Integrated Care Delivery with Cellma and the NHS Plan

As of October 2023, there were an astounding 7.7 million people waiting for NHS treatment in England. With the introduction of integrated care systems (ICSs) and improved digital solutions, that number dropped to 7.6 million by February 2024. However, the end of long waits for treatment is nowhere in sight. In January 2025 alone, over 221,000 patients waited over 4 hours for emergency admission after the decision to admit. Over 129,000 patients waited for over 12 hours from their arrival to their admission in A&E (an all-time high). This is a clear signal that there are significant bottlenecks in care pathways, and an urgent need, across all health providers, to achieve a sense of urgency in the emergency care system. 
 
These are not mere numbers, they are accounts of delayed care, system overwhelm and disparate services. The challenge is sometimes not the lack of care, but the lack of connection. In response, the NHS introduced the ‘Fit for the Future’ 10-Year Plan, focusing on prevention, people-centred care, digital transformation, and, above all, integration. 
 
This is where Cellma, our NHS-aligned Electronic Health Record (EHR) and care coordination platform, plays a transformational role in enabling true Integrated Care Delivery. 

Why Integrated Care Delivery is the Future – And the Present 

Between December 2021 and November 2023, the NHS completed over 6.15 million patient pathways across hospital and community settings, a 46.8% increase. But managing millions of patients through fractured systems is unsustainable. Integrated care means building connected pathways, where a patient’s journey is supported from GP to discharge, home care to rehabilitation, without gaps, repetition, or loss of information. 

Integrated Care Systems and neighbourhood-based models demand not just clinical excellence, but digital architecture that supports collaboration across providers. Cellma, a modern age EHR, makes that vision a reality, every day, across the UK and internationally. 

Understanding How Cellma Supports Integrated Care at Every Step 
From entry to the system, to discharge, to follow-up, Cellma supports the full integrated care flow, bringing primary care, secondary services, mental health, community teams, and social care services on one digital platform. 

This is how: 
Entry & Risk Stratification 
Patients who enter care are typically via the GP, A&E, 111, or community referrals. 
With Cellma the entry to care is documented immediately, and risk stratified using the tools that can be configured to reflect the identification of frailty, long-term conditions (LTCs), or complex social needs, which is the pursuit of the patient. Care coordination starts early, with automated alerts and team assignment. 

Holistic Assessment Across Care Domains 
Cellma captures not just medical data, but also: 

• Mental health evaluations 

• Social determinants (housing, food insecurity, carer support) 

• Functional assessments (mobility, ADLs) 

By bringing all of this into one shared EHR, Cellma ensures every stakeholder sees the full picture, not just their slice of it. 

Shared, Patient-Centred Care Planning 
With Cellma, care plans are: 

• Co-created with patients and carers 

• Accessible to all members of the MDT: GP, nurse, mental health worker, physio, pharmacist, voluntary sector, and more 

• Customised with patient goals, lifestyle considerations, and clinical needs 

Care plans are stored directly within the EPR and accessible across ICSs — reducing duplication and enabling real-time updates. 

Collaborative Delivery Across All Aspects of Care 
Cellma allows all care professionals across settings to:

• View notes, referrals, diagnostics and prescriptions in real-time 

• Link appointments, reviews, home visits and therapies 

• Take advantage of automated notifications, clinical flags and tracking of adherence 

• Link to social and voluntary care services encompassing food deliveries, befriending and transport 
  
  

Continuous Monitoring, Feedback and Adjustment 
Cellma enables: 

• Dashboards for Patient-Reported Outcome Measures (PROMs) and Experience Measures (PREMs) 

• Scheduled MDT reviews at 3, 6 or 12 months according to risk 

• Real-time feedback loops to adapt care plans if the needs of the patient changes 
  
  

Cellma is a living system, not a static record. 

Crisis Support & Escalation Without Fragmentation 
Cellma helps de-escalate pressures on A&E by facilitating:  

• Rapid response teams 

• Virtual wards 

• 24-hour 7-day community support lines
  
  

If hospital admission is necessary, Cellma ensures every care provider has access to the full patient record so that potential unsafe duplications and wasting time in critical moments, are avoided. 

Integrated Discharge & Reablement 
Discharge planning begins at admission. Cellma enables Integrated Care Systems (ICSs) to:

• Operationalise Discharge to Assess (D2A) pathways 

• Facilitate intermediate care and home reablement service provision 

• Link post-discharge reviews, medication reconciliation and community visits – all on one system
  
  

End-of-Life & Long-Term Care 
Cellma supports:

• Advance Care Planning 

• DNACPR documentation 

• Hospice and palliative input with shared visibility across all settings 
  
  

This ensures dignified, person-centred care until the very end. 

Digital Foundations for a Healthier NHS 

Cellma doesn’t just digitise records, it digitises collaboration. It supports over 30 medical specialties, communicates via NHS-standard protocols (FHIR, HL7), and integrates effortlessly with existing systems. It’s:

• Cyber Essentials Plus Certified 

• GDPR Compliant 

• Aligned with NHS DSP Toolkit 

• Featuring role-based access control and multi-factor authentication.
  
  

Cellma can integrate all the various fragmented systems into a single, unified digital platform. Cellma becomes a Single Source of Truth, removing data silos, reducing mistakes, and informing more rapid, more confident clinical decision making. 

Delivering the NHS’s Long-Term Plan Today 

The NHS envisions a future of digitally enabled neighbourhood care where prevention, personalisation, and integration are the norm. But that future isn’t distant. It’s happening now in ICSs, Trusts, and community teams already using Cellma to coordinate care. 
 
Ready to support true Integrated Care Delivery?