Care Pathways for Quality Improvement; conference report

Care Pathways for Quality Improvement – Learning from the Liverpool Care Pathway

On Wednesday February 12, delegates met in London to consider the impact of the Liverpool Care Pathway, and recent national review on pathways more generally. The conference was chaired by Ruben van Zelm, E-P-A secretary. In his Welcome and opening, Ruben highlighted the importance of definitions and terminology regarding care pathways. He explained the E-P-A definition, focusing on the concept of ‘complex interventions’. A care pathway is more than a piece of paper!

Highlights from Rubens presentation available here

Next speaker was Deborah Murphy, Directorate Manager & National Lead Nurse- LCP Royal Liverpool & Broadgreen University Hospitals NHS Trust and Associate Director of the Marie Curie Palliative Care Institute Liverpool (MCPCIL), University of Liverpool. She explained the history of the Liverpool Care Pathway. Developed as a local pathway, to support health care professionals in delivering high quality and respectful care for the dying, the LCP became a national and even international care pathway. In it’s original, local setting, a number of conditions were set and met before implementation of the pathway. With the spread of the document to other regions and hospitals, these conditions were not always met, resulting in poor implementation. This is supported by the Neuberger Inquiry and report. Of the 44 recommendations in the report, only 2 focus on the LCP as tool (definition / name). The other recommendations are aimed at the care process.

Information on Deborah’s speech is available here

The next speakers presented examples of care pathway work, not only for the dying, or end of life phase, but for other clinical areas as well. Dianne Tetley and Martin Vokes, Lincolnshire Partnership NHS Foundation Trust, showed an example of a Single Point Access for mental health. Single Point Access can only work if care pathways are in place to provide transparency for both care professionals and users.

Helen Mitchell, Betsi Cadwaladr University Health Board, and Marlise Poolman, Bangor University, explained the Wales perspective of using an ICP for the last days of life. They have combined the care pathway, audits, variance tracking and analysis, and benchmarking into a working quality system. The care pathway is not used as a means in itself, but as a tool to achieve goals.

Information on the Welsh session here

Mark Flemming, Healthcare Improvement Scotland, presented the Scottish approach to developing national condition specific standards for care pathways. Rather than developing national pathways, national standard for pathways are developed, leaving room for local adaptation.

Highlights from Marks session:

A care pathway for an acute condition, Paracetamol poisoning, was showed by Janice Pettie. After an initial successful implementation, Janice was forced to de-implement the pathway. The guidelines regarding paracetamol poisoning had changed, and these changes needed to be incorporated in the care pathways. As Janice put is, many nurses felt that their ‘comfort blanket’ was taken away. Only for a short period; the update care pathway is now been used again.

Jonathan Webster, CWHHE CCGs Commissioning Collaborative, and Rob Sainsbury, Hammersmith & Fulham CCG showed the development of care pathways for frail elderly. These generic pathways use whole system approach to plan and deliver Out of Hospital care for frail elderly. The pathways do not focus on a specific condition or procedure, but on more generic aspects of care.

The conference yielded some good learning points. First, care pathway development and implementation is never just about content, the context (culture, politics, …) is equally important. Second, there is still a lot of misunderstanding regarding terminology. There are many definitions, and we tend to forget that healthcare workers might have a different understanding of the term ‘pathway’ than service users. Third, the successful examples in today’s conference all had in common that the project lead or care pathway facilitator really connected with the intended users. First hear, then speak. Finally, there was concern that the recommendation of the Neuberger Inquiry that the Liverpool Care Pathway should be replaced, will lead to ‘losing the comfort blanket’ as one of the delegates quoted Janice Pettie. The LCP is still regarded as a good tool, but it was the implementation was problematic in some cases.

A number of the presentations is available via: