Skip to content

Q logo

Meet the team


  • Careen Mullen-Mackay ANP
  • Elaine Colville Palliative Care Lead
  • Alison Clement, GP and Clinical Director

What is the challenge your project is going to address and how does it connect to your chosen theme?

The challenges are two-fold:

1. How to reliably deliver community based palliative care around Anticipatory Care Planning. Currently characterised by unnecessary referral to acute care, poor communication and access to information,  concerns around clinical competency, confidence and support to integrated teams causing  distress to people, carers and staff.

2. This work involves several organisations: health agencies, social care agencies, private providers, voluntary providers and sometimes others. We feel some of the challenges with multi-agency working (different language, different performance frameworks, different ethos, different drivers etc) could be addressed with a programme of QI education centred on the reliable provision of ACPs, with the person at the heart, and could give these services a more reliable set of processes to work with and a means of working together well.

What does your project aim to achieve?

·        Improve care pathways, and quality of care, ensuring people and carers are central to the process of Anticipatory Care Planning.

·        Develop a shared understanding of ACP with integrated teams, supporting an infrastructure that promotes quality of care.

·        Support the development of QI skills and capabilities across the service fostering  a collaborative approach to improvement.

.        Stronger working relationships across agencies

QI Methodology will help us identify and develop our key measures, driver diagram and improvement plan and will include reduction of unnecessary referral to acute care, improved resident, patient, carer and staff experiences, ACP in place and shared appropriately, was preferred place of care/death achieved, reduction in Out of Hours call outs and visits to care homes, and people in their own homes, and development of knowledge and education of teams.

How will the project be delivered?

The project will be led by a local Advanced Nurse Practitioner and Senior Nurse for Palliative Care with expertise in ACP use in the community setting. The ANP is also a recent graduate of the Scottish Improvement Leader programme, and both are well known across the partnership.

The plan is for the ANP and Senior Nurse for Palliative Care to support and build on local improvement work,  to develop a tailored programme of QI education, and to convene a learning programme over the year for people working in agencies not perhaps as far along in their QI learning. The focus of the learning will be ACP for people in the community.

This project will allow us to develop expertise and strengthen the leadership and capabilities of our current staff which will inspire and influence others to improve care. This will support innovative redesign within the partnership, supporting local and national priorities and the development of the Angus Care Model.

What and how is your project going to share learning throughout?

Progress will be tracked and shared online as well as locally at events and in newsletters. If successful in obtaining funding through Q, then case studies will be submitted on the Q website and a willingness to host learning within Q events through the year.

How you can contribute

  • Local Improvement work has taken place across Angus and it would be helpful to build on this further with the continued support from our Improvement Academy and Clinical Governance Teams. Working closely with a variety of professional groups and opportunities for networking will also help us learn from other areas that may have previously developed similar project work.

Plan timeline

29 Jul 2019 Consultation and Engagement with patients, carers collated
29 Jul 2019 Driver Diagram,Improvement Plan, Test of changes implemented
2 Mar 2020 Recruitment to Band 6 post
12 Apr 2020 Staff Engagement and Feedback collated and analysed
6 Dec 2020 Evaluation, next steps for improvement work
7 Mar 2021 Project complete with recommendations for sustainability


  1. Hi Jackie

    Have you got a link with the Ambulance Service locally?  If not, let me know and I can link you in.  There is currently a project in Forth Valley that the Scottish Ambulance Service in conjunction with Macmillan is running that you may be interested in linking with?

    This project sounds like it will cross a number of services and links with the ethos of the Ambulance Q SIG bid -

    I can see the SAS potentially being able to contribute to all of your evaluation elements.  The ACP embedded in KIS and communication of it being there is certainly an important element in communicating wishes and needs to pre-hospital / unscheduled care providers.

    Good luck.


  2. This is a great idea. We have started rolling out ReSPECT across the West of England recently and, apart from standardised documentation, it is focusing minds on the 'conversation' with patients and their loved ones as people approach a palliative phase in their care. Having ACP type conversations earlier in someone's journey does allow for a better 2 way conversation around care needs before a deterioration or crisis. As one of our receptions recently framed it, it is like a birth plan for dying which I thought was a powerful analogy. I think having a dedicated person to fulfil the role will really help and my only suggestion would be ensuring it joins up with the many other pieces of work going on in  your area

  3. Jackie,

    This sounds like a very wide reaching and worthwhile project and I will follow your progress with interest.

    Good luck.


    1. Thankyou very much Tanya for the comments and feedback

  4. Guest

    Cat Sullivan 1 year, 6 months ago


    I'm doing a fellowship based related/similar project in London looking at the flow of information from hospital from GP.  Is Coordinate my Care (currently a London centric web based database we can and should use locally) a consideration to help your clinicians?

    Perhaps we will have a chance to speak sometime?

    Good luck


    1. Thankyou Cat, Would be great to chat more about this

  5. There is a number of research projects that have tried to introduce an advance care planning intervention in single systems and as a result there is breakdown once expert facilitation has been withdrawn. Systems and processes as well as communication are all barriers to implementation of Advance planning of any kind and so are a real area for development.

    There a number of very successful systems  in the US that take a multi-agency approach and also see this type of conversation as every bodies business including the local community leaders. It might be good to establish some links over there.


    Best wishes


    1. Thankyou very much Louise.

      We would also be grateful to hear about the work in the US? We are aware of RESPECT and can anyone tell us if this process has helped address ACP challenges please?

    2. It’s so helpful to hear about the work in the US. Do you have any links?

      thanks so much


  6. Guest

    Graham Martin 1 year, 9 months ago

    This sounds like a very interesting project. Do you have a sense of what the incentives and drivers might be in the care home setting, and whether it might be possible to align the project with these? Do you have any thoughts on how you might evaluate the project at some level?

    1. Thankyou very much Graham for your feedback and comments.

      Having refined our project to focus on community, not only care homes our initial thoughts are:

      Person centred care at the heart- "nothing about me, without me".
      Services delivered at "right time, right person, right skill, right place"

      National Drivers

      •       As identified by National Guidance “My Anticipatory Care Plan”, (Healthcare Improvement Scotland, 2017) implementing evidence base practice around ACP is key to support people to make informed choices about their care and treatment and place of care.
      •       Working to ensure carer support is aligned with ACP (Carers Scotland Act, 2016)

      Local/Regional Drivers
      •       NHST have also recently implemented an accelerated change programme to address inpatient capacity and flow and a key aspect of this involves care home improvement work ensuring the implementation of ACP and changing models of assessment and support for care home residents.  A standard has been set to reduce unnecessary admissions from care homes by 25% by July 2019. (NHST Unscheduled Care Project, 2018)

      •       Angus Health and Social Care Partnership strategic plan 2019-2022 have identified improving the health, wellbeing and independence of individuals as a priority in delivering person centred outcomes and implementing ACP is key.

      • Feedback from local public consultation has highlighted a desire for people to remain at home or as close to home as possible at the end of their lives.

      Evaluation is key in informing and developing improvements and will incorporate the following;

      • Patient Stories, journeys.( snapshot baseline data collected)
      • No of people whose preferred place of care/death is achieved (snapshot baseline data collected)
      • Feedback/Experience of staff
      • Feedback/Experience of relatives/carers
      • Reduction in admission/transfer to acute hospitals (baseline data collected at present)
      • No of people with an ACP in place and communicated to GP System/eKIS (snapshot data collected

      Would welcome any thoughts or advice you have and thanks again



Leave a comment

If you have a Q account please log in before posting your comment.

Read our comments policy before posting your comment.

* required fields

This will not be publicly visible

Please note that you won't be able to edit or delete comments once posted.