Article Text

Download PDFPDF

50  Making ACP work for people in practice: Implementation of a structured advance/anticipatory care planning intervention in Scottish primary care (4ACP)
  1. Bruce Mason,
  2. Anne Canny,
  3. Emma Carduff,
  4. Juliet Spiller,
  5. Rebecca Patterson and
  6. Kirsty Boyd
  1. University of Edinburgh


Introduction Advance/Anticipatory Care Planning (ACP) for people with terminal illnesses helps deliver personalised care, support wellbeing, and reduce healthcare crises. Patient and family acceptability/engagement, timely approaches from professionals, and sensitive communication are key. Four ACP steps use nationally recommended interventions; ‘AnticiPal’ primary care electronic record search (READ code-based screening), GP review (identification and assessment); ACP public information from NHS Inform ( plus professional education (REDMAP framework for ACP discussions –, and electronic care planning records (Key Information Summary care coordination system).

Aims To implement and evaluation integrated ACP in Scottish primary care using the ‘Four Actions ACP’ process.

Methods A mixed-method, healthcare implementation study following StaRI guidelines. National primary care datasets from approximately 5,800,000 GP-registered patients screened using AnticiPal conducted before and after ACP implementation case studies with 16 diverse GP practices in four Scottish Health Boards lasting 12 weeks each (study population approximately 100,000). Practice case study data include; AnticiPal screening outputs, GP ‘Thinking Aloud’ interviews of AnticiPal list assessments, patient-carer and linked GP interviews following ACP conversations, ACP plans recorded, AnticiPal cohort outcomes.

Results Approximately 0.6% of GP registered patients in Scotland screened positive for ACP review/planning discussions (pre-excluded if on palliative care register). Of these, 61.6% had no Key Information Summary or documented ACP. Practices found 4ACP straightforward to implement with potential to improve ACP for significant numbers of deteriorating patients known to clinicians but not identified for ACP or palliative care. Ongoing qualitative interviews with patients, families and GPs, and ACP outcomes data will be available for presentation.

Conclusions Effective ACP depends on implementation into routine practice of a feasible intervention acceptable to patients, families, and professionals alike. 4ACP provides robust evaluation of national ACP programmes in Scotland and informs refinement and implementation at scale of the AnticiPal search tool and outputs for GP practices.

Impact National (Scottish) data provides key public health information about the unmet need for anticipatory care planning. Implementation of screening in 16 diverse GP practices provides a systematic process for identification of ACP needs in practice, impact ca 100 K patients. Use of NHS Inform/REDMAP tools for clinicians will directly impact all patients undertaking ACP in the case study practices. Robust evaluation of the implementation impacts policy about and provision of ACP in Scotland and, through our contacts in England and Northern Ireland, at a UK level.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.