Proactive Care Plan View

What is the PCP view? 

In 2014/15 a word template, known as the Proactive Care Plan (PCP) was developed in response to a requirement from NHS England that GP practices identify the 2% of patients most at risk of unplanned hospital admission and then produce and share anticipatory care plans to reduce their risk of admission. The scope has since been increased to include care home residents and patients on the palliative care register

  • The information on the PCP is currently being shared with Out of Hours GPs and the 111 services as an emailed document.

GPs at EMIS practices are now able to create the care plans directly onto their clinical system, using a data entry template. This means that the information is now available to the Oxfordshire Care Summary.

What is different about the PCP view?

The PCP view in the OCS is a combination of information. Some of the information is already available in the standard views and some is new information relating to care plans. The information is presented in a series of tabs, with the intention of assisting clinicians providing unplanned care including:

  • Summary Tab containing information on resuscitation status, anticipatory care planning and patient preferences
  • Care planning tab containing information on community care planning, religion, and accommodation
  • Advance planning tab containing information on powers of attorney and advance directives
  • Carers and other professionals tab
  • Recent observations tab
  • Attached documents and other useful information tab

Where explanation of terms may be required, we have added information in hover boxes in the OCS.

It is anticipated that improvements will be required to the layout and content; regular reviews are planned and comments from all users are welcome.


How do I upload a document to the PCP?

  • There is user guidance that is linked on the foot of this page
  • Alternatively, you can visit the OCS user resources page


Frequently asked questions

Why is there a message to say that the GP did not intentionally create a PCP?

In order to complete the PCP, GPs use the data entry template. This template uses Read codes, which are the coding terms used in GP clinical systems. It is possible that GPs may enter information under these Read codes without using the PCP data entry template. The information you see will be accurate and up-to-date, and may well be useful, but it is likely that far fewer of the fields will be complete.

Why do I get a message about INPS patients?

At present, the data entry template is only available for EMIS practices. INPS practices will continue to complete a Word template, which they will post to the OCS as an attached document. Please note that the information on these documents will not necessarily be the latest information. Some of the information may also be available in the standard OCS views

Why isn’t there more information about informal carers?

We have to be sure that informal carers consent to their details being shared. Processes are being developed to enable this; we hope to be able to add this information in future releases

There is an entry to indicate that an advance directive exists, but I can’t see the document. Why is this?

It is possible to upload documents to the OCS, but the GP may not yet have done so, or may not have access to the document

Why don’t you show all recent tests?

The tests in the PCP view were identified by the clinicians who developed the PCP as being the most useful. You may wish to refer to the tests and investigations tabs in the standard view.


Comments and questions are always welcome:

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