How to win an integrated pathways challenge

This e-book is designed for anyone interested in improving the way in which care guidance is communicated to clinicians during patient consultations. It will help you understand the benefits of implementing a care pathway programme that unites all aspects of the care community, with patients at the centre.”
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CARE CARE PATHWAY Map referral LOCAL health
About manojranaweera

CARE CARE PATHWAY Map referral LOCAL health
<p>HOW TO 
WIN THE 
INTEGRATED  
CARE 
PATHWAYS 
CHALLENGE
Whether you are mapping pathways for your CCG, 
developing your  Sustainability and Transformation
Plans (STPs), or if you are an accountable care system, 
Map of Medicine has the solutions to support you to 
work more effectively.
CO-ORDINATE YOUR  
CARE SERVICES 
AND SUPPORT 
YOUR CLINICIANS
GET PATIENTS ON THE 
RIGHT CARE PATHWAY 
FOR YOUR LOCAL AREA 
IN ONE POWERFUL, 
INTEGRATED SOLUTION.
Our mission is to help you to develop co-ordinated
planned care pathways and  to share your local guidance 
across your health economy to ensure that all healthcare 
professionals, in all care settings, have a single
source of knowledge to support their decision making.
2
3
OVERVIEW
Our care pathways experience                      
Let’s define what a care pathway is
DESIGNING CARE PATHWAYS
Why is it so important to have 
system-wide care pathways?
Designing pathways: who, when and how?
Let’s talk timelines for pathway transformation
So who should be involved designing 
the ideal care pathway?
SHARING INFORMATION  
AT THE POINT OF CARE
How do you communicate the pathways to the 
healthcare professionals that need to know them?
CASE STUDIES
Signposting of local services
Bringing together integrated care organisations 
to develop care pathways
Benefit to GPs
Care pathway development and rapid uptake
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OVERVIEW
SECTION ONE
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This e-book is designed  
for anyone interested in 
improving the way in  
which care guidance is 
communicated to clinicians 
during patient consultations.  
It will help you understand  
the benefits of implementing  
a care pathway programme 
that unites all aspects of  
the care community, with  
patients at the centre.”
Jennifer is a Senior Programme 
Consultant at Map of Medicine.  
Her expertise is in change 
management, stakeholder 
engagement and major change 
implementations in environments 
where behaviour and cultural 
change is required at all levels, 
to secure implementation 
success of each project.
OUR CARE 
PATHWAYS 
EXPERIENCE
Jennifer Dennington
“I know first-hand the 
pressures facing healthcare 
and I’ve seen how great 
decision support 
technologies can help our 
NHS work more efficiently. 
However, the true power of 
decision support and other 
technologies lies within 
having locally relevant 
clinical evidence and an 
adoption strategy that works 
for your locality. I’ve been 
working with healthcare 
organisations across the 
country to help them drive 
down unwarranted variations 
in GP referrals by providing 
them with a proven structure 
to do this, and the findings 
have gone into this e-book.
5
Jeff Dienhart 
For more than 30 years, 
Hearst Health International’s 
solutions have been helping 
the NHS to deliver actionable 
evidence into the hands 
of clinicians. 
Our care guidance and 
decision support solutions 
enable NHS organisations 
to address both national and 
local strategic goals, and 
drive change through their 
clinical and partner teams. 
In the last year alone, 
Map of Medicine and FDB 
OptimiseRx have been used 
by vanguard communities 
and integration pioneer 
CCGs to support new care 
models, while FDB Multilex 
and ZynxOrder are 
Jeff is the Senior Managing 
Director for the International 
businesses of Hearst Health, 
including Map of Medicine. 
6
supporting health care 
professionals in recently 
announced digital exemplar 
trusts. 
We’ve learnt a lot over the 
years, and through this 
e-book hope you will benefit 
from some of the expertise 
our teams are sharing with 
your neighbouring NHS 
organisations. Hearst Health 
International are always 
seeking to improve and 
innovate our clinical decision 
solutions to better address 
the NHS’ evolving care 
models and outcome 
priorities. We look forward 
to hearing of your latest 
plans and goals, and 
hopefully having a chance 
to help you to achieve them.
LET’S DEFINE 
WHAT A CARE 
PATHWAY IS...
7
A good care pathway 
should include all aspects 
of health and social care, 
not forgetting self-care, and 
importantly should move the 
patient towards a defined 
positive clinical outcome. 
All of this should be based 
on the best clinical evidence 
available, from reputable 
evidence-based sources, 
such as NICE, SIGN and 
the Cochrane Database
of Systematic Reviews.
A care pathway is the ideal journey of care that a 
patient should receive within a healthcare community. 
Visualise the patient journey 
from presentation to referral 
Redesign pathways 
and base discussions on 
evidence-based best practice
Promote self-care and share 
decision making
Introduce a governance 
structure to maintain  
local pathways
Standardise diagnostic 
work-up of patients
Communicate 
a standardised clinical approach
Highlight red flag clinical  
features requiring urgent 
assessment
Co-ordinate care and 
referrals more effectively
8
Map Pathways is the ideal starting  
point for turning care pathway plans into  
real resources that clinicians can interact  
with at the point of care.
DESIGNING
CARE
PATHWAYS
SECTION TWO
9
WHY IS IT SO IMPORTANT
TO HAVE SYSTEM-WIDE 
CARE PATHWAYS?
The Five Year Forward View 
and the GP Forward View 
lay out the need for the 
NHS to break down barriers 
between GPs, hospitals, 
social, physical and mental 
health care to provide an 
integrated service that 
delivers a seamless 
journey for patients.
NHS England stated that for 
health care to be integrated 
it must be person-centred, 
coordinated, and tailored to 
the needs and preferences 
of the individual, their carers 
and family.  
 
This means moving away 
from episodic care to a more 
holistic approach to health 
that puts the requirements 
and experience of patients 
at the centre of how services 
are planned and provided.
There are significant 
challenges in making this 
a reality in everyday practice, 
not least in managing patient 
flow through referrals to 
the most appropriate areas 
of care.
NHS England’s planning 
guidance asks NHS 
organisations to proactively 
develop locally agreed 
pathways as part of their 
‘Local Digital Roadmaps’ 
and improve the 
communication of care 
pathways and decision 
support using digital 
technologies by March 2019. 
Solutions such as those 
from Map of Medicine 
can help to enable 
organisations to go 
paper-free at the point 
of care. 
10
Map Pathways includes evidence-based 
pathways on on musculoskeletal conditions, 
gastroenterology, urology, dermatology, 
paediatics, eye health and many more. 
There are also thousands of locally 
developed care pathways from many 
organisations across the NHS – so you 
can share best practice, and 
learn from peers.
Mental 
health
Long term 
conditions
Child  
health
Self
care
Earlier
diagnosis
Prevention
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DESIGNING  
PATHWAYS:  
WHO, WHEN  
AND HOW? 
We’ve been working with 
local health economies for 
more than 10 years and 
we understand that no two 
organisations are the same.
Location, demographic 
make-up, rural or urban, 
make every CCG unique. 
Local services and provisions 
also different by CCG, which 
is why Map of Medicine 
solutions can be localised 
to reflect this diversity. 
No-one knows the local 
health community and its 
challenges like the local 
clinical team, which is 
why it’s important to bring 
together clinical champions. 
This understanding allows 
commissioners and planned 
care teams to put in the 
right measures across their 
area, which they know will 
help improve the health 
outcomes of their patients.
12
Expert care 
pathway development
Point of
care
Repository of
knowledge
GPs
Planned
care
 Social
care
Commissioners
Community
care
Clinical
governance
13
“As well as improving the technical aspect of disseminating 
local best practice, Map of Medicine’s care pathway 
experts can help improve the human side. My team of 
clinical experts will work with your organisation to develop 
a clinical pathway strategy, and help define the areas of 
priority that will deliver the highest value to your 
organisation. By engaging and training your local 
teams, Map of Medicine can help to speed up the 
adoption process and help to ensure your local health 
community are adhering to your processes.” 
Gajan is Head of Clinical Strategy at Map of Medicine. His team of 
clinicians work with hundreds of healthcare professionals and health 
leaders to advise of clinical strategy for care pathway development.
Dr Gajan Srikanthan
Use high-quality evidence-based care pathways to agree 
your local pathways with multidisciplinary stakeholders 
Transform your guidance into  
easy to read online care pathways
Approve care pathways in line with  
your local governance structure
Connect all the knowledge around the 
pathway, including a repository of 
referral guidance and templates
GP and healthcare professionals access 
via clinical system at the point of care
LET’S TALK TIMELINES
FOR PATHWAY
TRANSFORMATION
14
When thinking about a 
timeframe for implementing 
a care pathway programme, 
allow yourself enough time, 
but set a schedule and  
stick to it.
Research from Map of 
Medicine shows that 
without support from Map of 
Medicine, NHS organisations 
can spend up to 18 weeks to 
design just one care pathway. 
You might be asking yourself 
why does it take so long? 
Well, first of all, trying to get 
the right people in the room 
is a challenge in itself with 
many stakeholders requiring 
many weeks’ notice to  
attend or take part in a 
pathway review.
It’s also really important to  
ensure that any pathways 
developed meet your 
local clinical governance 
standards, so allow enough 
time to include that within 
your development schedule.
y
Nurses
CCGs
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SO WHO SHOULD
BE INVOLVED
DESIGNING THE
IDEAL CARE
PATHWAY?
NHS England say that CGs 
are expected to coordinate 
this development process, 
ensuring Health and Well-
being Boards are engaged, 
as well as acute, community, 
mental health and local 
authorities. 
Healthcare has many key 
decision makers across 
many different locations  
– it’s important to consult 
with all stakeholders when 
developing your care 
pathway programme. 
To facilitate adoption and 
collaborative working, it’s 
really important that you 
consider the right governance 
process for your area.  
GP
PATIENTS
We recommend that you 
prepare draft care pathways, 
and that you invite 
stakeholders from across 
your health economy to 
review and provide feedback. 
For example, your local 
provider services, trust, 
and community care 
services will be able to 
provide feedback and 
information on what happens 
in those care settings.
If it’s not possible to consult 
with all, then start with those 
that are engaged and take  
it from there.
CCGS
MULTI- 
DISCIPLINARY
TEAMS
PRACTICE 
MANAGERS
PHARMACISTS
NURSES
CLINICIANS
16
Map QuickStart is a professional service 
from Map of Medicine which includes support 
in pathway development, implementation 
and adoption. 
We also give you access to a range of starter  
content that you can rapidly localise, known 
as ‘Summary care maps’.
SHARING  
INFORMATION 
AT THE POINT  
OF CARE
SECTION THREE
17
HOW DO YOU 
COMMUNICATE 
THE PATHWAYS 
TO THE 
HEALTHCARE
PROFESSIONALS  
THAT NEED TO  
KNOW THEM?
Now that you’ve agreed 
your care pathways and 
referral guidance, and 
they meet your clinical 
governance standards, 
you’ll want to start sharing 
them with your healthcare 
professionals. 
There is increasing pressure 
within the NHS to get more 
done in less time. This is  
a daily struggle across 
care settings, and, 
understandably, a problem 
that most would like a 
magic wand to help fix. 
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Map Referrals is designed by clinicians for 
clinicians, and helps to save clinicians time. 
From instantly sharing referral guidance across your 
CCG, to one-click auto-populated referral forms, 
Map Referrals removes excess administration 
to allow GPs more time to concentrate on patient care 
and improve efficiency. 
With a single sign on via EMIS Web, TPP SystmOne 
and INPS Vision, Map Referrals can be accessed 
instantly by GPs during a patient consultation. Map 
Referrals has been designed to be a central repository 
of localised clinical and administrative guidance that 
GPs can trust because it is maintained by the CCG.  
19
These simple steps, and the tried 
and tested Map of Medicine 
methodology for pathway 
development offer a really easy 
way to make sure that you are 
on track to deliver your local 
care pathway programme.
YOUR CHECKLIST 
FOR CREATING 
CARE PATHWAYS
Understand that a good care pathway should 
include all aspects of health and social care
Design your care pathway from high-quality 
evidence-based sources such as national clinical 
guidelines and systematic reviews
Keep abreast of changes in the evidence base 
and update your pathways regularly
Work with stakeholders from across your local 
health economy to agree local pathways, including 
acute, mental health, community care and other 
integrated care services
Ensure care pathways are available at the point of  
care, and link with patient records in GP systems  
so that clinicians can access them at the right time
Enable GPs and practice teams to access  
collection of referral forms that auto-populate 
with demographic and clinical information 
Develop an ongoing governance and content 
improvement structure so ensure that your  
pathway is up to date
It’s a challenge that all healthcare 
organisations are facing, but with 
our help it’s a challenge that can 
be won, and you can transform 
the way in which care guidance 
and pathways are developed 
and communicated to your 
health economy.
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CASE
STUDIES
SECTION FOUR
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Map of Medicine solutions are used in all GP Practices across 
Sunderland, as part of the All Together Better Vanguard. 
GPs access a wealth of locally customised care pathways for 
urgent referrals and 2 week wait, long-term conditions, and 
guidance on the assessment and initial investigations for patients 
with abnormal test results. 
The Vanguard site has linked Map Pathways to their local Individual 
Funding Request (IFR) platform. This means that when a GP is 
following the referral guidance within an online Map Pathways 
care pathway, and determines that the patient meets the criteria 
for treatment that currently falls outside of care routinely provided 
by the NHS, the GP can immediately be directed to the platform in 
a single click to make an IFR. Furthermore, should a referral be 
required then the referral process can be started instantly with 
Map Referrals which is integrated with the GPs clinical system. 
Sunderland GP Alliance 
(Vanguard)
SIGNPOSTING OF 
LOCAL SERVICES
CASE STUDY #1
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Map Referrals is part of NHS Cumbria CCG’s digital health strategy, 
which is partly funded by the Safer Hospitals, Safer Wards 
Technology Fund. Through this strategy, NHS Cumbria aims to 
transform the way in which referrals are managed across primary 
care, acute trusts, community and mental health trusts, and to 
enable commissioners and providers to proactively identify 
and manage blockages in patient flow.
Through a comprehensive development programme with 
Map of Medicine, a broad range of clinical topics have 
been created and adapted from best practice evidence. 
The visual algorithmic care pathways include: guidance on 
commonly encountered and long-term conditions such as 
Low back pain and Asthma; localised guidance on 2 week wait 
referrals; and local referral protocols for procedures of limited 
clinical value. In total, 75 care pathways and referral templates 
have been developed and reviewed within 5 months. 
NHS Cumbria CCG
CASE STUDY #2
BRINGING TOGETHER 
INTEGRATED CARE 
ORGANISATIONS TO 
DEVELOP CARE 
PATHWAYS
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Within NHS Islington CCG, Map of Medicine is the single source of 
information for care pathways, referral guidance, and referral form 
templates. GPs and practice teams can access local information 
through Map Referrals. 
The CCG has received positive feedback from Practice Managers 
and GPs alike, expressing that Map Referrals’ central information 
repository is useful and supports them with bridging the gap 
between clinical and administrative workflows.  In particular, 
that using Map Referrals is user-friendly and time-efficient for 
GPs and Practice Managers as it minimizes the need for 
healthcare professionals to contact individual provider services 
for current pathway or referral information. 
NHS Islington CCG
BENEFIT TO GPs
CASE STUDY #3
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In NHS Cannock Chase CCG, 33 local Map Pathways care 
pathways have been developed, including Anaemia, Back pain, 
Suspected hearing loss and pathways that depict local processes 
for procedures of limited clinical value.
The CCG’s goal is to carry out evidence-based clinical 
commissioning as a means of identifying those services or 
interventions which might be decommissioned on the basis 
of lack of efficacy or cost-effectiveness. Map Referrals supports 
the CCG’s goals by supporting GPs and primary care staff to 
automate referrals in line with the evidence base, and act as 
a central repository for all referral guidance and referral form 
templates.  More than 17,000 referrals have been made 
through Map Referrals in a 3 months period alone.
NHS Cannock Chase CCG
CARE PATHWAY 
DEVELOPMENT 
& RAPID UPTAKE
CASE STUDY #4
Our solutions include:
Evidence-based care pathways 
to help healthcare organisations 
communicate best practice at 
the point of care
Seamless solution to standardise 
referrals across a CCG
Professional services to help 
kick-start local pathway 
programmes
Map of Medicine, 
FDB (First Databank), Zynx 
Health and MCG comprise 
Hearst Health International. 
Together, we help guide the 
most important care moments 
by delivering vital information 
into the hands of everyone 
who touches a person’s 
health journey. 
With over 100 people based in the UK, our team 
comprises both depth and diversity of industry 
knowledge and expertise including medical 
doctors, registered nurses, pharmacists and 
healthcare IT specialists, dedicated to serving 
the NHS.
We have more than 30 years’ experience of 
developing and implementing clinical decision 
support solutions with around 180 customers 
across CCGs, secondary care and community 
trusts, as well as a community pharmacies and 
mental health trusts.
Map of Medicine understand the importance of local 
health communities being able to define and apply 
local solutions to the niche challenges affecting their 
area, whilst applying continually evolving best 
practice and clinical guidelines to their pathways. 
Want to find out more? 
Contact us today for a demonstration 0207 492 6300
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