Clinical pathways can help to ensure consistency of approach and efficient use of resources. We hear about new developments in the UK.
Variation in ENT care
In today’s data-driven healthcare landscape, significant variation persists in the provision of ENT services – even within a nationalised system like the NHS. These differences span operational capacity, referral thresholds, waiting times, investigations, treatment options and follow-up protocols. While some variation reflects legitimate differences in population needs, much of it stems from entrenched working patterns, outdated decision-making processes and a lack of momentum for meaningful change.
The role of pathways
Clinical pathways serve as evidence-based roadmaps designed to reduce unwarranted variation in practice. By breaking down the patient journey into discrete, manageable steps, pathways enhance operational efficiency, improve care quality and support cost-effective service delivery. They also facilitate increased patient throughput and can, in some cases, be a useful resource for patients and families.
Evidence, experience and clinical judgement
Pathways are typically derived from clinical guidelines, which in turn are informed by systematic reviews of best available evidence obtained from research. However, robust evidence is lacking for many aspects of ENT practice. Much of what clinicians do is shaped by their training and experience. It is important to remember that the absence of evidence is not evidence of absence. Ongoing research and the work of professional bodies are essential to refining practice and reaching pragmatic consensus.
At the same time, patients often present in ways that do not align neatly with standardised algorithms. It is the responsibility of ENT surgeons to treat each patient as an individual, applying clinical judgement rather than relying solely on protocol.
This day case adenotonsillectomy in children pathway is reproduced with the permission of the Getting It Right First Time (GIRFT) programme[SD1.1] – https://gettingitrightfirsttime.co.uk/wp-content/uploads/2025/04/Day-Case-Paediatrics-Adenotonsillectomy-Pathway-April-2025-FINAL.pdf
Benefits
Consistency and Safety
Standardised processes based on clinical guidelines promote patient-centred, evidence-based care, improving safety and reducing medical errors.
Resource Optimisation
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Pathways support efficient use of personnel, equipment and facilities, minimising delays and enhancing patient satisfaction.
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Some administrative steps in the pathway lend themselves to automation and the use of technology such as AI to decrease the need for face-to-face interaction and clinician workload.
Interdisciplinary Collaboration
Clear delineation of roles and interventions fosters teamwork among healthcare professionals, which is especially vital in complex cases.
System Efficiency
By reducing variation and streamlining care, pathways help healthcare organisations achieve better outcomes at lower cost.
Patient Empowerment
Shared decision-making tools and patient reported questionnaires, often incorporated into pathways encourage active patient participation in their treatment plans leading to better engagement and self-management.
Risks
Limitations of Evidence Base
Pathways are often based on data from carefully selected patient cohorts. Not all patients may fit these demographics and may require alternative approaches.
Oversimplification and Lack of Nuance
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Algorithms may fail to account for the unique circumstances, medical history, or subtle clinical cues that experienced clinicians rely on.
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Patients whose presentations do not align with standard pathways might experience delays in diagnosis or appropriate treatment.
Challenges to Innovation
Established pathways can potentially create obstacles to adopting new or unconventional practices.
Limitations of Digital Systems
Incorporating pathways into the Electronic Patient Record (EPR) remains a challenge and it is important that pathways are integrated in a way that does not add to administrative burden.
GIRFT: standardising for improvement
Getting It Right the First Time (GIRFT) is an NHS England initiative aimed at improving standards and reducing variation through data analysis and standardised, best practice approaches. GIRFT benefits from senior-level managerial endorsement, which is critical for successful implementation across healthcare systems.
Operationalising pathways
Best practice – whether based on guidance from professional bodies, findings from GIRFT national reviews, or scientific literature – is turned by GIRFT into simple, step-by-step flowcharts that can be easily understood and followed by both clinical and non-clinical teams. These visual tools support the design and enhancement of systems and processes that enable streamlined patient flow through ENT services.
In summary
Clinical pathways are effective tools for standardising care and improving efficiency, enabling identification of bottlenecks and scope for improvement at various points in the patient journey, and supporting a collaborative approach between clinicians and operational teams to address them. Nevertheless, they must be applied with caution and flexibility. The complexity of human health, variability in patient presentations and the need for nuanced clinical judgement mean that no algorithm can fully replace the expertise of experienced clinicians. To truly serve patients, pathways should be viewed not as rigid rules but as adaptable frameworks – ones that support, rather than constrain thoughtful and individualised care.
"Clinical pathways serve as evidence-based roadmaps designed to reduce unwarranted variation in practice"
GIRFT has recently released a new suite of best practice pathways for ENT procedures. These were developed or refreshed in collaboration with ENT UK and other specialist organisations, and can now be viewed and downloaded from the GIRFT website: https://gettingitrightfirsttime.co.uk/
The pathways offer guidance from referral through to discharge and follow-up, including best practice for preoperative assessment, surgical planning and safe discharge protocols. They include pathways for myringoplasty and tympanoplasty, mastoidectomy, stapedectomy, paediatric recurrent acute otitis media (rAOM), paediatric otitis media effusion (OME), nasal airway surgery, endoscopic sinus surgery (ESS), submandibular gland excision, parotidectomy, day-case paediatric adenotonsillectomy and adult tonsillectomy.
Acknowledgement
We would like to thank the National ENT GIRFT Team for their assistance in preparing this article, as well as for their ongoing hard work and support to the clinical leads.
Declaration of competing interests: None declared.
