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Functional Neurological Disorders (FNDs) are characterized by the symptoms experienced by the individuals but also by how they express personal experiences and concerns related to the clinical condition. Access to care programs for functional neurological symptoms appears challenging and may entail circular, self-perpetuating healthcare pathways. Given the challenging and misleading interpretations around FND, in advocating for care pathways beyond medical therapies, we designed a scoping review to map recently suggested practices and interventions. We identified 31 relevant papers published between January 2018 and December 2022. Most of the literature was gathered from the US and UK healthcare experiences, with documented interventions provided by multi-professional teams or stand-alone psychotherapists. We found different care pathways addressing either motor or non-motor manifestations. Persons with Functional Motor Disorder are more likely to be referred to physical therapy first, while Persons suffering from Non-Epileptic Seizures are to mental health services. A narrow focus was given to minor components of multimodal approaches (e.g. social workers, and occupational therapists). High heterogeneity was found between assessment instruments as well, reflecting different perspectives in selecting treatment outcomes (e.g., reduction of non-epileptic events, psychological functioning, motor symptoms). Among healthcare professionals, neurologists and (neuro)psychiatrists are typically engaged in formulating and delivering diagnoses, while treatment is often administered by physiotherapists and/or psychologists. In the context of FNDs, the complex etiopathological nature of the condition, including comorbidities, suggests the recommendation of multidisciplinary treatments adopting a stepped care model progressing from standard to higher level individualized modules may better suit individual complexities. [ABSTRACT FROM AUTHOR]

This article outlines the current guidelines and recommendations for pre- and post-discharge care and rehabilitation of survivors of out-of-hospital cardiac arrest (OHCA) and their families. Although many OHCA survivors make an overall good physical and neurological recovery, many others experience a combination of cognitive decline, emotional problems, fatigue and difficulties in reintegrating in the community and in the workplace. Current pathways of care in the UK are not well suited in identifying and addressing these issues. Neuropsychologists, in particular, are rarely involved in the care of these often-complex patients who fall on the boundaries of neurology, cardiology and critical care. In this article we summarise the current best practice in the development of a pathway of care and rehabilitation for OHCA survivors in the UK. The role of Neuropsychology is discussed, and clinics are invited to collaborate in the development and evaluation of this pathway of care. [ABSTRACT FROM AUTHOR]

People with Parkinson's disease (PD) may find it difficult to identify and access the wide number of services they need and are entitled to along their complex PD journey. As part of the project OPTIM‐PARK – Optimisation of community resources and systems of support to enhance the process of living with Parkinson's Disease, document analysis was developed to create overviews of existing resources and systems of support in Denmark, Norway, Spain and the United Kingdom. Documents on community resources, policies, guidelines and professional recommendations were the main sources of information. They were sought systematically at official websites of the public sector (national and regional levels) and websites of non‐governmental organisations and scientific societies; searches were performed in October 2020 and updated in September 2021. A higher‐level cross‐national content analysis integrated all the country‐specific information. Data‐ and concept‐driven coding frames were developed; trial coding and peer review strengthened face validity and reliability. The analysis led to overviews of: (1) Key aims at patient and societal levels. (2) Key elements in form of professional approaches. (3) Community resources. (4) Legally anchored services. In general, clear descriptions of how to implement care pathways and tools to facilitate delivery were missing in the included documents, and pathways and guidelines did not include referral to general social support, social security support or labour and employment support. The results shed light on the complex support systems and resources and can inspire the planning of more comprehensive care pathways for people with PD and other long‐term conditions. [ABSTRACT FROM AUTHOR]

Objectives: The risks of developing cancer and dementia increase as we age; however, this comorbidity remains relatively under-researched. This study reports on the challenges that people affected by comorbid cancer and dementia face when navigating engagement with cancer treatment within secondary care. Materials and methods: An ethnographic study recruiting 17 people with cancer and dementia, 22 relatives and 19 oncology staff in two UK National Health Service Trusts. Observations (46 h) and informal conversations were conducted during oncology appointments involving people with dementia. Semi-structured interviews (n = 37) with people living with cancer and dementia, their relatives and staff working in various roles across oncology services were also carried out. Data were analysed using ethnographically informed thematic analysis. Results: People with cancer and dementia experienced challenges across three areas of navigating cancer treatment and care: navigating through multiple services, appointments and layers of often complex information; repeatedly navigating transport to and from hospital; and navigating non-dementia-friendly hospital outpatient environments alongside the cognitive problems associated with dementia. Conclusions: Dementia impacts patients' abilities to navigate the many practical aspects of attending hospital for cancer treatment and care. This study indicates the importance of addressing ways to improve the experience of travelling to and from the hospital, alongside extending the ongoing efforts to develop 'dementia-friendly' hospital in-patient areas and practices, to outpatient departments. Such steps will serve to improve hospital-based cancer treatment and care and more broadly outpatient appointment experiences for people with dementia and their families. [ABSTRACT FROM AUTHOR]

Objectives: Young onset dementia is associated with distinctive support needs but existing research on service provision has been largely small scale and qualitative. Our objective was to explore service use, cost and satisfaction across the UK. Methods: Information about socio‐demographic characteristics, service use and satisfaction were gathered from people with young onset dementia (YOD) and/or a family member/supporter via a national survey. Results: Two hundred and thirty‐three responses were analysed. Diagnosis was most commonly received through a Memory Clinic or Neurology. The type of service delivering diagnosis impacted on post‐diagnostic care. Those diagnosed in specialist YOD services were more likely to receive support within the first 6 weeks and receive ongoing care in the service where they were diagnosed. Ongoing care management arrangements varied but generally care was lacking. Around 42% reported no follow‐up during 6‐weeks after diagnosis; over a third reported seeing no health professional within the previous 3 months; just over a third had a key worker and just under a third had a care plan. Satisfaction and quality of care were highest in specialist services. Almost 60% of family members spent over 5 h per day caring; median costs of health and social care, 3 months, 2018, were £394 (interquartile range £389 to 640). Conclusions: Variation across diagnostic and post‐diagnostic care pathways for YOD leads to disparate experiences, with specialist young onset services being associated with better continuity, quality and satisfaction. More specialist services are needed so all with YOD can access age‐appropriate care. [ABSTRACT FROM AUTHOR]

In the United Kingdom, one‐in‐four individuals with mental health problems access mental healthcare with police involvement. However, little is known about police officers' perceptions of their role in pathways to services. The aim of this study was to examine UK police officers' views and experiences of their involvement in mental healthcare, focusing on decision‐making in emergency situations. Using volunteer sampling, we recruited 15 police officers from a large metropolitan conurbation in the North West of England. Semi‐structured interviews, including a vignette depicting a mental health emergency, were used to elicit data. Interviews were transcribed verbatim and analysed at the manifest level using thematic analysis, yielding three main themes: 'Doing What's Right', 'Challenges of Working Together' and 'Training versus Experience'. Our findings indicate that, while police officers believe they have a duty of care to protect people in mental health emergencies, they sometimes lack relevant knowledge, skills and confidence in decision‐making. Challenges associated with multi‐agency working were also perceived as impeding officers' ability to effectively manage these emergencies. Our findings suggest that strengthening multi‐agency working and improving training might positively influence police officers' views of their role and maximise their contribution to improving emergency mental healthcare. [ABSTRACT FROM AUTHOR]

Introduction Complex orbital fractures require multi-specialty input. The United Kingdom currently has no agreed best practice guidelines. A systematic review and meta-analysis found a significantly increased adverse outcome of persistent diplopia in patients operated on more than 14 days after initial injury. At our tertiary centre, we felt patient outcomes may be affected by investigative and referral pathway limitations so evaluated to assess and attempt to improve these. Methods This was a two-stage service evaluation study of all orbital trauma patients requiring specialist oculoplastic and orbital input. The initial phase included all orbital trauma patients referred to our department in April–November 2014. We assessed relevant key performance indicators and then implemented changes to our referral system, educated referring departments and formed a multidisciplinary team clinic to manage complex trauma. We then re-evaluated, collecting data on all patients referred March–May 2015. Results Most patients were male and victims of assault. Following intervention, there was a significant reduction in the injury to eye clinic review time (3.45 weeks to 2.22 weeks, p = 0.01) and multidisciplinary team review time (3.86 weeks to 2.71 weeks, p = 0.04). Injury to discharge time was significantly reduced from 6.15 weeks to 3.36 weeks (p = 0.002). Discussion Our study shows that a multidisciplinary team approach and structured pathways can improve assessment and intervention times for orbital trauma patients. This may have a beneficial effect on patient outcomes. In the absence of guidelines in the United Kingdom, we believe similar improvements could be implemented by other national centres and outcomes evaluated to assist future guidance formation. [ABSTRACT FROM AUTHOR]

In 2014, the body that leads the National Health Service in England published a new strategic vision for the National Health Service. A major part of this strategy was a three-year-long national programme to develop new care models to coordinate care across primary care, community services and hospitals that could be replicated across the country. Local ‘vanguard sites’ were selected to develop five types of new care model with support from a national team. The new care models programme provided support for local leaders to enable them to collaborate to improve care for their local populations. We interviewed leaders in the vanguard sites to better understand how they made changes to care locally. Drawing on the insights from these interviews and the literature on cross-organisational change and improvement we devised a framework of 10 lessons for health and care leaders seeking to develop and implement new models of care. The framework emphasises the importance of developing relationships and building capability locally to enable areas to continuously develop and test new ideas. [ABSTRACT FROM AUTHOR]

This paper examines the effects of New Public Management reforms on the information infrastructure underpinning the work of public service professionals. Focussing on the case of the British National Health Service (NHS), the paper argues that hospital accounting reforms played a significant role in the emergence of standardised models of clinical practice. The paper moreover argues that, under the label 'care pathways', such standardised models of clinical practice became embedded in the information infrastructure of the NHS and concludes by discussing their implications for the work of doctors and hospital accountants. [ABSTRACT FROM AUTHOR]

Women’s enhanced medium secure services (WEMSS) is a model of care aimed at providing a more appropriate level of security for women and, in so doing, reducing the number of women in high secure psychiatric services. In 2007, three Department of Health commissioned WEMSS pilots became operational. This study compared the clinical outcomes of women in WEMSS with control women in six standard medium secure services and one high secure service matched on key clinical and risk characteristics, in order to examine their pathways of care. Our findings confirm that the WEMSS pilots were successful in transitioning women from high secure services who had previously been thought unsuitable for medium secure services. However, WEMSS showed no additional clinical benefit, suggesting that these women could be cared for equally well within standard medium secure services. We make recommendations about WEMSS and the future shape of women’s secure care in England. [ABSTRACT FROM PUBLISHER]

Aims and objectives To explain how the healthcare needs of transgender personnel are met within the United Kingdom Armed Forces. Background It may be that when transgender people disclose their gender preference that they are at increased risk of social exclusion. The United Kingdom Armed Forces has an inclusive organisational policy for the recruitment and management of transgender personnel. Design This is a position paper about how the healthcare needs of transgender military personnel are met by the United Kingdom Armed Forces. Methods United Kingdom Armed Forces policy was placed into context by reviewing current research, discussing medical terminology and describing the policy. This was followed by an account of how UK AF policy is applied in practice. Discussion Where armed forces had an inclusive policy for the management of transgender personnel, there seemed to be little cause for secrecy and zero tolerance of discrimination when compared to nations where this was not the case. Medical terminology has changed to reflect a more inclusive, less stigmatising use of language. The United Kingdom Armed Forces policy has been described as progressive and inclusive. The application of this policy in practice may be dependent upon strong leadership and training. The wider United Kingdom Armed Forces seems capable of adopting a pragmatic and flexible approach to meeting the healthcare needs of transgender personnel. Conclusion The United Kingdom Armed Forces value diversity within their workforce and have a progressive, inclusive policy for the recruitment and management of transgender personnel. Relevance to Clinical Practice When supporting a transgender military person, healthcare professionals, civilian organisations and military line managers should consider referring to United Kingdom Armed Forces policy as early as possible. Other military and uniformed services may wish to examine the United Kingdom Armed Forces exemplar in order to consider the applicability within their own organisational setting. [ABSTRACT FROM AUTHOR]

Currently, 250 000 men are affected by prostate cancer in the UK. Clinical guidance is crucial for nurses involved in the care delivery for men with advanced prostate cancer and for their families to maximize their quality and quantity of life. It is essential that nurses understand how prostate cancer is diagnosed, can recognize signs of disease progression, are familiar with disease management, and can educate patients and manage any symptoms appropriately and effectively. Therefore, the aim of this paper is to review current evidence‐based guidelines in relation to care delivery for men with metastatic prostate cancer in order to optimize best supportive care. A literature review was conducted in a range of electronic databases (DARE, Cochrane, MEDLINE, BNI, PsychINFO, EMBASE and CIHAHL) to identify studies employing qualitative and/or quantitative methods. National (UK) and European clinical guidelines were also reviewed. Methodological evaluation was conducted and the evidence‐based recommendations were integrated in a narrative synthesis. Supportive care is a person‐centred approach to the provision of the necessary services for those living with or affected by cancer to meet their informational, spiritual, emotional, social or physical needs during diagnosis, treatment or follow‐up phases including issues of health promotion, survivorship, palliation and bereavement. A multidisciplinary and proactive approach to the management of men with metastatic prostate cancer ensures safe and effective supportive care delivery. Nurses involved in the care delivery for this patient group need to be aware of the complex physical and psychological supportive care needs, and evidence‐based management care plans to ensure a personalized and tailored support to optimize quality of life. [ABSTRACT FROM AUTHOR]

This article describes the initial development and subsequent evolution of a simple referral assessment tool for stoma care. The first author's personal experience identified that there was widespread inconsistency in perceptions of local multidisciplinary teams as to when it was appropriate to refer to specific specialist nursing teams. This resulted in both inappropriate and delayed referrals. A 'Think Specialist Nurse' initiative was developed across the author's trust, building on the traffic light template from the 'ThinkGlucose' tool, to facilitate referrals to clinical nurse specialists. The stoma-care specific tool, 'Think Stoma Nurse', has subsequently evolved beyond its initial audience, and has been adapted into materials aimed at patients and carers. [ABSTRACT FROM AUTHOR]

The prevalence of allergic diseases is increasing, with estimates suggesting that 3.9% of 0-19 year olds have a food allergy. Adolescents are seen as a high-risk group for anaphylaxis because of their risk-taking behaviours and challenges in using adrenaline auto-injectors. The Royal College of Paediatrics and Child Health provides an allergy care pathway to assist health professionals with these issues. The pathway could be implemented more effectively with the adolescent age group if education on how to follow it was improved for young people and their parents/carers. Healthcare staff also need training on how best to deliver information to this age group and to monitor them. More technically stylish adrenaline auto-injectors, designed with the involvement of adolescents, together with clearer food labelling, would also help avoid episodes of anaphylaxis. [ABSTRACT FROM AUTHOR]

The author discusses the enhanced skills of dentists and the possible role of the profession in the pathway approach to the delivery of clinical care in Great Britain.

As a profession, district nursing has experienced significant depletion in recent years. However, district nurses are centre stage in terms of the delivery of government policy to move care closer to the patient’s home. This article reviews some of the challenges faced by district nurses, such as the changing patient demographic and delivering specialist care in people’s homes, the effect of current policy and the development of a new course in one university designed to equip practitioners with the skills required to address the demands of the 21st century. INSET: Origins of district nursing. [ABSTRACT FROM AUTHOR]

This article presents the characteristics of 83 looked after and 67 adopted children at the time of their first assessment by a designated mental health team in the context of potential appropriateness of this service. Attachment and mental health problems were significantly associated across most subscales of the Relationships Problems (RPQ) and the Strengths and Difficulties Questionnaires (SDQ). Adopted children were younger and were rated higher on both measures. One-third of the children were rated below the clinical cut-off SDQ score. The service appeared to adopt broad referral criteria to include attachment difficulties rather than just mental health disorders. The findings are discussed in relation to the varied interpretation of the constructs of attachment difficulties and disorders, and the future development of care pathways for looked after and adopted children. [ABSTRACT FROM PUBLISHER]

Healthcare pathways are a relatively new approach to delivering care in intellectual disability services. The authors endeavored to ascertain and explore successes and challenges in the implementation of care pathways in a National Health Service adult intellectual disability service in Leicestershire, UK. Data were obtained from a variety of sources including observations of multidisciplinary team meetings, issue logs, and feedback from health professionals. Constant comparative analysis identified 10 themes: communication between health professionals; clarity and dissemination of relevant documentation; multidisciplinary working; role of health professionals; role of administrative staff; locality differences; information technology systems; care pathway procedures; attitudes toward care pathways; and impact on clients. It was found that a new implementation of care pathways approach to service delivery in the healthcare setting can be challenging for health professionals. Some of the challenges were generic to service change and could be addressed through careful and organized preplanning of the implementation process. Others, such as organizational culture and attitudes within the organization, were contextual and may be unique to each service and warrant significant advance consideration when attempting implementation. [ABSTRACT FROM AUTHOR]

Objective: To investigate how religion influences care pathways for black and minority ethnic individuals with dementia. We conducted a systematic search of the literature to explore how religion affects later presentation to care services, absence of care-seeking and dissatisfaction with care. Exclusion and Inclusion criteria were applied to the research literature. Qualitative and quantitative papers were included. Included studies were assessed independently by four authors according to quality criteria. Two US studies adhered to the final screening stage. Findings from these papers postulated that religion influences care in two polarised ways: (1) Religion hinders access to the traditional health care pathway. (2) Religion assists in positive coping. Collaboration between religious institutions and health care providers is required to improve care referral, provide information dissemination and relieve care-giver burden. UK research in this area is necessary. [ABSTRACT FROM AUTHOR]

Objective: To explore the role of specialist outpatient eating disorders services and investigate how direct access to these affects rates of referral, admissions for inpatient treatment, and continuity of care. Method: Services beyond primary care in Greater London retrospectively identified adolescents who presented with an eating disorder over a 2-year period. Data concerning service use were collected from clinical casenotes. Results: In areas where specialist outpatient services were available, 2-3 times more cases were identified than in areas without such services. Where initial outpatient treatment was in specialist rather than nonspecialist services, there was a significantly lower rate of admission for inpatient treatment and considerably higher consistency of care. Discussion: Developing specialist outpatient services with direct access from primary care is likely to lead to improvements in treatment and reduce overall costs. © 2012 by Wiley Periodicals, Inc. (Int J Eat Disord 2012) [ABSTRACT FROM AUTHOR]

Following an audit of practice in North East London Foundation Trust (NELFT), obstacles in the management of lower limb conditions were identified. An appraisal of needs in terms of skills and theory updates for staff led to a fixed-term 'honorary contract' between the trust and a wound-care company to facilitate a rolling programme of education, to upskill staff in terms of assessment and treatment, and develop standardised care pathways. After 3 months, a repeated practice audit revealed a reduction in nurse contact hours of 1156 hours. The partnership with industry proved to be beneficial and did not compromise care, and trust staff were not obligated to use their product. [ABSTRACT FROM AUTHOR]

Introduction: This article, co-authored by experts in research, child and adolescent mental health, occupational therapy and education services, considers service provision in Attention Deficit Hyperactivity Disorder (ADHD). Contents: This article outlines the roles of those who are involved in service provision for children and young people with ADHD, and identifies the challenges faced by ADHD services. Care pathways are then described, with details of factors that need to be considered in the mapping of potential local pathways. Conclusions: The development of local care pathways for the diagnosis and management of ADHD is suggested as a method of meeting the challenges identified. [ABSTRACT FROM AUTHOR]

The Rapid Recovery Program (RRP) is an accelerated discharge programme aimed at reducing the length of stay (LOS) and improving patient satisfaction. Its principles are discussed, and our early experience of 847 hip and knee arthroplasty patients described. Three groups were identified: Pre-RRP implementation (Pre-RRP), Post-RRP implementation who did not attend our pre-operative educational Joint Replacement School (JRS) (RRP-JRS) and Post-RRP who did attend JRS (RRP + JRS). Mean LOS (days) for hip arthroplasty was 11 (Pre-RRP), 6.4 (RRP + JRS) and 8.7 (RRP-JRS) ( P < 0.05). Mean LOS (days) for knee arthroplasty was 8.5 (Pre-RRP) ( P < 0.05), 5.9 (RRP + JRS) and 5.8 (RRP-JRS). RRP reduced LOS and pre-operative education further reduced LOS in hip arthroplasty. We believe these effects are produced by streamlining perioperative processes, education and improving patient experience. [ABSTRACT FROM AUTHOR]

Recent changes in UK immigration policy have led to increasing deportation of foreign national offenders and more than 5000 were deported in 2008. This rise follows a review in 2006 which found that some foreign national offenders were being lost due to disposal or transfer through mental health services. As a result, a department was set up within the United Kingdom Border Agency (UKBA) to identify and review those detained under Restrictions Orders who were due to be conditionally released from hospital, so that they could be considered for deportation. As a result of these changes, forensic clinicians are more frequently presented with detained patients who have immigration problems that can lead to problems in the care pathway through secure services. A local audit was carried out in an inner-London medium secure service to quantify the number of detained patients who are born abroad, and to review their care pathways to determine whether they are affected by immigration difficulties. It is hoped that the discussion of the issues identified by this audit can support service improvement and provide better care for patients in medium secure services. [ABSTRACT FROM AUTHOR]

Abstract: Care pathways are multidisciplinary care management technologies which map out chronologically activities in a healthcare process. In the UK, they are advanced as a mechanism for enacting the changes called for under clinical governance. The terminological imprecision of care pathway methodology has enabled it to align clinical, management and service user interests and helps to explain the growing popularity of care pathways as quality improvement tools. Whilst it is possible to identify a ‘zone of agreement’ between these social worlds, there exists a fuzzy periphery characterised by conflicting agendas, which presents challenges for those charged with inscribing these interests into the pathway artefact. Drawing on a qualitative case study of a mental health safety care pathway in the UK, this paper examines the processes by which originators negotiated and settled upon a given design. The data reveal inherent tensions within pathway technology and the knowledge developers draw upon in devising strategies to overcome these challenges. [Copyright &y& Elsevier]

Primary objectives: To identify the health and social care services used by young adults aged 18-25 years with acquired brain injury (ABI) and the costs of these supports. Research methods: A review of existing literature and databases and contact with academics and stakeholders working with people with ABI. Main outcomes and results: The likely care pathways of young adults with ABI were mapped over a notional 1-year period after presentation at hospital accident and emergency departments. Most young adults with ABI will use minimal health and social care support following injury but those with subsequent disabilities may cost the health and social care budget in excess of £47.2 million per year. Conclusion: Lack of available data mean the service use and cost estimates draw from a range of sources. However, the costs may under-estimate the true impact on budgets as incidence rates may be higher than identified and conservative values were selected for unit costs. The model estimates the cost of treatment and support as provided today, but high levels of unmet need remain. [ABSTRACT FROM AUTHOR]

A fundamental platform of healthcare reform in the UK is the commissioning of services on behalf of primary care trusts, supported by the use of a tariff, payment by results and pay for performance. The basic currency of commissioning is care pathways and the aim of this paper is to identify how commissioning of laboratory medicine (pathology) services fits into this commissioning framework. The paper describes how the laboratory services contribute in several ways to optimise the care pathway, to secure the best outcomes for patients and the best value for money for the taxpayer. In so doing it highlights the fact that the laboratory service is a key enabler of change, and that commissioning of laboratory services should be based on what it contributes to the care pathway, rather than the number of results that it can deliver for a given price, ie commissioning vs procurement. Some examples are given where tests facilitate redesign of care pathways, as well as how the laboratory plays a role in performance management of services. The reader will also become aware of the challenges of commissioning laboratory services from this perspective - as well as the benefits of this approach. [ABSTRACT FROM AUTHOR]

This article reports an important multi-centre practice-based review that identifies good practice and an ideal pathway for the healthcare of frail older people, which, if replicated nationally, could result in improved quality of care and better value for money for the NHS. Data on healthcare resource groups (HRGs) in England were examined as a marker for the management of elderly people through the healthcare system. Care pathways in several different NHS trusts were explored via staff interviews. A high variation in treatment outcomes across centres was found. Principles of best practice were identified and include: comprehensive geriatric assessment; the availability of specialist geriatric teams and wards; and shared assessment and co-ordination between care agencies. [ABSTRACT FROM AUTHOR]

The author discusses the issues of care pathways in dentistry in Great Britain.

Purpose: The purpose of this paper is to describe current care pathways for children with autism including enablers and barriers, as experienced by health professionals, education professionals and families in South Wales, UK., Design/methodology/approach: This study is based on a mixed-methods approach using focus group discussions, creative writing workshops and visualisation using rich pictures., Findings: The experiences of the care pathways differed significantly across the three groups. Health professionals described the most rigidly structured pathways, with clear entry points and outcomes. Education professionals and parents described more complex and confusing pathways, with parents assuming the responsibility of coordinating the health and education activity in a bid to link the two independent pathways. All three groups identified enablers, although these differed across the groups. The barriers were more consistent across the groups (e.g. poor communication, missing information, lack of transparency, limited post-diagnosis services and access to services based on diagnosis rather than need)., Practical Implications: This research could inform the design of new services which are premised on multi-agency and multi-disciplinary working to ensure children with Autism spectrum disorders (ASD) receive joined up services and support., Originality/value: Although this study did not represent all professional groups or all experiences of autism, the authors examined three different perspectives of the ASD pathway. In addition, the authors triangulated high-level process maps with rich pictures and creative writing exercises, which allowed the authors to identify specific recommendations to improve integration and reduce duplication and gaps in provision.

Aim: To understand what contextual influences, mechanisms and outcomes affect the implementation and use of localised, online care pathways (HealthPathways) in primary and secondary care., Design and Procedure: Mixed-measures design. Q uantitative data included number of page views and conditions viewed. Qualitative data from semistructured interviews and focus groups were gathered over a 6-month period, and analysed using NVivo software., Setting: The first HealthPathways UK site, South Tyneside, England., Participants: General practitioners, nurses, practice managers, hospital consultants and system leaders (managers, commissioners) (n=76)., Results: Use of the pathways significantly increased over time. Themes were developed showing how online care pathways were used-leadership, pre-existing networks and relationships; development of systems and processes for care pathways, the use of online care pathways to support decision-making and referral, and perceived availability of resources. Inter-related themes were arranged into configurations consisting of contextual influences, mechanisms and outcomes. Recommendations were made for future implementations, such as improved data collection processes to understand how and why there was variance in the use of pathways., Conclusions: This study was early in the implementation process; however, emerging themes will facilitate the future implementation and use of online care pathways. Recommendations are made for further research to include other health and social care users and patients to inform future developments., Competing Interests: Competing interests: IG is married to a member of the executive team in South Tyneside Clinical Commissioning Group., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The number of people in the UK with three or more long-term conditions continues to grow and the management of patients with co-morbidities is complex. In treating patients with multimorbidities, a fundamental problem is understanding and detecting points of conflict between different guidelines which to date has relied on individual clinicians collating disparate information., Objective: We will develop a framework for modelling a diverse set of care pathways, and investigate how conflicts can be detected and resolved automatically. We will use this knowledge to develop a software tool for use by clinicians that can map guidelines, highlight root causes of conflict between these guidelines and suggest ways they might be resolved., Method: Our work consists of three phases. First, we will accurately model clinical pathways for six of the most common chronic diseases; second, we will automatically identify and detect sources of conflict across the pathways and howthey might be resolved. Third, we will present a case study to prove the validity of our approach using a team of clinicians to detect and resolve the conflicts in the treatment of a fictional patient with multiple common morbidities and compare their findings and recommendations with those derived automatically using our novel software., Discussion: This paper describes the development of an important software-based method for identifying a conflict between clinical guidelines. Our findings will support clinicians treating patients with multimorbidity in both primary and secondary care settings.