> ## Content Index > Fetch the complete content index at: https://med-techinsights.com/llms.txt > Use this file to discover other available public pages before exploring further. # Making care plans work across hospital and neighbourhood care - URL: https://med-techinsights.com/making-care-plans-work-across-hospital-and-neighbourhood-care/ - Published: 2026-05-27T12:30:32.000Z - Updated: 2026-10-22T08:32:17.000Z - Description: Yossi Cohen, Physician Executive at InterSystems argues that meeting England’s 2027 health targets requires upgrading shared care records to allow true cross-organisational co-authorship. He recommends piloting this collaborative, patient-inclusive approach with small cohorts before scaling it acros - Author: Oliver Johnson - Tags: Insights, Digital Health & AI ###### [***Yossi Cohen***](https://www.linkedin.com/in/yossic/?ref=med-techinsights.com)*, Physician Executive at* [***InterSystems***](https://www.linkedin.com/company/intersystems/?ref=med-techinsights.com) *argues that meeting England’s 2027 health targets requires upgrading shared care records to allow true cross-organisational co-authorship. He recommends piloting this collaborative, patient-inclusive approach with small cohorts before scaling it across the NHS.* --- England’s [10 Year Health Plan](https://www.gov.uk/government/publications/10-year-health-plan-for-england-fit-for-the-future/fit-for-the-future-10-year-health-plan-for-england-accessible-version?ref=med-techinsights.com) sets a clear target: by 2027, 95% of people with complex needs should have an agreed care plan in place. That marks a significant shift from the current position, where only around one in five people with a long-term condition has one. The case for change is also strong. The plan cites that every £1 invested in personalised care planning for frequent users of healthcare services can deliver £3 in value. This makes care planning more than a policy ambition. It is a practical foundation for better outcomes, more coordinated care, and a health service that can support more people closer to home. Realising that ambition, however, will take more than setting targets. Care plans must remain current, accessible, and useful as people move between primary, secondary, and community care. This becomes even more important as more care shifts into the community through the [Neighbourhood Health Service,](https://www.gov.uk/government/publications/neighbourhood-health-framework/neighbourhood-health-framework?ref=med-techinsights.com) backed by £300 million for NHS technology and 250 new [Neighbourhood Health Centres](https://www.gov.uk/government/news/chancellor-to-double-down-on-drive-to-cut-nhs-waiting-times-and-rollout-of-new-neighbourhood-health-centres?ref=med-techinsights.com). If care is to move more fluidly across settings, the information that supports it must do the same. This is where the challenge begins. As care plans themselves are not new, many teams already hold their own versions. ###### **From visibility to shared ownership of care plans** Shared care records have improved visibility by bringing together information from across settings, including medications, treatment plans, and escalation arrangements. Yet better visibility is not the same as shared authorship. In many places, what is still missing is a single cross-organisational care plan that can be updated by the teams involved throughout a person’s care journey. The consequences of that gap are often most visible at points of transfer, for example discharge, when responsibility for follow up moves from acute care to community services. Without a shared plan in place, duplication, weaker decisions, unclear accountability, and inappropriate placement of care can follow. What this shows is that care planning only works at scale when the plan functions as a shared working view, updated through routine care rather than revisited only at moments of escalation. For that to happen, clinicians need to trust the plan as something they can rely on in day-to-day practice. That trust is more likely to develop when ownership is clear, review dates are visible, changes can be tracked, and access reflects the role of the person using it. In other words, a care plan becomes useful not simply because it exists, but because it stays relevant. The same principle applies to the patient’s role within it. When patients are not simply passive readers of their plan but can contribute to it, engagement can improve. Ownership of care is often framed around which provider is responsible at a given moment, but patients are central to that process as well. Giving them a voice within the plan can support stronger adherence and better-informed clinical decisions. ###### **How shared care records can support care planning** Shared care records already offer a collaborative environment for care teams, enabling them to share information in order to improve decision-making and reduce waste. Significant energy and money were invested into expanding these across England over the past 10 years. As a result, they can now provide a strong foundation for cross-organisational care planning. A care planning solution based on shared care records offers several advantages: - Access – Shared care records have already established robust user access management across disparate organisations in the health economy through launching in context, Active Directory and SSO integration, as well as other approaches. A care planning solution integrated with shared care records will, therefore, be able to build on this existing investment rather than duplicating it - Governance – Cross-organisational care planning requires a coordinated approach across the care economy. Most shared care records are already supported by a governance structure that can be reused for coordination of the effort - Reuse of information – Shared care records often already contain clinical information, which is relevant for care plans, such as patient alerts, next of kin, and treatment plans, for example. This information can either be incorporated as is into 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 record by all providers anyway - Patient Access – Shared care records can enable patient access to the shared information. The same patient access mechanism can be leveraged to enable patient contributions into care plans ###### **One cohort at a time** While technology is an important enabler, a major challenge for cross-organisational care planning is change management. Even when a shared planning tool is introduced, its success depends on teams across different organisations being willing to work together collaboratively. That means that they need to agree what the shared care plan template should include, how responsibilities should be allocated across the care journey, and how far patients should contribute. A realistic way forward is to begin with one defined patient cohort of manageable size (perhaps several hundred people) and develop the relevant cross-organisational care plan for that group. This helps build confidence, not only in the technology but also in the organisational ability to use it and experience the associated benefits. Once the first model is working and governed effectively, 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 – and so, for the NHS, the message for the future is clear: scalable care planning is more likely to come from steady local progress that shows joined up planning can work across the whole care pathway.