Help Others Discover – Click to Share!
THE INTEROPERABILITY GAP: In 2025, 93% of NHS provider organisations had an Electronic Patient Record — but only 30% had fully integrated, bi-directional data flows.
In 2025, 93% of NHS provider organisations had an Electronic Patient Record, but only 30% had fully integrated, bi-directional data flows. District nurse numbers had fallen 43% between 2009 and 2024, from 7,643 to 4,322, while 100,100 NHS vacancies remained, including 25,600 nursing vacancies.
The pressure points, at a glance:
Metric | Figure |
NHS providers with an EPR (2025) | 93% |
Providers with fully integrated, bi-directional data flows | 30% |
Decline in district nurse numbers (2009–2024) | 43% |
NHS vacancies remaining | 100,100 |
Nursing vacancies | 25,600 |
Hospital bed days: medically fit for discharge | ~11% |
Estimated cost of delayed discharges (2025/26) | £2.7bn |
Virtual ward beds per 100,000 people (Mar 2025) | 20 |
Admissions avoided via virtual wards (South East) | 9,000 |
These numbers point to a clear problem: demand for care closer to home is rising, workforce capacity is under pressure, hospital capacity is constrained, and disconnected systems are making it harder to deliver safe, coordinated home based care for patients.
The NHS is moving care closer to where people live. District nursing, community rehabilitation, virtual wards, hospital-at-home services, remote monitoring and end-of-life care are becoming increasingly important parts of the healthcare pathway.
The NHS 10 Year Health Plan for England, published in July 2025, puts this direction at the centre of its strategy through three major shifts:
✓ Hospital to community
✓ Sickness to prevention
✓ Analogue to digital
Home and community care sits directly at the intersection of all three. The plan also supports Neighbourhood Health Services, Integrated Neighbourhood Teams, virtual wards, earlier intervention and greater use of digital technology, AI and remote monitoring.
For healthcare providers, this means technology cannot simply support what happens inside a hospital. It must connect the entire patient journey, from referral and assessment to home visits, monitoring, escalation, discharge and long-term follow-up.
This is where Cellma fits.
Having an EPR is no longer enough.
A district nurse visiting a patient at home may need access to their GP information, hospital history, medications, allergies, referrals, care plans, test results and previous community visits. A virtual ward team may also need real-time monitoring information. The patient may need to manage appointments, communicate with their care team or access relevant information through a patient portal.
If these systems cannot communicate, clinicians are left searching across applications, manually entering information or relying on fragmented communication.
THE RESEARCH SHOWS: Although 93% of NHS providers use an EPR, only 30% have fully integrated, bi-directional data flows. Similarly, all ICBs have commissioned virtual wards, but only 86% of providers report having hospital-at-home services operationally in place, and only around two-thirds of those can share data digitally for clinical decision-making.
Cellma is designed around connected healthcare rather than isolated workflows.
Its interoperability capabilities include:
Together, these capabilities provide the digital foundation required for connected community and home-based pathways.
A successful home-based model is not only about giving clinicians better tools. Patients need a digital front door too.
A patient portal can give people greater visibility of their appointments, communications, care information and interactions with healthcare teams without requiring every interaction to begin with a phone call.
For community services, this becomes particularly useful when patients are receiving ongoing care at home. Appointment management, digital questionnaires, document sharing and secure messaging can help patients remain involved in their care while reducing unnecessary administrative contact for stretched teams.
Cellmaflex supports this patient-facing approach with features such as:
✓ Online booking
✓ Digital questionnaires
✓ Document upload
✓ Secure messaging
✓ Access to patient records
✓ Multi-factor authentication
The NHS App is also becoming an increasingly important access point for digital healthcare. The research pack identifies self-referral, appointment management and access to care plans as growing uses of patient-facing digital tools, while highlighting the importance of digital inclusion.
For community and district nursing services, connecting the clinical EPR with patient-facing services creates a more continuous digital journey—rather than treating the home visit as a separate episode of care.
A connected home-care pathway can involve several teams, systems and points of contact. Cellma brings these workflows together through a single patient record and connected clinical processes.
1. Referral and Identification
Patients can enter a home-based pathway through a GP, hospital discharge team, community service or other referral route.
Cellma’s PAS module and referral capabilities can support the movement of information from referral through assessment, helping teams work from structured patient information rather than fragmented paperwork.
With interoperability through HL7, FHIR, APIs, GP Connect and NHS e-RS, information can move between relevant systems rather than remaining locked within one organisation.
2. Assessment and Care Planning
Once a patient is referred, community nurses, therapists, GPs and other members of an Integrated Neighbourhood Team need a shared understanding of their needs.
Cellma’s EPR module provides access to clinical information, documentation and care plans, giving professionals a connected view of the patient’s journey.
WHY IT MATTERS: The number of people aged over 85 in England is projected to reach 2.6 million within 25 years, while the proportion of people aged over 65 living with two or more long-term conditions is projected to increase from 54% to around 67.8% by 2035.
As complexity increases, the ability to coordinate care around the individual becomes increasingly important.
3.Virtual Wards and Remote Monitoring
Virtual wards are becoming a core part of the NHS’s shift towards care outside traditional hospital settings.
Remote monitoring can capture information from the patient’s home, while clinical teams need to be able to interpret that information alongside the patient’s wider record.
Cellma’s interoperability framework can connect external systems, while its BI dashboards, reporting capabilities, AI alerts and clinical intelligence roadmap can support teams in identifying information that requires attention.
The objective is not simply to collect more data. It is to make relevant data available to the right team at the right point in the care pathway.
4. Mobile Community Working
Home visits present very different working conditions from an acute hospital environment.
District nurses and community clinicians need to access patient information, record observations, update care plans and document interventions while working across multiple locations.
A community-focused EPR therefore needs to support clinicians beyond the hospital workstation.
Cellma’s mobile and web-based approach supports access to clinical workflows while clinicians are delivering care in the community. Combined with voice-to-text capabilities and AI-enabled documentation on its development roadmap, this can help reduce the amount of time clinicians spend completing repetitive administrative tasks.
CAPACITY UNDER PRESSURE: District nurse numbers fell 43% between 2009 and 2024, while approximately one in four band 6 or above district nurses left the profession in the year to September 2024.
Technology cannot replace skilled community clinicians. But it can reduce the amount of clinical time lost to disconnected processes and documentation.
5. Escalation and Continuity
A patient’s condition can change quickly when care is delivered at home.
If deterioration occurs, the patient may move from community care to urgent care or hospital services. At that point, clinicians need access to an accurate history.
Shared Care Records, GP connectivity and interoperability with acute systems can help prevent the patient journey from becoming fragmented when their care setting changes.
This is particularly important because one of the major problems identified in current home-care pathways is the lack of visibility between hospital, community, primary care and social care.
With Cellma, the goal is to maintain continuity around the patient, rather than around the organisation providing the care.
Workforce Pressure
Community teams are being asked to manage increasing demand with limited workforce capacity.
Cellma can support this through structured workflows, digital documentation, automated communications, reporting, task management and AI-enabled capabilities such as voice-to-text, predictive analytics and intelligent alerts.
The result is a technology environment designed to support clinicians rather than create another layer of administration.
Fragmented Information
When information sits in separate systems, clinicians may spend valuable time searching, checking and re-entering data.
Cellma’s standards-based interoperability, including HL7, FHIR and APIs, is designed to connect systems and support the movement of information across care settings.
This is particularly relevant when the NHS is seeking genuine bi-directional interoperability, rather than simply having an EPR in place.
Delayed Discharge
Delayed discharge is not solely a hospital problem. It is also a community capacity problem.
The research pack identifies insufficient step-down, reablement and home-based care capacity as a significant contributor to delayed discharge. The financial impact reached an estimated £2.7 billion in 2025/26.
By supporting referral management, care coordination, community workflows, patient engagement and connected clinical information, Cellma can form part of the digital infrastructure needed to support patients moving safely from hospital to home.
Documentation Overload
Home visits should be about the patient, not the paperwork.
Cellma’s voice-to-text capabilities, AI roadmap, automated notifications, digital documentation and structured clinical workflows can help reduce repetitive administrative activity.
The NHS is also moving rapidly towards AI-enabled documentation. A national registry of 19 ambient voice technology suppliers was published in January 2026, demonstrating the growing focus on AI-supported clinical documentation.
Digital Exclusion
Digital care should not mean digital-only care.
A KEY FINDING: 31.5% of patients referred to a virtual ward during a North West London evaluation did not use the associated digital app, citing barriers including language, access, training and IT skills.
This is why digital innovation in home-based care for patients must be supported by inclusive pathways. Patients should be able to engage digitally where appropriate, while alternative channels remain available for people who need them.
The future of community care will involve more than simply moving existing hospital processes into the home. It will require a connected ecosystem where:
✓ Patients can access information and interact with services
✓ District nurses and community teams can view and update patient information at the point of care
✓ GPs and hospital teams can access relevant information when patients move between settings
✓ Virtual ward teams can bring monitoring information into clinical workflows
✓ Managers and commissioners can use reporting and analytics to understand demand, outcomes and capacity
✓ Integrated Neighbourhood Teams can coordinate care around the patient rather than around individual organisations
Cellma brings these requirements together through its EPR, PAS, interoperability framework, patient-facing capabilities, reporting and analytics, clinical workflows and AI-enabled roadmap.
The shift from hospital to community is already underway. Virtual wards have moved beyond pilot programmes, neighbourhood care is becoming a central NHS delivery model, and digital technologies are increasingly being used to support clinicians and patients outside traditional healthcare settings.
But technology only delivers value when systems can communicate, clinicians can access information where care happens, and patients can participate in their own care.
The NHS 10 Year Health Plan has established the direction: hospital to community, sickness to prevention, and analogue to digital.
Cellma provides the digital infrastructure to support that direction, connecting clinical information, community workflows, patient engagement, interoperability, analytics and emerging AI capabilities across the care journey.
Because better home-based care for patients does not begin when the clinician arrives at the front door. It begins with connected information, coordinated teams and a digital healthcare ecosystem designed around the patient’s journey.
Discover how Cellma can support community services, district nursing, virtual wards and integrated care with a connected EPR built for modern healthcare delivery.
Book a free Cellma demo and see how connected digital care can support your move from hospital to home.
Recent Blogs
Let’s transform healthcare together. Speak with RioMed for a tailored solution.
Cellma connects patient records, referrals, care plans, clinical documentation, community workflows and patient-facing services in one connected digital ecosystem. Its interoperability with systems such as GP Connect, NHS e-RS, Shared Care Records, HL7 and FHIR helps clinicians access relevant information across care settings.
Cellma supports mobile working, digital documentation, care coordination, automated communications, reporting and AI-enabled capabilities such as voice-to-text and intelligent alerts. This can help community teams spend less time managing paperwork and more time delivering patient care.
Yes. Cellma's patient-facing capabilities, including Cellmaflex, support online booking, digital questionnaires, document uploads, secure messaging, access to patient records and multi-factor authentication. These tools can help patients stay connected with their care teams while supporting the NHS's shift towards digital-first community care.
