The health inequalities of people with learning disabilities are well documented in the literature, with increased risks for many physical and sensory health issues as well as mental health issues and responses from health services have often been poor, as documented in the Michael Report. In recent years, the healthcare pathways approach has been introduced into many health services. This is an approach to identifying the steps in care and treatment for a health issue, along with key milestones with a view to identifying the most effective clinical interventions. A number of care pathways have been relatively recently introduced into services for people with learning disabilities but the approach is still relatively new.
The researchers in this study work with an NHS Trust service for people with learning disabilities, which covered seven localities with each locality having a multidisciplinary team to manage the support. Discussions in the trust following the publication of the Michael Report (2008) led to an agreement to introduce a care pathways approach in the service in order to reduce variability in practice and increase adherence to agreed clinical standards.
The service was in the process of implementing eight care pathways:
Autism; Challenging Behaviour; Complex Physical Disability; Dementia; Eating and Drinking; Epilepsy; Mental Health; and Forensics.
The development of each pathway was led by a professional supported by a multidisciplinary team. In addition there was a “Core” care pathway for all clients of the service.
The Clinical Director of the service chaired a care pathways implementation group which oversaw the project and received information on decisions to place clients onto a care pathway during the first stage of implementation in order to have a discussion at the group around any concerns raised.
The researchers in this study were interested in exploring the perspectives of the health professionals involved in the transition process to a care pathways approach.
What they did was to analyse (with consent) the correspondence of health professionals (written e-mails and issue logs) in relation to care pathways.
In addition one researcher recorded comments and issues about care pathway implementation from all multi-disciplinary team meetings over a period of three months and read e-mail correspondence to the overarching implementation group.
One researcher also observed meetings where the issues were discussed to record comments.
They analysed the data to identify themes using constant comparison analysis which enabled the construction of a thematic map.
They identified ten themes from their analysis:
1. Communication between health professionals
They found that professionals believed that communication within had been heightened with an increase in access to other professionals as well as more input and discussion, although they believed that communication from the overarching implementation group had been inconsistent.
2. Clarity and dissemination of relevant documentation
On the whole, the professionals found the pathway protocols clear and easy to follow although there were some problems with the dissemination of documents and some confusion over the existence and location of the latest versions.
3. Multi-Disciplinary Team working
They found professionals had identified increased understanding of the roles of different professionals and improved interdisciplinary relationships. In addition, the need for clear leadership to facilitate the care pathways approach was identified and the researcher observed that there was less adherence to the care pathways approach without this leadership.
4. Role of health professionals
Health professionals had to take on a number of new roles including that of care coordinator which sometimes required additional skills and knowledge and the need for training was highlighted. There was also concern expressed by some that the approach increased the demands on their time which created some difficulties for smaller teams and short-staffed disciplines.
5. Role of administrative staff
Administrative staff were required to take on a number of new roles and renewal of role and job descriptions was highlighted. These caused some difficulties in the localities where there was less administrative support than in others.
6. Locality differences
There were differences in implementation found across the localities, some of which were related to the size of the team and therefore the amount of professional resource that was available for the implementation.
7. Information technology systems
Unsurprisingly, there were issues with IT, in particular the need for version control of pathways in the shared folder and problems with the existing clinical information system database when trying to code with new care pathway terminology.
8. Care pathway procedures
The understanding of the pathways and the new approach was developing throughout the research period and the support and guidance was often requested from the overarching implementation group. One approach that appeared to work well was to use real life examples to highlight good practice and barriers to improvement.
9. Attitudes toward care pathways
Most comments in the transcripts were positive and those negative attitudes expressed concerned pressure and the demand of changing working practices
10. Impact on clients
This study did not measure impact directly, but did identify the reports of the professionals involved, who felt clients benefitted but that identifying care pathways was more difficult for ‘complex’ clients, in particular where people may be allocated to more than one pathway.
Conclusion and comment
This is a relatively small scale study, but interestingly, involved all the health professionals employed in the NHS Trust learning disability service under scrutiny. The research also took place at an early stage of the implementation, so many of the positive comments on impact may be a reflection of optimism related to change.
The authors comment on concerns about potential bias. They used an audit trail and a constant comparative approach to try to minimise this and the researcher was a new employee of the service not directly affected by pathway implementation.
Despite this, the findings at this stage show a positive response to the implementation of a pathway approach. The use of the overarching implementation group appears to have offered a good structure for the early development of pathways, but also acted as a responsive forum for issues and concerns throughout the implementation process.
It is clear that those involved felt that inter-disciplinary communication improved and that there were clear benefits to clients of the service.
However, there were challenges identified, including the need for new skills and competences associated with new roles and the new demands on administrative staff.
Overall, this study seems to suggest that the approach to care pathways was positive in initial outcome. There were clear challenges to introduction and implementation of the new approach, but that these could be managed with appropriate pre-planning and considerations of through pre- planning of the implementation process.
Successes and Challenges in the Implementation of Care Pathways in an Intellectual Disability Service: Health Professionals’ Experiences, Wood S et al., in Journal of Policy and Practice in Intellectual Disabilities, 11 1, 1–7