Considering the Anticipatory Care Planning Process

It is estimated that 5–6% of the population have the complexity of need where they could potentially benefit from ACP. Individuals should be identified and offered interventions in a timely way to enable informed choice and ensure optimal outcomes.

Starting ACP can be prompted by a range of triggers. These can be thought of as a series of prompts for health and care professionals based on the individual's situation, condition and assessment.

ACP triggers


Frequent unscheduled contacts

Carer and family stress

Unplanned hospital admissions

Complex physical or mental health needs

Babies, children and young adults with complex or palliative care needs

Living in a care home

Receiving respite care

Long term housebound (all ages) or living alone

Recognised as vulnerable due to social or environmental circumstances


Deteriorating long term condition or conditions


Requiring specialist nurse or multidisciplinary team input

On certain disease registers, including palliative care, dementia, mental health, learning disability


Identifed as vulnerable using risk predictive tools

Polypharmacy review

Falls assessment

Identified as vulnerable or unstable by professional or team


Recognising health inequalities

It is important to recognise that ACP may be a factor in recognising and helping to reduce health inequalities.

Socio-economic disadvantage and inequalities are inter-related.

In the most affluent areas of Scotland, men live an average of 12.5 years longer than those in the most deprived areas (and women 8.5 years).

In deprived areas, on average, the number of years living with poor quality health is also significantly higher. Multimorbidity is also more common.

Health inequalities also exist between groups of people based on personal factors such as gender, sexuality, ethnicity, disability, homelessness or being a carer.

Discrimination and lack of awareness can result in poor health literacy and outcomes and cause barriers to accessing services, employment and education.

In addition to the guidance for health and care professionals, a number of other national documents have been developed to support ACP across Scotland:

  1. My Anticipatory Care Plan (PDF) (Please note that this an interactive form that can be completed, saved and emailed. It may not be accessible on mobile or tablet devices, in which case users can download the app for Android and for IOS)
  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 (PDF)
  4. Anticipatory Care Planning – Things to think about (PDF)