Anticipatory Care Plan

Anticipatory care is healthcare or support that focuses on people with long-term conditions or complex needs. It doesn’t matter the person’s age or if they have multiple conditions, the goal is for care to support independence and wellbeing as much as possible.

This is the simplest anticipatory care definition, but there is more to it, and this is where the similarities appear with and why it can also be referred to as Future Care Planning. Anticipatory care is about plotting out what care is needed going forward ahead of time. In contrast, my colleague Claire Wardle defines preventative care as the following in her article, linked in the introduction:

Preventative care aims to avoid or reduce the occurrence of health problems and illnesses before they develop or cause more critical situations to take place. Preventative care is often argued to be a core approach within the shift to proactive care as it offers the opportunity to address symptoms before they are present, to help individuals maintain good health and prevent diseases.  

Prevention includes things such as health check-ups, screenings, vaccinations, and the general promotion of a healthy lifestyle and being engaged with your own care.

As mentioned before, anticipatory care also supports palliative cases; people who cannot recover with treatment (perhaps due to terminal illness) and who instead need maintenance of their current health or even a managed decline to ensure minimal impact to their lives as individuals and how they can interact with friends, family, and their community.

Anticipatory care plans are a non-binding, voluntary plan of action set out by a client with carers, or a patient with clinicians. The goal is forward planning: to think ahead and discuss your future health and wellbeing, and to put in preferences for your care, support or treatment should circumstances change or your health deteriorate.

Carers Together have a great anticipatory care plan PDF that walks readers through the process of establishing a care plan and what details go into it. Within ‘My Anticipatory Care Plan’ they explain what anticipatory care planning is:

“Anticipatory Care Planning (ACP) is about thinking ahead and understanding your health. It's about knowing how to use services better and it helps you make choices about your future care. Planning ahead can help you be more in control and manage any changes in your health and wellbeing. Talking to the people who matter to you helps shape the right plan for you.”

Their anticipatory care plan example runs through the core pillars of what an anticipatory care plan form should be establishing:

• Core details about yourself, and potentially additional information (such as if you have a will)
• Your responsibilities (are you a carer yourself, a parent, guardian, pet owner etc)
• Next of Kin/important contacts (such as a guardian, advocate or Named Person)
• Your carers or doctors
• What areas of life you need support with
• Your preferences regarding care (inc. Power of Attorney)
• Your medical conditions and medications
• Your concerns
• Thoughts on End of Life care and resuscitation

There is no one anticipatory care plan template, but there are plenty of examples of anticipatory care plans available online, such as this care plan from Parkinsons UK or the Covid-19 anticipatory care plan for the NHS, but the clearest or easiest to understand – at least from our research – has been the Carers Together guide linked above. We would strongly recommend visiting their site and reading their literature to see for yourself how straightforward but potentially beneficial such a plan can be.

An anticipatory care framework is a plan of action for clinicians and carers alike to follow regarding an individual’s suitability for intervention. Such frameworks are developed through collaboration between key stakeholders; people living in care homes, people receiving domiciliary care, their families, care workers, doctors and any other relevant parties. The goal of this collaboration is to ensure no aspect of care has been missed or ignored in the process of best accommodating individuals receiving care, and beyond that the potential to adhere to their wishes in the future. This is important to mention as these anticipatory care plans are not binding. They are an individual’s wishes and, as such, are rightly taken seriously and adhered to as much as possible, but there may be instances where this isn’t viable or the best option. A framework helps establish how to handle all situations.

This might sound like it clashes with the concept of anticipatory care: after all, the idea is that you as an individual are putting in personal preferences ahead of time to ensure that your wishes are adhered to even at a time that perhaps you’re unable to confirm them.

The framework is for later in the care process however. It is used at the point that your wishes need to be considered based on your anticipatory care plan, and serves metaphorically as a handrail for professionals to hold on to, so that they can follow protocol and best practice when approaching complex or sensitive matters such as long term illness or end of life care.

Here you can read an example NHS Anticipatory Care Interventions Framework in PDF format.

You might be wondering what is anticipatory care in NHS England. Not too much comes up with search engines compared to NHS Scotland and that can be confusing. This is for two reasons:

• NHS Scotland pioneered anticipatory care
• Anticipatory care is often referred to instead as Advanced Care Planning

Bath and North-East Somerset NHS Trust has an example anticipatory care framework, which ties in with our previous section, but also specifically mentions interventions – something that NHS England seems more focused on from research than other devolved NHS groups.

Alternatively you can read a broader NHS England anticipatory care framework here.

Anticipatory care is a more established concept in Scotland than it is in England or Wales. Virtual wards touches upon some of the care provided in Scotland by the ‘Hospital at Home’ scheme, and NHS Education for Scotland has the REDMAP framework, from which NHS Scotland operates. This six part plan is as follows:

• Ready – Can we talk?
• Expect – What do you know or want to ask?
• Diagnosis – We know or we don’t know
• Matters – What’s important to you/family
• Actions – What can be done to help/support
• Plan – Future preparations

Anticipatory care planning in Scotland is – on the surface at least – receiving much more support and a much more targeted approach to encouraging people to form a plan and to speak with their GP or carers.

The Scottish Government website has a list of frequently asked questions regarding anticipatory care planning. NHS Scotland also offers an anticipatory care planning toolkit, such as the one provided by Health Improvement Scotland. This serves as a guide to establishing a plan, talking it over with loved ones and healthcare professionals, the important documentation, and then regular reviews – as one would with a will – to ensure it still matches your wishes and intentions.

Palliative care is a delicate subject, and the anticipatory care literature available online is quite limited when discussing matters such as anticipatory drugs in palliative care or an anticipatory grieving care plan.

Truthfully though there’s no difference between an anticipatory care plan and accounting for palliative care needs. A care plan should be regularly updated, and any such decline in personal health should have been accounted for and contrasted with existing wishes – or the wishes of family.

One aspect of planning though is the aforementioned drugs or medications. Marie Curie is one of the few to reference anticipatory medicines on its website, defining the term as referring to an individual’s access to prescription drugs as and when they experience difficulties or ‘distressing symptoms’ as they put it. These are clinically prescribed in advance, ready for administration at the crucial moments.

The NHS wouldn’t be pursuing anticipatory care planning if there weren’t benefits to them, and while uptake is a steady pursuit, there are plenty of plus points to such plans:

• More individual agency: you have choice and control
• Specified wishes for End of Life care, especially around resuscitation
• Better quality of life
• Fewer needless hospital admissions or GP appointments – problems are foreseen and accounted for
• Reduced stress or anxiety
• Less burden on family or friends
• Better communication between care experts and family or friends to properly articulate a person’s condition or wishes
• Greater education and preparation
• No inappropriate interventions from clinicians
• Your choice of where to die (in End of Life cases)

There are likely many more benefits to be had to, but ultimately it’s about the individual. We can tailor their care to suit them and ensure they have the best possible outcome – even if that’s ultimately one where they pass away. It’s a clinical duty to support them until the end, and if it can be done in a cooperative fashion between clinicians and carers then that’s even better.

For local authorities and integrated care systems to enact anticipatory care they need to be generating and sharing data between teams and services. For data to be shared in a quick and impactful fashion we need digital tools.

Tools like Assure and Oysta are what’s generating data, and that data is what is going on to inform the healthcare professionals of a person’s current status. Such devices can also report back their information, which in turn builds up a pattern or trends of how a person’s health relates to their behaviour and how their health varies over time. This might assess daily behaviours round the home, weekly levels e.g. a person goes out to a community group on a Wednesday then shows signs of fatigue on a Thursday, or it might look at a monthly level and see that they struggle in certain seasons or temperatures. There are so many variables and possibilities.

There is so much important personal data regarding blood pressure, heart rate, pulse, oxygen saturation, skin temperature and much more. The methods to capture it have often been cumbersome or unable to communicate their findings beyond in-person monitoring. We’re now in a prime position to monitor remotely, accurately, and to communicate findings back to a centralised source from which other clinicians can work when dealing with the individual.

Anticipatory care isn’t free of challenges though. Funding is typically the first problem, at a time when the UK has high inflation, a cost of living crisis off the back of a pandemic, and the NHS is fighting an ever-tightening budget. Then there’s the issues of accessibility and demand for patients or clients, as well as the digital telecare switchover regarding the complete closure of phone lines and how that relates to home support kits. Technology offers a lot, but change will take time.

An anticipatory care plan relies on information and strong technological solutions that can perform analysis and generate data insights. These insights will inform carers or doctors and allow a much more personalised approach to care and treatment in future. The better the plan, the better the outcome.

While there are the challenges we’ve mentioned, anticipatory care planning is a serious benefit to modern healthcare, and technology is what makes the process efficient. It invites collaboration and encourages regular communication; not just with other healthcare professionals but also the individual receiving care too. As with other forms of care assessing and planning, it also makes the overall process more efficient, reducing the amount of time that is spent on simple administrative tasks.

Technology can, with the right provider and solution, be interoperable. It can work with wearables and other home devices and carry that crucial personal data to an electronic patient record or health record; updating a person’s file in real time. Anticipatory care can exist without technology, but digital tools make is faster, easier, and more accurate.

This brings us to the end of our anticipatory care plan article. You now understand what such plans are, who uses them, and the importance of them. The anticipatory care approach is a pillar of the NHS ‘Ageing Well’ longer term project. It’s a bigger picture action in conjunction with Integrated Care Systems (ICS) to ensure broad reaching care that doesn’t skip a beat when the most vulnerable patients are passing between hospitals and care environments.

This matters because it focuses on a person’s healthcare journey and looks to where we can save wastage. Anticipatory care, proactive care, preventative care, advanced care planning… they all work in sync and all point to the same goal – avert deterioration of health and you’ll avert medical crisis, sharp expenses, and crucially avoid long term damage to patients.

Joined-up care is the future of healthcare and the NHS is waking up to this fact, and anticipatory care will grow to be a big part of this cooperative picture.