The discontinuity involved in a system with multiple different teams can mean that patient care pathways are disjointed and relevant interventions not implemented or even considered. As services are again transformed, integrated care pathways and outcome measurement can guide this process. These pathways can act by empowering service users, carers, staff and commissioners, guiding them through a complex system, which need not be chaotic, making choice and effective treatment available, driving necessary change while improving efficiency and quality92.
The care programme approach was established to co-ordinate care when there was evidence of service users with severe problems losing contact with services and becoming homeless or imprisoned. It provides for a care coordinator, care plan and defined review date to be established for this group. Eligibility criteria exist but are variably applied.
Interfaces between and within services for adults, children and adolescents and older people can interrupt care pathways and be particular points of risk and dislocation; good practice in jointly developed transition protocols exist but often not implemented93.