Frequently Asked Questions

Please find the most frequently asked questions, and corresponding answers about Anticipatory Care Planning, below.

Anticipatory Care Planning (ACP) is a "thinking ahead" approach that requires health and care practitioners to work with people and their carers to ensure that the right thing is done at the right time by the right person with the right outcome.

It is about having the right conversations with people about what matters to them. It puts them at the centre of the decision-making process about their health and care needs. ACP can help manage change in an organised way, prevent crisis, reduce future stress, and gain the best possible personal outcomes and quality of life. It helps people make informed choices about how and where they want to be treated and supported.

A National Action Plan for Anticipatory Care Planning ensures that the work’s profile is raised with the public and practitioners. The importance of recognising the needs of carers and supporting the legislation outlined in the Carers Act is also prioritised. This links to the Chief Medical Officer’s "Realistic Medicine" approach and is prioritised through the integration of health and social care.

Anticipatory Care Planning is about thinking ahead and being in control of any changes in your health conditions. Anyone at any age may benefit from having an Anticipatory Care Plan. It can be started at any stage of a person’s care.

At present, the focus is on ensuring that people with more complex needs receive support that is co-ordinated, suits their care needs, and is informed by their choices and situation.

Starting the Anticipatory Care Planning process can be prompted by a range of triggers. These could include planning for the future, hospital admission or deterioration in health. The following triggers have also been identified:

  1. people who are elderly, housebound or living alone
  2. people with complex physical, mental health or social support needs
  3. infants, children and young people with complex and palliative care needs, and
  4. family or carer stress.

Good professional judgement and teamwork often help identify individuals who would benefit.

An Anticipatory Care Plan is a record that should be developed over time through conversations, collaborative working and shared decision-making between people and their practitioners.

The plan should reflect:

  1. a summary of the "thinking ahead" discussions between the person, those close to them and health and care professionals supporting them
  2. a record of the person’s personal goals, preferences, views and concerns
  3. a record of the preferred actions, interventions and responses that care providers should make following deterioration in health or a crisis in the person’s care or support, and
  4. reviewed and updated information as the person’s condition or needs change and different things take priority.

An Anticipatory Care Plan can be recorded using the My Anticipatory Care Plan document or the My Anticipatory Care Plan "Let’s think ahead" App.

Conversations should involve simple and clear language as much as possible. It can be useful to discuss:

  1. concerns and goals for the future
  2. current plans in place such as Power of Attorney, Welfare Guardianship and wills or the need to set these up, and
  3. wishes and views about end of life care, including preferred place of care, as well as the person’s views about whether or not cardiopulmonary resuscitation is appropriate or wanted.

A number of Anticipatory Care Planning documents have been developed for use across Scotland:

  1. My Anticipatory Care Plan
  2. My Anticipatory Care Plan "Let’s think ahead" App – available for download free of charge from the App Store
  3. Anticipatory Care Planning – What you need to know
  4. Anticipatory Care Planning – Things to think about

These documents are available from GP practices or the website myacp.scot.

A series of short films and patient stories are also available on the website. These include:

  1. ACP Matters 2017
  2. Jack’s Story
  3. Evelyn’s Story
  4. Fiona’s Story
  5. Alice’s Story (teaching aid)