Leading System-wide Collaboration and Integration of Health Pathways - from National Policy to Frontline Practice in Wales

Background: Welsh Government policy is to deliver integrated care services closer to citizens’ homes. However, how frontline services could deliver improved services focussed on populations or patient groups has not been detailed or evaluated. From 2018, the capital region of Cardiff successfully implemented a local CommunityHealthPathways programme, publishing 500 evidence-based clinical pathways systematically developed by joint working between primary, secondary and mental health care clinicians, providing just-in-time guidance appropriate to the local context of the citizen.   Welsh Government has consequently commissioned a national CommunityHealthPathways programme, with strong system-wide governance and leadership to support standardised delivery of integrated care.

The programme exploits a ‘Once for Wales’ approach to maximise value of investment through a shared national pathway development process, governance and outcome measures.

Approach: Using learning from Cardiff, Welsh Government/NHS Wales have developed a national approach to development of integrated pathways, supporting care of citizens in the community and describing interventions and standards for delivery, and also for subsequent localisation that reflect local population or workforce needs. Essential programme components include Leadership from a national programme management team and National Clinical Networks, which can include patient/citizen voices and third sector, as well as local leadership from primary and secondary care and clinical editors in local Health Boards, with patient/carer support encouraged.

Results: Since the ‘Once for Wales’ national programme was launched on 1/3/2023, national clinical editors have published over 230 CommunityHealthPathways ready for localisation in each Health Board in Wales, with 229 more in development. With 1,426 digital pages of referral guidance and thresholds, there have been over 700,000 pathway page views, across 5 digital platforms.

Health Boards and GP clusters have used the localised pathways to help review outpatient waiting lists, and have supported patients’ own GPs to review whether patients need to continue waiting for consultant review or whether an integrated service could provide an alternative. Typically 40% of patients can be removed from waiting lists safely through this mechanism, and up to 72%.  

Health Boards have also recruited Interface GPs who work supportively with specialists to lead clinical working groups and develop pathways, new services, and even triage referrals from GP peers, based on locally agreed CommunityHealthPathways. In Cardiff, these roles have helped reduced need for consultant outpatient assessments by around 10% typically.

Use of CommunityHealthPathways to enforce changes in clinical practice, has been successfully used in conjunction with Remote Guidance services for GPs to discuss with specialists those cases that do not fit a CommunityHealthPathway. As a result MRIs of lumbar spine have reduced by 72% and ultrasound scans of shoulders have reduced by 92% in Cardiff. Savings of £400,000 have been reported with an associated growth in referrals to physiotherapy.

Implications: This programme demonstrates how the national policy of development of clinical pathways, localised to reflect population and workforce need, has been implemented at speed, at scale, with strong governance and leadership through adapted learning across a nation. Patient/Carer/Third sector voice is apparent at national and local development stages.