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.
“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 Training Hub.
The Anticipatory Care Programme, which launched in April 2020, is available to support all staff across the Board with information and training. There is an eModule and a variety of virtual training delivered by the ACP Team and Realistic Medicine Teams including walkthroughs of Clinical Portal and communication skills with case studies to discuss. All training is open to all staff in any role and at any level. For more details please visit the Training Hub.
The ACP Team have also created a wealth of resources for the public including webpages which explain many different aspects of future care planning. They have 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 regularly host events covering various topics – these are open to both staff and the public.
Over the coming months we will be working closely with members of the Scottish Government to ensure that the work that has already taken place in GGC can be shared with other Health Boards and that we continue to align with any national programmes and messaging. We will also continue to work with colleagues in various services and programmes including the Realistic Medicine Team and Unscheduled Care.
We will also begin to change some of the language we use, particularly in public facing areas, to reflect the new term “Future Care Planning”, however during this transition period the phrase “anticipatory care planning” and “ACP” may still be used. The form on Clinical Portal will continue to be called the “Anticipatory Care Plan Summary” until further notice.
Full details of the approach to Anticipatory Care Planning/Future Care Planning within NHSGGC can be found in the Guidance/Standard Operating Procedure Document. Please note this will be updated to reflect the new terminology in coming months.
You can contact the ACP Team at ggc.HomeFirst@nhs.scot with any questions or for further information.
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.