Anticipatory Care Planning in a COVID landscape

29 May 2020 

Continuing the theme of silver linings and lessons learned from COVID-19, this week I wanted to reflect on Anticipatory Care Planning (ACP) and share some of the progress we have made around this in recent weeks.

Recognition of the role of Anticipatory Care Planning

As GPs, we have long-recognised the importance of ACP conversations, where patients and families are given the opportunity to explore what matters to them, should their health deteriorate, and treatment decisions need to be made.

This has always been a core part of our work, but in normal times we would have the luxury of being able to have these sensitive discussions in person, often over several conversations, with family present to support.

None of these luxuries have existed during COVID-19, and this has made difficult conversations all the more challenging, especially when we are having to work at pace and scale.

GPs and their teams have made thousands of outreach phone calls to our most medically vulnerable patients, who are often frightened and anxious. In a small number of cases, it has not gone as well as we would have hoped, and this has caused distress for everyone involved.

But many patients report feeling reassured by the proactive contact and the opportunity to talk through their wishes and jointly plan for their future.

Practices have done truly amazing work in increasing the number of Key Information Summaries (KIS) available for the highest risk groups.

In January 2020, 338,961 patients in Scotland had a KIS (4.77% of the population).

By May 2020, this number had increased to staggering 1,185,749 patients, which is 16.7% of the population.

This is a fantastic achievement and represents a real team effort across practices.

For me, the main silver lining has been the increased recognition that proactive anticipatory care planning is an essential part of good patient care.

These conversations really need to be happening before a crisis hits, and to do this effectively there are several enabling factors:

  • a wider collective responsibility across the health and social care workforce for ACP conversations
  • training for those who need it
  • software that adequately supports a pan-NHS (and social care) approach
  • time, time, time.

We also, as a society, need to find a way to chip away at our ingrained cultural resistance to talking about deterioration, dying and death and to instead view these conversations as a means of ensuring that we (as citizens) remain at the heart of individual care planning discussions.

Perhaps another silver lining from the pandemic is an increasing recognition that it’s important to be able to proactively discuss and share our wishes with those that we love, and those that care for us.

Meeting with the Cabinet Secretary for Health and Sport

I met with the Cabinet Secretary for Health and Sport in February, in a pre-COVID world, where we discussed these very things.

It was a positive and productive conversation, and she was supportive of making these things happen then. Since this time, the landscape has clearly changed beyond recognition and I was therefore very pleased to be able to meet with the cabinet secretary again yesterday where we continued this discussion.

I spoke of the need for robust, positive national messaging to complement the work on ACP to ensure that the public understand the benefits of engaging in these discussions during 'normal times'. 

I also expressed the need for clinicians and members of the multidisciplinary team (MDT) to feel comfortable in having these discussions – both in terms of adequate training and support, and also ensuring that there is time within the working day to allow for these meaningful discussions to take place.

I believe that there is real momentum now around this to build upon as we move into the recovery phase of COVID-19.

I am acutely aware that residents in care homes are among the most vulnerable to severe illness from COVID-19 and that care planning conversations are particularly important for them.

I have had some useful resources shared with me that focus specifically on support for ACPs in care homes, taking a whole team approach, which have been evaluated positively by care home residents, staff, families and practices.

This work was a winner of the RCGP Bright Ideas Awards in 2017, and has continued to progress since then, with a plan for toolkits that have been developed to be rolled out across Scotland.

In our conversation yesterday, the cabinet secretary asked me to personally pass on her thanks to all of you for everything that you have done to adapt to this pandemic and ensure that general practice has remained open and safe for our patients during this crisis.

She described the work of GPs as 'invaluable' during the pandemic – sentiments which I of course echo!

I am hugely proud of what we have been able to do in very challenging circumstances.

I look forward to continuing to work constructively with the cabinet secretary and her team as we move into the recovery phase of this pandemic, to help ensure that general practice is stronger than ever.

Shielding concerns

Finally, I wanted to update you briefly on the work we've been taking forward at the College around shielding.

I know this has been an area of the pandemic response that has caused a great deal of concern amongst the profession. Protecting our most vulnerable patients has always been a key priority for general practitioners.

However, I recognise and share concerns about certain aspects of this work and the implications that it has had, and will continue to have, for general practice and for our patients.

We need a proportionate, sustainable and consistent approach to shielding moving forward.

Please be assured that we have fed in the challenges being faced to the Scottish Government where they are being urgently considered by the Clinical Cell.

As we move into Phase 1 of lockdown easing, I hope you get to enjoy some of the sunshine that is forecast for this weekend.

Post written by

Dr Carey Lunan, Chair RCGP Scotland

Dr Carey Lunan is a GP partner in one of Edinburgh's Deep End practices and is the current Chair of RCGP Scotland.

Prior to this, she held the role of Executive Officer for Patients and Public and Interface working. She also sits on the RCGP Ethics Committee.

Her priorities during her time as Chair include a focus on practitioner wellbeing, improving the interface between primary and secondary care, and growing and retaining the GP workforce.

She has made tackling health inequalities a high priority and has consistently called for the need to engage the public in a national conversation about the realistic role of the modern NHS and the importance of collective social responsibility.

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