Local clinical pathway for MS
Susie MacAllister, Senior Physiotherapist
Wandsworth Community Neuroteam, St John's Therapy Centre, Wandsworth
Way Ahead 2010;14(3):10-11
There is increasing popularity in the development of commissioning, clinical, and care pathways as quality improvement tools. Indeed, the MS Trust developed one of the first successful long-term conditions commissioning pathways using the Department of Health's 18 week pathway template. This web-based tool is a 'living' guide that informs commissioning teams who have little knowledge about MS, its investigation, diagnosis and treatments. In the following article, Susie MacAllister demonstrates the versatility of the pathway format, describing the development of a locally specific MS clinical pathway for multiple sclerosis in the London Borough of Wandsworth.
Introduction
In 2008 a project started in Wandsworth with the aim of developing a clinical pathway for MS that could be used to guide and direct referrals between GPs and hospital and community teams in order to inform and facilitate timely referral and cross-service working.
Method
Expert advice and ideas were sought from across the community health and social care teams with particular input from the hospital-based MS specialist nurses at St George's Hospital and from other nurse specialists working in acute and primary care in the Borough.
A questionnaire was sent to people with MS living in the Borough asking where they go when looking for advice and treatment for MS-related problems; and a GP survey was sent to the 49 practices in the Borough to ascertain how many people with MS were registered.
For 46% of people with MS their GP was the first point of contact for any MS-related problems; while for 25% it was their MS nurse. This response highlighted the need to offer GPs and healthcare professionals easy access to information to assist in directing people to appropriate services in the Borough and in making timely referrals when necessary.
From the surveys that were returned from 39 practices, the total number of people with MS registered with those GPs at the time was 294. Interestingly, a number of GP practices had no people with MS registered and the maximum was returned by three separate practices, each having 19 people with MS.
Other issues explored by the project group included the following:
Cost and reasons for admissions to hospital
Cost and reasons for admissions to hospital - to determine whether a quality audit could be set up to assess the impact of improved communication between community teams on the number of avoidable admissions. Data was collected for admissions to St George's Hospital and included information about MS diagnosis; respiratory, skin, and bladder conditions; and lower limb fractures.
Pressure ulcers
Pressure ulcers - have been clearly identified by NICE1 as a sentinel marker of quality. In Wandsworth Borough ulcers graded 2 and over are reported as a clinical incident. However, pressure ulcer data is currently not collected in diagnostic groups and this has been recommended. A detailed clinical guidance document had already been written and placed on the Wandsworth Trust website by the tissue viability specialist nurse and a series of training tutorials are taking place throughout 2010.
Single point of contact
Although there is a well-established MS nursing service at St George's Hospital, there is no multidisciplinary MS team in Wandsworth Borough. When discussing the issues around provision of a single point of contact or key worker for people with MS, the consensus was that this should be developed across the Borough for people with long-term conditions, not just MS.
Format and content of the Wandsworth MS clinical pathway
Discussion with community and hospital health and social care professionals with experience of working with people with MS informed the content of the pathway. It was agreed that the Wandsworth pathway should be locally specific and simple to use. The project group agreed that specific information was required about relapse management, bone health, pressure ulcer care and bladder and bowel management.
A Trust template for the design of clinical pathways was not readily available so a simple grid design was developed and the expertise of a web manager was used to set up links to appropriate websites. It was important that this pathway should be quick and easy to use, as GPs in particular, are often under considerable time pressure.
The web-based information grid is available to staff at NHS Wandsworth and to Wandsworth-based GPs.
| A Diagnosis |
B Symptom Management |
C Relapse Management |
D Nursing |
E Neurotherapies |
F Specialist Services |
G The Borough |
The headings of the MS clinical pathway are listed above. Behind each of these boxes, users can find specific information such as: clinical guidelines; referral details; links to locally specific services, and links to relevant websites. The aim of the grid is to provide health professionals with quick access to relevant information when offering advice and treatment to people with MS living in Wandsworth.
Outcome
The Wandsworth clinical pathway for people with MS is now accessible to employees of NHS Wandsworth on the staff intranet and to all 49 GP practices through their GP referral toolkit intranet. To ensure that this is seen as a reliable and useful resource an annual update will be undertaken by the administration and clerical staff of the community neurorehabilitation team with guidance from the web designer. Thus comments are welcome and further amendments and enhancements will be possible.
The MS pathway will soon be accessible via NHS Wandsworth with a link through Wandsworth Careline. The advantages of making the MS clinical pathway available on the internet include the following:
- All boroughs have boundaries and not all patients receive health care from the Borough in which they live and everyone now has more choice of where they receive treatment. The timely provision of care is often slower with cross boundary referrals as staff try to find the right form for the right team in the right place. It is envisaged that this Pathway will be useful to professional colleagues in the adjacent boroughs to access our services directly and so best support our residents.
- As health and social care professionals and third sector organisations work to assist people with MS to manage their long-term condition and as people with MS and their families try to access relevant and useful information when they need it, it is hoped that people with MS will also use this pathway and contribute to its further development.
Future
There is a long-term neurological conditions project now running in Wandsworth in conjunction with Neurological Commissioning Support (NCS) and reaching across health and social care. This project has a clinical network arm, a users/carers group and a steering group. It has been suggested that the issues around cost and a single point of contact are taken to that forum for further discussion and action.
If you would like further information about the pathway contact Susie Macallister by email.
Acknowledgements
My thanks go to the MS Project Steering Group: Dr Soori, Consultant in Rehabilitation Medicine at Queen Mary's Roehampton; Rachel Sibson, Clinical Team Leader for Neurological Rehabilitation Community Services Wandsworth; and Claire Ward, Clinical Specialist Physiotherapist in Neurology and to Allan Ruan, Web Development Manager, for their expertise and guidance.
Reference
- National Institute for Clinical Excellence.
Multiple sclerosis: management of multiple sclerosis in primary and secondary care.
NICE Clinical Guideline 8. London: NICE; 2003.
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