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Protocol Based Care

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Protocol Based Care

What is it and how can it help me?

Protocol based care enables NHS staff to put evidence into practice by addressing the key questions of what should be done, when, where and by whom at a local level.  It provides a framework for working in multi-disciplinary teams.  This standardisation of practice reduces variation in the treatment of patients and improves the quality of care.

Protocol based care
Local protocols are the descriptions of the steps taken to care for and treat a patient. They are sometimes called the ‘integrated care pathway’ and are designed to:

  • Implement national standards such as national services frameworks and guidelines and appraisals produced by the National Institute for Clinical Excellence (NICE)
  • Determine care provision by using the best available evidence if national standards are not available

Developed by multi-disciplinary teams, local protocols reflect local services and staffing arrangements. They identify who carries out key parts of the care or treatment and where they should be delivered. Examples of local protocols are:

  • Patient group directions
  • Referral advice 

They usually include decision support systems to help make decisions about appropriate care for specific clinical circumstances and may form all, or part of the record of care.

Protocol based care can help reduce unnecessary variations in treatment and outcomes, but shouldn’t constrain clinical freedom. Variations between planned and actual care may still occur as clinical judgements vary to meet the needs of patients. These variations should be noted so that there is a record of what happens in practice.

When does it work best?

The standardisation of practice reduces variation in the treatment of patients on the same pathways. Working to stipulated protocols also provides the opportunity for redesigning and extending roles, for example nurse led discharge which can improve patient experience, reduce length of stay and releases some of the doctors’ capacity.

Protocol based care optimises patient flow by examining what should be done, when and by whom, thereby reducing delays for patients.

How to use it

When should I use local protocols?
You should develop local protocols in response to the publication of national standards, or when local service improvement priorities have been identified e.g. pathways with a high variation.

Try looking for these characteristics when selecting local service improvement priorities:

  • The condition or disease follows a relatively predictable course and the process of care is relatively standardised
  • Large numbers of people require care for the condition or disease
  • The procedure is high cost
  • The area represents a high risk to the organisation
  • Clinical governance considerations indicate that action is necessary

Who should use local protocols?
You must involve all clinical and non clinical staff responsible for the delivery of care if you want to implement and sustain the protocol successfully

How do I go about it?

The multi-disciplinary team first needs to establish and confirm their objectives. The most successful protocols are simple documents that guide staff through the process, not those which describe how each procedure is delivered to the patient.

A more detailed explanation of each of these steps can be found in the resource guide.

1. Select and prioritise a topic that is important for your service. You can do this through two main routes:

  • The statement of national standards, including NSFs, NICE guidance and national plans and agreed national guidance on service delivery
  • The identification of local service improvement priorities in areas not covered by NSFs or NICE guidelines.

2. Set up a multi-disciplinary team, including representatives of all clinical and non clinical staff involved in the selected area of care. The role of the team is to oversee all aspects of the protocol development.

3. Involve patient, service users and carers and ensure they actively participate in the decision making process.

4. Agree objectives that are specific, measurable and have targets for achievement.

5. Build awareness and commitment within the organisation. You need high level support to successfully implement the protocol. Use NICE guidelines, NSFs and DH guidance as a basis for raising awareness.

6. Gather information to underpin the protocol development, including:

  • National standards such as NICE guidelines and NSFs
  • Published evidence of good practice
  • Other organisations’ experiences and protocols
  • The views of patients and users.

7. Perform a baseline assessment to determine current performance.

8. Produce the protocol which should be a simple document that guides staff through the process.

9. Pilot the protocol to address any operational problems and amend if necessary. Use the PDSA cycle to test your protocol.

10. Implement the protocol: you may need to support this with training and written instructions. Aim for the protocol to become an integrated part of daily practice.

11. Monitor variation from the protocol to help establish what actually happens in practice.

12. Review the protocol to ensure that it continues to be safe, appropriate, based on up-to-date evidence of effectiveness, and measures and quantifies benefits for patients and staff.


The Role of Protocols for a Peri-operative Specialist Practitioner at Macclesfield District General Hospital
Macclesfield General Hospital are developing the role of peri-operative specialist practitioner (PSP). PSPs are trained to carry out clinical tasks, such as venepuncture, electrocardiographs and consultations; tasks which up until now were only carried out by consultants at East Cheshire NHS Trust.

In order to practise at that level, the PSP and the consultant drew up new protocols to enable the PSP to carry out several tasks. These include daily reviews of patients, patient discharge, certification of death, marking of operation sites, and providing discharge summaries. Each week, the effectiveness of the protocols is discussed by the PSP and the consultant, and a detailed review of the work is undertaken once a month. This ensures that the protocols evolve to reflect the ongoing development of the PSP role, providing practice flexibility and avoiding the protocols becoming too restrictive.

These protocols have provided a robust framework for expanding the PSP role and have given the PSP a license to practise at a higher clinical level. They have also enabled the PSP’s skills to become transferable between different consultants. In terms of patient care, the role of the PSP has enabled a speeding up of care delivery whilst at the same time patients have benefited from having more dedicated one-to-one care from the PSP.  

What next?

Having gained confidence in developing your protocol, go onto the next area. We suggest you focus on clinical pathways with large variation.

The following tools relate to protocol based care:

Additional resources

Resource documents:
‘Step by Step Guide to Developing Protocols’ 


Map of Medicine’ provides a visual representation of clinical pathways developed and updated to reflect current best practice. Map of Medicine is available to all NHS organisations in England.

Access can be gained by contacting your organisation's local service provider who can provide you with the password.

National Library for Health has a protocol and care pathway database.

European Pathway Association - an international network of clinical pathway/care pathway networks, user groups, academic institutions, supporting organisations and individuals who want to support the development, implementation and evaluation of clinical/care pathways. The Association has an email based discussion forum where you can seek advice, post articles and network.


In November 2002, the National Institute for Clinical Excellence and the Modernisation Agency produced a pack called ‘Protocol Based Care… Underpinning Improvement’ which provides practical step by step advice on how to develop and use protocols and pathways. This document acknowledges that the NHS has a long tradition of using them to improve the safety and consistency of care, as well as providing a framework for developing services. The pack aims to help spread good practice.

Acknowledgements / sources

NHS Modernisation Agency and NICE

© Copyright NHS Institute for Innovation and Improvement 2008