Other than the patient themselves and their loved ones the person who knows most about the needs of someone with complex and often multiple health problems is their GP. GPs are aware of not only a person’s complex medical needs but also their social circumstances. But what happens when a crisis occurs in a patient’s condition out of hours and they are not seen by their own GP but by an out of hour’s service or A&E where the full complexity of their circumstances is not as well known? The answer is that often they are admitted to hospital – sometimes this is entirely appropriate but sometimes it’s not. And this is where Anticipatory Care planning comes in.
An individual’s Anticipatory Care plan is developed with them and their carers by their GP with input from other health and social care services. Its sets out exactly what is to happen in the event of a ‘crisis’ in and out of hours. This way those who are coming into contact with the person for the first time will know exactly what the patients circumstances are and can follow the care plan which has already been agreed. Central to this plan is the aspiration for the patient to be supported locally at home or in the community and not admitted to hospital inappropriately.
As part of the Renfrewshire Development Programme all 13 GP practices in Paisley are working with their patients who have complex needs to put Anticipatory Care plans in place. To ensure that these plans are used in the most effective way new electronic systems have been developed to ensure that they are shared with out of hours GP and A&E colleagues so that they are available at the touch of a button as and when required in or out of hours. A hard copy will also be in place in the person’s home or care home so that health and social care professionals supporting the patents can continually refer to the plan as necessary to ensure that the actions agreed are carried out in line with the wishes of the patient.
Anticipatory Care planning is very much about sharing the detailed knowledge that GPs have about their complex patients with other health and social care professionals who may come into to contact with them in the future so that the very best possible care and solutions can be put in place day or night.