In this blog, we hear from Dr Saif Ahmed, Clinical Digital Lead for Transformation at Health Innovation Manchester, a leading voice in digital transformation across Greater Manchester’s health and care system. Saif explores how the GM Care Record is not just a digital tool – but a cornerstone of the region’s evolving neighbourhood model. With a focus on integrated, person-centred care, Saif outlines how the GM Care Record enables clinicians and care teams to access real-time, comprehensive patient information across primary, secondary, community, and social care settings. This seamless access supports safer, more coordinated decision-making and empowers local teams to deliver care that is truly tailored to the needs of their communities. His insights offer a compelling look at how data-driven innovation is helping to reshape care delivery across Greater Manchester.

When we talk about delivering truly integrated care in Greater Manchester, the conversation always comes back to one thing: connection. Connection between services, connection between people, and crucially, connection through data.

The GM Care Record (GMCR) is one of the most powerful enablers we have for this. It already gives clinicians and professionals across health and care a single, secure view of key patient information. But I believe its true potential lies in becoming the backbone of our neighbourhood model of care.

Connecting services at neighbourhood level
Neighbourhood models thrive on bringing together general practice, community services, social care, mental health, voluntary sector, and acute teams around the needs of a defined population. The challenge has always been: how do we get everyone working from the same page?

That’s where GMCR makes the difference. By linking data from across settings, it ensures that whichever professional a resident sees, whether it’s a GP, district nurse, social worker, or hospital consultant, they can access the same information and understand the person’s journey without asking them to repeat their story.

Shared care plans as the glue
Beyond information sharing, care planning within GMCR is where we can really deliver transformation. Shared care plans—covering long-term conditions, frailty, dementia, heart failure and end-of-life care (EPaCCS)—provide a live, dynamic record of what matters most to a person and how different services can coordinate around it.
• Frailty care plans allow us to anticipate and prevent crises, supporting people to live well at home for longer.
• Dementia care plans ensure continuity, dignity, and shared understanding as needs evolve.
• EPaCCS (Electronic Palliative Care Coordination System) plans are already proving powerful in Greater Manchester, ensuring that people’s end-of-life wishes are visible
and respected across services.

These plans are not “documents” but living agreements between the resident, their family, and the professionals supporting them.

Driving the three “left shifts”
The NHS 10-Year Plan sets out the need to shift care:
1. From hospital to community
2. From treatment to prevention
3. From analogue to digital

GMCR is already enabling this shift. By embedding shared care plans and expanding their use across neighbourhoods, we can move from reactive, episodic care to proactive, person centred models that make sense for residents and professionals alike.

Health Innovation Manchester: Three Programmes of Work
To make GMCR truly meaningful, Health Innovation Manchester has been leading three major programmes of work. Each one strengthens the reliability, reach, and impact of the GMCR, ensuring it is trusted by professionals and delivers benefits for residents.

1. Increasing GMCR Usage through Clinical Engagement
Adoption only happens when frontline teams see value. Through ongoing engagement with GPs, nurses, hospital consultants, social workers, and community teams, we’ve been embedding GMCR into daily workflows. Usage continues to grow, reflecting the confidence clinicians now have in it as the “go-to” source for shared patient information.

2. Data Optimisation of Feeds
The GMCR is only as good as the data it holds. By improving the quality, completeness, and timeliness of feeds across GP, hospital, mental health, social care, and community systems, we’re building a record that professionals can rely on. This optimisation work ensures that every click into GMCR provides meaningful, accurate, and actionable insight.

3. New Models of Care
The GMCR is not just a passive information store—it’s being actively woven into new models of care. Frailty, dementia, and EPaCCS (Electronic Palliative Care Coordination System) are prime examples. Shared care plans provide a live, collaborative record of what matters most to people and how services will work together around them. These models are proving how digital tools can directly enable prevention, continuity, and dignity in care.

A foundation for innovation
In Greater Manchester, we now have 6,500+ live EPaCCS plans and more than 15,000 completed. Outcome data from over 800 patients with a GMCR EPaCCS showed that a preferred place of death was achieved in 84% of cases compared to a national average of just 50–55%. That’s not just a statistic its a powerful example of how digital tools, used well, can improve outcomes and support what matters most to people and families at the most difficult time of their lives.

The next step is scaling this across every neighbourhood, linking frailty, dementia, and longterm condition care planning so that the GMCR becomes the central nervous system of our integrated care system. This work is clinically led, operationally delivered, and digitally enabled through the GMCR, ensuring that transformation is rooted in frontline leadership, supported by operational delivery, and powered by digital innovation. This is not just about technology it’s about culture, trust, and the confidence that when you open GMCR, you see the whole picture of a person’s care.