please email ACPSupport@ggc.scot.nhs.uk.

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For NHS Staff

(GGC 028: Anticipatory Care Planning)

Accessible to Everyone

Case Studies

Morag Smith

Paul Smith

James Fulton

Further Information

Participant Information

Using MS Teams

Joining a MS Teams Call

Clinical Portal Documents

ACP Summary

Morag Smith – Completed ACP Summary (PDF)

Copy of Morag Smith’s Clinical Portal ACP

Across NHSGGC we aim to deliver person-centred care. To do this we need to work with everyone – the person, those who matter to them and the other health care professionals involved in their care.

If the person you work with is supported by friends, family or neighbours in a caring capacity you should refer them to carer support services

Information for Current Staff

Information for New Staff & Students

If you are new to NHSGGC then we would recommend that you take a look at our training hub. This will help you understand what happens in our Health Board and what role you can play. There may also be specific training for your specific role or area. Check with your line manager or practice development team.

Information for Care Home Staff