The local NHS, end of life charity Marie Curie and St Christopher’s Hospice have joined forces to ensure the care wishes of local people are recorded and available to paramedics, GPs and other NHS and adult social care staff involved in their care.
The new pilot project, paid for by a South West London Innovation Fund grant worth over £96,500, aims to support over 250 housebound people living with a multiple long-term conditions to develop ‘universal care plans’.
Universal care plans enable south west Londoners to have their care and support wishes shared with healthcare professionals across the capital – sometimes hospital care is not a person’s first preference, especially if it could be avoided.
South west London GPs have identified people who they believe will benefit the most from the creation of a plan, Including those who have visited A&E several times or who have been admitted to hospital in an emergency.
The plan is created following a detailed conversation between a Marie Curie or St Christopher’s nurse and the person involved. Throughout the conversation, the nurse will 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 patient’s care, such as relatives.
Adebusola Olalekan-Sule, Marie Curie Clinical Nurse Manager and Urgent Care Plan Clinical Lead said: “Having a care plan ensures that your wishes and preferences, as well as the plan for an urgent situation, are always considered when healthcare professionals are caring for you or providing you with medical treatment. Feedback from patients we have spoken to so far has been really positive.”
Ellie Suthers, Clinical Nurse Specialist, Advance Care Planning from St Christopher’s said: “Care planning also values you as an expert in the planning and management of your own health and wellbeing. This ensures that your care is delivered in line with what matters to you.”
The pilot began on 13 January 2023 for three months and is due to end mid April 2023.
About the Universal care plan
The plan is a record of people’s healthcare and support wishes. They are available digitally to all the health professionals involved in a person’s care – such as clinicians in hospitals, GPs, paramedics from the London Ambulance Service, clinicians from community health services and other appropriate NHS staff as well as adult social care colleagues.
The plans can be accessed 24/7 – which means they are available in an emergency as well as for routine care. Marie Curie and St Christopher’s nurses will be using the London Universal Care Plan digital system to create the plans.
The plan can be developed online, by phone or face to face, as required, based on people’s needs, wishes and their digital skills. The nurse’s notes will form the basis of a comprehensive personalised plan.
The plan helps people with multiple physical and mental health conditions make decisions about managing their health based on what matters to them. Importantly, care plans also recognise that, for many people, their needs arise from circumstances beyond the purely medical, and will support them to connect to the care and support options available in their communities.
A plan also supports end of life care planning for some people – where appropriate – but it is not limited to this.
Plans can be continuously updated throughout the person’s life, depending on their needs and wishes. As soon as information is recorded in the plan it becomes available digitally to those professionals caring for the person.