Small steps to giant leaps: promotion of active change during care pathway re-design
Navigating the development of clinical care pathways for ADHD can be a time consuming and frustrating process for clinicians - often something that’s ‘slotted’ in between clinics or in their own time.
Some clinics have the luxury of an ‘away day’, but this falls short of the time needed to design an effective pathway. Yet, the importance of such an undertaking should be prioritised. Undoubtedly, care pathways have the potential to improve clinical care, patient outcomes and improve efficiency. But, the true impact is limited by significant barriers that hinder both the development and implementation of a pathway. Success can only be achieved if barriers to change are firstly identified, evaluated and steps put in place to overcome them put in place.
Challenge 1 - the development phase
Sometimes, years can be spent in the development stage due to the complex relationship between the variety of organisations, professionals involved and differing funding streams and budgetary constraints. These all mean that sometimes practical ‘small step’ improvements are put on hold whilst the pathway is being ‘redesigned’ and opportunities for improvement are lost.
In the meantime, whilst consensus about what needs to change or be improved is being sought over a prolonged period, resources may have changed or have been lost, patient through-put increased and new guidelines or key performance indicators may have been introduced rendering the newly rolled out pathway obsolete.
Challenge 2 – auditing and evaluation
Difficulties evaluating and auditing clinical pathways mean that the ‘evidence’ for the care pathway is sometimes sketchy. Clinicians often find it difficult with the current IT infrastructure to have any accurate information on the number of patients both already within the service or indeed for the influx of new patients. Data is not often collected on the number of appointments taken to reach a diagnosis and the time that takes. Nor is the prevalence of co-morbid conditions alongside the initial cause for referral. Without clear data it’s difficult to make clear decisions.
Challenge 3 – capacity management
Capacity management also needs to be thrown into the mix. But again, without accurate numbers, this can be nigh on impossible to plan. Decision makers need to be able to identify how many sessions are available, they need an awareness of how many potential patients may access their service over time. In addition, the numbers of the chronic caseload should be an important part of process mapping to facilitate change. The IT resources are not available to support clinicians to be able to collect or access such data due to a generic system. It is time consuming and soul-destroying and inevitably lengthens the process of redesign.
Compounding the challenge is that within one geographical area CAMHs may be funded by a Mental Health Trust whilst paediatrics may sit in an Acute Trust which hinders collaboration. In a cash strapped NHS, many services are raising clinical thresholds. This is an attempt to manage growing waiting lists, staff cuts and scarce resources, where they are not willing to take on any more workload. It is an often too common objection that “..we aren’t commissioned to do ADHD”, but the irony is that that many services aren’t either. However, there has been a historical footprint for the service many years before with an individual professional who ‘had an interest’. The disparity both amongst different teams and also within teams is evident, leaving patients and their families not only frustrated but waiting several years for a diagnosis. This is heart rendering for clinicians who want desperately to provide the very best care for their patients.
The funding cycle within the NHS can sometimes impede change. Managers juggling a yearly budget find it increasingly difficult to adopt an invest-to-save model of efficiency that may span several funding cycles. Sometimes, improvements in clinical care that are much needed fall by the wayside, casualties in this period of austerity. Consequently, the inertia of normal practice that may be years old, halt the progression of true innovation and opportunity.
Fortunately, as with all good innovations, tenacious individuals are motivating their colleagues and teams by bringing stakeholders together to highlight the barriers outlined above, and, some progress is starting to emerge. Communication and collaboration are the strongest precursors for change and along the way marginal gains driven by small step changes are fuelling the feel good factor that fosters momentum. Progress may still be a slow process, but small steps can lead to giant leaps.
In conclusion, clinical care pathways are both necessary and important to improve clinical care and efficiency but innovation should not be put on hold whilst they are being redesigned. The production of a flow-chart, document or White Paper, is only part of the journey, the end goal should be successful implementation making a real difference to the patients it serves.
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