1.3 Identify the national, local and organisational agreed ways of working for advance care planning

This guide will help you answer 1.3 Identify the national, local and organisational agreed ways of working for advance care planning.

Advance care planning (ACP) is the process of discussing, recording and reviewing a person’s future care preferences. In the UK, national guidance shapes how health and social care workers should carry this out. These agreed ways of working ensure care is safe, lawful and person-centred.

National guidance is developed by government departments, independent bodies and professional regulators. This includes the Department of Health and Social Care, the National Institute for Health and Care Excellence (NICE), the Care Quality Commission (CQC) and NHS bodies. These organisations issue standards and recommendations that workers are expected to follow.

Key national policies and frameworks include:

• The Mental Capacity Act 2005 – provides the legal framework for decision-making, including advance decisions and lasting powers of attorney.
• NICE Guidelines on End of Life Care – set out best practice for support, assessment and communication.
• NHS England ACP Policies – offer practical guidance for integrating ACP into patient care.
• General Medical Council (GMC) Guidance – advises doctors on decision-making and advance care.
• Care Act 2014 – places duties on local authorities which influence how care planning is carried out.

National guidance covers:

• Promoting choice and control for the individual.
• Respecting decisions even if the person later loses capacity.
• Recording plans clearly and storing them securely.
• Reviewing plans in response to changes.
• Communicating sensitively with individuals and families.

Health and social care workers must be aware of these frameworks, as they outline what is lawful and expected across the UK.

Local Agreed Ways of Working for Advance Care Planning

Local agreed ways of working are developed by local authorities, integrated care boards (ICBs), NHS trusts and local health and wellbeing partnerships. They adapt national laws and policies to reflect local needs and services.

These can include:

• Local ACP protocols developed by hospitals or community health trusts.
• Multi-agency agreements for sharing information between GPs, hospitals, hospices and care homes.
• Area-specific formats for advance care documents, such as local “My Care Plan” forms.
• Local training programmes for staff on ACP communication skills.
• Referral pathways to specialist palliative care teams.

Local policies take into account community services, cultural factors, and available resources. For example, some areas may have close working links with local hospices or voluntary sector providers. Local policies might also address language access or faith-based considerations.

Following local agreed ways of working helps create consistent standards between professionals in the same area. This prevents confusion and ensures the individual’s preferences are respected across different care providers.

Organisational Agreed Ways of Working for Advance Care Planning

Organisational ways of working are the policies, procedures and standards specific to an individual employer or service. These detail how staff are expected to put national and local guidance into everyday practice.

Typical organisational procedures include:

• Step-by-step guidance on how to start ACP discussions.
• Standard forms and documentation policies.
• Confidentiality protocols for storing and sharing plans.
• Role descriptions setting out who is responsible for ACP reviews.
• Record-keeping requirements, including use of care planning software.
• Supervision and support arrangements for staff involved in ACP.
• Policy on involving families, advocates or independent mental capacity advocates (IMCAs).

Organisational procedures must comply with national law and local agreements, but they may be more specific in how tasks are carried out. For example, an organisation might require that ACP plans are stored both digitally and in a paper care plan at the service user’s home.

Working Within the Mental Capacity Act

Many ACP decisions involve consideration of the Mental Capacity Act. The Act:

• Presumes every adult has capacity unless proven otherwise.
• Requires support to be given before deciding someone lacks capacity.
• States decisions must be made in the person’s best interests if they cannot decide.
• Allows for advance decisions to refuse treatment.
• Recognises lasting powers of attorney.

Workers must document all capacity assessments and decisions made. Organisational policies often include MCA assessment forms and guidance on how to apply the law during ACP discussions.

Recording and Sharing Advance Care Plans

Accurate recording is central to ACP. National rules, such as the Data Protection Act 2018, require information to be stored securely and shared only with authorised people.

Organisations may use:

• Electronic patient record systems.
• Secure email for transferring plans between providers.
• Paper records in the client’s home or at the care facility.

Local agreements often set out shared systems for urgent care, such as the Electronic Palliative Care Co-ordination System (EPaCCS). This allows plans to be accessed quickly by health professionals who need them.

Communicating Preferences

National guidance highlights the need for open and honest communication. Workers should:

• Use language that is clear and understandable.
• Work at the person’s pace.
• Be respectful of cultural and religious views.
• Ask permission before involving family members.

Organisational policies usually provide training in sensitive conversations. They may also set standards for the environment, such as holding ACP discussions in a private space.

Reviewing and Updating Plans

An advance care plan is not fixed. It should be reviewed at agreed intervals or when circumstances change. For example:

• Diagnosis of a new health condition.
• A significant change in prognosis.
• A move to a different care setting.
• Change in family circumstances.

National and local policies stress the need to keep plans current. Organisational procedures may set review schedules, such as every six months, and allocate responsibility for reviews.

Involving Families and Advocates

ACP often includes discussions with family, friends or advocates. The Mental Capacity Act requires family involvement in best interest decisions if the person lacks capacity.

Organisational protocols cover:

• Consent for involving family or others.
• Confidentiality boundaries.
• Referral to advocacy services if the person has no family support.

Equality and Diversity in ACP

National law such as the Equality Act 2010 requires that ACP respects all people regardless of age, disability, race, religion, gender or sexual orientation. Local procedures may include:

• Access to interpreters.
• Faith-specific care guidance.
• Culturally appropriate support services.

Organisational policies usually reflect this by promoting inclusion and reasonable adjustments.

Safeguarding and ACP

Safeguarding legislation applies to ACP when there is risk of abuse, neglect or exploitation. Workers must:

• Follow organisational safeguarding policies.
• Know how to report concerns.
• Respect the person’s wishes unless there is significant risk.

Local safeguarding boards issue procedures that link into ACP where there are concerns about capacity or undue influence.

Training and Professional Development

National bodies like Skills for Care provide frameworks for training in ACP. Local training programmes may be delivered by local hospices, NHS trusts or adult education providers.

Organisations often make ACP training part of mandatory induction or specialist development. Topics covered could include:

• Law and ethics.
• Communication skills.
• Recording systems.
• Cultural awareness.

Auditing and Quality Assurance

National regulators such as the CQC check ACP practice during inspections. Local commissioners may also monitor quality through contract reviews.

Organisations may carry out audits by:

• Reviewing sample ACPs for completeness.
• Checking records for timely reviews.
• Gathering feedback from service users and families.

Final Thoughts

Advance care planning is about giving people a voice in their future care. Your role is to make sure their plans are recorded, respected and reviewed. National, local and organisational ways of working all connect to make that possible.

By understanding how the three levels fit together, you can work with confidence and clarity. This approach helps protect rights, build trust and deliver care that reflects each person’s values and choices.