Staff have a responsibility to ensure that carers are identified, involved and supported.
Could you be a carer?
If you think you are a carer and are looking for support to help with a work/life balance, there is information on HR Connect with details on how NHSGGC can support you.
The Carers (Scotland) Act 2016 gives unpaid carers new rights to help support carers to continue to care, for as long as they choose, in better health and to have a life alongside caring. It provides a legal framework for Local Authorities and the NHS to ensure that carers are;
recognised for the role they provide
offered an outcome-focused support plan which identifies their support needs
involved in discharge planning for the person they support
provided with support from local authorities for their identified eligible support needs
We now have a legal duty to involve carers in discharge planning for the people they support. Therefore it is important for staff to recognise when someone is a carer and offer them support. We are also trying to encourage carers to identify themselves to staff as soon as possible so that we can work together and make decisions about care and discharge.
Further Information
You can find more information about the Act in these links:
You should identify if someone has a carer as soon as possible. Remember this might not necessarily be someone’s next of kin.
Once you establish what support the carer provides you should record this. You should also speak with the carer to check if this level of support is appropriate and sustainable. This will allow everyone to begin to plan what support will need to be available for a successful discharge.
All this information can be recorded in the MAR and the Record of Communication.
Involve Carers
In order to deliver person-centred care you should always try to involve the person and those that matter to them in any discussions and decisions making processes. You also have a legal duty to involve carers in discharge discussions.
A requirement of the Act is that you evidence that you have Identified, Involved and Supported carers. To do this, the Record of Communication with Relatives and Carers document has been updated. This multi-disciplinary record should be completed by all staff who have a conversation with relatives and carers. These should be kept in the patient file.
Do you think you or your team could benefit from face to face training? Contact HIAdmin@ggc.scot.nhs.uk for more information.
Listening to what carers have to say
Engagement with Carers
We have worked with carers to understand what being informed and involved means to them. We used this information to help make staff training and the develop resources.
Listen to carers from West Dunbartonshire talk about their experiences in their caring role at local engagement events.
Young Carers’ Experience
Caring for someone living with dementia
Caring for someone with a learning disability
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.
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.
Please be aware that the location of the service who will support you is dependent on where the person you care for lives. If you are unsure which services to contact please use this postcode checker first (this will open a new window).
Otherwise please find details of your local carers service below:
Services within NHSGGC
East Dunbartonshire Carer Services
Carers Link East Dunbartonshire 0141 955 2131 (for Carers or Professionals) 0800 975 2131 (Freephone for Carers)
The Carers (Scotland) Act 2016 gives unpaid carers new rights to help support carers to continue to care, for as long as they choose, in better health and to have a life alongside caring.
One of the most important rights that carers now have is the right to be involved in discharge planning for the people they care for. If the person you care for is currently in hospital please speak to the ward staff and let them know you are their carer. This will help us make sure that we are involving you as much as possible in the decisions regarding care and discharge.
There is also a Carers’ Charter that will let you know your rights as a carer.
Leaflets to help carers understand their rights
The Coalition of Carers have worked with a variety of carers, carer organisations and health and social care staff to design leaflets for carers. They let you know about your rights and what to expect when you are
This is a service provided by NHS Greater Glasgow and Clyde with centres in the Queen Elizabeth University Hospital, New Victoria, Stobhill, Glasgow Royal Infirmary and the Royal Hospital for Children. It is available to all hospital users including patients, visitors and staff. A wide range of support is available including money advice and carers support.
You can drop into one of the centres, phone 0141 452 2387 or email sis@ggc.scot.nhs.uk
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 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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