HealthPathways: A Canterbury tale From paper tiger in Christchurch to asset in consult rooms globally

"They were debating whether to put it in a ringbinder or, it was 2007, to get sophisticated and put it on a CD"

It began with a thick wodge of paper sitting on a table.

But, as in all good origin stories, there are slight variations in the telling.

As Ian Anderson recalls it, he came across specialist GP Graham McGeoch wondering how to get that paper wodge, detailing a new respiratory clinical pathway, out to Canterbury general practices.

“They were debating whether to put it in a ringbinder or, it was 2007, to get sophisticated and put it on a CD,” Mr Anderson remembers with a chuckle.

Mr Anderson, as the co-founder of technical writing business Streamliners, suggested they leave it with his team. A week later he returned with the first online HealthPathways prototype.

It offered GPs a web-based, clickable local guideline to assessing, managing and referring patients with chronic obstructive pulmonary disease to Canterbury specialist services.

HealthPathways now covers 600- plus clinical conditions and is used by GPs, nurse practitioners, nurses and allied health clinicians across New Zealand, Australia, England and Wales.

The pathways web platform was launched in 2008 as a collaboration between Canterbury DHB, local GPs and Streamliners. When other DHBs started knocking on Canterbury’s doors wanting HealthPathways, they were pointed towards Streamliners for support to localise and implement pathways in their regions.

The Christchurch-based company now provides ongoing pathways management and coordination for the 11 regional groupings that cover the country and another 50 health systems globally. Together they make up the HealthPathways Community collaboration.

Streamliners, meanwhile, has gone from eight staff in 2008 to 150 in 2023 and a $20 million turnover. The company is doubling the size of its Christchurch-based headquarters to support the international growth in HealthPathways.

Dr McGeoch, dubbed the “father of HealthPathways”, says he had no idea back in 2007 it would go global. He just wanted to build a locally consistent clinical guidance manual.

The first pathway, co-written with respiratory physician Roland Meyer with DHB funding, was the typically textheavy guideline you might expect from two slightly academic doctors, he says.

The DHB, then under the leadership of chief executive David Meates and innovative planning and funding manager Carolyn Gullery, was fostering the “high trust, clinician-led, management-supported, whole system” approach to health that Canterbury became famous for after the 2010/11 earthquakes.

Part of that whole-of-system approach is the Canterbury Initiative, a collaboration of GPs and hospital specialists focused on using innovation and integration to improve healthcare.

Dr McGeoch says the initiative was kicked off in 2007 when the DHB funded him and fellow specialist GP and Pegasus Health founder David Kerr to work with project manager Bruce Penny to “sort out the referrals process”.

Mr Anderson, who had been a Canterbury Health planning manager in the 1990s before he founded Streamliners, offered the trio a neutral space to meet: in his company’s building.

And that is how Mr Anderson came upon them debating whether, as Dr McGeoch recalls it, to distribute the COPD pathway as some kind of flipchart, a printed document or maybe the “really modern” CD-ROM. “None of which anybody would have looked at,” agrees Dr McGeoch in retrospect.

Instead, Mr Anderson took the complex document to the “mother of HealthPathways”, Streamliners technical writer Juanita Gibson, to pare it down to key items in a template structure that has stood the test of time.

GPs’ positive feedback to this pilot pathway led to other respiratory pathways being added, along with gynaecological referral guidelines written by specialist GP Clare Healy and gynaecologist Mike East.

Now having critical mass, the project launched the HealthPathways website in 2008. By the end of 2009, 135 pathways offered succinct evidence-based information on assessing and managing patients with everything from headaches to bowel cancer symptoms.

Consistent guidance for specialist referrals was also being negotiated between specialist GPs and hospital specialists and updated regularly to reflect what hospitals could deliver.

At the same time, funding and training to deliver services including spirometry to pipelle biopsies and to access diagnostic testing was being devolved from secondary to primary care to reduce avoidable referrals.

Come 2013 and Canterbury clinicians and Streamliners had developed over 600 HealthPathways being used by nearly all Canterbury GPs along with local variations available across most of New Zealand and in many Australian states.

That same year, HealthPathways was hailed by the UK’s The King’s Fund as being part of the integration-led “transformation” of the Canterbury health system.

The increased international profile and positive research findings on reduced waiting lists and avoidable referrals saw HealthPathways taken up by some NHS regions in the UK. A successful rollout in Cardiff and Vale led to the NHS Wales in April signing up to implement HealthPathways nationally – the first country in the world to do so.

It has been a heady 15 years for Mr Anderson as HealthPathways took Streamliners from a local technical writing start-up to a global player with its Christchurch-based clinical editors and technical team working with 61 regional health systems.

His own induction to the health system came in 1995, during the Crown Health Enterprise days. The commerce graduate, with a background in the manufacturing and electricity sectors, became Canterbury Health planning manager, responsible for Christchurch Hospital.

“I was one of the commercial people brought in to ‘fix’ the health system,” he says.

It took a couple of years for him to realise health didn’t fit the normal business model and “you are in the rationing business”.

And, Mr Anderson says, he found people working in the health system weren’t motivated by commercial drivers but by “delivering really good health and social outcomes for patients”.

He also noted the sector was “a concentration of the brightest people in the country”.

In time, he concluded that what works for the health system is hightrust, effective relationships and getting the right information to front-line people to let them do their job. That was the culture of the much-missed “dream team” of Mr Meates and Ms Gullery, whom Mr Anderson worked with in the 2000s and until their departures in 2020.

But first he had to deal with the damning 1996 Patients are Dying report into Christchurch Hospital patient deaths by senior clinicians, and the follow-up 1998 report by health and disability commissioner Robyn Stent.

“It was a horrible time,” he recalls. “Treasury had a philosophy of setting the board against the management and management against the clinicians. It was a divide and conquer mindset and it was a disaster, in my opinion.”

He left Canterbury Health in 1999, setting up Streamliners with his technical writer wife Emma Harding while continuing some health planning contract work in the company’s early days.

Streamliners launched the policy documentation SchoolDocs platform in 2006 (now a standalone sister company), followed it up with the general practice-focused GPDocs in 2016 and, more recently, the student wellbeing pathway platform Stronger Schools.

But it is HealthPathways and its association with the Canterbury health “transformation” that has led Streamliners’ global expansion. There are more countries on the horizon; Mr Anderson had an early morning online meeting with a Canadian health authority the day of his interview with New Zealand Doctor Rata Aotearoa.

I was one of the commercial people brought in to “fix” the health system

At home in New Zealand, some GPs have had mixed feelings about HealthPathways as it became associated with rationing of scarce secondary health services.

Wellington specialist GP Emma Dunning wrote in 2016 of it sometimes seeming “secondary care is using HealthPathways as a tool against us”.

Last year, Whangārei specialist GP Paula Mathieson talked of HealthPathways becoming a “de facto means to decline referrals”.

The father of HealthPathways is not surprised at the guarded response from some GPs.

“HealthPathways needs to be good, accurate clinical guidance for general practice teams,” Dr McGeoch says. “But it also needs to be a negotiating tool for what the hospital is actually going to do and what public services are going to be available to patients in a transparent and equitable manner.”

Few, if any, regions around the country took Canterbury’s comprehensive approach to HealthPathways as a tool for health improvement and change management.

One result is that the number of generic pathways that have been localised to reflect and respond to the reality of secondary services varies significantly across the 11 HealthPathways regions.

Streamliners data show Canterbury clinicians use of HealthPathways remains two to five-fold higher per capita than most other regions.

Some DHBs “starved” their HealthPathways programmes by not investing the time and money to create localised pathways that were correct and current and had buy-in from secondary clinicians, Mr Anderson says.

“You need trust and agreement between primary and secondary clinicians,” he says. “And it’s hard to get agreement if you don’t have the trust.”

When GPs click on HealthPathways and find them out of date and out of touch with referral realities, their engagement wanes.

RNZCGP medical director Luke Bradford says GPs support and make good use of pathways where they are well established, backed by clinician working groups and reflect local services.

“But I suspect where the mahi behind it and the clear roots aren’t there, then they are just not used…they are seen as just another button to press that doesn’t help,” says Dr Bradford, a Tauranga specialist GP.

Mr Anderson is used to HealthPathways being criticised by some as being a rationing tool.

But he says a good HealthPathways programme just tells the truth and reflects the reality.

“Would they rather it didn’t tell the truth? If [secondary services] are not going to see patients below a certain threshold of need, surely the GP and the patient need to know that?”

The key, he says, is that if patient access to specialist services is restricted, then planners and commissioners have to be upfront and support general practices to keep managing those patients in the community.

“Just hiding the problem is not good for anybody.”

Dr McGeoch says an example in the early days of HealthPathways was the Canterbury Initiative negotiating training and funding for GPs to do routine skin lesion removals in response to a backlog of plastic surgery referrals.

More recently, when Te Whatu Ora Canterbury had no dermatologist for some time, HealthPathways were updated regularly to keep clinicians in the know.

Mr Anderson says doctor shortages, overloaded hospitals and ambulance “ramping” are making headlines in every country where Streamliners is working.

The answer is making better use of primary and community services and that means funding them “properly” to deliver extra services, he says.

“You can’t just keep saying, ‘we’d like general practice to do that or this community service provider to do that’ without remunerating them to do it,” Mr Anderson says.

And he believes HealthPathways – that wodge of paper that grew into a global health tool – can play its part in revealing health system strengths and weaknesses, and finding solutions.