Published: 13/05/2004, Volume II4, No. 5905 Page 14 15

Integrated care pathways need the input of both healthcare professionals and patients if they are to succeed. Mark Davis explains how to set them up Integrated care pathways are rapidly becoming part of 21st century healthcare.

A properly constructed ICP, developed in consultation with all relevant parties, has the potential to streamline healthcare practices, reduce healthcare inequalities and implement best practice (see guide, right).

So how do you go about setting up an ICP?

Step one: identify where a care pathway is required, such as acute treatment of stroke patients. A single ICP is unlikely to map the patient's entire journey, which is more likely consist of a series of complementary pathways describing a phase of care, such as preferred interventions or criteria for assessment.

Step two: invite participation from healthcare professionals from all relevant disciplines in both primary and secondary care.As a consensus of care provision, an ICP must be designed and implemented by those who will use it. For example, a diabetes team might consist of a diabetologist, specialist nurses, specialist paediatrician, psychologist, and representatives from the following secondary care departments: cardiology, vascular surgery, renal, obstetrics, podiatry, ophthalmology, urology and nutrition. For primary care, team members might include a GP, advanced nurse practitioner, practice and community nurses, an optometrist and administrative support.

In this way you can ensure that all those involved in the ICP's delivery and development understand its objectives and are 'on side - without their support implementation is unlikely to occur. Befriend potential 'blockers' by working through the mapping process with them to foster their commitment to the project.

Step three: set and agree a realistic, achievable time limit and appoint a designated facilitator to manage the process.

With so many demands on healthcare professionals' time, disciplined planning is required to gather the relevant people in the same place at the same time on a regular basis to discuss, develop and hone the pathway.

Calculate the number of meetings required and ensure that dates are put in diaries. If meetings are too frequent, busy GPs will not attend; if they are too infrequent, the project will run out of steam. Allocate responsibility for each task so that development and implementation can proceed according to the predefined schedule and all parties know and agree in advance the time investment required of them.

Ringfence additional resources you may require, such as secretarial support for drafting documents and organising meetings, and a convenient meeting place.

Step four: gather all the research and best practice for your chosen area of clinical intervention using national guidelines or, in their absence, best available clinical evidence.

Throughout the process, draw on gathered evidence, members' clinical expertise, patient and carer experience, and that essential ingredient - common sense.

The National Pathways Association can provide its members with a network of professionals interested in developing, sharing and promoting the use of care pathways via meetings, a newsletter, website and register of care pathways being developed by members.

Step five: agree clear inclusion and exclusion criteria to make sure patients are put on the correct pathway for their condition.Map the patient's journey, specifying the sequence of care, the elements of care, potential complications, and their treatment and expected outcomes. Some professionals find it easier to start with the desired outcome and work backwards.

Step six: once the care pathway is mapped, prepare a concise, user-friendly draft for all the parties involved to approve (see box, left).

Patient involvement Consultation with patients, their carers and patient groups is essential at some stage of the process to achieve a truly patientcentred pathway.

As the NHS plan recognises: 'The patient's voice does not sufficiently influence the provision of services.'

Despite the recommendations from the Bristol inquiry on baby deaths, patient involvement is often limited to spokespeople from patient groups who may only represent certain sets of patient.

Medical professionals may think they know what patients want, but when a patient poll revealed fatigue to be the worst symptom of cancer treatment only 37 per cent of oncologists were aware of this. Patients found fatigue so debilitating that they rated it worse than pain or nausea, both of which can be regulated by medication.

Similarly, while medical staff research has used cessation of voices as a measure of the effectiveness of schizophrenia medication, patients claim they can cope with hearing voices as long as they are benign.

There is also a huge variation in the treatment that individual patients will tolerate.While one cancer patient may accept aggressive chemotherapy and all its side-effects, others may refuse all treatment.

Maintaining progress Once you have set the process in motion, how do you maintain momentum? A workshop can be a useful tool to develop ICPs and prevent projects from floundering.

Twenty-seven delegates from four multidisciplinary NHS modernisation teams from Leeds, Wales, London and North Devon met at a two-day workshop, which provided a review of the rationale behind ICPs and protected time in which each team could advance their chosen ICP to the next stage.

Although the teams were at different stages of ICP development, all had chosen an area of clinical intervention. They were encouraged to review research and proven practice in their chosen area - including available clinical knowledge or evidence, the experiences and contributions of patients and carers - and to evaluate different pharmacological and nonpharmacological treatments.

On the first day there were talks on the policy drivers behind IPCs, areas for development, and the patient and carer experience. Delegates attended workshops at which they constructed their own ICPs by mapping the patient journey and identifying where department interfaces could break down.

Workshops on the second day allowed delegates to review standards and clinical evidence of best practice that underpin any ICP, then to agree detail and delegate action points to ensure future implementation.

All four teams had made significant progress by the end of the two days.

Positive feedback from delegates indicated that a workshop of this type could be the catalyst to jumpstart a stalled ICP, and as many as 96 per cent said it helped them to develop skills relevant to their job.

Dr Mark Davis is a GP in Leeds, a member of of East Leeds PCT's professional executive committee and secretary of the Primary Care Cardiovascular Society.

Tips for success: drafting a viable ICP

Use secretarial support wherever possible to free up healthcare professionals' time.

Be concise and user-friendly: a five-page flow chart/checklist is more likely to be used than a 30-page document.

Be realistic: a long drawn-out ICP to cover a 48-hour care pathway for a terminally ill patient is unlikely to be a useful tool.

Be consistent: style should be consistent with ICP documents in use in other clinical areas.

Include the following:

a chronological care path with clear start and finish points;

a clear assessment procedure to ensure the right patients are on the right pathway;

an agreed diagnostic process;

patient education and health promotion;

clear and measurable outcomes;

an audit tool for evaluation and regular analysis of variance.

Key points

When setting up an ICP, invite participation from all relevant healthcare professionals in both primary and secondary care.

Gather all research and best practice using national guidelines or best available evidence.

Consult patients: they often have knowledge unavailable to medical professionals.

Further information

National Pathways Association www. the-npa. org. uk

To contribute articles to HSJ's clinical management section, please e-mail ann. dix@emap. com

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