A digital Proactive Care Plan (dPCP) to improve care for patients with complex needs

Oxfordshire CCG

The digital Proactive Care Plan (dPCP) is a Bright Idea developed in Oxfordshire in response to the direct enhanced scheme (DES) released by the government in 2013/14.

This included two key points, which the Oxfordshire Clinical Commissioning Group (OCCG) sought to address:

  • A named GP will be accountable for ensuring that a proactive care plan is provided for the 2% of a practice’s adult population most at risk of admission (total in Oxfordshire ≈11,300 patients within 77 practices)
  • A particular focus on reducing unnecessary hospital admissions and supporting appropriate admission and follow-up care

dPCPFrom this directive, the multiple care plans from practices and organisations across Oxfordshire were consolidated into one universal (paper) Proactive Care Plan.

In early 2014, the Department of Health announced that the NHS must be Paper Free by 2018, and in April 2014 the idea of a dPCP was developed.

A template to aid completion of the dPCP was designed in-house by an Oxfordshire GP working in collaboration with the EMIS Web team and South Central Commissioning Support Unit (CSU). The template was designed using the EMIS software and included Read codes with associated free text to ensure the structure of the information was consistent.
The Oxfordshire Care Summary is a local platform on which clinicians can share and view information.

GP Adoption

This has been a countywide project involving many motivated stakeholders, including GPs, secondary care, urgent care and social care providers. The majority of practices use EMIS Web – only two practices will use Vision by year-end.

The motivation has been sustained from all parties throughout the process of adoption due to the obvious potential of the dPCP in assisting with improved patient care and reduced unplanned admissions.

GP practices were required to take an active role to ensure the success of the dPCP. This required the practices to:

  • Sign information sharing protocols, as much of the data would be taken from the practice systems
  • Notify patients of the use of their information and provide an opt-out option
  • Identify patients to include 2% of the practice population in the unplanned admissions avoidance DES, palliative care register & patients residing in a care home
  • Complete a digital care plan using the template and use the template to update the care plan where appropriate 


The dPCP adoption has been a positive learning experience for all seventy-seven practices and the urgent care providers working within Oxfordshire.

EMISThe dPCP software was developed for the EMIS Web system by the EMIS Web team in collaboration with an Oxfordshire GP and the CSU team. The EMIS template is a plug-in for this system and is filled out by a GP using Read codes with associated free text. The Read-coded information can then be arranged into a specific view according to the end user, making the most useful information more accessible for the clinician.

The roll out and manual installation of the dPCP software to practices using EMIS Web was achieved either by each practices manually downloading the template or via the local EMIS Web support team.

The dPCP manual is part of a selection of training resources available to clinicians across the county. A number of videos showing how to set up and use the dPCP software within EMIS Web are available on YouTube.com, and we frequently hold training webinars.

We have had feedback from the GPs filling in the template, as well as from the urgent care clinicians who use the dPCP to assist with clinical decisions. This feedback has come from locality meetings with GPs, from project meetings with urgent care providers and through feedback options on the dPCP itself. The user feedback has been invaluable in shaping the project and making the dPCP reach its potential as a reliable, comprehensive yet concise clinical document.

Following this feedback, the dPCP is currently undergoing revision in addition to being developed for direct “one-click” access from urgent care IT systems, as having to access an isolated document costs time in urgent situations. The new version will also include electronic special patient notes as well as a more streamlined and user-friendly template.

Benefits – better patient care

The dPCP speeds up the process of care planning by creating an accurate and legible Proactive Care Plan in real-time. The efficiency benefits of using the dPCP during reviews of care are that often only small changes to the data are required, and any changes need only be recorded once in one place.

The dPCP can be used with GP2GP Version 2.2, as this allows files greater than 5 MB to be transferred. Patient records can be transferred between Oxfordshire surgeries using GP2GP so that the patient arrives with a fully prepared dPCP. This greatly reduces the burden of reviewing and updating their care plan.

Since 2010, there has been a national drive for provision of an Electronic Palliative Care Co-ordinating System (EPaCCS). The Oxfordshire Care Summary was released in March 2013 and is a portal able to provide this solution. General practice data is pivotal to providing up to date timely information for EPaCCS.
The creation of a digital PCP “View” on the OCS opens a live page reflecting the up-to-date care plan (within seconds of it being created by data entry). The need to transmit and
upload separate documents to external agencies has been eliminated, resulting in time-efficiencies.

Encoding plans digitally will enable both internal and external audit of care plan data for items such as:

  • Admission status of the case management register
  • Number of patients with a decision matrix
  • Common actions needed during reviews
  • Key health problems & care elements documented that may affect the decision to admit
  • Patients’ end of life care wishes, awareness of their diagnosis and prognosis and anticipatory medications

As every practice in Oxfordshire has signed an Information Sharing Protocol for the dPCP, the practices have agreed to a change in data sharing with other care providers. This initial change has acknowledged the positives of sharing patient data, which has the potential to benefit patients in future projects.


The dPCP is an innovative idea that sought to utilise the information technology available within the NHS in order to help keep care consistent for patients with complex needs. It has been developed through feedback from users, which has both helped to keep the dPCP user-friendly, as well as maintaining strong support from GPs and urgent care users alike.
Since July 2015, it has been used by urgent care providers, helping to reduce non-elective admissions and have care delivered in line with patients’ wishes. 

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Dr Catherine Laws

am EOLC Lead SDCCG I have been writing an EOLC proactive care plan, frankly yours looks much better! I would like to view it in its entirety before committing our GPs to using it.

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