MMargaret67 · Type 2 diabetes · annual reviewEMISRecord linked
Goal · agreed with Margaret
No care plan yetStart with a goal you agree together.
Cut down on sugary drinksWalk more each daySleep better
GoalWalk more each dayIn her language
Walk after lunchAction · every day
Getting started with walkingVideo
Local walking groupService near her
Send in Margaret’s language
Suggested for this goal
Walk after lunchAction · every day+
Getting started with walkingVideo+
Local walking groupService near her+
Share with Margaret
Built in under 5 minutes†
Margaret’s care planGoalWalk more each day
Walk after lunchAction · every day
Getting started with walkingVideo
Local walking groupService near her
10:42
TodayHello, Margaret
Your care plan will appear here
Your care planFrom Priya, Practice NurseGoalWalk more each dayWalk after lunchGetting started with walkingLocal walking group
Healum · nowYour care plan from Priya, Practice Nurse
A neighbourhood team
One plan instead of five
Jo leads the Northgate neighbourhood team. When Gareth falls for the second time this year, the GP, the nurse, the pharmacist, the link worker and the coach work from one record, and give him one plan.
The neighbourhood team
HomeInsightsPeopleTeamsMessagingManagePS
Team Members5members
Services3services
Referrals Handled48▲ 12%vs previous 30 days
Joint Plans31▲ 26%vs previous 30 days
PracticesNorthgate - 58%Beck Lane - 42%
Set UpOct 12026
MembersTeamsNorthgate neighbourhood teamSearch members...Add member
NameRoleOrganisationServices
JBJo BellPractice nurse · team leadNorthgate Medical PracticeLong-term conditions
DSDr Sarah LeeGPNorthgate Medical PracticeLong-term conditions
RCRhys ColeHealth and wellbeing coachNorthgate PCNHealth checks
Long-term conditionsReferred by: GP, practice nurseDiabetes, COPD, heart failure reviews Referral route setFalls preventionReferred by: GP, community nursing, selfStrength and balance, medicines, home checks Referral route setNHS Health ChecksInvited by text, from the registerAges 40 to 74, every five years Referral route set
One neighbourhood teamFive professionals, their services and referral routes.
The neighbourhood
HomeInsightsReportsPeopleMessagingManagePS
People Supported412people
Joint Plans31plans
From the Most Deprived Areas46%▲ 8%vs previous period
Falls Referrals38▲ 15%vs previous 30 days
Repeat Assessments Saved96so far
ServicesLTC - 52%Falls - 23%
Northgate neighbourhood
By service and deprivationExport
People Supported, by ServiceLTCFallsChecks
By Deprivation (1 = Most Deprived)
Falls, Before and After a Joint Plan
Where to focusThe neighbourhood by service and deprivation, to export.
His record
HomeInsightsPeopleUsersMessagingManagePS
/Users/Gareth Hughes
GHGareth HughesActiveConfirmedAge 63 yearsGender Male
Profile completeness100%9 of 9 sectionsLast loginOct 12, 2026ConfirmedAug 11, 2026Point of contactJBJo BellShareEditChatsSendMore
OverviewTasksNotesCommsEpisodesInsightsUpdated Oct 14, 2026
Next appointment22 Oct · 09:30Falls review, at homeSchedule
Open tasks2 dueHome hazard checkNew task
Latest note13 Oct · Note“Second fall this year, at home”Add note
From the practice’s clinical systemSynced today, 08:00ConditionsCOPDHypertensionFalls2 this year · latest 6 Oct, at homeMedicinesAmlodipine 10 mgZopiclone 7.5 mgTiotropium inhalerSalbutamol inhalerBlood pressure, sitting142/84Blood pressure, standing118/70
Upcoming appointmentsScheduleThu22OctFalls review, at home09:30 – 10:00JBJo BellPractice nurseThu22OctCoaching: first session09:30 – 10:00RCRhys ColeWellbeing coachMon2NovMedicines review11:00 – 11:20NBNikhil BainsPharmacistThu22OctFalls review and coaching09:30 – 10:15JBRCJo and RhysNurse and coach
Health informationEditConditionsCOPDHypertensionAllergiesNone knownHealth objectivesStay steadyGet out moreTopicsFalls preventionHealth concernsFallsBreathlessnessGP practiceNorthgate Medical PracticeReason for referralFalls prevention
One record for all fiveWhat the practice knows, and two bookings at 09:30.
The team, talking
HomeInsightsPeopleMessagingChatsManagePS
Messages Sent2,904▲ 21%vs previous 30 days
Chats Created188▲ 14%vs previous 30 days
Attachments Shared612▲ 33%vs previous 30 days
Chat by PlatformApp - 79%Web - 21%
Total Chats1,866chats
Active Conversations214▲ 15%vs previous period
AllCreateArchived chatsNNNorthgate neighbourhood teamLet’s go together: one visit…TodayEWEat well groupNew chat inviteYesterdayARAisha RahmanThanks, see you ThursdayOct 7, 2026MEMargaret EllisHi Margaret Here are a few things for this week, picked for your plan. Thanks PriyaOct 7, 2026DODavid OkaforReading sent: 138/86Oct 7, 2026MMMove more group1 item sharedOct 7, 2026JWJohn Whitfield1 item sharedOct 7, 2026HMHealthy minds groupLewis joined the chatOct 6, 2026
NNNorthgate neighbourhood teamOfflineDr Sarah LeeGareth fell again last week. His blood pressure drops when he stands, so I’ve lowered his amlodipine.10:12 AMNikhil BainsMedicines review done: I’ve stopped his sleeping tablet.10:19 AMFiona HendryHe wants to get out more. There’s a strength and balance class at the community centre on Thursdays.10:26 AMRhys ColeJo, we’ve both booked him for Thursday at 09:30.10:33 AMJo BellLet’s go together: one visit. And one plan for him, with his falls, his COPD, his medicines and the class. I’ll share it today.10:40 AMType a messageSend now
One visit, not twoThe team talk it through in their own chat.
ScheduleEverything he gets, week by week: the whole plan at a glanceContentGoalsCheck-insMessagesTasksSent on its day · ↻ repeats · click a card to change it, drag it to another week
Week 15 itemsWeek 23 itemsWeek 33 itemsWeek 42 itemsWeek 53 itemsContentStaying steady at homeJB+Using your inhaler wellNB+Moving more with COPDRC++What to do if you fallJB+GoalsStrength and balance classFH+Stand up slowly, count to fiveDS++Walk to the shops twice a weekRC++Check-insCOPD check-inJB++Falls check-inJB++COPD check-in ↻JB+MessagesYour new medicines, from NikhilNB+How was the first class?FH++From Fiona: the walking groupFH++TasksHome hazard checkJB++Blood pressure, standingDS++Review with JoJB+
AutomationsRules that change the plan to how he’s actually doing2 active
When acheck-in scoreisbelow40thenadd contenttoweek 5When agoal is missedby the end ofweek 6thensend a messageWhena week is completedthenopen the next week
Plan summaryDuration12 weeksContent4Goals3Check-ins3Messages3Tasks3Automations2 activeJoin automaticallyOn
CancelSave & Close
One plan, five handsEach adds their part to the same plan, with their initials.
HomeInsightsPeopleTeamsMessagingManagePS
Team Members5members
Services3services
Referrals Handled48▲ 12%vs previous 30 days
Joint Plans31▲ 26%vs previous 30 days
PracticesNorthgate - 58%Beck Lane - 42%
Set UpOct 12026
MembersTeamsNorthgate neighbourhood teamSearch members...Add member
NameRoleOrganisationServices
JBJo BellPractice nurse · team leadNorthgate Medical PracticeLong-term conditions
DSDr Sarah LeeGPNorthgate Medical PracticeLong-term conditions
RCRhys ColeHealth and wellbeing coachNorthgate PCNHealth checks
Long-term conditionsReferred by: GP, practice nurseDiabetes, COPD, heart failure reviews Referral route setFalls preventionReferred by: GP, community nursing, selfStrength and balance, medicines, home checks Referral route setNHS Health ChecksInvited by text, from the registerAges 40 to 74, every five years Referral route set
HomeInsightsPeopleReferralsMessagingManagePS
Referrals Created126▲ 18%vs previous 30 days
Referrals Enrolled74▲ 9%vs previous 30 days
Referrals by StatusEnrolled - 58%Created - 42%
Referrals by SourceGP - 64%Self - 21%+3 more
Acceptance Rate81%
Total Referrals1,284referrals
Falls preventionAll stagesSearch referrals...Create new
NameServicesStageContactLast updatedPriority
GHGareth HughesFalls preventionIncoming07700 900906gareth@example.comOct 13, 2026Created on: Oct 13, 2026
EPEdna PriceFalls preventionTriaged07700 900351edna@example.comOct 12, 2026Created on: Oct 8, 2026
BFBill FosterFalls preventionActivated07700 900362bill@example.comOct 9, 2026Created on: Oct 2, 2026
MDMaureen DaleFalls preventionEnrolled07700 900373maureen@example.comOct 7, 2026Created on: Sep 24, 2026
GWGeorge WillsFalls preventionEnrolled07700 900384george@example.comOct 5, 2026Created on: Sep 18, 2026
PSPat SuttonFalls preventionCompleted07700 900395pat@example.comSep 30, 2026Created on: Jul 21, 2026
HomeInsightsPeopleUsersMessagingManagePS
/Users/Gareth Hughes
GHGareth HughesActiveConfirmedAge 63 yearsGender Male
Profile completeness100%9 of 9 sectionsLast loginOct 12, 2026ConfirmedAug 11, 2026Point of contactJBJo BellShareEditChatsSendMore
OverviewTasksNotesCommsEpisodesInsightsUpdated Oct 14, 2026
Next appointment22 Oct · 09:30Falls review, at homeSchedule
Open tasks2 dueHome hazard checkNew task
Latest note13 Oct · Note“Second fall this year, at home”Add note
From the practice’s clinical systemSynced today, 08:00ConditionsCOPDHypertensionFalls2 this year · latest 6 Oct, at homeMedicinesAmlodipine 10 mgZopiclone 7.5 mgTiotropium inhalerSalbutamol inhalerBlood pressure, sitting142/84Blood pressure, standing118/70
Upcoming appointmentsScheduleThu22OctFalls review, at home09:30 – 10:00JBJo BellPractice nurseThu22OctCoaching: first session09:30 – 10:00RCRhys ColeWellbeing coachMon2NovMedicines review11:00 – 11:20NBNikhil BainsPharmacistThu22OctFalls review and coaching09:30 – 10:15JBRCJo and RhysNurse and coach
Health informationEditConditionsCOPDHypertensionAllergiesNone knownHealth objectivesStay steadyGet out moreTopicsFalls preventionHealth concernsFallsBreathlessnessGP practiceNorthgate Medical PracticeReason for referralFalls prevention
HomeInsightsPeopleUsersMessagingManagePS
/Users/Gareth Hughes
GHGareth HughesActiveConfirmedAge 63 yearsGender Male
Profile completeness100%9 of 9 sectionsLast loginOct 12, 2026ConfirmedAug 11, 2026Point of contactJBJo BellShareEditChatsSendMore
OverviewTasksNotesCommsEpisodesInsightsUpdated Oct 14, 2026
Next appointment22 Oct · 09:30Falls review, at homeSchedule
Open tasks2 dueHome hazard checkNew task
Latest note13 Oct · Note“Second fall this year, at home”Add note
From the practice’s clinical systemSynced today, 08:00ConditionsCOPDHypertensionFalls2 this year · latest 6 Oct, at homeMedicinesAmlodipine 10 mgZopiclone 7.5 mgTiotropium inhalerSalbutamol inhalerBlood pressure, sitting142/84Blood pressure, standing118/70
Upcoming appointmentsScheduleThu22OctFalls review, at home09:30 – 10:00JBJo BellPractice nurseThu22OctCoaching: first session09:30 – 10:00RCRhys ColeWellbeing coachMon2NovMedicines review11:00 – 11:20NBNikhil BainsPharmacistThu22OctFalls review and coaching09:30 – 10:15JBRCJo and RhysNurse and coach
Health informationEditConditionsCOPDHypertensionAllergiesNone knownHealth objectivesStay steadyGet out moreTopicsFalls preventionHealth concernsFallsBreathlessnessGP practiceNorthgate Medical PracticeReason for referralFalls prevention
HomeInsightsPeopleUsersMessagingManagePS
/Users/Gareth Hughes
GHGareth HughesActiveConfirmedAge 63 yearsGender Male
Profile completeness100%9 of 9 sectionsLast loginOct 12, 2026ConfirmedAug 11, 2026Point of contactJBJo BellShareEditChatsSendMore
OverviewTasksNotesCommsEpisodesInsightsUpdated Oct 14, 2026
Next appointment22 Oct · 09:30Falls review, at homeSchedule
Open tasks2 dueHome hazard checkNew task
Latest note13 Oct · Note“Second fall this year, at home”Add note
From the practice’s clinical systemSynced today, 08:00ConditionsCOPDHypertensionFalls2 this year · latest 6 Oct, at homeMedicinesAmlodipine 10 mgZopiclone 7.5 mgTiotropium inhalerSalbutamol inhalerBlood pressure, sitting142/84Blood pressure, standing118/70
Upcoming appointmentsScheduleThu22OctFalls review, at home09:30 – 10:00JBJo BellPractice nurseThu22OctCoaching: first session09:30 – 10:00RCRhys ColeWellbeing coachMon2NovMedicines review11:00 – 11:20NBNikhil BainsPharmacistThu22OctFalls review and coaching09:30 – 10:15JBRCJo and RhysNurse and coach
Health informationEditConditionsCOPDHypertensionAllergiesNone knownHealth objectivesStay steadyGet out moreTopicsFalls preventionHealth concernsFallsBreathlessnessGP practiceNorthgate Medical PracticeReason for referralFalls prevention
HomeInsightsPeopleUsersMessagingManagePS
/Users/Gareth Hughes
GHGareth HughesActiveConfirmedAge 63 yearsGender Male
Profile completeness100%9 of 9 sectionsLast loginOct 12, 2026ConfirmedAug 11, 2026Point of contactJBJo BellShareEditChatsSendMore
OverviewTasksNotesCommsEpisodesInsightsUpdated Oct 14, 2026
Next appointment22 Oct · 09:30Falls review, at homeSchedule
Open tasks2 dueHome hazard checkNew task
Latest note13 Oct · Note“Second fall this year, at home”Add note
From the practice’s clinical systemSynced today, 08:00ConditionsCOPDHypertensionFalls2 this year · latest 6 Oct, at homeMedicinesAmlodipine 10 mgZopiclone 7.5 mgTiotropium inhalerSalbutamol inhalerBlood pressure, sitting142/84Blood pressure, standing118/70
Upcoming appointmentsScheduleThu22OctFalls review, at home09:30 – 10:00JBJo BellPractice nurseThu22OctCoaching: first session09:30 – 10:00RCRhys ColeWellbeing coachMon2NovMedicines review11:00 – 11:20NBNikhil BainsPharmacistThu22OctFalls review and coaching09:30 – 10:15JBRCJo and RhysNurse and coach
Health informationEditConditionsCOPDHypertensionAllergiesNone knownHealth objectivesStay steadyGet out moreTopicsFalls preventionHealth concernsFallsBreathlessnessGP practiceNorthgate Medical PracticeReason for referralFalls prevention
HomeInsightsPeopleMessagingChatsManagePS
Messages Sent2,904▲ 21%vs previous 30 days
Chats Created188▲ 14%vs previous 30 days
Attachments Shared612▲ 33%vs previous 30 days
Chat by PlatformApp - 79%Web - 21%
Total Chats1,866chats
Active Conversations214▲ 15%vs previous period
AllCreateArchived chatsNNNorthgate neighbourhood teamLet’s go together: one visit…TodayEWEat well groupNew chat inviteYesterdayARAisha RahmanThanks, see you ThursdayOct 7, 2026MEMargaret EllisHi Margaret Here are a few things for this week, picked for your plan. Thanks PriyaOct 7, 2026DODavid OkaforReading sent: 138/86Oct 7, 2026MMMove more group1 item sharedOct 7, 2026JWJohn Whitfield1 item sharedOct 7, 2026HMHealthy minds groupLewis joined the chatOct 6, 2026
NNNorthgate neighbourhood teamOfflineDr Sarah LeeGareth fell again last week. His blood pressure drops when he stands, so I’ve lowered his amlodipine.10:12 AMNikhil BainsMedicines review done: I’ve stopped his sleeping tablet.10:19 AMFiona HendryHe wants to get out more. There’s a strength and balance class at the community centre on Thursdays.10:26 AMRhys ColeJo, we’ve both booked him for Thursday at 09:30.10:33 AMJo BellLet’s go together: one visit. And one plan for him, with his falls, his COPD, his medicines and the class. I’ll share it today.10:40 AMType a messageSend now
ScheduleEverything he gets, week by week: the whole plan at a glanceContentGoalsCheck-insMessagesTasksSent on its day · ↻ repeats · click a card to change it, drag it to another week
Week 15 itemsWeek 23 itemsWeek 33 itemsWeek 42 itemsWeek 53 itemsContentStaying steady at homeJB+Using your inhaler wellNB+Moving more with COPDRC++What to do if you fallJB+GoalsStrength and balance classFH+Stand up slowly, count to fiveDS++Walk to the shops twice a weekRC++Check-insCOPD check-inJB++Falls check-inJB++COPD check-in ↻JB+MessagesYour new medicines, from NikhilNB+How was the first class?FH++From Fiona: the walking groupFH++TasksHome hazard checkJB++Blood pressure, standingDS++Review with JoJB+
AutomationsRules that change the plan to how he’s actually doing2 active
When acheck-in scoreisbelow40thenadd contenttoweek 5When agoal is missedby the end ofweek 6thensend a messageWhena week is completedthenopen the next week
Plan summaryDuration12 weeksContent4Goals3Check-ins3Messages3Tasks3Automations2 activeJoin automaticallyOn
CancelSave & Close
HomeInsightsPeopleUsersMessagingManagePS
/Users/Gareth Hughes
GHGareth HughesActiveConfirmedAge 63 yearsGender Male
Profile completeness100%9 of 9 sectionsLast loginOct 12, 2026ConfirmedAug 11, 2026Point of contactJBJo BellShareEditChatsSendMore
Goals Joined, This WeekkeyBalance class · 100%Stand up slowly · 86%
Actions Completed, by Day
Content Viewed, by Type4ItemskeyVideosArticlesExercises
HomeInsightsReportsPeopleMessagingManagePS
People Supported412people
Joint Plans31plans
From the Most Deprived Areas46%▲ 8%vs previous period
Falls Referrals38▲ 15%vs previous 30 days
Repeat Assessments Saved96so far
ServicesLTC - 52%Falls - 23%
Northgate neighbourhood
By service and deprivationExport
People Supported, by ServiceLTCFallsChecks
By Deprivation (1 = Most Deprived)
Falls, Before and After a Joint Plan
11:13
11:13
Wednesday 14 October
Messages · 11:12
Northgate Medical Practice
Hi Gareth, the team’s plan for you is in the Healum app: one plan, from all of us. Jo
11:15
My Plans
NewActiveCompleted
Plan84 days
Staying steady at home
Currently on: Day 0/84
Plan7 days
Getting started with Healum
Currently on: Day 0/7
Plan Preview
Staying steady at home
Duration: 12 weeksGoals: 3Resources: 2
From Northgate neighbourhood team
One plan from your neighbourhood team: your GP, nurse, pharmacist, link worker and coach.
Goals to complete
Day 1
Strength and balance class
Day 1
Use your inhaler as prescribed
Day 8
Clear the hallway
CancelJoin Plan
11:17
Goals
Your health coach assigned 3 goals to you. If you like them, start them.
Goal Preview
Goal
Strength and balance class
The Thursday class at Northgate Community Centre: gentle exercises that make falls less likely.
Aim: Stay steady
Frequency Weekly, Thursdays 10:00Duration 12 weeks
Tracking: Classes attended
CancelStart this goal
11:19
Dashboard02
To do TodayCompleted: 0/2
Show all actions
ThursdaysTap to complete
Strength and balance class
Staying steady at home
DailyTap to complete
Stand up slowly, count to five
Staying steady at home
Swipe the action card to the left to see actions
Upcoming AppointmentsView all
Falls review and coaching, at home
Thu, 22 October 2026 09:30 - 10:15Accepted
Jo Bell and Rhys Cole
Active PlansView all
Plan84 days
Staying steady at home
Currently on: Day 1/84
DSNBFHRCJB
A neighbourhood teamOne plan instead of five
One neighbourhood teamFive people from the practice and the PCN, set up with the services they run, each with its referral route.
Referred for fallsGareth, 63, has COPD and fell at home again last week. His GP refers him to falls prevention.
One record, already filled inWhat the practice’s clinical system knows is there for all five: his conditions, medicines, falls and blood pressure.
Booked twiceThe nurse and the coach have both booked him for Thursday at 09:30.
Talked throughThe team talk about him in their own chat, and Jo and Rhys make Thursday one visit.
One plan, five handsEach of them adds their part to the same plan, with their initials on it.
On his phoneA text, the plan from all five, and the class at the community centre as a goal he starts. One visit on Thursday.
What the team seesA week on: the goals he joined, the actions he ticked and what he read.
Where to focusThe neighbourhood’s report, by service and by deprivation, ready to export.
One plan, the whole neighbourhood around it
In their words
A key challenge in long-term condition management is to motivate and support patients to make healthy choices and understand how to best manage their diabetes in a way that means something to them.
Dr Adrian HealdConsultant Physician in Diabetes and Endocrinology, and Chief Investigator of the Healum RCT
App engagement
84%†
used the app at least twice in the first 30 days
Care planning
280†
goals agreed with patients and shared in care plans
The neighbourhood model
Built for integrated neighbourhood teams
GP federations, PCNs and community partners share one record and report outcomes to commissioners.