The New NHS white paper mentions establishing 'programmes of care' for patients which will flow across organisational boundaries and will determine the integrated support to meet patients' needs over time.
One of the tools suggested is pathways of care, also known as integrated care pathways and critical care maps. This tool, which involves setting out the anticipated course of treatment for a particular condition, was first developed in the US as part of the introduction of managed care and case management systems.
The National Pathway Association was set up to provide information for organisations developing pathways in England and Wales: there is a similar organisation in Scotland. The association carries out an annual survey of members. It gathered quantitative data on how widely the pathway tool was being used in England and Wales; how far trusts and other healthcare organisations had adapted the tool in the UK; how much concordance there was in what was being implemented; and, given the lack of empirical research on the subject, whether pathways were delivering the benefits described in anecdotal evidence.
4NPA says that an integrated care pathway 'determines locally agreed, multidisciplinary practice based on guidelines and evidence where available, for a specific patient or client group. It forms all or part of the clinical record, documents the care given and facilitates the evaluation of outcomes'.
A postal survey was sent to all 157 members of NPA in May 1997. A 64 per cent response rate was achieved, although the individual response rate varied between questions. The membership list of NPA shows that there is usually one member of NPA per organisation. The questionnaires were coded so that if multiple responses were received from one organisation these could be identified and their results compared and combined where necessary. The composition of respondents was analysed by organisational type to determine whether the responses were representative of the overall membership. There was a slight under-representation of community units; the rest of the sample appeared representative.
The group that most favoured pathways was the acute trust, and the second was private healthcare (see table 1).
However, there was also representation from trusts that provided primarily community services, but which could encompass mental health and learning difficulties. A number of responses were from trusts that had integrated acute and community and/or mental health and/or learning difficulties services. There were also some responses from purely mental health trusts. The table shows how pathways are being used not merely in acute settings, but in all areas of care, including those where it is more difficult to predict the care to be provided.
Respondents listed the pathways in use and these have been categorised into specialties. Table 2 shows the number of respondents who reported having one or more pathways.
The distribution of pathways is shown this way because it was recognised that a specialist hospital could skew the results by having a lot of pathways in one specialty.
Orthopaedics is the specialty where the largest number of respondent organisations have developed pathways. General surgical and medical (plus care of elderly people) come an equal second. Again, the wide spread of specialties in which pathways are developed shows how (in England and Wales) they are seen not merely as surgical tools.
NPA wanted to establish how consistent was the content of the pathways being developed. Respondents identified which of the elements listed were contained in their pathways. The six most common elements were:
multidisciplinary documentation - 92 per cent (n=87);
use as all or part of individual clinical patient records - 92 per cent (n=86);
incorporation of guidelines/protocols - 91 per cent (n=85);
inclusion of some form of clinical outcome measurement - 85 per cent (n=77);
incorporation of quality standards of clinical care - 82 per cent (n=73);
inclusion of patient education/information - 78 per cent (n=72).
This shows that some elements consistently feature in pathways.
As so often with new tools, the cited benefits are numerous. NPA wanted to discover how far the commonly listed benefits were being achieved. When asked how useful respondents found pathways to various developments within their organisation (on a five-point rating scale: 1 = very useful, 5 = of no use), the seven highest scorers in the 'very useful' and 'useful' categories were:
setting and implementing standards of care - 91 per cent (n=83);
improving quality of care - 90 per cent (n=82);
improving communication between staff - 90 per cent (n=81);
development of multidisciplinary team working - 83 per cent (n=83);
promoting evidence-based practice - 81 per cent (n=73);
improving clinical documentation - 80 per cent (n=73);
clinical audit - 80 per cent (n=73).
How much pathways assist costing and cost control is less clear: 37 per cent (n=33) of respondents said they found them 'very useful' or 'useful' to control costs, and 33 per cent (n=30) said the same about costing activity. However, 30 per cent (n=27) of respondents found them 'of no use' or only 'slightly useful' to control costs, and 38 per cent (n=34) said that about costing activity.
This data shows how the tool is being adapted from the US model, where it is used primarily as a method to reduce and control costs in a managed-care environment. In the UK, the tool appears primarily to be used for improving the quality of clinical care.
Consensus on the main benefits of introducing pathways would be of little use if they were proving very difficult to implement. The survey asked about usage. A total of 48 respondents said they had pathways in use and 88 respondents said they had them under development. A total of 424 pathways were in use, with just over 800 being developed across England and Wales. The highest number of pathways in use in any one organisation was reported as 100, and over 10 per cent of respondents had 10 or more. The most usual figure was one. The greatest number being developed within one organisation was 82, and over 17 per cent of respondents said they were developing more than 10. Eight organisations stated that they had discontinued some pathways, mainly due to a lack of commitment from clinical staff.
Respondents also identified the main criteria for successful implementation. By far the most popular criterion cited is clinical ownership/amenability to change: 48 per cent of responses mentioned this.
The criteria for success identified by respondents were analysed by type of organisation, to see if there were differences in criteria which were related to type of organisation.
There appeared to be no substantial difference related to the type of organisation. For example, 48 per cent of acute units identified clinical ownership/amenability to change, and 44 per cent of private hospitals, 48 per cent of community units and 38 per cent of integrated units mentioned this.
The results show that obtaining clinical ownership and commitment is vital if an organisation is to expect any success in implementing pathways and reaping their benefits.
NPA also wanted to see how pathways were being used outside the organisation. The question asked was: how many pathways in use or in development include the provision of care across organisational boundaries? The results showed:
32 respondents had pathways involving GPs;
30 respondents had pathways involving social services;
23 respondents had pathways involving more than one trust;
14 respondents had pathways involving voluntary organisations.
These results suggest that pathways involving more than one organisation are not yet in extensive use. This may be due to the relative newness of this management tool in the UK.
Kathryn Riley is care packages researcher at Kidderminster Health Care trust.
Key Points Care pathways are most commonly used in acute trusts and private hospitals, according to a survey by the National Pathway Association.
Orthopaedics is the specialty most likely to employ pathways, followed by surgery, medicine and care of elderly people.
A third of respondents found the tool helped control costs, but a similar number found it did not.
Setting and implementing standards of care and improving communication between staff are the most commonly reported benefits of using care pathways.
REFERENCES
1 The New NHS - Modern, Dependable. Stationery Office, 1998.
2 Hampton D. Implementing a managed care framework through care maps. JONA 1993; 23(5): 21-27.
3 Clark C, Steinbinder A, Anderson R. Implementing clinical paths in a managed care environment. Nursing Economics 1994; 12: 4230-34.
4 Hale C. Issues in the evaluation of multidisciplinary pathways of care. In Wilson J. Integrated Care Management. Butterworth/Heinemann, 1997.
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