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 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.

As a person’s health starts to decline, it is even more important to start planning ahead.

 Health Improvement Scotland (HIS)

National Anticipatory Care Planning Programme.
There is a patient-held Scottish Anticipatory Care Plan: MyACP

ACP leaflets 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.

There is an ACP guide for health and care professionals.

EC4H resources

The EC4H programme offers workshops on Anticipatory Care Planning.

We use a 6-step approach to these conversations called RED-MAP

Download a copy of the  REDMAP Guide to talking about ACP

ACP-Talk guides and videos aim to help professionals use effective approaches for these discussions. If the person or their situation is more complex, consider asking for advice and support from an experienced colleague.

ACP-Talk 1: Future care planning helps older people and people with long term conditions or complex health needs; and anyone who has a life-limiting or serious illness.

ACP-Talk 2: Planning ahead is important when a person’s health is starting to deteriorate. It’s time to talk about what the person would like to happen or would not want. We can ‘hope for the best’ and ‘plan for when/if’ things change.
ACP-TALK 2 video: Planning ahead when I’m back home from hospital
ACP-TALK 2 video: Staying in my care home or going to hospital

ACP-Talk 3: When someone is seriously ill and at risk of dying, talking about an individual care plan with the person and those close to them is important.

  • It includes talking about outcomes, benefits and harms of treatment, place of care, and specific decisions (e.g.cardiopulmonary resuscitation, hospital admission, or IV antibiotics).
  • We talk about what we can do to help; and explain why some treatments do not work or are not of benefit for this person.

ACP-TALK 3 video: Planning good care in the last days of life 

Patient and family information leaflet: What happens when someone is dying (2019)

Read more in the EC4H Web Resources

Building on the Best in Scotland

The Building on the Best programme aims to improve ACP and shared decision-making in acute hospitals across Scotland. Many of the resources can be used in other settings too.

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 start anticipatory care planning. The  SPICT 2017 and (SPICT-4ALL) in non-clinical language are available with resources to support their use from the SPICT website