Planning for your care - the urgent care plan and what it means for patients and health professionals - Dr Lyndsey Williams, NW London GP and Clinical Lead for End of Life and Care Homes and Michelle Scaife, Programme Delivery Manager – Last Phase of Life, NW London Local Care Team in discussion with Nick Evans, Internal Communications Manager, NHS NW London.
Nick Evans: What is a care plan?
Dr Lyndsey Williams: So a care plan is created following a conversation between healthcare professionals such as a doctor or nurse, and a person in their care. It's through those conversations, where the professional will listen, understand, and make notes about what's important for patients and their preferences about their care, where they want to have that care, what they want it to look like, what's the support they may need and where is the best place to access that. So some coordinating and then some information to share with others who may be involved in their care and important to them, like a relative or a carer.
Care plans are usually documented. And so if it's with your GP, for example, it'll be documented on your GP records and then that will be an opportunity to communicate that information with anyone that then looks at your medical records.
Nick Evans: What is urgent and advanced care planning?
Dr Lyndsey Williams: So urgent or advanced care planning is a discussion as part of the whole care planning discussion, and it's that important information that usually comes with considering any emergency or urgent information. So say that patient is likely to have an urgent healthcare need and London Ambulance Service get involved or 111. It's the information that would be most relevant in an urgent or an emergency situation.
When we say advance care planning, usually we use that in patients who may have a terminal illness or a more of a chronic condition whereby we would expect them unfortunately to have other healthcare needs, particularly in that last phase of life, and that information needs to be communicated. So what’s really important is that this forms part of the whole care planning discussion for those with emergency or urgent needs.
Nick Evans: Why is care planning important?
Dr Lyndsey Williams: The NHS has an aim to provide that personalized care for patients and, you know, ask the question, what matters to you? Putting the patients at the centre of their care. So having a care plan ensures that the patients’ wishes and their preferences are always considered when healthcare professionals caring for them, are providing medical treatment. So the care planning values the patient as an expert in the planning and management of their own health and wellbeing. It puts them at the centre. It can also continuously be updated through the patient's life to reflect their changes and their needs.
Like we just discussed about an urgent or advanced care plan, when this needs to change to reflect more urgent and advancing conditions and illnesses. So we know that early and continuous care planning helps achieve the patients preferred place of care. So for example if they want to stay at home then early discussions about this would help them achieve that and get the care that they need. We also know that it helps with carer and family burden and for those close to them, this is important., if they understand early what matters to the patient and where they would like to be cared for, it's more likely to be achieved through having these discussions and documenting these discussions as a care plan.
Nick Evans: What is the London Urgent Care Plan?
Michelle Scaife: The London Urgent Care Plan is an NHS service that is going to be replacing Coordinate My Care, or CMC as it's often referred to, for the whole of London. This is a service that has been commissioned for all of the ICS’s across London and by South West London on behalf of all of our London ICB's. The London Urgent Care Plan is a way of recording and digitally sharing the patients advance or urgent care plan that has been talked about with them by their healthcare professional and the Urgent Care Plan tool enables those care plans to be shared across all of the various care sectors. So not just primary care, having it on their system, it will be available to acutes, to our hospice colleagues, district nurses and they can all update and see it in real time.
So basically, as Lindsey has explained, you will have a conversation around your advanced care plan and where you'd like to receive your care. That will then be recorded on the Urgent Care Plan. As soon as it's admitted to the system, it's available for other health care professionals to see, so it works across all clinical and organizational boundaries. One of the big benefits about having the London Urgent Care Plan is that our London Ambulance Service, our 111 colleagues and out of hours GP services are also able to see this care plan in the event of an emergency. And one of the other things that the Urgent Care Plan is also doing is integrating with existing electronic record systems that we're already using. So the information that is available to clinicians can move between these existing systems and the Urgent Care Plan.
Nick Evans: When does it go live?
Michelle Scaife: We are very fortunate that the Urgent Care Plan has actually launched today, the 27th of July and we have heard that all is going well with the launch so far and that things are working according to plan. So this means that after extensive testing we were able to cut over from the old CMC system and start up with the new UCP Care plan today. So that clinicians across our areas and across the whole of London are able to access the new Urgent Care Plan tool and the care plans which will be migrated to the Urgent Care Plan.
Nick Evans: Which care plans will be migrated to the Urgent Care Plan?
Michelle Scaife: So all existing CMC care plans that have been published for our patients will be migrated across to the Urgent Care Plan. So if they are a published care plan, they would have moved across. Unfortunately, none of the draft care plans, those are ones that have not been published would have migrated across and that this is something that we advised our colleagues on ahead of time to ensure that they got those draft care plans completed. So there will be no need to transcribe any published care plans as these would have all migrated across.
Nick Evans: What improvements to care planning can we expect from the Urgent Care Plan?
Dr Lyndsey Williams: So the good news is that there was extensive stakeholder engagements between October 2020 and March 2021 to find out what was needed as a care planning solution. The stakeholders identified the following functionalities which the Urgent Care Plan is going to provide.
Firstly, it talked about duplication. The good news is this new Urgent Care Plan will reduce the duplication because it prepopulates with relevant information from a GP's records. So that's from EMIS and SystemOne, reducing the need for duplicating and transcribing between them.
Improved accessibility is another benefit, so users won't have to separately log in to access each care plan, so they'll access it via, as I said, the GP electronic patient record and the care plans will continue to be universally accessible by all clinicians. So that's urgent care and London Ambulance Service and out of hours services. But the benefit is that you don't need a separate login, it's a single sign in. This is particularly a benefit for the GP colleagues of mine as there’s an instant access route through our GP electronic records like EMIS and SystemOne.
Finally, there's some good template development. Colleagues will know when completing care planning documents that it's important to have a nice flow of conversation when discussing care planning, because it's a very personal, what matters to the patient, discussion and it can be quite emotional as well. Particularly in regards to an urgent or advanced care plan, when someone is talking about when they may need urgent or emergency treatments or maybe in that last phase of their life. This new template helps facilitate having those conversations. It flows a bit better. So when we're having them, it's easier to document and it makes more sense. It's not just limited to urgent and end of life care, but it does include some other areas as well and has the potential in the future for a greater variety of other clinical pathways and care plans. But as I said for now it's an Urgent Care Plan and end of life care plan, but it does have that potential.
Nick Evans: How will patients be able to access their care plans?
Dr Lyndsey Williams: The patients should speak to their healthcare professionals if they would like to see an up to date version of their care plan. A way to enable patients to view or edit their care plan is in development and it will be introduced at a future date.
Nick Evans: Who can see or access the care plan?
Michelle Scaife: Any healthcare professional that's involved in a patient's care will be able to see the patients care plan on the Urgent Care Plan portal and this could be a nurse or a doctor or urgent care services like NHS 111 or London Ambulance Service. They will be able to either read or update that person's care plan wherever necessary or appropriate. The information that's held is kept in a secure location and access restricted to authorized staff only.
The NHS digital code of practice and confidential information applies to all staff and they are required to protect patient information, as they would do with any other patient activity. All staff with access to personal data are trained to ensure information is always kept confidential and hopefully this gives assurances that patients information is kept and secure.
Nick Evans: Where should people go for more information of the urgent care plan?
Michelle Scaife: So there is a huge amount of helpful information and support for healthcare professionals who are accessing the new UCP and there are various access routes depending on which sector you are working for. So for example, in primary care you will be accessing this via EMIS or SystemOne, whereas for our acute services we have a different route which is via the London care record. So on the UCP website there is a host of materials, including videos that provide step by step guides and can take you through which access route you would be needing to use, as well as various roadshows and Q&As that have been hosted in the past. This is covered on our NHS NW London website as well. You can find a whole information section there for the Urgent Care Plan and professionals. But do go to the main UCP website. That's probably the best place to find the most up to date information.