ACP involves conversations between individuals, their families, carers, and professionals. It helps people communicate goals and preferences, and gives them opportunities to consider realistic options and plan for future changes in their health and care that can be recorded, shared and reviewed.

ACP is a person-centred, proactive approach to help people consider what is important to them and plan for their future care. Planning ahead can help people feel more in control and able to manage any changes in their health and wellbeing. People should be offered opportunities to take part in care planning and receive information about its benefits.

Understandably, they may have worries and concerns that need explored. Sometimes people will not wish to engage in these discussions, or may prefer to delay them until another time when they are ready.

Thinking ahead about ‘what matters to me’ is relevant at any age or stage of life. Undertaking ACP is particularly beneficial for those:

• living with one or multiple long term health conditions
• living with disabilities and/or complex health and care needs
• whose health and wellbeing is changing or deteriorating due to physical and/or mental health problems
• approaching the end of their life, and
• children and young people with life-limiting conditions.

Central to ACP are conversations between individuals, those people who are important to them (for example: a relative, close friend or carer, or a legal proxy), and their health or social care professionals. These conversations inform shared decisions about future care and can include:

• reflections on an individual’s situation, goals, priorities and preferences in relation to their health and care
• involving the right people and supporting them to be part of discussions and decisions about future treatment and care, and
• discussing and agreeing realistic treatment or care options in line with what matters to them.

These discussions and decisions are recorded in an anticipatory care plan and shared with the people that need to know about it. Care plans must be reviewed if the individual’s health condition or social situation changes, or as they wish to do so.

ACP has benefits for individuals, families and professionals:

• allowing an individual to feel valued by listening to what matters to them in the context of their current and future health and care
• supporting patient autonomy and quality of life through shared decision-making
• involving and supporting family members, carers, and legal proxy decision-makers
• delivering realistic healthcare with timely investigations and treatments and fewer interventions of low benefit, including unwarranted hospital admissions
• effective care coordination to reduce repeated conversations with different professionals and teams
• helping to recognise and reduce health inequalities
• improving quality of care towards the end of life, and
• enabling more people to die in the right place for them.

These webpages are split into three main sections:

1. A toolkit bringing together all the resources relating to ACP. The intention is that this will be develop over time. The toolkit has been split into four key steps:

     a. Preparation and planning

     b. Meaningful conversations

     c. Documentation and sharing

     d. Regular review

2. Information on ACP in different contexts. This includes resources for using ACP to support people living in care homes and people with neurological conditions. There is also information about ACP in the context of Covid-19, including resources developed during the pandemic. 

3. A summary of all the links and downloads across all these pages.