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" Successful self management relies on people having access to the right information, education, support and services. It also depends on professionals understanding and embracing a personcentred, empowering approach in which the individual is the leading partner in managing their own life and condition(s)" 3.

Anticipation and mutuality

In this time of economic recession, the World Health Organisation (WHO) has been quick to outline the main consequences of the financial downturn on human health1. They highlighted that no part of the global health system was exempted from the consequences of recession and that there was now an even greater urgency to ensure that the values of social justice underpinned healthcare.

The WHO report1 draws out the themes identified in a high-level consultation that took place in January 2009. Two themes are relevant to the continued support and development of anticipatory care. The first is ensuring there is sustained investment in healthcare. This investment has to be linked to more effective and efficient use of funding, based on universal access to services through primary care. The second is sustained support for prevention, ensuring that preventative activities do not fall victim to budgetary pressures.

Within Scotland, population-based preventative practice and a focus on the universal availability of primary healthcare are brought together within the overall policy of creating sustainable anticipatory care.

What is anticipatory care?

Anticipatory care has been defined as healthcare professionals 'reaching out' to those 'at greatest risk'2. It differs from routine reactive healthcare in that it involves the health service being proactive to identify those people at risk of developing a health condition (primary prevention) or those with existing conditions who are at risk of further complications or poor management of the condition (secondary prevention). This has the potential to shape a different relationship between the 'patient', who has not necessarily sought support or care and the healthcare professional offering that support or care. It can reach out to patients at risk, without creating new health inequalities.

Anticipatory care services, primary and secondary prevention, are available in Lothian. One commonality between the different forms of anticipatory care is their commitment to supporting patients by addressing the wider determinants of health including isolation, employment, debt and poor housing. They have also sought to improve identification and management of mental health problems.

One of the most innovative anticipatory care initiatives being undertaken in NHS Lothian is the 'Keep Well' project which is working in areas of socio-economic deprivation to identify people at risk of coronary heart disease. Currently General Practices in deprived communities in Edinburgh are offering health checks to people aged 45-64 to identify risk factors such as cigarette smoking, high cholesterol levels, high blood pressure, high alcohol use, low levels of physical activity or poor diet as well as wider social issues. People can then be offered treatment and support for these within the practice or referred to a range of services, often in the voluntary sector, to address these issues. The project is being expanded this year to West Lothian and specific at risk populations including Gypsy Travellers, people from minority ethnic communities and prison leavers.

People with established long-term conditions can be identified by their risk of emergency admission to hospital. Those with greatest need are being identified using a predictive model developed nationally and piloted in Lothian called SPARRA (Scottish Patient at Risk of Re-admission and Admission). In this model, any patient who is aged over 65 and who has been admitted to hospital as an emergency at least once in the preceding three years has a score calculated. This score helps predict their risk of being admitted to hospital as an emergency in the following year. Edinburgh Community Health Partnership staff have pioneered the use of the predictive information for active case finding by community nurses in the Improved Anticipatory Care and Treatment (IMPACT) team. By working with practice teams, the IMPACT team use this information combined with locally held data to refine the search to identify patients who may benefit from further review. Many of the patients identified go on to receive enhanced case management or care co-ordination.

Anticipatory care - a shared responsibility

Anticipatory care emphasises that professional input and self-care are both needed as a means of preventing illness or its consequences. For people with a long term condition, encouraging and supporting appropriate self-care and selfmanagement is an integral part of the anticipatory care offered. When patients first hear the term self care or self-management they may think that they are at risk of losing services and will be expected to look after themselves. This is not the case.

[ Box 1 ]

The Long Term Conditions Alliance Scotland (LTCAS) uses the following definitions to clarify some of the terms used by government bodies and health professionals:

  • Self care is what each person does on an everyday basis
  • Self-management is the process each person develops to manage their conditions
  • Support for self care and self-management is the responsibility of health and social care providers and unpaid carers

Anticipatory Care Plans are documents held by patients with established long term conditions and the healthcare professionals providing their care. They are agreed jointly between the patient and those providing care. The anticipatory care plan includes: the patient's usual treatment, how to recognise a deterioration in the patient's condition and options for the action required in the event of their condition deteriorating. The plans are shared with other professionals who might be involved in caring for the patient, particularly at night time or at weekends.

How will we know it is working?

Anticipatory care services have introduced new ways of providing services to patients. It is important to know whether they work. The 'Keep Well' initiative is being evaluated nationally and locally. An evaluation framework for services for people with long term conditions is being developed in Lothian. This includes trying to find a way of measuring whether patients get what they want out of anticipatory care. Extensive research has established a range of outcomes that are important to patients (see Box 1). These are included within the 'Talking Points' tool, formerly known as the User Defined Service Evaluation Tool4. We are currently piloting the use of Talking Point5 to evaluate the anticipatory care services. At the same time, Voices of Carers across Lothian (VOCAL) have used 'Talking Points' to capture outcomes important to carers. Together, these approaches will be used to assess progress in reaching the desired outcomes.

[ Box 2 ] Anticipatory Care

Talking Points8: Outcomes Important to Service Users

Quality of Life Process Change
Feeling safe Listened to Improved confidence and skills,
Having things to do Having a say Improved mobility
Seeing people Treated with respect Reduced symptoms
Staying as well as you can be Treated as an individual  
Living where you want/as you want Responsiveness  
Dealing with stigma/ discrimination Reliability  

Talking Points8: Outcomes Important to Carers

Quality of life for the cared for person Quality of life for the carer Managing the caring role Process
Quality of life for the cared for person Maintaining health and well-being Choices in caring, including the limits of caring Valued/respected and expertise recognised
  A life of their own Feeling informed/skilled/equipped Having a say in services
  Positive relationship with the person cared for Satisfaction in caring Flexible and responsive to changing needs
  Freedom from financial hardship Partnership with services Positive/meaningful relationship with practitioners
      Accessible, available and free at the point of need

Mutuality and anticipatory care

Anticipatory care is a marked departure from a health service that waits for people to attend. It is a key component of the evolving model of care outlined first in Delivering for Health2 and subsequently endorsed by Better Health Better Care6. Through the development of agreed anticipatory care plans, it leads to a mutual responsibility for patients' health shared between the patient and healthcare professionals. Mutuality is also enhanced by the multidisciplinary approach and team work involved in anticipatory care services. Effective communication and trust between the patient, healthcare and social care professionals, carers and voluntary sector organisations is critical7.

Key messages

  • In a time of recession, the WHO has advocated very strongly that healthcare needs to become more preventative in focus and to ensure universal primary healthcare is sustained. In Scotland, anticipatory care is one of the approaches that contribute to the delivery of this requirement.
  • It is a marked departure from reactive care where the patient is a passive recipient and redefines the relationship between patients and healthcare professionals as patients have not sought care.
  • Self care and self-management are important aspects of anticipatory care.
  • Many different types of anticipatory care services are being provided in Lothian and it is important that we find out how effective they are.