Anticipatory Care will form part of the Primary Care Network (PCN) Contract DES from 2023. An ICS AC Steering Group with system-wide membership has been established to ensure our system is prepared.

The AC operational guidance was due to be published by NHSE in March 2022 and has been delayed. NHSE regional colleagues have advised that they will be in touch as soon as they have further clarity on a publication date, planning timeline, and funding release process.

In the meantime, the ICS is undertaking patient engagement to inform our system plans. HWLincs have been commissioned to undertake a survey as well as group and 1-2-1 sessions.

There is information on registering interest/consenting to these activities on the survey. Please mention it to your patients and help us to identify suitable individuals.

To help you to raise awareness we have included some posters, which can be printed or used online. We hope you can display these for us in each of your practices and spread the word amongst your healthcare team.

Background Information

Anticipatory Care (AC) is a model of proactive care in the community for multimorbid or complex individuals who would benefit from integrated evidence-based care. Professions from across acute, mental health, community, primary care and social care will be involved to ensure Anticipatory Care models locally result in:

  • Reductions in morbidity and premature mortality
  • Reductions in unplanned use of the health system
  • Addressing specific health inequalities
  • Improved patient experience

Delivery of AC broadly consists of five elements:

  1. Population Cohort Identification
  2. Proactive Care Needs Assessment 
  3. Personalised Care and Support Planning
  4. Digitally Enabled Multi-Disciplinary Teams
  5. Care Coordination

To note: The AC DES will not include residents in Care Homes as proactive care for care home residents is delivered via Enhanced Health in Care Homes (EHCH)

Further details available from, or


Thinking Ahead – We want to know if patients’ health and social care needs are being covered by their individual healthcare plans.

An Anticipatory Care (AC) Plan is designed to help people to plan for their future health needs, including care and treatment. We are conducting a survey to help gain insight into how this type of care plan is currently being used, and how effective it is. We are therefore inviting any individuals (or their carers) who are either living with more than one health condition or disability, living with frailty and/or long-term conditions, or perhaps approaching the end of life.

By sharing your views and experiences you can help to shape services for the future, improving the care provided locally.

The survey can be found here: and via the attached QR code. The survey is open until 17th of July.

Paper copies of the survey can be obtained from HWLincs and returned using their freepost address.

Please contact HWLincs and quote ACP

Tel: 01205 820892

HWLincs Focus Groups and 1-2-1s

We would also like to actively engage with individuals who are happy to share their experiences in more detail with us. We are looking for people to attend our focus groups and/or to participate in one-to-one interviews. These are informal, friendly and designed to understand how the Anticipatory Care Plan is working and how it can be improved.

One-to-one interviews will take place on Friday 15th July, Tuesday 19th July and Thursday 21st July - times and method of the interview will be agreed with the individuals. These interviews can be carried out over the telephone or via video call. To book one, please contact HWLincs using the details provided above.