Your health

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A Future Care Planning Champion can be any professional who has an interest in helping us create a culture of open and honest conversations about future planning.

If you would like to find out more you can download this Role Description

To become a Future Care Planning Champion please register. 

Please note you will need to have permission from your Line Manager before becoming a Future Care Planning Champion.

If you are a professional and have an interest in this area, you might be interested in joining our Clinical Advisory Network. This network offers comment and feedback to help us create the right resources for staff. 

Future Care Planning helps people to think ahead and understand their health. It helps people know how to use services better and it helps them make choices about their future care.

This is a process and should involve ongoing conversations between a person, the people that matter to them and the health care professionals involved in their care.

The decisions made during these conversations are recorded in a Future Care Plan.

The plan should include:

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

Future Care Plans will often include information about care at the end of life. This includes where people would prefer to be cared for and their wishes about different treatments, including resuscitation. All these discussions should be had sensitively and with consideration.

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. 

A Future Care Plan can help us plan for where treatment should be delivered and this in turn may lead to discussions about the level of treatment which can be provided in these locations. It is important that we come to an understanding with people regarding their health goals so that we can make realistic plans.

What is a TEP?

A Treatment Escalation Plan (TEP) is a document which is completed during a hospital stay (usually on admission or following a change in circumstance). This document records decisions related to escalation of treatment, and the investigations and interventions that are deemed appropriate in the event of deterioration. The aim of this process is to give clear instruction so as to avoid any unnecessary or non-beneficial interventions at the end of life.

A TEP is only valid until a the person is discharged or has died. Upon each new admission a new TEP must be completed.

What is a Future Care Plan?

A Future Care Plan (also known as an ACP) documents the goals and preferences of the person, which may include decisions about end of life care and treatment. This helps everyone make a unique treatment plan which reflects the person’s wishes and values. A Future Care Plan is a record of ongoing discussions which may evolve as circumstances change. A Future Care Plan may be used in acute or community settings. Anyone may have a Future Care Plan and the document is valid at all times.

A Future Care Plan may inform what information is recorded in a TEP (review the Portal Future Care Plan on admission). Similarly any new discussions or decisions that are made when making the TEP should be recorded on the Portal Future Care Plan so that colleagues out-with acute setting have all the relevant information they require.

More information on TEPs is available on the NHSGGC Right Decision’s webpages. 

Most services will have their own paperwork which they use to document important conversations and decisions. For instance, social work might be aware of any home care services which are used; physiotherapy may have had a conversation about what is a realistic mobility goal; the district nurse may have spoken to the person about where they would prefer to receive end of life care.  As health care professionals it is your responsibility to try and ensure your colleagues in other departments know this information.

Using the Future Care Plan Summary is a good way to share this information (also known as an ACP Summary).

You do not need to complete every part of the document. If we all take responsibility for inputting the information we have gathered in our own assessments, then this will help ensure the final Future Care Plan has all the information needed.

Key information will be recorded in lots of different places. Your department might have their own records and documentation that they use. 

The people you work with may also be using different documents to record their thoughts about Future Care Planning. They might have a “My Anticipatory Care Plan” or a ReSPECT form. There are other planning tools they might have used as well.

We can still use all these different documents. However the most important thing is key information from all of these places is recorded in the ACP summary which is available on Clinical Portal. It is your responsibility to help summarise this information and add it to the shared document.

This will ensure that your colleagues in different departments and services can access the information they need, and will also allow you to see information that other professionals have gathered.

The Future Care Plan Summary is held on Clinical Portal. For more information see “Sharing Future Care Planning Information”.

It is really important that this information is shared with all health and social care partners so that any treatment plans reflect people’s wishes.  The easiest way to ensure that information can be accessed by everyone who needs it is through 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 an 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 (it will sit under “Care Plans” in the Clinical Documents), or services can use an interactive PDF.

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

If you do not have access to Clinical Portal you can fill out this interactive PDF and email or post a copy to the GP. 

Remember, if any changes are to the Future Care Plan 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)

Good communication is the key to success. 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.

It may be useful to have an introductory conversation with people and those that matter to them, explaining that you would like to have further conversations soon. You can signpost them to the information in these pages.

These discussions are really important; however we understand that some staff members might not always feel comfortable having them.  Try not to overcomplicate the matter – we can often start conversations with a simple question like ‘what matters to you?’ or ‘how would you feel if you have to go to hospital?’ and we often find that people are keen to discuss this, as are those who matter to them.

What should we DISCUSS?

We have created some resources to help you think about the different topics you could talk about as part of an Future Care Planning Conversation. They use the “DISCUSS” framework. 

You may also 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@ggc.scot.nhs.uk

During these conversations, it is important that everyone is given a chance to express their views so that we can make shared decisions. It is also important for professionals to check in with people to make sure that they understand what is being discussed and are happy with the plan.

The BRAN Questions can be a useful way to check that everyone has the information they need to make an informed choice about different treatments or plans. These are four questions that ask about the benefits, risks and alternatives of treatment, as well as what would happen if we did nothing.

B – What are the Benefits of this test or procedure?
R – What are the Risks of this test or procedure?
A – Are there any Alternatives?
N – What if I do Nothing?

BRAN also applies to clinicians! We should also ask ourselves:

B – Will this patient really Benefit from this test / procedure / hospitalisation?
R – Am I exposing this patient to Risks?
A – What Alternative options have we discussed?
N – if I were this patient, would I consider doing Nothing at this stage?

Visit the NHS Inform: It’s Ok to Ask website for more information.

Communication is a skill which needs practice. There are lots of different courses and resources available to help you think about how to communicate with other. Here are some of our recommendations:

Face to Face Training Courses*

Sage & Thyme Communication Training

The MAP of Behaviour Change

*Please note that some of these course may not currently be running or may have moved to a virtual platform. 

Online Modules

We have created our own online e-learning module which gives you a general overview of Future Care Planning.

There are 2 Learnpro Modules we would suggest. Please note you will need to have a Learnpro account to access these.

GGC 028: Anticipatory Care Planning

GGC 053: Palliative End of Life Care

The NHSGGC Primary Care Palliative Care Team run a variety of online and face to face training, including sessions on Future Care Planning, communication skills and DNACPR. 

Macmillan Learnzone Resources

Please note you will need to make an account. 

Suggested Courses: 

Changing children’s attitudes to death

Working with children pre-bereavement

Coronavirus: Communication and Difficult Conversations

Palliative and End of Life Care including Bereavement

Personalised Care and Support – Building on the Recovery Package

Supporting Carers: A Professional’s Toolkit

NHS Education for Scotland (NES) Resources

Please note you may need to make a TURAS account to access these resources. 

Suggested Courses:

Realistic Conversations – Shared Decision Making

Developing Practice Module 2

Building a Shared Understanding

Informed about palliative and end of life care

Other Resources

EC4H (Effective Communication For Healthcare)

Difficult Conversations – Talking About Death and Dying (Video)

SPICT Tools

Delivering Bad News Video – Irish Hospice Foundation

Take some time to think about what matters to you and who matters to you.

Everyone is unique and has their own ideas about what they would like. However there might be things you’ve never considered like where you would prefer to receive treatment, or what treatments you would or would not want. Talk to people involved in your care and ask them to explain all the options that are available so that you can make an informed choice.

Let them know that you think this is really important and you want to have this conversation. Often we don’t talk about these topics because we think it will be upsetting for everyone involved, but these conversations give people the opportunity to learn more about each other which many people appreciate. It is also reassuring for people to know what your wishes are so that if they need to, they can make decisions that match these.

You don’t need to make a formal plan right away but it can be helpful to take some notes while you think about these topics. You can then use these notes when it comes to filling out the proper documentation.

Everyone has the right to change their mind. Situations can change and what matters to you might change to reflect what is going on in your life. It is important to revisit these conversations with the people that matter to you and any health care staff involved in your care so that everyone is aware of any changes in your wishes. These can then be updated in the documentation.

When plans are being made, it is important that everyone is given a chance to express their views so that we can make shared decisions and find the best option for you.

The BRAN Questions can be a useful way to check that you have all the information you need to make an informed choice about different treatments or plans. These are four questions that ask about the benefits, risks and alternatives of treatment, as well as what would happen if we did nothing.

B – What are the Benefits of this test or procedure?
R – What are the Risks of this test or procedure?
A – Are there any Alternatives?
N – What if I do Nothing?

When you are talking to any professional about different options, don’t be afraid to ask these questions – we are more than happy to talk about all of these with you!

Visit the NHS Inform: It’s Ok to Ask website for more information.