Universal Care Plan (UCP)

What is the Universal Care Plan?

The Universal Care Plan (UCP) is a digital personalised care plan available across all of London. 

It captures what matters to the patient, their care preferences, and clinical updates.

It is visible in real time to London Ambulance Service, GPs, community, OOH teams and A&E departments.

It is a vital tool to enable the right things to happen especially in a crisis.

Who is it for?

Any patient who would benefit from proactive, coordinated planning.

Prioritise patients on your palliative / end of life register, frailty register, care home list, or those with frequent unplanned admissions. 

Where do I find it — do I need a separate login?

No separate login is needed for most NWL practices. Access it directly from your clinical system:

  • EMIS Web - launch via the UCP widget within the patient record

  • SystmOne - access via the integrated UCP link within the patient record

  • Web portal access - ucp.onelondon.online

How do I identify patients and create a plan?

Use the EARLY toolkit (available in EMIS and SystmOne) to flag patients who may benefit from a care planning conversation.

Then open the UCP from within the patient record, search by NHS number, and work through the template.

Save at any point — the plan is immediately visible to other services.

What are the key fields to complete

The minimum information should include CPR status, professional and family contacts plus key symptom management plans e.g. what if pain or breathing deteriorates

Who can see it and does the patient need to consent?

Yes, verbal consent is needed. ''Are you happy for me to complete an electronic care plan to keep everyone involved in your care up to date?''

It can be accessed by the London Ambulance Service, NHS 111, OOH GPs, community nursing, and hospital teams - and patients can view it themselves via the NHS App. 

When should I update it?

After any hospital or hospice admission, on significant clinical change.

Keeping it current is what makes it useful in a crisis.

 

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St Luke's Hospice at Home

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Referral form for clinician use only.

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Rapid access services

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T. 0208 102 5000

W. https://www.pembridgehospice.org/

Pembridge Hospice provides palliative care services and advice to the residents of Brent, Central London, West London and Hammermith and Fulham.

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Urgent rapid response visits can be made to patients registered with a Harrow GP

 

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T. 020 7806 4027

St. John's Hospice provides palliative care services to the residents of Brent and Westminster.

Telephone response will be received within 2 hours.

Inclusions are: Terminal care last 2 weeks of life, 24 hour, admission avoidance, facilitated discharge and respite care escorting a patient.

Referral form for clinician use only.

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Overnight/weekend services

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24 hour Helpline Pall24 for North Brent and Harrow

T. 03000 200 224

This service was formerly known as Single Point of Access (SPA)

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St John's Hospice at Home

T. 020 7806 4027

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Telephone response will be received within 2 hours.

Inclusions are: Terminal care last 2 weeks of life, 24 hour, admission avoidance, facilitated discharge and respite care escorting a patient.

Referral form for clinician use only.

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