Background Advance care plans (ACP) allow individuals to specify their wishes and preferences for future treatment and care. An effective ACP needs to be available to the patient and all relevant health and care professionals (Lund, Richardson, May, 2015). Currently there is no consistent approach to recording, updating and contemporary sharing of an individual’s end-of-life care preferences, decisions and plans between health and care providers, patients and their family or carers in our Integrated Care System (ICS).

Aim Current ICS strategic priorities include developing personalised care planning approaches to improve shared decision making. Digital sharing of ACPs in real time, accessible to all health care providers, and to patients, carers and families via an online patient portal will support patients to share what really matters to them, reduce the need to re-tell their stories and achieve better care preferences.

Methods A key enabler was the developing system-wide digital shared care record programme. To deliver a digital ACP collaboration between patients, carers and health and care providers was facilitated by a focused review of current approaches to ACP, delivery of virtual workshops based on a co-production approach, and wide stakeholder involvement.

Results As part of a wider shared care record across the ICS, the digital ACP will deliver an accessible person-centred, real time record. Equality, diversity and inclusivity especially digital exclusion, have been addressed throughout the project. Synergies with the national ‘What Matters conversation movement’(End of Life Care Think Tank, 2021) and the personalised care (NHS: Delivering universal personalised care) agenda have also been prioritised.

Outcome On completion of the technical build, user acceptance testing will be performed before implementation. The ACP digital document will then ‘travel’ with patients wherever their care takes place, whether at home, ambulance, hospital, care home or hospice. Real time updating ensures their plan will be contemporary, supporting ‘What Matters’ to individual patients to remain central to the care they receive.