Yossi Cohen, Physician Executive at InterSystems, said on May 27 that achieving England’s 2027 health targets will require upgrading shared care records to allow cross-organisational co-authorship of care plans. Cohen recommended piloting this collaborative and patient-inclusive approach with small cohorts before expanding it across the National Health Service.
England’s 10 Year Health Plan aims for 95% of people with complex needs to have an agreed care plan by 2027, a significant increase from the current rate where only about one in five people with a long-term condition has such a plan. The plan argues that every £1 invested in personalised care planning can deliver £3 in value, positioning care planning as both a policy goal and a practical tool for better outcomes and more coordinated services.
Cohen said that setting targets alone is not enough, "Care plans must remain current, accessible, and useful as people move between primary, secondary, and community care," he said. This need becomes more urgent as more healthcare shifts into the community through initiatives like the Neighbourhood Health Service, which is supported by £300 million for NHS technology upgrades and the creation of 250 new Neighbourhood Health Centres.
Shared care records have improved visibility by consolidating information from various settings but do not yet provide true shared authorship. Cohen said 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." He highlighted issues such as duplication of work and unclear accountability when there is no shared plan during transitions like hospital discharge.
Cohen also addressed the importance of patient involvement: "When patients are not simply passive readers of their plan but can contribute to it, engagement can improve." He outlined how existing shared care record systems could support these changes through established access management structures, governance frameworks, reuse of clinical information already held within records, and mechanisms for patient access and contribution.
To address challenges in change management across organisations, Cohen suggested starting with defined patient cohorts before scaling up. "A realistic way forward is to begin with one defined patient cohort...and develop the relevant cross-organisational care plan for that group," he said. He concluded that scalable progress will likely come from steady local efforts demonstrating joined-up planning across entire pathways.
