The likelihood of living with multiple chronic or complex conditions increases with age. It is essential that a proactive and forward thinking approach is adopted and relevant steps are put in place to ensure that models of care are designed to meet the many needs of individuals. Anticipatory Care Planning facilitates a whole-systems approach for people living with long-term conditions, ensuring that person-centred care and personal outcomes are achieved.

  • More than 55,000 people die each year in Scotland, with over half of the deaths taking place in hospital
  • Of those that die, 40,000 have palliative care needs, but only 12,000 are on the QOF register for palliative care
  • In the year 2012/13 82% of people within the final six months of life experienced a hospital admission
  • In the same year 1.2m bed days were used by those within the final six months of life

Anticipatory Care Planning links to end of life care, as they both have a focus on how individuals and care providers can better plan to improve an individual’s health and wellbeing. By discussing together their personal goals and wishes, an individual’s decisions can be respected in the event of a gradual or sudden decline.



This programme of work is finishing in June 2018, and we are now embedding an ACP approach across all of our areas of work.

Service Description

The Anticipatory Care Planning workstream is finishing in June 2018, and focused on developing a national approach to anticipatory care planning to enable people living with long term conditions to live in the community and avoid hospital admission where safe to do so. A national Anticipatory Care Plan document My ACP was developed for individuals to use and support with planning ahead their future health and care needs and to help reduce health decline. An educational framework ACP Toolkit with accompanying  support resources were also created to support local implementation of the ACP process by NHS boards and Health and Social Care Partnerships.

Influencing the national eHealth strategy to improve the electronic information summary system used to access individuals’ anticipatory care plans across the health and social care system was a key part of this programme of work.


The team worked closely with Health and Social Care Partnerships and strategically through a national ACP Programme Board to progress ACP activity through different settings, e.g. in Glasgow City, North Lanarkshire, Orkney Islands and South Lanarkshire, and offered roadshows, workshop training and support to other partnerships during the course of this programme.


NHS boards and Health and Social Care Partnerships

Benefits of programme

A study was undertaken in 2010 to evaluate the impact of introducing Anticipatory Care Plans (ACP) for a cohort of people from a general practice in Nairn, Scotland, that were considered to be at high risk of experiencing a hospital admission. When comparing the 12 months preceding the introduction of ACPs to the 12 months following (for those that were still alive in the second 12 months), the group of individuals for which ACPs were introduced saw a 52% reduction in the number of days spent in hospital. The study also found that for those who died during the second 12 month period, individuals with an ACP were more likely to be able to die at home[1].

A similar study of Anticipatory Care Plans was undertaken in a care home in NHS Lanarkshire in 2009. Evaluation of the study found that when comparing the six month periods prior to and following implementation of the ACPs, there was a 34% reduction in the number of inpatient admissions and over 50% reduction in the number of hospital bed days[2].

[1] Anticipatory Care Planning and Integration: a primary care pilot study aimed at reducing unplanned hospitalisation: British Journal of General Practice, February 2012

[2] NHS Lanarkshire, Long Term Conditions Team, Anticipatory Care Plans in Lanarkshire Evaluation, April 2010


Sheila Steel, Associate Improvement Advisor