The future of Hospital HealthPathways: are we killing the goose?

The fable of the goose that laid golden eggs describes a desire for short-term gain destroying something that has long-term value.¹ Is this what is happening to Hospital HealthPathways?

In this issue of the New Zealand Medical Journal (NZMJ), Ardagh (who also co-authored this editorial) celebrates the success of 10 years of Hospital HealthPathways (HHP) in the Waitaha Canterbury health system.² HHP started as a companion to Community HealthPathways (CHP), as a tool in the toolkit used to build an efficient and integrated health system. It described carefully constructed, evidence-informed, practical, locally agreed, accessible, “how we do things around here” guidance for hospital clinicians. Over those 10 years, as detailed in Ardagh’s paper, it has become inextricably woven into the fabric of the Canterbury health system. It is well used and greatly liked by hospital clinicians. No matter how you measure value (opinion, process improvements, cost or clinical outcomes) there is evidence for its value. A second site was developed in the MidCentral region, and there was hope that it would spread throughout the motu, with localised iterations in each region.

However, in the time between acceptance of Ardagh’s paper by the NZMJ and its publication, Health New Zealand – Te Whatu Ora suddenly and surprisingly announced that the contract for HHP with Streamliners (the technical writers and platform providers for HealthPathways iterations in over 60 sites around the world, and the provider for HHP and CHP in Canterbury from the beginning) would be discontinued, and instead Health New Zealand – Te Whatu Ora would provide its own “in-house” technical writing and platform.

Regrettably, this decision was made without consulting either the users or creators of HealthPathways. Despite the national care pathways programme having clinical advisors, no clinical advice was sought. Instead, the relevant deliberations and the ultimate decision were not communicated widely until after the event. Indeed, no advice was sought from anyone with knowledge of how HHP works nor experience in its operations. Subsequent advice from such people that this decision is short sighted, ill informed and is a risk to patient safety has been dismissed.

What is at-risk is described in Ardagh’s paper. It was hard won, clinically led, opportunistic at times, sometimes serendipitous, but ultimately highly successful by any measure. Its role in the Canterbury health system is a manifestation of the strong and trusting relationships with the clinical community. Pathways are written prioritising end user experience, with easy-to-follow content but with comprehensive information tucked away in “drop-boxes” (often going four or five levels deep).  Formatting is done by those with expertise in maximising end user clarity and navigability, following a detailed style guide. There are links to information within HHP, its sibling CHP site, or elsewhere. The content can be aligned with any of the wider New Zealand and international HealthPathways sites, but is defined, localised and approved by local clinicians. Users are able to provide feedback directly from a pathway page, and this feedback, in conjunction with planned reviews, keeps the information in a pathway correct and current.

The Health New Zealand – Te Whatu Ora plan is to take all the Hospital HealthPathways content, in the form of approximately 900 two-dimensional PDFs, and disconnect them from the complex systems that create, maintain and display them. CHP in New Zealand will remain with Streamliners, so the new HHP will be expected to continue technically separated from its sibling CHP and from the international network of HealthPathways teams with which material and work is currently shared. It is unclear how the integration objectives of HHP and CHP working together and sharing content will be maintained, if at all. Nor is it certain that much of the content that HHP users currently access via links to CHP will still be available. Maintaining currency of HHP depends on close relationships with the health system, frequent updates and a regular 3-year review cycle. No detail has been provided about how the new site will be maintained.

The authors, among many others, think it is unlikely that this transition will successfully recreate a site achieving the success of the one it is replacing. To the casual observer, there might still appear to be a goose in the farmyard, but, to users, it will be clear that it is not the same goose.

While the authors’ view might be challenged by those who made this decision, why are we taking the risk when the current site is so successful? Of course, the reason is cost. A budget sheet has seduced fiscally pressured decision makers with the promise of short-term cost savings. However, the promised cost savings are likely specious, with efforts to match the value of the incumbent site ultimately requiring more and more investment. In the fable, the hoped for cache of gold was not found inside the slaughtered goose, but only then, after realising the folly of the decision, did they see there was no going back.

Apparently ignored in the deliberations about the future of HHP is the potential to negotiate a reduction in the cost of the current provider, thereby achieving the cost-saving objective while keeping the goose alive.

Aesop allegedly told the fable about the goose that laid golden eggs more than two and a half millennia ago. If he was admitted to hospital in Canterbury now, he might be pleased his fables remain popular but disappointed we have not learnt from them. If he was asked to contribute to this discussion he would, no doubt, join the chorus urging us not to kill the goose.