Published: 13/05/2004, Volume II4, No. 5905 Page 25

Integrated care pathways are local care plans that recommend steps in the care of patients with a specific condition and detail their expected progress. They are a tool for managing clinical care processes and patient outcomes, which aim to have the right people doing the right things in the right order, at the right time and place, with an anticipated outcome. A genuine ICP must also include a method of tracking any variation between planned and actual care so that the pathway can be updated as evidence and practice change.

What are the benefits?

Reported benefits include shorter hospital stays, the practice of evidence-based medicine, better clinical outcomes and improved patient satisfaction. ICPs also involve patients in planning their care, facilitate clinical audit and enhance collaboration between multidisciplinary teams. An evidence-based ICP can help to disseminate best practice by facilitating implementation of national standards or, where there are none, by determining the best care pattern based on available clinical evidence.

Incorporating national clinical guidelines and audit procedures into an ICP not only helps the NHS meet government targets, but encourages health professionals to meet or exceed best-practice standards. Patients benefit because ICPs encourage a systematic approach to patient care; they improve access to and equity of care, and help eliminate variations in practice.

Any downsides?

There is some evidence that ICPs promote written communication at the expense of face-to-face interaction.

Where does the idea come from?

ICPs were developed in the US profit-driven healthcare system to maintain consistency of care and costs. The concept was imported in the early 1990s to help the NHS improve clinical outcomes and provide measurable results that can be used for continuous audit.

How does it translate in the UK?

Because the US has a vertically integrated healthcare system, the same company carries out commercial management of primary and secondary care, so it is easier to design a care pathway to suit both.

In the UK's politically driven healthcare system, where there is greater clinical freedom, designing a pathway to suit both primary and secondary care is fraught with problems.However, these are not insurmountable.

Who's doing it?

Last October, the National Electronic Library website showed 232 pathways in use, ranging from ACE inhibitors to wound care management. In addition, 1,054 were being implemented and more than 1,600 were in development.

What can go wrong?

Ifan ICP is drawn up without consulting all the appropriate healthcare professionals, implementation is more likely to fail because people are less inclined to adhere to a pathway to which they have not been invited to contribute. Similarly, unless a schedule is set and agreed, there is a danger that a pathway will be abandoned due to lack of time, consensus and resources, or will remain 'in development' until it is out of date. Potential setbacks are moving political goalposts, funding restraints, the involvement of multiple providers and people's reluctance to change. People can also rebel against restrictions on their clinical freedom. Mark Davies