Abstract
Background: Welsh Government policy to deliver integrated care services closer to citizen home has been developed over the last decade. However, how frontline services, whether in primary, secondary care or social care, could deliver improved services focussed on populations or patient groups has not been detailed or evaluated. From 208, 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 very local context of the citizen. Welsh Government has consequently commissioned a unique national programme, with strong system-wide governance and leadership, to roll out CommunityHealthPathways across the whole of Wales, to support standardised delivery of integrated care.The programme has exploited the advantages of a Once for Wales approach to maximise value of the investment through shared national pathway development processes, governance and outcome measures. This pathway approach has already opened opportunities for streamlining services, improving referral quality, innovations in widening service delivery, and recording and analysing data. Ultimately the published platforms with their hundreds of pathways is proving to be a strong foundation on which to build service integration and transformation for citizens.
Approach: Using learning from the initial Cardiff iteration of CommunityHealthPathways, Welsh Government/NHS Wales have developed a national approach to development of integrated pathways, that support care of citizens in the community and describe the interventions and standards for delivery, and also for subsequent localisation that reflects 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, and local leadership from primary and secondary care and clinical editors in local Health Boards, with patient/carer support encouraged. This approached has released opportunities for innovations at multiple levels.
Results: Since the Once for Wales national programme was launched on /3/2023, national clinical editors have published 60 CommunityHealthPathways ready for localisation in each Health Boards in Wales, with 220 more in development. There have been 436,000 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 0% 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 almost pound;400,000 have been reported as a result. There has been an associated growth in referral to physiotherapy as a result.
ImplicationsThis 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.