Digital transformation in the NHS is too often packaged as a "project." A project gets a business case, a steering board, and a delivery team. It runs for 6, 12, or 18 months. Boxes are ticked, outputs are delivered — new dashboards, new portals, new log-ins. Then the fanfare fades, frontline staff slip back into old patterns, and patients barely notice the difference.
Pathways are different.
A pathway is the lived reality of care. It's the frailty patient who moves from GP to hospital and back, with a community nurse checking in along the way. It's the diabetic patient juggling pharmacy visits, dietician support, and yearly reviews. It's the cancer survivor balancing oncology follow-ups with mental health support.
When transformation is framed as a pathway, the unit of success isn't "did the project deliver?" but "is the patient journey safer, faster, and more joined-up?"
Why Projects Fail, Pathways Endure
Projects fragment outcomes. They solve slices of the problem in isolation, often duplicating work or introducing new handoffs.
Pathways align with ICS goals. Integration, prevention, flow, and equity all hinge on the journey across settings, not isolated milestones.
Projects deliver outputs. A new system is "live."
Pathways deliver outcomes. Readmissions fall, discharges speed up, long-term control improves.
In short: projects make IT happy; pathways make patients and staff happy.
Tools for NHS Teams
1. Lightweight Value Stream Mapping
Value Stream Mapping (VSM) lays out the entire patient journey step by step, showing where time, cost, and effort is wasted.
- Run 90-minute sessions with small groups (clinician, analyst, manager).
- Use existing process data and digital whiteboards.
- Prioritise high-friction pathways (frailty, COPD, stroke discharge).
A single session might generate 5–10 improvement actions. Each action typically requires 2–3 analyst days and 0.5–1 PMO day for follow-up, plus clinical backfill for validation. A modest pilot (2 sessions + follow-up) might cost ~£15–20k in analyst/PMO time plus ~£5–10k in clinical backfill.
2. The Five Whys
Five Whys digs beneath the surface of bottlenecks.
Take delayed discharges:
- Why waiting? → Meds not ready.
- Why? → Pharmacy got request late.
- Why? → Ward only phoned after patient fit to leave.
- Why? → EPR doesn't send alerts.
- Why? → Discharge module not configured for that workflow.
The problem isn't "slow pharmacy" — it's missing integration.
Addressing the Hard Realities
Projects vs Pathways: Pathways aren't a replacement — they're the lens. Projects remain the scaffolding, but business cases and deliverables must be tied to pathway outcomes, not just IT outputs.
Evidence Base: Variation-reduction programmes like RightCare and GIRFT show data-led redesign works. Internationally:
- Dutch Diabetes Care Groups: GP-led cooperatives signed bundled contracts with insurers, subcontracting hospitals and allied health, embedding quality metrics (HbA1c, foot checks, retinal screening). Within 3–5 years, this reduced unwarranted variation and improved outcomes.
- Danish Heart Failure Clinics: Municipal–hospital co-funding of nurse-led services cut readmissions by ~10–15%. UK councils don't have the same statutory role, but the transferable lesson is governance: joint funding agreements and shared clinical oversight reduce duplication and shift accountability from individual providers to pathway boards.
Accountability: A lone "Pathway Owner" lacks authority. Instead, create Pathway Steering Groups with a named SRO plus formalised gain-share or outcome-based contracts. Accountability must rest on governance, not goodwill.
Resources: Even lightweight VSM costs time. Prioritise with a Pareto approach: start with the 20% of pathways driving 80% of costs and harm. Pilot 2–3 pathways first, prove ROI, then scale.
Measurement: Cross-system data is fragmented. Begin with proxy metrics (DNAs, LOS, readmissions), add narrative audits (patient journey tracing) within 3–6 months, and evolve towards FHIR-based event datasets over 2–3 years as shared care records mature.
Politics: Pathways cross budgets. Gain-share agreements and outcome-based contracts take 12–18 months to formalise. Interim solutions include ICS discretionary transformation funds, shadow gain-share accounting, and pump-priming budgets to cover short-term imbalances. Without aligned incentives, accountability collapses.
The Economics of Delay
Every delay carries a price. For example: a two-week wait for blood results can cost:
Across 100,000 patients in an ICS = ~£425m
The figures are directional, not precise — but they make visible the economic reality: delay is expensive, not neutral.
Cross-Sector Lessons
Finance
Banks reframed projects around journeys like mortgage origination.
Retail
Retailers map click-to-delivery as a value stream, not IT milestones.
Healthcare
NHS RightCare and GIRFT show pathway-first redesign reduces variation and cost. Dutch and Danish examples prove multi-org governance is achievable when incentives and contracts align.
Takeaway
Projects provide the structure. Pathways provide the lens. Together, they can deliver outcomes that patients and staff actually feel.
By using lightweight VSM, Five Whys, and reframing economics through pathway outcomes, ICS leaders can make transformation real — while still respecting the governance frameworks the NHS runs on.