Frequently Asked Questions
Accessing the Universal Care Plan
The Universal Care Plan is an NHS service that enables every Londoner to have their care and support wishes digitally shared with healthcare professionals across the capital.
A care plan is created following a conversation between a healthcare professional (such as a doctor or nurse) and the person in their care. Throughout the conversation, the healthcare professional will listen, understand and make notes on:
- What is important to the person in their day-to-day life
- Their preferences or wishes about their care
- What support they need and who is best placed to provide this
- Information about others who may be involved in that person’s care, such as relatives
The care plan is then created following this conversation using the Universal Care Plan. As soon as information is saved on the plan, it is visible to all health and care services who use it. This includes the London Ambulance Service, 111 and Out of Hours GP services who may see the person in an emergency.
Click here for more information about personalised care and support planning from the NHS website.
Click here for publications and resources for care planning in palliative and end of life care, provided by NHS England.
Users of the following Electronic Patient Record (EPR) systems have access to care plans via their EPR system without the requirement for logging in twice or entering separate credentials*:
- EMIS
- EMIS Community
- TPP (SystmOne)
- London Care Record (provided by Cerner Health Information Exchange)
- Advanced Adastra
- Cleric ePCR
Users of EMIS and TPP will need to register their CIS (Care Identity Service) Smartcard prior to go-live. Please visit the Resources section for information about how to do this.
Users of other EPR systems can access the Universal Care Plan via the London Care Record (Cerner Health Information Exchange) or via the UCP Web Portal.
Access to care plans via the below EPR systems without the requirement for logging in twice or entering separate credentials will be available as part of the digital roadmap for Phase 2 and Phase 3:
- Vision
- Cleric CAD
- Cerner Millennium
- Servelec RIO
- System C Medway
- Azeuscare
- Advanced CareNotes
- Allscripts Sunrise
- Care First
- Corelogic
- Epic
- iSoft iCM
- Liquidlogic
- Lorenzo
- Servelec Mosaic
- Silverlink PAS
- SMI iCare.
Integration with Cleric CAD will be complete once Cleric CAD is implemented across London Ambulance Service in the summer of 2022. Cleric CAD will show that a care plan exists and the care plan and the Universal Care plan can be launched.
* This is also known as ‘federated access’ or ‘contextual launch’.
Valida is a piece of software that allows EMIS and TPP SystmOne users to access care plans via their EPR system.
Instructions on how to install and configure Valida, and register user smartcards can be found on the Resources section. If you do not have the Valida client installed on your desktop, please contact your IT service desk to install the client.
If you are are unsure about how to configure EMIS or register user smartcards, please contact your local GP IT Facilitator or visit the Resources section.
Care plans can be accessed via the UCP Web portal. New users will need to complete a User Access Form. Please visit the Access page for more information.
No. If your Electronic Patient Record system is integrated with the UCP, your user credentials for accessing your Electronic Patient Record system will be used to authenticate your access automatically. This is the same for users of the London Care Record (Cerner HIE). This will enable users to launch the care plan without having previously registered for an Urgent Care Plan account.
The UCP Programme training materials have been published, providing information on how to use and access the Urgent Care Plan. Please visit the Training page.
Training materials have been co-designed with our UCP Champions, who represent care services across London.
You are accountable to your organisation, in regards to the use of the Urgent Care Plan.
Staff are individually accountable for the sharing of information in accordance with relevant organisational policy and GDPR regulations.
Staff are individually accountable for the accuracy of information that they record in the care plan, and for ensuring that information is recorded within their professional scope of practice.
Clinical training and clinical engagement will be co-developed, produced and delivered by the UCP Programme, in partnership with London networks, systems and stakeholders. Organisations will need to incorporate clinical training regarding care planning within organisational training programmes.
Using the Universal Care Plan
Extensive stakeholder engagement was conducted between October 2020 and March 2021 to find out what was needed from a care planning solution. Stakeholders identified the following functionalities, which the Urgent Care Plan provides:
- Reduced duplication: Care plans can be pre-populated with relevant information from the patient’s GP record from EMIS and TPP SystmOne. This reduces the need for transcription.
- Improved accessibility: Users don’t need a separate log-in to access care plans when accessing the solution via a connected Electronic Patient Record systems (EPRs). Care plans can be universally accessible by all clinicians involved in a patient’s care. Urgent Care Services, including the London Ambulance Services, NHS 111 and Out of Hours GP services will be able to access care plans without the need for a separate log-in when accessing care plans via their EPRs.
- Template development: We will be able to create and edit the care plan templates, making it possible to support a greater variety of clinical pathways, including, but not limited to Urgent Care and End of Life Care.
Patients should speak to their healthcare professional 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 plans is in development which will enable them to view or edit their care plan in the future. Patients who are interested in being involved in the design, can use our contact form on the Contact Us page. We would love to involve as many patients in this piece of work as possible.
The Universal Care Plan Programme team are working with Business Intelligence (BI) teams to establish data flows and integrate data from the Universal Care Plan system into local and regional dashboards. This will enable BI and transformation teams across London to view care planning data in a more holistic way. The earliest date that data reporting will be available will be October 2022.
The Universal Care Plan enables information about a person’s urgent care needs and wishes to be communicated with health and social care services. The information recorded in the UCP is shared to enable health and care professionals to care for individuals.
The processing of personal data in the delivery of direct care and for providers’ administrative purposes in your organisation and in support of direct care elsewhere is supported under Article 6 and 9 conditions of the General Data Protection Regulation (GDPR).
Article 6(1)(e) ‘…necessary for the performance of a task carried out in the public interest or in the exercise of official authority…’.
Article 9(2)(h) ‘necessary for the purposes of preventative or occupational medicine for the assessment of the working capacity of the employee, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services…”
Under GDPR regulations, this information must only be shared and accessed on a strictly need to know basis by health and care staff.
Staff must make or share information in accordance to the GDPR regulations. Staff are individually accountable for the sharing of information in accordance with relevant organisational policy and GDPR regulations.
Clinical Responsibility
There is no field to mandate the recording of consent for sharing of information via the Urgent Care Plan.
Care planning embraces the care of people with and without capacity to make their own decisions. It involves a process of assessment and person-centred dialogue to establish the person’s needs, preferences, and goals of care, and making decisions about how to meet these in the context of available resource.
The UCP strongly advocates the involvement, by professionals, of people they care for. It remains best practice that there should be no surprises to people.
Staff are individually accountable for the accuracy of information that they record in the care plan, and for ensuring that information is recorded within their professional scope of practice.
Contracting and Finance
The future service will continue to be funded by the five London CCGs.
The new digital provider underpinning the future Universal Care Plan is Better. An IT Implementation project, led by the Chief Technology officer for London, has been established to oversee the implementation plan for the digital solution, to ensure that all parties bought into the requirements for the new service.
Better is a leading technology company supporting the NHS with their Digital Health Platform. The Better platform enables fast and agile creation of forms and clinical applications, separated from the data, for instant data access, re-use and expansion. The company’s solutions are putting organisations in control of their data, with the aim of simplifying the work of care teams and accelerating digital development of all data for the lifetime of the person. In the last three decades, Better has provided solutions for more than 150 clients across 16 countries worldwide with their OpenEHR and open standards-based platform and applications.
The future contract will be awarded for 3 years (April 2022 to March 2025) with an option for 2 x 12-month extensions.
Frequently Asked Questions
The current way that clinicians can share End of Life and Urgent Care plans across organisations in London is to document this information on Coordinate My Care (CMC). CMC is contracted to deliver this service until 31st March 2022. It is a legal requirement to conduct a procurement exercise for a contract for such a service following the expiry of the contract with CMC.
We consulted with stakeholders, including patient representatives and existing users of CMC, who stated that it is important to communicate the purpose of the care plans, which is to share patient wishes and important information with health and care services. The main use case for CMC and the principle of the care plan template at go-live is as an Urgent Care Plan.
Therefore, Urgent Care Plan is the term that will be used to refer to the care plan and application that will be available from go-live. The Urgent Care Plan fulfils the requirements of an Electronic Palliative Care Coordination System (EPaCCS).
Future care plan templates that are developed after 1st April 2022 will be named by stakeholders based on the clinical purpose of the care plan, for example a Treatment Escalation Plan or Mental Health Plan.
The programme leading the implementation of the Urgent Care Plan is called the Urgent Care Plan (UCP) Programme. This programme is hosted by South West London CCG on behalf of London. The programme oversees the following projects:
- IT Implementation, in partnership with OneLondon and Better
- Clinical Design & Engagement
- Clinical Governance
- Information Governance
The new digital provider underpinning the Urgent Care Plan is Better. An implementation project group, led by the Chief Technology officer for London has been established to oversee the implementation plan for the digital solution, to ensure that all parties bought into the requirements for the new service.
Better is a leading technology company supporting the NHS with their Digital Health Platform. The Better platform enables fast and agile creation of forms and clinical applications, separated from the data, for instant data access, re-use and expansion. The company’s solutions are putting organisations in control of their data, with the aim of simplifying the work of care teams and accelerating digital development of all data for the lifetime of the person.
In the last three decades, Better has provided solutions for more than 150 clients across 16 countries worldwide with their OpenEHR and open standards-based platform and applications, such as their Electronic Prescribing and Medicines Administration product BetterMeds. Better’s clients include Suffolk and North-East Essex ICS (SNEE). In partnership with Better, SNEE were able to create a dynamic and integrated care planning platform to enable patients and care teams to gain easy and real time read-write access to a single source of information focused on patients’ needs, anticipatory care and wishes, in 12 weeks.
All suppliers who responded to the Market Engagement Questionnaire were invited to bid. Potential suppliers were evaluated by an independent evaluation panel, using a scored evaluation framework. The framework focussed on how well the suppliers could meet the core technical requirements, such as integration with electronic patient record (EPR) systems, transition, development and implementation plans, skills and expertise, ability to meet patient use cases and the strategies to support transformation, engagement, training and partnership. Better was the highest scoring bidder, demonstrating the ability to launch Care Plans in the context of an end user EPR. The evaluation panel assessed Better to have a strong delivery team with relevant experience.
Extensive stakeholder engagement was conducted between October 2020 and March 2021 to find out what was needed from a care planning solution. Stakeholders identified the following functionalities, which Better have committed to deliver:
- Reduced duplication: Care plans can be pre-populated with relevant information from the patient’s GP record from EMIS and SystmOne. This will reduce the need for transcription.
- Improved accessibility:
- Users won’t need a separate log-in to access care plans when accessing the solution via a connected Electronic Patient Record systems (EPRs). Care plans will continue to be universally accessible by all clinicians involved in a patient’s care.
- Urgent Care Services, including the London Ambulance Services, NHS 111 and Out of Hours GP services will be able to access care plans without the need for a separate log-in when accessing care plans via their EPRs.
- Template development: We will be able to create and edit the care plan templates, making it possible to support a greater variety of clinical pathways, including, but not limited to Urgent Care and End of Life Care.
Initially, the main difference will be that the technology underpinning the Urgent Care Plan will be provided by Better, replacing the current solution commissioned by CMC. The current care planning format and principles will be transferred to the new platform, so the majority of the care planning process will be the same. As the implementation progresses, it will also be easier for the majority of users to access to care plans. Based on the on the recommendation from a clinical advisory group, agreement will be sought to pre-populate relevant information that is recorded in GP record systems to care plans.
All existing, clinically published care plans for patients that are alive will be migrated to the Urgent Care Plan. There will be no need to transcribe existing care plans to the new solution. Access to and visibility of care plans will be tested before go-live, to ensure that no data is lost.
Draft CMC plans, outstanding myCMC requests and restricted care plans will not be migrated to the Urgent Care Plan. In order to ensure that care services are able to make the best use of care plan information from CMC, the following actions are required from GPs:
- Please ensure that all draft care plans are finalised and published (i.e. clinically approved) as soon as possible.
- Please process all outstanding MyCMC patient requests as soon as possible.
- Please contact patients who have a restricted record, to offer them the option for their record to be un-restricted. With your permission, CMC are able to contact the patient to do this.
Communications to notify care providers of deadlines to take necessary action and instructions for how to do this will be shared with relevant services.
Yes, all existing care plan attachments for patients that are alive, will be migrated to the Urgent Care Plan’s digital system, provided by Better. There will be no need to print these in advance. Access to and visibility of care plan attachments will be tested before go-live, to ensure that no data is lost.
Yes, all existing care plan DNACPR information, including attached DNACPR forms, for patients that are alive will be migrated to the Urgent Care Plan, provided by Better. There will be no need to print these in advance, from the existing solution. Users will also be able to print a red border DNACPR from the new solution. Access to and visibility of care plan DNACPR information will be tested before patient care plans are migrated, to ensure that no data is lost.
There is likely to be a short period of time where the care planning system will be unavailable, whilst the migration of care plans to the new system takes place. We will try to ensure that this period takes place outside of core business hours. Users of CMC will be notified in advance of the down-time period.
CMC currently provide a patient facing portal, myCMC, which was developed by CMC as part of the service roadmap. However, this service is not commissioned by South West London CCG. Further information about provision of myCMC, will be shared by Royal Marsden NHS Foundation Trust in due course.
The UCP Programme IT Implementation Project are making arrangements with the NHS App and personal health record providers to provide patients with access to their care plans.
We anticipate that the same role-based access rights will be used after transition. However, a pan-London clinical working group will review this and recommend a role-based access policy. As part of the information sharing agreements, organisations will also be asked to identify a clinical lead to oversee access to, and utilisation of care plans in their organisation.
The way users access care plans will depend on the EPR system used within your organisation. The table below outlines the access option for each phase of implementation, and the steps required to get access. The UCP Programme team will be in touch with your organisations to make necessary arrangements and to support user migration.
Users of the following EPR systems will have access via their EPR without the requirement for a separate log-in (‘federated access’), which will provide you with the same level of contextual launch.
- EMIS
- EMIS Community
- TPP (SystmOne)
- Cerner HIE
- Advanced Adastra
- Cleric ePCR
Users of EMIS and TPP will need to register their CIS smartcard (Care Identity Service) prior to go-live. This is currently being coordinated with ICS leads and primary care IT providers at an ICS level.
Users of the following EPR systems will be able to access the Urgent Care Plan via the local Health Information Exchanges (London Shared Care Record) or via a web portal using two-factor authentication from the point of go-live:
- Vision
- Cleric CAD
- Cerner Millennium
- Servelec RIO
- System C Medway
- Azeuscare
- Advanced CareNotes
- Allscripts Sunrise
- Care First
- Corelogic
- Epic
- iSoft iCM
- Liquidlogic
- Lorenzo
- Servelec Mosaic
- Silverlink PAS
- SMI iCare.
Access via these EPRs will be available via your EPR without the requirement for a separate log-in (‘federated access’) as part of the digital roadmap. We anticipate these integrations will be available for these EPRs by April 2023.
Care plans can be accessed via web portal using two-factor authentication. Existing CMC users will be contacted by the Urgent Care Plan Programme to support them to register. The web portal will be available from the point of go-live?
The UCP Programme and Better are working directly with EPR system providers including EMIS, SystmOne, Advanced, Cerner HIE and Cleric to ensure that the necessary configurations are established for users to access the Urgent Care Plan from within the context of the EPR. The UCP Programme are in the process of contacting care providers that are required to support this work or make arrangements for local configurations. Please be assured that you will be contacted if any arrangements are required.
Yes! It is important that clinicians continue to plan care with their patients and record these wishes and preferences on CMC.
The information currently recorded on CMC supports clinicians, especially ambulance clinicians, to make good clinical decisions. All existing, clinically published care plans will be migrated to and accessible via the new system.
CMC staff have been offered the opportunity to transfer to South West London CCG on the 1st April 2022 to support the UCP Programme with training, engagement, and transformation. Support for training will be provided in a different way going forwards:
- Initial system training will be coordinated by the UCP Programme, with “train the trainer” training commencing in February 2022. Organisations will be contacted in due course to make arrangements.
- Training for new users will be delivered to individuals and organisations, via a “Train the Trainer” approach, accompanied by webinars and video training.
- User guides developed by the UCP Programme will be available.
Clinical training and clinical engagement will be co-developed, produced and delivered by the UCP Programme, in partnership with London networks, systems and stakeholders. Organisations will need to incorporate clinical training regarding care planning within organisational training programmes. Clinical training is expected to start after the initial implementation phase.
Familiarisation sessions and resources will be available to existing CMC users, however we expect the new system to be intuitive, as the care plan format and principles will be maintained within the new platform.
The future service will continue to be funded by the five London CCGs.
The future contract will be awarded for 3 years (April 2022 to March 2025) with an option for 2 x 12-month extensions.
For any further queries relating to the Urgent Care plan programme or transition of CMC, please contact the Urgent Care Plan Programme team:
Urgent Care Plan Programme (ucp.programme@swlondon.nhs.uk)
Murrae Tolson (murrae.tolson@swlondon.nhs.uk) – Strategic Commissioner for London
Lucy Colleer (lucy.colleer@swlondon.nhs.uk) – Project Officer – UCP Programme
For information regarding local implementation, you can contact your ICS Lead:
North West London: Michelle Scaife (michelle.scaife@nhs.net)
North Central London: Patrick Schrijnen (patrickschrijnen@nhs.net)
North East London: Toyin Ajidele (t.ajidele@nhs.net)
South East London: Holly Eden (holly.eden@nhs.net)
South West London: Else Krajenbrink (else.krajenbrink@swlondon.nhs.uk) or Viccie Nelson (Viccie.nelson@swlondon.nhs.uk)
