Over the coming months we will be changing some of the language we use to talk about planning for care. 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.
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.
If you are having difficulty accessing any document please contact ACPSupport@ggc.scot.nhs.uk 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 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.
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.
Future Care Planning (also known as Anticipatory Care Planning or 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.
Future Care Planning 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 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 ACPSupport@ggc.scot.nhs.uk.
How do you complete a Future Care Plan?
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.
Future Care Planning Care Home Projects
There are currently many projects happening in Care Homes across NHSGGC to help improve the use of Future Care Plans. These include projects focused on:
content of a Future Care Plan
identifying and recording frailty
ensuring key information is easily identifiable in residents files
ensuring Future Care Planning 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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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.
“Anticipatory Care Planning” is becoming “Future Care Planning” – An Update From The Programme (Oct 2023)
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 a Lunch & Learn session – more details available on the ACP 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 ACP 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 ACPSupport@ggc.scot.nhs.uk with any questions or for further information.
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.
Are you looking after someone? If so you could be a carer.
There are many reasons why people might need some extra support – they could have a physical or mental illness, they may be frail or have a disability, or they could be struggling with an addiction. They might need physical or emotional support or need practical help to manage day to day tasks.
Carers often provide this type of support to relatives, friends or neighbours even though they are not paid to do so. Carers might not live with the person they support and can be any age.
If you think you might be a carer, you are not alone. There is help and support for you and the person you look after.
Announcement – Changes to the Unpaid Carer Referral Process
As of the 1st May 2024, the Carers Information Line (CIL) will no longer be operational. Whilst a new central referral process is being explored, all unpaid carers can be referred directly to their local services. For contact information and online referral portals please visit the NHSGGC Carers Pages – https://www.nhsggc.scot/your-health/carers/contact-information/
If you are working or visiting an acute site you can visit one of the Support and Information Services based within the hospital who can help you with a referral.
In light of this change, staff are asked to review any information they may have either on webpages, leaflets or in public areas and remove any information which still has the Carers Information Line number (0141 353 6504). These will likely be any yellow posters/flyers that have the title “Are you looking after someone?” or posters/leaflets from Glasgow City HSCP with the same title.
Staff are reminded that everyone has a duty to support carers and signpost them to local support. Local services can provide information, income maximisation, training, emotional support and ensuring carers have a voice in local and political decisions making.
At times in our life, we can all find it difficult to cope, sometimes we harm ourselves or think of ending our lives.
Self-harm is a way of coping with very deep distress. The ways in which people harm themselves vary and can be physical such as cutting or less obvious such as putting themselves in risky situations or not looking after their physical or emotional needs.
There are many different ways people can intentionally harm themselves. These include:
Cutting or burning their skin
Punching or hitting themselves
Poisoning themselves with tablets or toxic chemicals
People often try to keep self-harm a secret because of shame or fear of discovery. For example, if they’re cutting themselves, they may cover up their skin and avoid discussing the problem. It’s often up to close family and friends to notice when somebody is self-harming, and to approach the subject with care and understanding.
Self-harm is not about trying to get other people’s attention. Usually, self-harm comes from feeling numb or empty, or wanting some relief. It might be linked to feeling depressed or anxious, low self-esteem, drug and alcohol abuse, relationship problems, bullying or worries about sexuality.
There are many reasons people engage in self-harm. If you are self-harming it may be because:
You want to feel in control in response to overwhelming feelings inside, low self-esteem or a feeling of powerlessness
You feel you need to punish yourself because you feel “bad” inside or guilty or ashamed about something
You feel numb or empty inside and want to feel something “real” or “physical”
You experience difficult memories or flashbacks of past abuse and harming yourself is a way of bringing yourself back to the present.
Self-harm is not a mental health problem in itself, but it is a behaviour, which is often linked to the experience of mental health problems, whether that is depression, anxiety, personality disorder or trauma.
If you are self-harming, you should see your GP for help. You can also call the Samaritans on 116 123 for support.
Suicide is the act of intentionally ending your life. Many people who have had suicidal thoughts say they were so overwhelmed by negative feelings they felt they had no other option at the time. However, with support and treatment they were able to allow the negative feelings to pass.
There is no single reason why someone may try to take their own life, but certain things can increase the risk. A person may be more likely to have suicidal thoughts if they have a mental health condition, such as depression, bipolar disorder or schizophrenia or if they have experienced abuse or trauma in their past. Misusing alcohol or drugs and having poor job security can also make a person more vulnerable.
More Information
What helps
Many people experience thoughts of suicide or self-harm. You are not alone in feeling like this. People struggle to cope at one point or another and going through a range of emotions during this time is common.
Self Harm
There is no magic solution or quick fix for self-harm, and making changes can take time and involve periods of difficulty. It is common to make some progress and then get back into old behaviours again. If this happens to you, remind yourself that this is all part of the process.
It can help to:
Work out your patterns of self-harm. Are there certain times of the day or week when you are more likely to self harm? It might help to keep a diary to chart this.
Learn to recognise triggers – What situations are likely to trigger the urge to self harm?
Learn to recognise urges – What feelings do you have before you self harm? Whereabouts in your body do you feel them?
Distract from the urge to self-harm –You will often find that the urge will reach a peak and then pass. Listen to music, do housework, exercise, cook a meal, phone a friend. Relaxation techniques like yoga or meditation can help.
Build your self-esteem –You might want to seek counselling or support for this or use a self-help book or website.
Look after your general wellbeing – eat regular healthy meals, ensure you get enough sleep, take regular exercise.
Reach out for support– If you are self-harming regularly it is important to get help. You can speak to your GP or call a support helpline such as the Samaritans (116123 freephone) or Breathing Space (0800 838 587 freephone)
Do something creative this can help you to express your feelings. For example, write a song, story or blog, paint or draw.
Spending time every week doing things that you enjoy, such as seeing friends or going for a walk, is also important. Try to make time to do this, no matter what else is going on.
Suicide
Thoughts of killing yourself can be complex, frightening and confusing. Many people have thoughts of suicide at one point or another. Not all people who die by suicide have mental health problems at the time of death. However, many people who kill themselves do suffer with their mental health, typically to a serious degree.
Sometimes, if a person has been feeling low for a long time, suicide can seem like the only logical way to stop feeling like that. However, feeling actively suicidal is often temporary, even if someone has been feeling low, anxious or struggling to cope for a long period of time. This is why getting the right kind of support at the right time is so important.
If you’re reading this because you have, or have had, thoughts about taking your own life, it’s important you ask someone for help. It’s probably difficult for you to see at this time, but you’re not alone and there is help available.
Samaritans 116 123
Breathing Space 0800 838 587 (Freephone)
If you find yourself in an emergency please call NHS 24 on 111.
Living with thoughts of self-harm or suicide
Thoughts of harming yourself can be deeply distressing. Having these thoughts and urges can make you feel isolated from other people as you don’t want to worry them or burden them with your difficulties. This can make it difficult to be supported by others at the time you need it most. It is important to remember that feeling actively suicidal is often temporary, even if you have been feeling low or struggling to cope for a long time. The urge often reaches a peak and then passes. This is why getting the right kind of support at the right time is so important.
The same applies to living with the urge to harm yourself. Self harm often develops as a way of managing difficult feelings. Once you become dependent on it as a way of managing these feelings, it can be difficult to stop. Again, it is important to remember that the urge often reaches a peak and then passes. Acknowledging that you are struggling and seeking help and advice is an important first step towards recovery.
If you’re reading this because you have, or have had thoughts about taking your own life, it is important you ask someone for help. It’s probably difficult for you to see at this time, but you are not alone and there is help available.
If you find yourself or someone you know in an emergency please call NHS24 on 111
These are free phone numbers, which offer confidential listening, advice and support:
Samaritans 116 123
Breathing Space 0800 838 587 (Freephone)
Looking after someone who has suicidal or self harming thoughts
It can be very upsetting to be close to someone who self-harms – but there are things you can do. The most important is to listen to them without judging them or being critical. This can be very hard if you are upset yourself – and perhaps angry or frightened – about what they are doing. Try to concentrate on them rather than your own feelings – although this can be hard. It is important to remember that most people who self harm do it as a way to cope and live with difficult feelings. It does not mean that they are suicidal. However, self harm should always be taken seriously and it is important not to minimise or dismiss the behaviour.
Things that you can do to help include:
Let your friend or family member know that you are there, if and when they are ready to talk. It is common for people to worry that they will be judged for their self-harm or that they will be a burden on others, so it’s important to let them know you are there for them if they want.
Show concern for their injuries, but at the same time, relate to them as a whole person rather than just someone who self-harms.
Offer them a chance to talk about how they are feeling. Try to understand and empathise with what they are saying even when it is hard to hear.
Try to understand that they may be scared of stopping self-harm if they use it as a way of coping. If they are finding it hard to stop, try to help them find other ways of coping and to seek help if they need it.
Let them be in control of decisions about support and any plans to reduce or stop their self-harm.
Emphasise other parts of their life where they are doing well and the good qualities that they have.
Supporting someone who is self-harming can be a long process with many ups and downs. It’s important to take care of yourself– this will help you to be able to stay involved for longer and avoid becoming unwell yourself.
Supporting and caring for a person who is thinking about suicide, or may have attempted suicide previously can be very stressful and difficult. You may feel alone and scared and not know how best to help the person in your life. There are organisations, which can help you.
One of the best things you can do if you think someone may be feeling suicidal is to encourage them to talk about their feelings and to listen with patience to what they say. Try to understand how they must be feeling and try to engage with any part of them that wishes to live.
If there is immediate danger, make sure they are not left alone and contact NHS 24 (111) for advice
At times in our life we can all find it difficult to cope, sometimes we harm ourselves or think of ending our lives, for help with these feelings please try the following sites.
Self Harm
There is more information about self harm from MIND
At times in our life we can all find it difficult to cope, sometimes we harm ourselves or think of ending our lives. Self-harm is a way of coping with very deep distress. The ways in which people harm themselves vary and can be physical such as cutting or less obvious such as putting themselves in risky situations or not looking after their physical or emotional needs.
NHSGG&C BSL A-Z: Mental Health – Suicide
Please note that this video is from a range of BSL videos published by NHS Greater Glasgow & Clyde
URGENT HELP
EMERGENCY – If you, or someone you know, need an immediate response call the emergency services on 999.
CONFUSED / DISTRESSED – If you are experiencing confusing or distressing thoughts, or if people around you have expressed concern about your well being, arrange an appointment with your GP or call NHS 24 on 111.
If you, or someone you know, are currently being seen by someone from a community mental health team and require urgent attention, please contact the Out of Hours Team by the number you will have been provided with.
SUPPORT – If you just need to talk with someone, then the following organisations are here to help:
Please note: if you go to an Accident and Emergency Department because of worries about how you are feeling or what you are experiencing, they will be able to assess your difficulties and arrange for you to see a specialist if needed. But Accident & Emergency is a busy and stressful place, and you may have to wait a long time. It can be quicker to phone NHS 24 on 111, as they can arrange for you to get to the right help.
Heads Up is not continuously monitored and is not able to provide direct advice or support to those in mental health distress.