A Power of Attorney (PoA) is a legal document which gives someone else the authority to make decisions on your behalf if you are unable to do so. This person is called your attorney. You can ask anybody that you trust to be your attorney.
Watch our video below to find out why it’s important to have a Power of Attorney in place.
FAQs
In this video we answer some of the common questions that people have about Power of Attorney.
You can also read answers to the some of these questions here.
What is a Power of Attorney (PoA)?
A Power of Attorney (PoA) is a legal document that lets someone else make decisions for you if you can’t do it yourself. The person you choose to make these decisions is called your “attorney.” You can ask anyone you trust to be your attorney.
There are two main types of Power of Attorney:
Welfare Power of Attorney – This allows someone to make decisions about your health and well-being.
Financial Power of Attorney – This allows someone to make financial decisions for you.
You can choose different people for each type of Power of Attorney, or the same person can handle both. If you have more than one attorney, you can choose if they have to make decisions together or can make them on their own.
You decide when your Financial Power of Attorney starts, but your Welfare Power of Attorney will only begin if you can no longer make decisions yourself. This is sometimes called “losing capacity”.
How do I get a Power of Attorney?
To get a Power of Attorney, you need to choose someone to act on your behalf while you are still able to make decisions.
Here’s how to get started:
Talk to people close to you about why you want a Power of Attorney.
Decide who will be your attorney. You can choose one person for welfare decisions and another for financial decisions.
Because it’s an important legal document, it’s a good idea to get help from a lawyer or solicitor to make sure everything is done properly. For more information, visit My Power Of Attorney – Scotland.
What does it mean to “lose capacity”?
“Losing capacity” means you can no longer look after your own financial and personal matters. This can happen because of health problems like dementia, a stroke, or other conditions. In Scotland, a person is an adult at 16 and can make their own decisions unless a doctor says they can’t.
Signs that someone has lost capacity include:
Forgetting decisions
Not being able to act on decisions
Not being able to understand or make decisions
Not being able to tell other people about the decisions they want made
Can my family make decisions on my behalf without a Power of Attorney?
Many people think that if they lose the ability to make decisions, their family can automatically help. But unless you’ve set up a Power of Attorney, your family can’t make decisions for you.
Without a Power of Attorney, the court will have to choose someone to be your “Guardian,” which can take a long time and be expensive.
There is a cost for registering a Power of Attorney. There may be other costs like legal fees or getting a “certificate of capacity”. However there may be financial help available to cover these costs. You can ask Citizens Advice Scotland or visit the My Power of Attorney website for more details.
I have a Power of Attorney. Do I need to do anything else?
After setting up your Power of Attorney, it’s important to talk with your attorney so they understand what you want if you can’t make decisions for yourself later on. You might want to write down your wishes in a Future Care Plan.
Let your doctors and health professionals know who your attorney is, so they can contact them if needed.
What can happen if I don’t organise a Welfare Power of Attorney?
If you don’t have a Welfare Power of Attorney set up, it can cause delays in your care. For example, some people stay in the hospital longer than needed because there is no one to make health decisions for them. This means that doctors and nurses are less able to help other patients who need care.
Why does having a welfare Power of Attorney matter to the NHS?
Right now, many people in the NHS Greater Glasgow and Clyde have to stay in the hospital longer because they don’t have a Welfare Power of Attorney. This takes up beds that could be used for other patients. It also means ambulances and staff can’t help as many people in the community or in emergency care.
Having a Welfare Power of Attorney helps keep things running smoothly and ensures patients get the care they need faster.
Power of Attorney Training and Resources
You can watch a recording of an information session on Power of Attorney below:
You can also join us for live sessions which happen a few times each year. You can find out when sessions are happening by visiting the HomeFirst Training Hub.
When you or someone you care about becomes ill, life can become very stressful. That is why we think it is so important for people to talk to each other and make plans before this happens.
To help people plan more, and stress less, we have created a toolkit of resources that we hope will be useful. This includes information sessions and checklists to help you get organised, as well as a plan to work out how you’d get home from hospital. We also look at some of the legal process and support that is available for those who care for you.
Even if you and those you support are perfectly healthy just now, you can still use these tools to help plan for the future!
We run online “Plan More, Stress Less” sessions which are for anyone interested in getting started with planning ahead. In this session we talk about what paperwork we can complete before a crisis arises, what actually happens when someone goes into hospital and how we can all work together to plan for a safe and timely discharge.
For our next dates and to register for a session, visit the HomeFirst Programme Events Page. Or you can watch a recording of a session here:
Alongside this video we have created two resources which anyone can use to help them plan for any future hospital admission. This could be a planned admission, for example if someone is going to hospital for an operation or to have some tests. However these resources can also be useful if someone needs to go to hospital in an emergency.
If you have any questions or feedback about these resources please email ggc.HomeFirst@nhs.scot
Preparing for Hospital Checklist
This checklist will help you think about all the different forms which you can complete just now that would be useful if you were ever in hospital. This includes things like a Future Care Plan and a Power of Attorney.
This resources lets you and the people who support you, think about what might need to happen in order to get you home from hospital in a safe and timely manner. This includes thinking about who could collect you from hospital and where you might need to live if you need some extra support for a short time or on a more permanent basis.
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.
Events run by the Team
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!
Please keep and eye on this page or our twitter feed for dates.
Death Cafes Around the Country (and world!)
Death Cafes are springing up all over the world and there are some that are local. Visit www.deathcafe.com to find your nearest cafe.
Some cafes we know of:
Glasgow Southside Death Cafe
This is an in-person cafe which usually runs the first Thursday of the month 7.30pm-9.00pm at Finns Place (Southside of Glasgow – Langside Church, 167 Ledard Road, Glasgow, G42 9QU). Free refreshments available. For more information and dates visit the Finn’s Place website. Email hello@curiousmortals.co.uk for more details.
Online Death Cafe
The online cafe runs the second Tuesday of the Month, 7.30 – 8.30pm, online via MS teams. You need to register (and make an account the first time) for this café so that you can be sent the joining link. Check out the Curious Mortals website for more details – Past and Future Events — Curious Mortals
This is a new cafe which takes place on the last Monday of the month at 7.30pm. These are hosted at The Moon Rooms, 81 Broom Road East, Newton Mearns, Uk G77 5LL. There is no need to register, just show up.
Govanhill Death Cafe
This is cafe is taking a little break but hopes to run a few sessions in 2025. We will post details when we have them.
Cambuslang Death Cafe
This is cafe is taking a little break but hopes to run a few sessions in 2025. We will post details when we have them.
Focused Fundamentals (Bite Sized Learning)
These sessions are bite sized learning events for staff which focus on a specific topic to provide an overview. Sessions are less interactive, focusing instead on delivering information, however there is an opportunity to ask questions at the end of each session. They usually last between 30 minutes – 1 hour.
Current Topics Covered
Future Care Plan Clinical Portal Walk Through
Future Care Planning Introduction
Rockwood Clinical Frailty Score
Power of Attorney
Recoding Future Care Planning on EMIS
Recording Future Care Planning on CNIS
If there is a topic you would like us to consider then please email at ggc.HomeFirst@nhs.scot
You can find more information including dates and registration links on our training hub pages.
Plan More, Stress Less Sessions
As part of our Plan More Stress Less toolkit, we host interactive sessions which cover all you need to know about getting yourself, and those you support prepared for any unexpected event including hospital admissions.
This session last approximately 1 hour and includes opportunities for you to ask questions. The sessions are online.
Topics covered in the session include:
Helpful paperwork
What to bring to hospital
What conversations we may have whilst in hospital
Planning for a successful discharge from hospital
Post-discharge support
Please click the date box to register your place, you will be re-directed to our booking website.
If you are an organisation who who like to organise a specific session for the people you support please email at ggc.HomeFirst@nhs.scot In some cases we may be able to offer this as an in-person session.
Alongside this session we have created two resources which anyone can use to help them plan for any future hospital admission. This could be a planned admission, for example if someone is going to hospital for an operation or to have some tests. However these resources can also be useful if someone needs to go to hospital in an emergency.
If you have any questions or feedback about these resources please email ggc.HomeFirst@nhs.scot
Preparing for Hospital Checklist
This checklist will help you think about all the different forms which you can complete just now that would be useful if you were ever in hospital. This includes things like a Future Care Plan and a Power of Attorney.
This resources lets you and the people who support you, think about what might need to happen in order to get you home from hospital in a safe and timely manner. This includes thinking about who could collect you from hospital and where you might need to live if you need some extra support for a short time or on a more permanent basis.
We have been thrilled to host many events over the years, highlighting some important topics. We have been able to record some of these sessions for people to view at a later date. Below you will find details of these events, alongside their recordings. If you have any feedback or wish further details then please get in touch atggc.HomeFirst@nhs.scot
Events by Name
A Day in the Life of… an Anatomical Pathology Technologist
Do you know what an Anatomical Pathology Technologist does? We’ll give you a hint – they work in our hospital mortuaries!
Whilst it may not be the career everyone imagines when they are younger, it can be a hugely rewarding and privileged role to have. This session allowed us to hear from someone with first-hand experience about what it is really like to work in a mortuary.
DNACPR Policy Update (NHSGGC)
Conversations about cardiopulmonary resuscitation can be tricky. From the mis-information that circulates, to the strength of emotion it can produce, we need a workforce which understands the intricacy of the policy and how to broach the subject in a sensitive way.
NHSGGC recently updated their DNACPR policy to clarify who should have these conversations, when they should occur and how to document them. Come along and listen to the team which have been leading this piece of work to tell you about their intentions and also the implication of this update – a must watch for all our staff!
This session is in partnership with the Realistic Medicine Team.
Future (previously 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 looked 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.
Future (previously 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.
In this session we discussed the plans that may be available, how to find them, how to improve them and how to initiate them and have the conversation.
How to Slow Down When Someone Dies
We partnered with Pushing Up The Daises and Caledonia Funeral Aid to a host session which aimed to shine a light on how people can attend to their own wellbeing following the death of a significant person, especially one they may have cared for. During the event we discussed
ideas for helping you to start your grieving process in a way that best serves you and the people around you,
the pros and cons of being actively involved yourself with arrangements for burial or cremation and also perhaps the person’s body,
practical information about the Funeral Support Payment which help people with certain benefits and tax credits to pay for a funeral,
the laws around death and funerals, and
why your choices are really important to help your grieving and for your long term well-being.
Involving and Supporting Unpaid Carers
This session looks at the legal duties of staff working in acute, community and/or primary care. In particular we discuss how staff can encourage carers to recognise their role, how to refer to support services and the legal duty staff have to involve carers in discharge planning. We also mention some of the systems which help us record information about any known carers and share this with other services.
Involving Unpaid Carers in Care Home Life
When someone moves into a residential or nursing home, it is important that friends and family are still able to be fully involved in their lives. This may include visiting and spending time together either in this new setting, or elsewhere. It is important that friends and family are still supported in their caring role, even if it may look a little different. As everyone adjusts to this “new normal”, there are lots of conversations and pieces of information which can be helpful so that everyone understands what is happening and can share their own views.
Let’s talk about…Anticipatory Grief
Whilst some deaths can be sudden and unexpected, most follow a period of illness which could last months or even years. During this time everyone can experience a wealth of emotions including anticipatory grief as we realise that a loss is coming.
This panel discussion explores anticipatory grief from various points of view including carers of those living with Dementia and parents who have a child with a life-limiting condition. There was also an opportunity to ask questions to our panel of experts who have backgrounds in various parts of this journey.
Let’s talk about…Bereavement At Workplace
All of us will experience bereavements throughout our lives, so it is very likely that some of these events may happen whilst you are working. Whether it is a sudden loss, or illness which develop over a longer time, trying to juggle work and personal life can be a challenge.
It can also be difficult for colleagues who don’t know what to say or do when someone is dealing with these issues, or returning after the death of someone close.
During this session we explored some of the things we can do to support each other in the workplace including things we can say, places we can signpost to and some of the policies organisations have to support their staff during these incredibly difficult times.
Let’s talk about…Bereavement Through Suicide
Stories From 88 Days on a Tandem Around the British Coastline
In January 2022, Xani lost his sister, Alice, to suicide. Since then he and his family have been navigating their own grief journey, supported by a number of different charities including SOBS (Survivors of Bereavement by Suicide).
In the summer of 2023, Xani decided to embark on a mammoth cycling expedition as a tribute to Alice and a way to reach out to others who have been affected by suicide, whilst also raising money for some great organisations. Over 88 days he covered over 3500 miles on a tandem around the British coastline, each day joined by a new person affected by suicide. Together as they pedalled, they shared the story of their experience and the wisdom they had gained. Not only this, he has also managed to raise over £36,000 for both SOBS and PAPYRUS.
From his time on the tandem, Xani has some incredible memories but has also gained a wealth of knowledge about the impact of grief and the different ways people begin to rebuild their lives after tragedy. During this session Xani shared his own story and reflections – from the importance of conversations to meaningful ways to honour those who have died.
Let’s talk about…Deathcare in the Queer Community
Whether it is planning a funeral, or ensuring that people know your wishes and preferences when it comes to end of life care, having people and tools to help your feel empowered is vital. For members of the Queer community there can be added anxiety about some of these aspects such as what happens with legal paperwork, and how to ensure that the people you want to be involved in care and planning can be.
This panel discussion discussed some of these questions and provided a space to discuss important topics including how we can create inclusive services which embrace and celebrate people’s identities.
Let’s talk about…Donating Your Body to Medical Science
What do you want to happen to your body after you die? For most of us, this question makes us think about funeral, burials, cremations. But what about donating your body to help the next generation of students and researchers understand the inner workings of the human body?
During this session we heard from colleagues at the University of Glasgow to learn all about the process that takes place when someone decides to go down this road.
This is in partnership with the University of Glasgow.
Let’s talk about… Grief
Grief is natural and something all of us will likely experience at some point. During this session we looked at some of the different models that people have used to describe the grief process and also bust some myths people might have about what is “normal”.
This session is in partnership with the Beatson Cancer Charity.
Let’s talk about… Hospices
Have you ever visited a hospice? Would it be somewhere you’d be afraid to go?
For many people the word “hospice” is associated with end of life care and death, however the truth is a little different. In this session we heard about all the amazing things hospices do to support people and those who matter to them, recognising that hospices are places of hope and warmth.
Let’s talk about…Making a 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 explored how to get started with Power or Attorney and making a Will, and why both of these things are so important.
We have split the recording into two parts.
Let’s talk about…Organ Donation
Did you know that there are around 500 people each year waiting on a transplant, but only about 1% of people die in the rare circumstances where organ and tissue donation may be able to go ahead? This means that every opportunity for donation is very precious!
Hear from the experts working in NHSGGC who are coordinating this life-saving treatment. We bust myths surrounding the process, and hear just what difference an organ transplant can make to someone and the people they love.
This session was in partnership with the NHSGGC Organ Donation Team.
Let’s talk about…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.
During this panel discussion, people could ask us anything – from “how did you get into this field?” to “what does a “good death” look like?” – the floor was yours!
Let’s talk about…Paying For A Funeral
With the average cost of a funeral in Scotland being over £4000*, the financial burden of death and dying can be overwhelming. Caledonia Funeral Aid aim to support people navigating this difficult time by offering advice, as well as practical and emotional support.
During this session we discussed some of the help that is available such as the Funeral Support Payment as well as thinking about creative ways we can honour and celebrate those who have died. There was also an opportunity to ask questions to our expert.
For many people pets are family and so it is only natural to grieve their loss. Wendy Andrew founded the Scottish Pet Bereavement Counselling Service to help others recover from the death of animal companions.
During this session we talked about everything from the wealth of emotion that accompanies a decision to euthanise a pet, to speaking to children about the death of a pet. We discussed some of the common feelings that people may experience and highlight different places where support is available. There was also an opportunity to ask questions.
Everyday people are left with the grief and trauma that often accompanies the loss of a pregnancy or baby shortly after birth. Whilst everyone’s situations are unique, as a society we can do much more to support one another in these difficult times, and that often begin with having a conversation.
During this session we discussed some of the common feelings that people may experience and highlight different places where support is available. There was also an opportunity to ask questions to our panel of experts who have backgrounds in various parts of this bereavement journey.
Let’s talk about… Spiritual Care Considerations at the End of Life
We were delighted to be presenting at NHSGGC Grand Rounds on the topic of spiritual care considerations at the end of life. We are lucky to live in a multi-cultural country, with people coming from all walks of life and bringing their own beliefs and views with them. However sometimes it can be difficult to remember all the different things that we can do to support someone, especially as they approach death.
During this session, colleagues from the spiritual care team explored some of the common, yet simple things we can do as staff to support patients as well as their friends and family, and also highlight some of the resources available to support staff deliver this person-centred care.
You can watch this on the Grand Rounds Stream Channel. Please note there may be restricted access to this video.
Let’s talk about… What Happens When Someone Is Dying
Dying is a normal process, but these days the process is often surrounded in mystery. During this sessions we learned more about what actually happens as someone approaches the end of their life and had an opportunity to talk to some experts.
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 gave 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.
Plan More, Stress Less
When you or someone you care about becomes ill, life can become very stressful. That is why we think it is so important for people to talk to each other and make plans before this happens.
As part of our Plan More, Stress Less Toolkit, is for anyone interested in getting started with planning ahead. In this session we talk about what paperwork we can complete before a crisis arises, what actually happens when someone goes into hospital and how we can all work together to plan for a safe and timely discharge.
Seasons of Change
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, throughout the Covid-19 Pandemic 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.
Below you can find copies of our past programme of events. You can also find copies of past resource lists which have further details of organisations and services who can support individuals and communities who are dealing with grief, loss or looking after others.
To keep up to date with future events make sure you are signed up to our mailing list..
Past Programmes and Resources
Carers Week
Carers Week occurs at the start of June each year, aiming to raise awareness of the challenges experienced by unpaid carers and host events that may be of interest and benefit to carers.
National Power of Attorney Day usually occurs in November. On or around this time we aim to host one of our “Power of Attorney Overview” session. Visit our training hubs for dates of future sessions.
“What Matters to You?” Day is an international initiative celebrated on or around June 6 that aims to foster meaningful conversations between patients, caregivers, and healthcare providers.
These guidance notes refer to different parts of the ACP Summary on Clinical Portal.
“Anticipatory Care Planning” becoming “Future Care Planning”
In relation to the recent letter from the CMO regarding the name change from “Anticipatory Care Planning” to “Future Care Planning” on 20th September 2023, we wanted to remind all staff of the current process by which people can share their views and wishes when it comes to future care and treatment within NHSGGC. We also wish to highlight the resources available to support both staff and the public.
Since 2019 we have been storing information about future care planning on the “Anticipatory Care Plan Summary” which sits on Clinical Portal. This document can be edited by any member of staff to record people’s wishes and preferences. It also gives the opportunity to document clinical management plans, record Power of Attorney details as well as DNACPR discussions. A copy of this document is automatically shared with GPs who can update information on the Key Information Summary (KIS). Primary Care staff can read the latest ECS and KIS directions from Scottish Government here. Staff should check both KIS and the ACP Summary to ensure they have all information available.
Within the Board, we believe future care planning is everyone’s responsibility. This is one of the reasons that we have chosen the Clinical Portal system to store future care planning information as it is accessible by Acute, Community and Primary Care as well as Social Work. This means that the majority of health and social care professionals can access and update this information.
We acknowledge that different services will have different conversations based on the roles and remits of the team, however by bringing this information into a central location we can easily share information and help to create person-centred care plans which reflect the wants and needs of people. Therefore our ACP Summary should not be viewed as the responsibility of one individual or service, but rather a dynamic document with many people contributing information.
It is also worth re-iterating that conversations about future care should not just be limited to people at or nearing the end of their life. These conversations can be useful for people at any age and stage of their life and the level of planning required will depend on where someone is in their life journey. We are also encouraging all staff to consider whether someone could benefit from a Frailty Assessment using the Rockwood Clinical Frailty Scale, the results of which can be recorded on the online summary. Early identification and monitoring of frailty is important to help create plans which can slow decline or in some cases reverse frailty. From more information about the Clinical Frailty Scale staff can attend an overview session – more details available on the Training Hub.
The Anticipatory Care Programme, which launched in April 2020, is available to support all staff across the Board with information and training. There is an eModule and a variety of virtual training delivered by the ACP Team and Realistic Medicine Teams including walkthroughs of Clinical Portal and communication skills with case studies to discuss. All training is open to all staff in any role and at any level. For more details please visit the Training Hub.
Over the coming months we will be working closely with members of the Scottish Government to ensure that the work that has already taken place in GGC can be shared with other Health Boards and that we continue to align with any national programmes and messaging. We will also continue to work with colleagues in various services and programmes including the Realistic Medicine Team and Unscheduled Care.
We will also begin to change some of the language we use, particularly in public facing areas, to reflect the new term “Future Care Planning”, however during this transition period the phrase “anticipatory care planning” and “ACP” may still be used. The form on Clinical Portal will continue to be called the “Anticipatory Care Plan Summary” until further notice.
Full details of the approach to Anticipatory Care Planning/Future Care Planning within NHSGGC can be found in the Guidance/Standard Operating Procedure Document. Please note this will be updated to reflect the new terminology in coming months.
You can contact the ACP Team at ggc.HomeFirst@nhs.scot with any questions or for further information.
Consent
We do not require explicit consent to share the information contained within the Future Care Plan. Therefore the Future Care Plan Summary no longer records if someone has given consent to have a Future Care Plan.
A Future Care Plan is a document brings many pieces of information together into a shareable format. Therefore by engaging in a Future Care Plan 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 Future Care Planning
Although we no longer record consent on the Future Care Plan Summary, the summary does include a question about whether or not an individual (or their legal guardian) wishes to have an Future Care Plan.
By asking this question we hope to enable staff to evidence when a conversation takes place, but the offer of a Future Care Plan is declined. We will monitor this data.
If a Future Care Plan 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 Future Care Plan 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).
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 a Future Care Plan, staff are encouraged to ask permission to record this decision on the Future Care Plan Summary so that other services are aware that a Future Care Plan 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:
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?
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?
If you were not eating or drinking because you were now very unwell, how do you think you would like to be cared for?
Over the coming months we will be changing some of the language we use to talk about planning for care.
Please get in touch if you need any further information or to report any broken links on these pages by emailing ggc.HomeFirst@nhs.scot.
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.
If you are having difficulty accessing any document please contact ggc.HomeFirst@nhs.scot and we will provide the most up to date version.
The ACP Summary was updated in July 2022. All guidance documents have now been updated to reflect these changes.
We are changing the term “Anticipatory Care Planning” to “Future Care Planning” to help show how broad these conversations can be, and encourage more people to take part. You can read our full statement about the change here.
Future Care Planning (ACP) Standing Operating Procedure
We have created some resources which help people think about all the different documents which could help them to be more prepared is an emergency happened or someone was admitted to hospital.
Plan More, Stress Less Online Session
We run online sessions which look at all the different documents which can help us prepare for the future. This includes thinking about Power of Attorney and Future Care Planning. We also discuss what might happen if someone is admitted to hospital including who you might meet and what conversations we may need to have.
Check our Events Page for future dates of sessions.
Preparing for Hospital Checklist
This checklist will help you think about all the different forms which you can complete just now that would be useful if you were ever in hospital. This includes things like a Future Care Plan and a Power of Attorney.
This resources lets you and the people who support you, think about what might need to happen in order to get you home from hospital in a safe and timely manner. This includes thinking about who could collect you from hospital and where you might need to live if you need some extra support for a short time or on a more permanent basis.
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.
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.
We would love to hear about your experience of Future Care Planning. Whether you have had a fantastic future planning conversation, or been able to use a Future Care Plan to help create bespoke treatment plans that are tailored to individuals, we want to hear about it!
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 ggc.HomeFirst@nhs.scot
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.
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.
It is very important for care home residents to be given to opportunity to have conversations about their wishes. This is why we have started a new project across the Health Board to train staff within these Homes to have good conversations and help residents, their friends and family create realistic Future Care Plans which will help ensure the right thing is done at the right time by the right person to achieve the best outcome.
Please find more information about the project below.
What is the project?
The My Health, My Care, My Home Framework identifies the importance of Future Care Plans (previously Anticipatory Care Plans) for all Care Home residents in Scotland.
Based on a project in NHS Lothian, called “7 Steps to ACP”, this pilot has been created to support care home staff, residents and families engage in good conversations and the creation of meaningful plans.
3 parts to the project:
Family meeting to explain Future Care Planning ( online, in person or on video)
Education for care home staff including training example
Completing a Future Care Plan for all residents including the “3 Questions”
Listen to Dr Jude Marshall talk more about the project and the benefits it can bring to residents, families and staff.
What are the 3 Questions?
It can be helpful for us to think about some scenarios which might occur, and what we should do in these situations. This means everyone understands what the plan is, if a crisis occurs.
Therefore we would like to speak to you, and the people who matter to you, about what would be the best thing to do if any of the following three things happen:
If you had a sudden collapse (such as a stroke or a heart condition,)
If you had a serious infection that was not improving with an antibiotic tablet or syrup
If you were not eating or drinking because you were now very unwell
We have three suggestions of possible plans for each of these situations:
Keep you comfortable, treat any pain or other symptoms and care for you at home.
Contact NHS24/GP (or family) to help decide whether to send you to hospital instead of dialling 999.
Send you to hospital for investigations and treatment such as drips and treatment into vein.
You might wish to have different plans for each scenario, this is okay.
By thinking about these situations beforehand, we all have time to discuss what really matters to our residents and their friends and family. Everyone has the opportunity to ask questions and find out about what treatment can be delivered in our Care Homes – this might be more appropriate that sending people to hospital which can be stressful.
We can record the answers to the three questions in the Future Care Plan and share this information with other services including the GP.
What training do the staff get?
The care home staff can attend a training session which covers:
The benefits of Future Care Planning
Who should be having Future Care Plans
How to have good conversations
How to document and share the information
The session also includes the opportunity to watch a “live” conversation to help staff identifying helpful communication techniques.
This training is delivered by local teams – usually Care Home Liaison Nurses (CHLN) or Practice Development Nurses.
I’m a Care Home Manager, how can my Home get involved?
We are currently rolling out this programme across NHSGGC. If you would like to put your Home forward for training then please contact your local care home service (this might be CHLN or Practice Development Team) to let them know you are interested. They will let you know about approximate timelines.
In the meantime, you may want to have a look at our other resources for staff engaging and recording Future Care Planning conversations.
I am a resident/ I have a friend or family member who is a resident, how can I get involved?
We are currently rolling out this programme across NHSGGC. Ask your Care Home manager if the Home is already engaged in the project.
Even if the Home is not yet involved in the project, you can still have a Future Care Plan. The Home might have their own version of a plan, or you can also use the NHSGGC Summary Plan. You can also discuss the 3 Questions with friends and family and record what you would like to happen in the “views on hospital admission” box. We would strongly recommend having a conversation with the staff at the Home as well, as they will be able to tell you more about the care and treatment which is available within the Home.
Below are some more frequently asked questions about Future Care Planning in Care Homes.
What is a Future Care Plan?
A Future Care Plan 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 a Future Care Plan?
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 Future Care Plans 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 Future Care Planning is. You can give them some information to read through and think about it. Let them know you would like to talk more about this in the future.
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 ggc.HomeFirst@nhs.scot
Are there any leaflets to help explain what Future Care Planning means to resident’s friends and family?
There are lots of resources available on on resources page, however here is a lost of resources that might be particularly useful in Care Home settings.
There are different ways of recording Future Care Plans 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 Future Care Plan Summary to record Future Care Planning 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 Future Care Planning/ACP tab), or services can use an interactive PDF.
Some Care Homes have access to Clinical Portal. Unfortunately this is only available currently for HSCP Care Homes. These Homes can fill out the summary directly on there. Clinical Portal will automatically send the Future Care Plan to the GP and they can if they wish transfer the information to the KIS.
For Homes which do not have direct access to Clinical Portal. they can fill out this interactive PDF and email or post a copy to the GP.
Remember, if any changes are made at the Future Care Plan review, this information needs to be sent to the GP so they can update the KIS.
How can you use a Future Care Plan 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 Future Care Planning 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 Future Care Plans would be reviewed perhaps every 6 months at the time of the resident’s reviews.
If you have any questions or would like more information please email ggc.HomeFirst@nhs.scot
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