Anticipatory Care Planning in Scotland

Anticipatory Care Planning is about helping people think ahead.

ACP is a process that helps people make choices about their future care. ACP is also about knowing how to use services better.

Planning ahead can help people to be more in control and more able to manage any changes in their health and wellbeing. It also helps people tell others about what matters most to them.

People of all ages who are living with long term conditions, complex care needs or serious health problems benefit from having their own Anticipatory Care Plan.

Resources from Health Improvement Scotland (HIS)

Anticipatory Care Planning documents have been developed for use across Scotland.
Copies of the Scottish Anticipatory Care Plan can be downloaded and printed from the website or are available from GP practices.
Some people like to use the ‘My ACP’ App available for download free of charge from the App Store.

There are ACP leaflets to explain more about the benefits of Anticipatory Care Planning
What you need to know
Things to think about

Videos show people telling their own stories about taking part in ACP conversations and planning.

NHS Inform also provides patient information and links for ACP.

Health and care professionals have an ACP guide help them to support people who would benefit from Anticipatory Care Planning.

EC4H resources

The EC4H programme offers workshops to help professionals talk about Anticipatory Care Planning.

Start to talk about thinking ahead and planning for the future when people are still well. Identify people who have poor or deteriorating health. Make plans for good care with people who are dying and those close to them. Read more about anticipatory care planning in the EC4H Web Resources

Try using the ACP-Talk guides developed by EC4H to help with these discussions. If the person or their situation is complex, seek advice from a senior colleague or someone with more experience.

1) ACP should be part of future care planning with all older people and people with long term conditions; and is offered to anyone who has been diagnosed with a life-limiting or serious illness.

ACP 1: Talking about the future

2) ACP is important if a person’s health is starting to deteriorate. It is time to talk about future care and what the person would like to happen or would not want.

ACP 2: Talking about deteriorating health

3) When someone is seriously ill and at risk of dying, talking about an anticipatory care plan with the person and the people close to them is important.

  • It includes discussions about the limitations of treatment, specific decisions (cardiopulmonary resuscitation, hospital admission, care in HDU/ITU, IV treatments etc) and place of care.
  • We talk about what we can do to help; and explain why some treatments will not work or not work well for this person.

ACP 3: Talking about dying

What happens when someone is dying– information leaflet for patients, families and professionals.

Scottish DNACPR Policy

Other weblinks and references are available within the Resources section – see menu to the right.

 SPICT (Supportive & Palliative Care Indicators Tool)

The SPICT™ is used as a guide to help health and care professionals identify people with deteriorating health for assessment and anticipatory care planning. The  SPICT 2017 and a version in non-clinical language (SPICT-4ALL) are available free to download along with resources to support their use from the SPICT website