Social Care Analytics Exemplar – Health Innovation Network South London: Advanced and Urgent Care Planning Accelerator

Advanced and Urgent Care Planning Accelerator

Ellen Pirie, Senior Project Manager (Healthy Aging), Health Innovation Network South London

20th August 2021 about a 4 minute read

In the summer of 2020 the Health Innovation Network (HIN) were commissioned to lead a programme of work across London to improve the adoption and quality of the advanced and urgent care planning system Coordinate My Care (CMC).  This digital system had been used in London for many years but the COVID19 pandemic had meant that there was an added urgency to ensuring that the needs and wishes of patients and their families were captured and shared across the London health and care system.

At the start of the pandemic there had been a big focus on creating new CMC records.  However it was felt that more needed to be done to encourage wider system use of these records and it was agreed that a number of projects across London would be given funding for additional staff to lead the adoption and quality drive within their organisations.  This would generate case studies and resources which could then be shared more widely across London.

The HIN appointed a senior project manager to lead the programme and she liaised with the 5 ICS/STP teams to discuss potential projects, the followed these up to producet project briefs and MoU. Regular progress meetings were held with each team and two collaboration events in November and March to enable the teams to meet each other.

Six of the eight projects identified were in Acute Trusts and usually were led by either the Palliative Care team or by the Frailty Teams.  Initially all the teams spent time ensuring that the data on their users was up to date and correctly structured to reflect their departmental structure.  This data then helped them to see where CMC was and was not being used.  They could then provide training and support in targeted areas to improve the access and use of the CMC records.

The remaining two projects were in primary care and these both used the additional resourcing to try out new models of engagement with CMC. In South East London a volunteer from an NHS commissioning background provided support to a GP practice responsible for care home residents and in Balham, Tooting and Furzedown Primary Care Network a paramedic was employed to help update and create CMC records.

All of the projects were delayed during January and February 2021 due to the impact of COVID19.  However by March most of the projects were able to restart.

An online conference was held on 6th July 2021 and all the projects presented their work and explained their approach.  Several of the teams used a QI approach and found that driver diagrams were very helpful in breaking down their goal into manageable elements. The conference was very well attended with 146 individuals taking part throughout the day. Feedback was very positive that the information shared was very interesting and useful.

The recordings from the conference, results of all the projects, including final posters, presentations, videos and resources available for others to use are published on

The HIN also produced a final poster highlighting our key recommendations based on our observations across all the projects:

  • Shared digital advance & urgent care planning should be part of organisation’s strategic planning.
  • Sustainable resources for leadership and training are required.
  • The culture and skills required need to be developed and embedded across the wider clinical workforce and supporting services (e.g., IT, HR, medical education).
  • Technology solutions should be better integrated (e.g., with organisational user directories and with primary and secondary care record systems) and more responsive (e.g., enabling adhoc local reporting) to make spread and adoption of shared digital care planning easier, more effective and higher quality.