For good measure

It is sometimes suggested that developing care pathways for mental health is more problematic than for other specialties because of the highly individual and multi-faceted influences on each person's problems.

Nonetheless, with the increasing emphasis on evidence-based services, clinical governance and the production of a national service framework for mental health, the direction of travel nationally is towards greater clarity of standards of care and examination of care processes and outcomes.

After two years the trust had developed mental health care pathways for eating disorders, acute admissions and acute psychosis and clinical guidelines on managing depression in secondary care.

Care pathways have been defined as being 'a tool which sets out agreed standards of care, forming part or all of the clinical record and which can be used to analyse variation from set standards'.

Their development has a number of potential benefits, including:

setting out what clinicians do;

seeing if we all do the same thing;

agreeing with the same things;

challenging what we do;

comparing it to the evidence base.

The trust has found that there is a good evidence base for many interventions in mental health. And pathways can be developed in areas where there is less evidence, provided that audit programmes are devised to aid evaluation. It was also recognised early on that care pathways are one of the tools that will help us to implement the clinical governance initiative and incorporate it into routine clinical practice.

The scope for clinicians to take a different approach to their work is perhaps more marked in mental health than in any other sphere. This difference between individual clinicians and clinical teams is often recognised, but rarely quantified. It may be reflected in a number of ways, including:

disposition to use inpatient beds;

extent and types of medication;

approach to risk management.

The starting point for care pathway development in Dorset Healthcare trust was to gather together groups of clinicians to look at different conditions.

The whole process was overseen by a personalised care management steering group chaired by the chief executive. This group took a coordinating and encouraging role, also monitoring the total programme to ensure that each pathway was being developed in line with the trust's aspirations - for example in engaging with service users and carers. It was also able to make links between the work of the individual groups and to help when problems arose.

A number of other initiatives were running parallel with personalised care management, including local needs assessment, community mental health team development programmes and the introduction of integrated case notes. The trust has a well-established history of developing, consulting and piloting new initiatives before full implementation.

Establishing groups of clinicians to look at each pathway had the advantage of beginning to make explicit the range of approaches taken by different clinicians and stimulating a dialogue about the reasons for this.

The schizophrenia care pathway development group, for example, noted that different teams had different practices - working with them to develop care pathways led to a process of change. It was important to us that this change began from within the group rather than being imposed from outside.

The first pathway to be developed was for eating disorders, and the back of the task was broken in a single two-hour session, led by the chief executive.

Two further sessions produced a basis for development. Our aim was commit something to paper, do it quickly, start simply and build up.

This initial care pathway was developed with reference to the evidence base for eating disorders and by taking soundings with service users about their experience and expectations.

On completion it was produced in a handbook which is given to people on admission to the service. This pathway was developed quickly and was kept as simple as possible. This was important because it was to be an information source and 'route map' for service users, as well as staff.

The later pathways began with parallel processes - setting out 'what we do' alongside a comprehensive review of the evidence base.

Information from these databases was discussed by the working group with a view to agreeing the clinical approach to be adopted in the guidelines. Extensive discussion was necessary because a range of views existed.

Each group found its own way of addressing these differences.

Sometimes different views were held by members of the same profession, and sometimes differences existed between professions.

Implementation and evaluation has varied between each of the pathways/guidelines, but for each there has been a programme of training, implementation and evaluation. The most extensive has been the introduction of the guidelines for the treatment of depression in secondary care.

These guidelines were designed to be used by all the community mental health teams as well as the inpatient and day services, so a major programme of training was necessary. The guidelines were launched at an event in January 1999 and an intensive period of training in their use followed.

Evaluation cycle Each of the pathways has an evaluation cycle, and the eating disorders pathway is now undergoing its first major revision.

Some of the evaluation findings were similar to those which have been gained from care pathways in acute general hospital specialties, such as identifying the need to reschedule procedures.

Integrated care pathways clearly have a developmental benefit to services, raising awareness about the evidence base for the team's work, and also raising awareness of the need for work to take place in different settings.

Other benefits included meeting the prime objective of making clarifying issues for patients and carers.

Pathways enable a dialogue to take place, and can provide a framework which patients and/or carers can take away afterwards by way of a reminder.

This can be seen as a contribution to 'levelling the playing field' between clinicians and patients - giving a structure to dialogue and information which patients can use to test and clarify their understanding. It can also, by making information available, help facilitate informed choice.

This dimension of care pathways has also been followed up by the depression guidelines group, which produced a brief leaflet for service users summarising the key features of the advice being given to clinicians.

The group is also working on a 'flow chart' that can be used during a consultation to discuss the treatment options available.

The evaluation highlighted the skills needed to deliver the eating disorders care pathway. Decisions about training priorities were thus given a boost in terms of the information available to managers to make evidence based decisions about the allocation of scarce resources.

The key ingredients for a successful programme have included sustained leadership, and provision of an infrastructure to complete the necessary research, including high-quality clinical audit staff. The pathway groups have been enabled to develop their own approach, and local ownership has been encouraged and nurtured.

While the initiative was taken by the trust, there has also been an emphasis on partnership throughout. This has resulted in the acute psychosis pathway - in particular embracing social as well as clinical elements.

The development of pathways and guidelines is good for users and carers. They can now readily have information about what's available, knowing that the standard of the work is high, enabling them to be better informed, more involved, and to make choices wherever possible.

Eating disorders protocol: food for thought What has been found following evaluation? An audit of the first six months of the eating disorders pathway found:

Duplication with care programme approach documentation meant this topic was infrequently completed on the integrated care pathway.

Alterations were needed to the timing of interventions, and to the professional carrying out the interventions.

There was a need to move towards planned admissions for all cases.

Clinicians were generally happy, but expressed concerns about extra paperwork and highlighted the need for a single set of notes. Also, nursing staff always recorded interventions by doctors - highlighting a need for more team ownership.

The experience of the eating disorder pathway was heartening for the trust, strengthening its faith in the approach. The many positive benefits found following the first evaluation included:

Generation of new ideas by the team and establishment of projects examining the admission and discharge process.

Increasing acceptance that interventions are required in different settings - outpatient, day-patient - to help individuals with complex problems.

Increasing awareness of best practice throughout the team.

Patients and carers being more aware of what to expect of treatment.

. Identification of training needs.