Demand optimisation in diagnostics: standardising diagnostic testing in NHS Boards

Executive Summary

It has been recognised for many years that there is considerable variation in the use of diagnostic tests across the NHS. While some of this variation can be explained by clinical circumstances and demographic differences, there still exists considerable levels of inappropriate requesting by clinicians, practises of over-requesting, under-requesting etc. In addition, lack of availability of certain tests across the NHS Boards may also limit their optimal universal utility.

Demand Optimisation is defined as the process by which diagnostic test use is optimised to maximise appropriate testing which in turn optimises clinical care and drives more efficient use of scarce resource. The process needs to consider:

• Minimising over-requesting and under-requesting, both of which can be damaging to optimal patient care.
• Reducing unnecessary repeat requesting.
• Ensuring appropriate and useful test repertoires are universally available across all healthcare outlets.
• Standardisation to reduce unnecessary variation - especially around IT definitions and clinical pathways that utilise diagnostic tests.

In 2016, Scottish Government set up the National Demand Optimisation Group ( NDOG). This multidisciplinary group brought together individuals from the main diagnostic disciplines within Laboratory Services and Radiology, along with support from Scottish Government, NHS National Services Scotland ( NSS) and the National Managed Diagnostic Networks ( NMDNs).

The NDOG met four times across 2016 and formulated a number of aims which covered information gathering on current good practice and Demand Optimisation activity in NHS Boards, production of guidance documents on strategy and support for some pilot work streams for potential national roll out. While reviewing existing practice and information, the group also explored links with local and national initiatives so that the demand optimisation agenda could be set in the context of major strategic initiatives already taking place. The concept of demand optimisation can be applied to many diagnostic services, however the main focus of the conclusions and recommendations of this group relate to laboratory medicine.

The NDOG made the following conclusions with related recommendations:-

Conclusions

• Demand Optimisation activity already has a high profile and good momentum within many NHS Boards driven by the current financial climate. This would benefit from a wider whole systems review, sharing of practice and central oversight.
• Collection of data that captures diagnostic test requesting activity is vital and underpins any Demand Optimisation Programme.
• Data can be obtained manually relatively easily from individual NHS Boards. The incorporation of such data into a comprehensive, accessible system across NHS Scotland would however need expertise and resource allocation.
• General Demand Optimisation Guidance produced by the NDOG, if implemented across all NHS Boards, would allow a coordinated, consistent approach to Demand Optimisation.
• Educational Feedback Programmes similar to the one being piloted across NHS Grampian Primary Care could be replicated across other NHS Boards. This consistent approach could lead to more rational use of laboratory and other diagnostic tests and reduce variation in practice.
• Information technology is fundamentally important to the delivery of many Demand Optimisation strategies. It is vital that systems supporting such activities are fit for purpose and that there is a degree of consistency across all NHS Boards.
• A programme of Effective Diagnostic Pathways, linked in with emerging work on Effective Care Pathways, could help promote rational, consistent pathways of care and unblock bottlenecks that limit the introduction of new tests and technologies as a result of silo budget inflexibility.
• Governance - in order to support and facilitate the roll out of a consistent, "Once for Scotland" approach to Demand Optimisation, it is vital that the appropriate governance and support structures are in place both centrally and locally within each NHS Board so as to enable definition of strategy, dissemination and implementation. Initial provider based strategy should make way for the longer term aims of developing a "whole systems approach".

Recommendations

1. Guidance - NHS Boards should adopt the recommendations within the General Demand Optimisation Guidance and IT Guidance documents produced by the NDOG (Appendices C and F).

2. NDOG Related Workstreams - The NDOG (revised as an implementation group) should continue to function into 2017, and beyond, to allow coordination and support for Demand Optimisation work streams and strategy implementation. The following work streams should be taken forward in collaboration with local Health Board leads, the Diagnostic Networks and the NHS Scotland Shared Services Health Portfolio:

2.1. Data Management. Data collection and reporting is a key enabler for all future work and will underpin all the work streams. This should be taken forward within existing work in the NHS Scotland Shared Services Laboratories project to meet the requirements set out for Demand Optimisation. The necessary resource allocation to allow local data collection with national level collation, analysis and presentation needs to be considered

2.2. Service Variation. This workstream needs to identify variation across NHS Boards both in terms of scope of available services and the actual use both in primary and secondary care. Regular collection/collation of data would allow an Atlas of both service and variation to be generated which would not only provide a snapshot but act as a rolling baseline to gauge progress.

2.3. Requestor Feedback. A common, consistent approach to providing requestors with information around their own activity should be considered. This information could be accompanied with peer comparison data, best practice guidance and related test cost data.

2.4. Minimum Retesting Intervals ( MRIs). Existing guidance on MRIs in lab tests should be consistently implemented across all NHS Boards to reduce unnecessary repeat testing. Addressing related IT bottlenecks needs to be prioritised.

2.5. Introduction of New Tests/Pathways. A more focused and collaborative workstream aimed at facilitating the introduction of new tests within definitive clinical pathways should be initiated. This effective diagnostic pathway approach could also be applied to existing tests.

2.6. Realistic Radiology. The Scottish Clinical Imaging Network will establish a subgroup to engage with the recommendations made by the NDOG with regard to imaging. This will include evaluating various clinical decision software options, with a view to piloting a preferred option in the near future

3. Information Technology ( IT). Shortcomings in IT functionality and lack of interoperability between systems limit the scope for successful demand optimisation strategy implementation. The Scottish Government, the shared services portfolio group, existing diagnostic networks and NHS eHealth leads should collaborate to explore solutions that would allow:

• Regular, consistent and automated data collection around diagnostic test activity.
• Improved standardisation across information systems, read codes and data repositories.
• True interoperability across systems.
• Optimum functionality for implementation of minimum retesting intervals including "live blocking" of inappropriate requesting

Fast tracking developments to support demand optimisation, with an initial focus on minimum retesting intervals, should be explored as part of this

4. Oversight, Collaboration and Governance. The success of any demand optimisation programme relies heavily on clear collaborative governance structures existing both centrally and locally within the NHS Boards. Much of this already exists in some areas but requires re-defining and prioritising. The following recommendations are made:

4.1. NHS Boards and Diagnostic Networks should continue to provide support to healthcare science leads, managers and diagnostics staff to work with the national healthcare science leads and diagnostic networks in collectively progressing Demand Optimisation work.

4.2. The national Diagnostic Steering Group ( DSG) should consider establishing an authorising subgroup made up of Board diagnostic services managerial and clinical leads to decide on, prioritise and approve NDOG/ NMDN recommendations including those related to demand optimisation.

4.3. NHS Boards should implement structures (where not already in place) that will enable Demand Optimisation strategies to be considered and implemented. This will require:

• Involvement of not just the diagnostic services but also ensuring that clinicians from Primary and Secondary Care, managers and finance are fully engaged as integrated teams to ensure delivery of optimal diagnostic services.
• Where not already in place, identification of a Demand Optimisation Lead (Board-level executive lead for Healthcare Sciences) to oversee the development of local infrastructure and enable linkage of local diagnostics demand optimisation activities

4.4. Diagnostics service providers and users should be supported by Boards to continue to

• Develop an embedded focus on diagnostics demand optimisation within their management and operational delivery structures.
• Engage in national and local data collection activity to identify overt variation in user practice and gaps in repertoire.
• Monitor demand optimisation strategy effect on local improvement in clinical outcome and/or efficiency of the service
• Feed back good practice examples into the existing test case library ( appendix B) - this will be managed by the existing NMDNs.

4.5. The relevant National Diagnostics Managed Network should provide national oversight and consistent quality, with operational leads for each discipline from each providing NHS Boards. Where national networks do not exist for a particular discipline, a community of practice should be established and supported, linked to Scottish Government's Healthcare Science Lead

4.6. Biannual reports from all disciplines should be provided to the Diagnostic Steering Group via the national networks or via the Scottish Government's Healthcare Science Lead, where no relevant network exists.