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.
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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.
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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.
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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...
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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
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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
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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.
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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.
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Expert care
pathway development
Point of
care
Repository of
knowledge
GPs
Planned
care
Social
care
Commissioners
Community
care
Clinical
governance
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“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
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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.
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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
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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
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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.
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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