Demand optimisation in diagnostics: standardising diagnostic testing in NHS Boards

Section 4: Synergies

There are clearly many other work streams running across NHS Scotland which the NDOG work aligns closely with - these are discussed below:

4.1 The Scottish Healthcare Science National Delivery Plan 2015-20

The National Delivery Plan for Healthcare Science published in April 2015 ( http://www.gov.scot/Resource/0047/00476785.pdf) states "Demand optimisation is defined as the application of processes and tools to maximise the "return" of effectiveness of healthcare science interventions, consequently freeing-up capacity, particularly in the life sciences stream". Basically, it is about providing the right test at the right time to the right person in the right way, reducing or eliminating unnecessary testing and enhancing decision-making in patient care."

Set within the plan is deliverable No.3 which states "To achieve our ambitions, NHS board healthcare science leads will work with stakeholders to develop local improvement plans to reduce unnecessary testing across primary and secondary care. This will free-up capacity to address rising demand and deliver testing that positively affects the patient pathway, supports primary care preventive measures and reduces hospital referrals and admissions. This will be achieved by the end of 2017, with full implementation by the end of 2019."

The work of the NDOG was initiated as a result of the publication of the National Delivery Plan as a means to enable National Healthcare science leads, NHS board healthcare science leads, managers and heads of services to work with NHS boards and diagnostic networks to reduce unnecessary testing and measure overall impacts on patient outcome.

4.2 Shared Services

A Senior Leaders Forum, comprising Board Chairs and Chief Executive Officers, was established to consider the key strategic challenges facing health in Scotland whilst addressing pressing current and emerging demands on the system. In January 2015 agreement was achieved to create a Shared Services portfolio approach for a number of support functions. One of the three portfolios is Health which includes Laboratories, Medical Physics, Pharmacy Aseptic Dispensing, Public Health and Radiology.

A Health Portfolio Board has been established, consisting of key stakeholders who have an interest in the delivery of the Health Portfolio. A Position Paper was discussed with the Chief Executives Group at the beginning of January 2016 where it was agreed that the first Health Portfolio programmes to be taken forward will be Pharmacy Aseptic Dispensing and Radiology.

Since the inception of the Radiology Programme within the Health Portfolio, work has been carried out with all NHS Boards to identify those individuals they believed to have the appropriate expertise within the service to help the work towards a "Once for Scotland" diagnostic imaging service. Engagement work had been started and information had been gathered about the current landscape of diagnostic imaging in Scotland. Dr Hamish McRitchie, Consultant Radiologist, NHS Borders has been appointed to the position of Radiology Programme Subject Matter Expert for the Health Portfolio.

The Laboratory Programme has been established more recently but is now gaining momentum. Dr Bill Bartlett ( NDOG member) has been appointed to the position of Laboratories Programme Subject Matter Expert for the Health Portfolio. Drawing on visioning documents prepared by the NMDNs, an initial stakeholder workshop has been held, identifying risks, issues, synergies and potential models to provide a once for Scotland approach to labs services going forward.

4.3 Healthcare Improvement Scotland

The Healthcare Improvement Scotland Effective Care Pathways programme aims to provide support to local NHS Boards to undertake optimisation of clinical pathways that have been identified as a priority at that local level. Examples of such pathways may include optimisation of care for inpatients who are diabetic or optimisation in reaching a diagnosis and then treating pneumonia. The benefits of such being to reach a diagnosis in a timely manner, reduce the risk of harm and ensure that patients are able to return to their home or a homely setting in as an efficient manner as is possible.

At the time of writing this report HIS were working to identify the data set required at the local level on which to determine the needs of those participating in the programme. They felt that there would be the need to work closely to understand the successful work undertaken as well as the enablers and barriers to success of the contributions submitted to the work of the NDOG and develop a simple and not overtly bureaucratic mechanism for boards to learn from process rather than the detail of specific solutions.

4.4 The National Clinical Strategy

The National Clinical Strategy published by Scottish Government in February 2016 aligns very well with the demand optimisation programme given the former's focus on reducing waste, harm and unnecessary variation.

In addition, the push for healthcare to be delivered more in the community will add pressure to the arrangement for diagnostic services provision - it is vital that a demand optimisation approach is adopted so that variation is limited and only proven, cost effective diagnostic strategies are implemented.

4.5 Choosing Wisely

This programme of work began in the USA and fits well with their healthcare system. A similar attempt to explore and develop its principles for use across the UK has been slowly developing through the Academy of Medical Royal Colleges ( UK), with specific input from the Royal College of Pathologists. The initial report has been published in October 2016 and it contains 5 Pathology specific examples. It remains uncertain just how useful, relevant or indeed what sort of impact this may make on overall appropriate test use across the NHS given its very limited scope and lack of implementation plan. Its vision of potentially giving patients more insight and say in how diagnostic tests are offered and chosen should be supported, however this is unlikely to make a significant impact on overall test ordering and should be looked at a parallel adjunct to the NDOG programme.

4.6 National Roadmap for Clinical Decision Support

NHS Education Scotland ( NES) are exploring the integration of clinical decision support into existing clinical software, with the potential to support demand optimisation. NDOG members have engaged with the NES team, who have been piloting a range of initiatives, including: a successful outcome of a pilot of patient-specific decision support integrated into SCI-Diabetes, the successful introduction of hyperlinks to evidence embedded within TRAKCare, the launch of an antimicrobial prescribing app and enabling electronic versions of handbooks.

This work will be ongoing and has been funded by the Digital Health and Care Institute for a Scottish Government eHealth/University of Glasgow-Industry project to:

• Scope the range of content and structures which would form the shared, national knowledge base underpinning clinical decision support solutions.
• Produce a specification for the publication and content management toolset which would deliver this knowledge base.

Any ongoing demand optimisation implementation could potentially link with this work.