Mapping Pathways in Multiple Sclerosis across Surrey Downs Health & Care

By Ruth Stross, MS Nurse Specialist, Surrey Downs Health and Care & Dr Ioana Cociasu Clinical Fellow in Neurology St George’s Hospital


This project was awarded winner .

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December 2019


Mentor: Sue Thomas

MS Intermediate MasterClass 8, 2019
This project was the winner of the MS Academy MasterClass Project Award

This was a joint project by Ruth Stross, Multiple Sclerosis (MS) Specialist Nurse, Surrey Downs Health and Care and Dr Ioana Cociasu, Clinical Fellow in Neurology, St George’s University Hospital with the aim to combine knowledge and expertise across both community and regional MS services to optimise the patient journey. With that in mind, they developed an integrated care pathway (ICP) for people diagnosed with MS within the new NHS integrated care system ‘Surrey Heartlands’.

This project’s aims were to reduce variation, highlight major gaps and critical areas for improvement in the current model of care for people with MS in Surrey and to initiate the transformation from the current hub and spoke model to a network model. This would be achieved by facilitating access to existing resources and by mapping the current pathways alongside the ideal pathways, using guidance and data available (Ref 1,2,3,4,5,6).

This redesign of the pathway took place through two stakeholder meetings, the first in August 2019 where 8 attended and subsequently a second meeting in October 2019 where 35 attended from many key areas across Health & Social care, including patient associations and patient representation. Many pathways have been started but the main ones are: Diagnosis, Psychological support, Disease Modifying Therapy and Symptom management. These meetings were excellent for pathway generation, but there was an additional benefit, that the stakeholders were able to meet and create working partnerships that did not exist before.

The positive results of developing and implementing this ICP across Surrey Downs Health & Care have been numerous. There was a recognition of sub-optimal care and a need to initiate change, including mapping pathways for patients with speech, swallow and communication problems in MS for which there is minimal information currently. The stakeholders identified an urgent need for more funding to support the disease modifying therapy service and psychological support from diagnosis onwards, where currently there is little available and often not specifically for people coping with a long term condition. Social Services have suggested MS Champions for each locality (Occupational Therapist & Social Workers), and the MS Trust have agreed in principle to fund one whole time equivalent MS nurse post in the area and the MS Society have developed an information leaflet on all available services in the area.

This pathway is a snapshot into current local practice and is meant to be a catalyst for the implementation of medium and long-term changes, effectively transforming good clinical practice into standard practice.


  1. GIRFT Neurology Methodology and Initial Summary of Regional Data (2019)
  2. NHS Right Care Neurological Conditions Toolkit
  3. NHS (2019) NHS Long Term Plan.
  4. NHS (2019) NHS Operational Planning and Contracting Guidance 2019/20.
  5. NICE (2019) Clinical guideline [CG186] Multiple sclerosis in adults: management.
  6. NICE (2016) Quality standard [QS108] Multiple sclerosis.

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