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Listen to Betty talk about why it is so important for people to realise they are a carer and get support.

Helping You Support Someone Else

I’m a carer, what are my rights?

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


All of these can be downloaded from the Coalition of Carers website.

What support can I get?

There are local carer support services which can give you help with:

  • Practical Information – learn about services that can help you and the person you care for in your local area
  • Training – get the knowledge and skills that can support you as a carer
  • Money Matters – learn about the financial support that may be available for you or the person you care for
  • Emotional Support – someone to be a listening ear
  • Having a Voice – helping you influence what happens in your local area

Listen to Lorraine from our Support and Information Service speak about the types of support carers can get access to.

Where can I get support?

British Sign Language (BSL) Resource – What support can I get and where do I get it?

Have you heard of the Support and Information Service?

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.

There have been some updates to the Future Care Plan document that we use in NHSGGC. You can read our full statement about the changes here.

If you have any questions please get in touch at ggc.HomeFirst@nhs.scot

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

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
DISCUSS Guides

These guides help people understand what topics could be discussed as part of Future Care Planning conversations.

There are guides for:

  • people who are thinking about their own future
  • friends, family and carers who are supporting someone to think about their future
  • staff who work with people who should be thinking about their future

Coloured versions are available, as well as black and white versions.

Plan More, Stress Less Toolkit

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.

A Plan To Get You Home

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.

Preparation Guides For The Public
Preparation Guides For Staff
Future Care Plan Documents (Person-Held Booklets)
Future Care Plan Summary Guides
Winter Planning Toolkits For Staff and Services

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

Future Care Planning and Winter Planning – Information for Staff and Services – PDF

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

Having Future Care Plan Telephone Conversations – Information for Staff – PDF

Library of Good Practice (Example Future Care Plan Summaries)

Click on the names to read their Future Care Plan:

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

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

Dave Langton – An older man living in sheltered accommodation.

Morag Smith – An older lady with COPD.

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

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

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

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

Sophie Morrow – A young woman with autism.

Margaret Quinn – An older lady living with dementia.

Sarah Rosenshine – An older lady living with osteoporosis.

Cathy Steel – An older frail lady receiving Palliative Care.

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

Tom Williams – A Care Home Resident.

Dougie Wilson – Adult living with a learning disability

Henry Harris – An older man living with frailty.

Other Resources

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! 

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

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.

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

If you are supporting someone who is experiencing a bereavement then you can find information on the Cruse Bereavement Support webpages.

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

Useful Websites and Organisations

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

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

Find information about other useful websites and organisations below.

Useful Websites

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

Useful Organisations

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?
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.  

Guide to updating Future Care Plans on Clinical Portal (PDF)

Guide to updating Future Care Plans on Clinical Portal (Video)

Guide for GPs Updating eKIS from Future Care Plan Summary (PDF)

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

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

Updates to the Future Care Plan Document (June 2025)

Since 2019 we have been storing information about future care planning on Clinical Portal. The 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 Future Care Plan Summary to ensure they have all information available.

In 2023, we started to use the phrase “Future Care Planning” instead of “Anticipatory Care Planning”. This helped us to emphasis how broad these conversations can be, and all the different topics we can talk about.

As of June 2025, our digital documentation on Clinical Portal now reflects this language. There have also been a few other changes to the documentation we wanted to highlight.

The document is now called the ‘Future Care Plan’ Summary, not the “Anticipatory Care Plan” Summary.

You will still find the document stored under “Care Plans” in the category view, or “Acute Specialities GGC” in the speciality view. The phrase “Anticipatory Care Plan” may still appear in places due to legacy systems, but this should not cause alarm. When creating a new plan you should still go to the “Forms & Pathways Tab” and then click “Add/update Future Care Plan” on the left hand side.

Remember if an old version of the plan exists (i.e. it is still called the Anticipatory Care Plan at the top of the form) please “close” the form, so that the new format can be activated at the next update. You can note that there is an older version on file within the “Special Notes” section of the new document. You don’t need to copy all previous information into the new form, staff should use their own discretion to transfer relevant information. 

New options for the Job Role, Area and Trigger drop downs

Care Home and Hospice staff should now select this as their “Job Role” and select the appropriate HSCP they are based in as their “Directorate”. This will help us identify local engagement more easily.

Additional “trigger” options have also been added to the digital document including “Hospital At Home” and “Assessed by HomeFirst Response service” – please use these when necessary.

Please note the PDF version of the form does not include these additional triggers, however it can be noted under “Other”.

Confirmation of Power of Attorney Documentation

Staff should ask to see a copy of any Power of Attorney documentation and record when this happened. Some people may be confused between different legal paperwork (Wills, Types of Power of Attorney, Guardianship Orders, Advance Directives etc) so this helps ensure that everyone knows who has the authority to make decisions for someone.

New question on Treatment Escalation Plans

Treatment Escalation Plans (TEPs) are becoming more common in our Acute sites. If someone has a TEP completed while in hospital this should now be recorded in the Future Care Plan, stating the date, which hospital they were in and the level of escalation suggested.

Recording this information will help us monitor TEP uptake as well as alert community staff to some of the conversations that may have occurred already and which they can build on as they continue to have Future Care Planning discussions.

The PDF version of the Summary has also been updated to reflect the new layout and data that is captured on Clinical Portal.

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 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 and other staff training visit the Training Hub.

There is a wealth of resources for the public including webpages which explain many different aspects of future care planning. There are leaflets which can be printed off with further information (these can be found on the Useful Documents and Resources section of the webpages) and also recordings of events covering various topics.

Full details of the approach to 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 ggc.HomeFirst@nhs.scot with any questions or for further information.

Information for Current Staff

Information for New Staff and Students

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

Information for Care Home Staff

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.

AnnouncementChanges 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.

If you have any questions please email ggc.HomeFirst@ggc.scot.nhs.uk