4-Actions Care Planning in Primary Care
Research type
Research Study
Full title
Implementation of an integrated care planning and electronic care coordination intervention in primary care for people living at home or in a care home at risk of deteriorating or dying: mixed-method study across Scotland. (4-ACP)
IRAS ID
291779
Contact name
Kirsty Boyd
Contact email
Sponsor organisation
University of Edinburgh
Clinicaltrials.gov Identifier
C-10779889, Data processing agreement
Duration of Study in the UK
1 years, 11 months, 31 days
Research summary
Research Summary
Anticipatory Care Planning (ACP) in Scotland helps people discuss their goals and preferences and make plans for future changes in their health and care that are recorded, shared and reviewed. ACP helps anyone with underlying health conditions or disabilities, particularly if their health is declining. ACP is about making plans in advance for healthcare if someone becomes seriously ill, is unable to make health decisions, or may die.
Four actions are needed for good ACP:
1.Searching GP practice records regularly to help primary care teams find people who can benefit from ACP.
2.Prioritising people and families with complicated needs, unstable or declining health for ACP.
3.Having individual ACP discussions with people living at home or in a care home and involving those close to them.
4.Sharing agreed ACP plans securely with NHS and care professionals/teams.To improve ACP in Scotland, this research involves patients, care home residents, families and primary care teams in 24-36 GP practices from four Scottish Health Boards.
1) The NHS Scotland approved IT company (Albasoft) can analyse data from GP practices across Scotland. Using our search tool for electronic records (AnticiPal), we can extract data securely and find out how many people in Scotland might need ACP. GP practices can use AnticiPal on their own registered lists of patients to help identify who might benefit from ACP.
2) Primary care teams and care home staff providing ACP for people registered with the study GP practices will work with the researchers, to record what happens, and look at how ACP can be improved and made available across Scotland.
3) People who have ACP discussions during the study are invited to take part in two interviews about their experiences, and the outcomes of having their own ACP plan.Our public-patient involvement team is advising us thoughout the project.
Summary of results
This study looked at how to improve care planning for people living at home in four health regions across Scotland. Planning ahead for changes in health and care can help people get better care if their health gets worse or they need help in an emergency. This is sometimes called advance care planning or future care planning.
We used an electronic tool that searched GP records to find out how many people living in Scotland might be helped by an invitation to take part in care planning with a GP or nurse from their practice. In 2023, we identified about 6% of people registered with a GP practice (35,600) but only 35% of them already had an electronic summary plan. Most were aged 65 years or above.
Next, we recruited GP practices from the four health regions (16 in total) aiming to include large and small practices in rural and in urban areas which looked after people from of different ages, and social circumstances. Each practice used the electronic tool to search their own practice population to give them a list of people to review. A lead GP looked at the records of each person and talked to a researcher about how they decided which patients could benefit from an invitation to take part. We also interviewed a small number of patients and/or family members (10). GPs used the lists in various ways to help them prioritise which patients to contact and found a list helped with this. Many demands and pressures of work limited their ability to offer care planning. People who had been invited to talk with their doctor about planning ahead appreciated being offered a personal discussion if this came at the right time for them. Opinions varied about readiness to talk about deteriorating health and topics like cardiopulmonary resuscitation.REC name
South East Scotland REC 02
REC reference
22/SS/0017
Date of REC Opinion
18 Feb 2022
REC opinion
Favourable Opinion