Scaling care plans from hospital to neighbourhood care

by Dr Yossi Cohen, Physician Executive, InterSystems UK & Ireland

The government’s Fit for the future: 10 Year Health Plan for England sets a clear expectation that, by 2027, 95% of people with complex needs will have an agreed care plan. Today, only around one in five people with a long-term condition has one. The 10-year plan also cites evidence that every £1 invested in personalised care planning for people who use healthcare services most often can deliver £3 in value.

That gap will not close through policy alone. It will close only when care plans remain current and usable as people move between primary, secondary, and community-based care. Such care plans can greatly support prevention, thus reducing the burden on acute care, and escalation when prompt and appropriate clinical action is required.

As the 10-year plan shifts more care into the community through the Neighbourhood Health Service, backed by £300 million for NHS technology and 250 new Neighbourhood Health Centres, the need for care plans to work across settings becomes ever more urgent.

Care plans are not new. Community teams have long had them, social care teams and even secondary care teams often hold their own versions as well. Shared care records (ShCR) have improved visibility across settings, helping clinicians access key information from other providers operating in the same geographical area. What they have not solved is the harder issue of jointly authoring and maintaining a single care plan across organisations. That is the challenge the NHS now needs to address.

Where care plans lose traction

Care plans start to lose traction when updates are made in different places and it becomes unclear which version is most up to date or complete. Where interoperability is limited, staff spend time checking details and re-entering data that should already be available. That creates delay, uncertainty, and avoidable risk. In addition, partial care plans cover only a portion of the patient’s care journey, thus not allowing a holistic and comprehensive view of a patient’s needs.

This is where the distinction between reading and authoring matters. Shared care records bring together up-to-date information across settings, such as medications, treatment plans, and escalation plans. That has helped to break down silos. However, it does not create a single cross organisational care plan that can be updated by the teams responsible for a person across the whole care journey.

The effect is felt most clearly at transfer of care points, for example discharge, where responsibility for follow-up passes from acute care to community services. If a joint plan is not created for a patient, duplication, sub optimal decisions, unclear ownership of care, and inappropriate place of care may follow. For hospitals for example, avoiding readmissions is a key test to determine how well joint care is properly coordinated.

Care planning works at scale when the plan acts as a shared working view that is kept up to date through routine care.

In practice, the plans that stay current are more likely to be trusted by clinicians, particularly when ownership is clear, review dates are visible, changes can be tracked, and access reflects the role of the person using it.

In addition, patient contributions to care plans further cement their value and significance. When a patient is not just a passive reader of their own care-plan but can write parts of it, compliance is greatly improved. We often think of ownership of care as which provider is responsible for the patient at a particular time while actually, patients are also and would like to be, the owners of their care. Authoring part of the care plan gives them both voice and ownership, and better clinical decisions are made when providers know patient wishes and preferences.

How can Shared Care Records support care-planning

ShCR already provide a collaboration platform for care teams. ShCR allow teams to share information in order to improve decision-making and reduce waste. Significant energy and money were invested over the past decade to grow ShCR all over England. These can now serve as a robust substrate for cross organisational care planning. A care planning solution based on ShCR offers the following benefits:

• Access – a mundane yet important aspect is managing user access. ShCR have achieved that already, via launching in context, Active Directory integration, SSO integration, and other ways, across many disparate organisations in the health economy. A care planning solution which integrates with ShCR can reuse this vast investment in user access management
• Governance – cross organisational care planning needs a coordinated approach across the care economy. Most ShCR are already supported by governance structure and activities that can be reused for coordination of the effort
• Reuse of information – ShCR often already contain clinical information which is relevant for care plans, e.g. patient alerts, next of kin, treatment plans, and more.  This information can either be incorporated as is in the care plan via interoperability, reducing the need to re-enter the same information twice, or if appropriate, be excluded from the care plan as it can be viewed directly in the ShCR by all providers anyway
• Patient Access – ShCR can enable patient access to the shared information. The same patient access mechanism can be used to enable patient contributions into care plans

One cohort at a time

While technology is an enabler, a major challenge for cross organisation care planning is change management. Even when a cross organisational care planning tool is implemented, its value and success depend on service users working across different organisations being willing to work together effectively. That means that they need to agree, for example, on what the shared care plan template looks like, how responsibilities are distributed across the care journey, and the extent of patient contribution to the care plan. This is not that simple to achieve. It takes time to build the organisational culture that supports such a collaborative regional effort. This culture needs to cross individual organisations and takes time to develop.

A concrete way forward is to choose a particular patient cohort, of medium size (around hundreds of patients) and build up the relevant cross organisational care plan for these patients. This builds confidence, not just in the technology but also in the organisational ability to use it and experience the associated benefits. Once this first care plan is embedded, working and governed appropriately, this can be used as a blueprint to expand to additional patient cohorts over time. This methodology has already proven itself in some Integrated Care Systems in England.