Anticipatory Care Planning in Scotland

Abstract

Background: Innovative work on Anticipatory Care Planning (ACP) is being undertaken across Scotland to ensure delivery of high quality, person-centred care. This aligns with the NHS Quality Strategy for Scotland, the 2020 vision and the Health and Wellbeing Outcomes supporting Health and Social Care integration. ACP has been prioritised nationally across Scotland and recognised as an exemplar by the International Foundation for Integrated Care (IFIC).Given the demographic and cultural similarities between Scotland and New Zealand we believe that there would be value in collaborating to share learning and best practice to take forward sustainable ways of working across our systems.ACP is a person-centred, proactive, “thinking ahead” approach, requiring services and professionals to work with individuals and their carers, have the right conversations and set personal goals to ensure that the right thing is done at the right time by the right person with the right outcome. It is about the individual’s situation and their conditions and helping people navigate the system and make informed choices about their care and place of care. Population stratification estimates 5-6% of the population could benefit from ACP. Initiation is prompted by a range of triggers and risk prediction tools based on situation, condition and assessment.Current work prioritises use of IT, including the Key Information Summary (KIS), to communicate between primary and acute services. A person-centred App “Let’s Think Ahead” has been developed to support ownership and improve health literacy. Two short educational films “Alice’s story” and “ACP matters” have been produced to increase public and professional awareness about ACP.A National Action Plan supports implementation of ACP principles across Scotland to deliver best-model, person-centred care close to home and consequently reduce avoidable hospital admissions. The aims are to build on good practice, mainstream ACP; focus services on sharing information appropriately, make decisions about the “whole” person and align ACP with work around carer support and Power of Attorney.ACP requires a cultural and resource shift to develop the right community infrastructure supporting early intervention about future health and care needs during the spectrum of care when complexity is recognised through to end of life care.Evidence suggests early intervention, at all ages, through ACP can optimise outcomes and improve quality of life and that appropriate access to community services, good anticipatory care supported by development of a Key Information Summary that contains the right information can reduce the risk of hospital admission by 30-50%.KIS, currently hosted on the GP IT system, enables electronic ACP access. 4.4% of the Scottish population now have a KIS accessible to unscheduled care services with 3.32m KIS accesses/annum outside general practice. Work is ongoing to enable greater accessibility to KIS.National role-out of a whole-system Scotland ACP model is co-ordinated through a series of national cross sector workshops overseen by a National ACP Programme Board and development of a learning and communication strategy.Impact will be assessed by quantitative and qualitative measurement, contribution analysis and health economic input.