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On the right track? How HealthPathways are improving care in Canterbury, New Zealand

Today, The King's Fund publishes a case study on the quest for integrated care in Canterbury, New Zealand. It's an ongoing six-year journey that has involved creating a vision; putting in place the processes to achieve that; and changing many things in the way primary care, the hospital and social care work. This has produced demonstrable improvements in hospital effectiveness and social care demand.

One of the more innovative items has been HealthPathways – a set of agreed local guidelines on what family doctors should do before referring patients for an outpatient consultation.

At first sight HealthPathways looks merely like another set of guidelines for treatment or the Map of Medicine. But the way it has been constructed, and what it contains, makes it much more than that. Developed from 2008, it is a set of highly applied and detailed local agreements on best practice. The agreements inform GPs not just about what needs to be done before a patient is referred, but precisely where they can get the services they need (such as X-rays, lab tests and physiotherapy) from the public or private sectors.

The pathways are based on the best international evidence. But where the availability of local services cannot meet this need, the pathways strive to be explicit about that, explaining why a higher referral threshold has been set.

To critics, this might look like the ultimate in cookbook medicine. But it has empowered GPs to do appreciably more in general practice and has helped to ensure that only those patients who need an outpatient appointment get one. Referrals are monitored: those that do not follow the pathway are rejected. GPs have to do more so that the patient arrives at hospital better 'worked up'. Consultants are working more intensively because more of the patients who turn up really need to be seen. But the result has been better use of hospital resources and a more professionally satisfying life for GPs. It has also produced better communication between specialists and general practitioners as cases can be discussed with the pathway open on each of their computers. With almost 500 pathways in existence, GPs can now more easily tackle the cases they might see only once every year or so.

But Dr Graham McGeoch, who was heavily involved in the design of HealthPathways, and others in Canterbury say the process of creating the pathways has been as essential as the outcome. It has forced hospital specialists and GPs to sit down together and overcome prejudices and misunderstandings. For example, GPs need no longer ask 'why are you following up on my patient for five years when I could be doing this, and you could be seeing the patient I can't get in?' – when the consultant thought that follow up was what the GP wanted.

Doctors in Canterbury are clear that HealthPathways is not a cookbook others can simply lift off the shelf and adopt: the communication between hospital specialists and general practitioners that it has forced has been an essential element in its success. But its results have been sufficiently impressive for others in New Zealand and Australia to attempt to replicate it.