Too many patients end their days in hospital, when they would far rather be at home with loved ones.
Now, for the first time, a secure on-line system links patients with GPs, hospitals and even paramedics, so that everyone can instantly see where patients want to go – and whether they want to be resuscitated.
The pilot project in London, called Co-ordinate My Care (CMC) plan, has seen marked changes in where people are dying, and the way in which they die.
Jane Leaver, who is a doctor herself, has multiple health problems and has had to confront her own mortality.
She told Channel 4 News that if she became unconscious she might, for instance, need intravenous feeding with a drip. But because that is not normally done at home, she has been able to say in advance that she does not want to be taken to hospital and a community health team can keep her at home.
CMC was started by Professor Julia Riley, a palliative care consultant who had seen her own sister-in-law struggle to have her wishes followed as she died from cancer.
Riley said: “She was looked after by two good hospitals, a good hospice, a community service, a GP – a very good GP. And yet those services run 9-5, which is one-third of the week.
“So when you call for help in the other two-thirds of the week you are getting people to care for you who don’t know you, haven’t seen you, don’t even know what the diagnosis is. Why could we just not all share that information?
“So when she did die, a group of us got together and we did a paper form of a care plan and then the paper form became digital and then the digital form connected to the urgent care services direct.”