Demand optimisation in diagnostics: standardising diagnostic testing in NHS Boards

Section 5: Organisational Approaches to Demand Optimisation Implementation

5.1 Background

Diagnostic services (Diagnostics) underpin the delivery of modern healthcare systems. In order to provide clinically meaningful information while reducing waste there needs to be a clear data set to identify outliers in terms of under or over requesting of specific diagnostics. Such waste decreases the value of investment in existing and new diagnostic investigations, modalities and service delivery models. Inequity also has the potential to impact on patient safety.

Realisation of the Triple Aim

Optimising demand of diagnostics across the wider NHS will have a positive impact on efficiency, effectiveness, and affordability of healthcare. If "demand optimisation" is achieved then desired outcomes from investment in Diagnostic Services are resultant and enable the delivery of Triple Aim ^1,2.

The Need for Co-production

An approach to laboratory diagnostics demand management has been proposed by Fryer and Smellie ³. They present a "demand management" tool kit with some principles presented that equally apply to other diagnostics ( e.g. clinical imaging). Their publication correctly identifies the need for co-production of demand management strategies with users and describes a number of approaches that may be used to not only manage demand, but also to optimise demand on diagnostic testing (diagnostics). This approach is delivered from the perspective that existing and future workloads need to be optimised, that demand is the issue to be focussed upon and that the legitimacy of that demand requires to be established and controlled.

This "provider driven" approach delivers a degree of complexity in optimising demand for diagnostics within any health care system. It reveals a requirement for a much greater understanding of the whole system impacts and benefits of investment in diagnostics to be shared by users and providers to enable user buy in and co-production of demand optimisation. It is critical that clinical users see the value of demand optimisation initiatives translated as mutual benefit rather than of one sided benefit to the provider ( e.g. reduced workload, reduced spends in the diagnostics budget silo).

In the provider driven approach it is therefore the diagnostics providers that are currently in the difficult and complex position of driving forward demand optimisation programmes to users that may not be engaged. This delivers difficulty in obtaining traction for such initiatives and resistance to change and results in comparatively small returns on invested effort.

The practical challenge therefore is to deliver an environment to develop an approach to demand optimisation that:-

• Encourages co-production
• Permeates through the wider health care system
• Ensures that investment in diagnostics delivers maximum potential benefit to patients and exemplifies good value.

An NHS Scotland Whole-Systems Approach

To date, demand optimisation has taken place in Scotland in isolated pockets of innovation, going back several years with limited shared learning. Local governance approaches have varied; as has national interest.

With the building momentum of several major initiatives including the Healthcare Science Delivery Plan, it is clear that NHS Scotland needs to implement the recommendations of the National Demand Optimisation Group; however the right conditions will have to be created for this to prove successful.

Demand optimisation from a provider perspective has a starting point of looking at the usage of a particular test as an end point to drive change, however solely this approach is likely to have limited success in changing the behaviours and culture of clinicians requesting tests. An alternative is to use a "whole systems approach" that is focussed on pathways rather than diagnostics. This correctly views the diagnostics as an integral part of a complex system of care.

Here the proposition is that if efficient and clinically effective pathways are designed well and consistently followed, then the use and demand of associated diagnostics should be de facto optimal. An advantage of this approach is that it necessarily results in a transfer of ownership and responsibility for optimisation of demand away from the diagnostics provider to the clinical users and embeds delivery of optimised demand into good clinical care processes.

This might be seen as a point of contention by some, but arguably the user has the ethical responsibility to ensure that patients have the correct investigations ordered on their behalf and that waste is avoided. The Academy of Royal Colleges have highlighted the role of Doctors promoting value and protecting resources ⁴.

The whole system approach does deliver whole system benefits and opportunities for co-production by users and providers bringing together their knowledge, skills and expertise to enable best value to be obtained from investment of current and future resources into patient care. The functionality of the service requested by the users will define the form of the services delivered by service providers.

Optimising demand of diagnostics therefore delivers a degree of complexity for the NHS as a consequence of need to consider the whole delivery system impacts and benefits. Users and providers of diagnostic services need to co-produce an environment, systems and processes, within Boards and across the NHS, that enables constructive challenge of current and proposed practice involving use of diagnostics and enables sharing of best practice, which delivers opportunities to optimise demand on services as a whole, that maximises the value from investment in diagnostics and is able to demonstrate that value. The challenge for the Boards and NHS Scotland is to deliver the infrastructure to achieve these aims.

5.2 Appropriate Governance

The way forward will require a combination of the "provider driven approach" and a "whole systems approach". Ultimately it will be the whole systems approach that delivers the benefit outlined earlier. That approach will require cultural changes within the NHS and the emergence of clinical leadership to deliver it. The NHS Scotland National Clinical Strategy and the Chief Medical Officer's report 2016 are promoting the discussions which will define the environment within which this should be achieved. In the context of optimised demand of diagnostics, Boards should ensure that clinical users and diagnostics providers are fully engaged as integrated teams within the emerging health care delivery model and working towards delivery of clinical services that ensure optimal use of diagnostics.

Operational Leads

Boards should have mechanisms in place to enable development and adoption of optimised demand on clinical services, employing evidence based pathways in the context of a realistic medicine approach and the national clinical strategy. On a practical level this might mean that all new clinical pathways and guidance involving use of diagnostics should have input from diagnostics teams.

The whole systems approach as identified above requires that users and providers need to co-produce optimisation of demand on diagnostics through the development of safe and effective evidenced based clinical pathways. This is a big agenda that requires both local and national focus with mechanisms in place to enable sharing of best practice across organisations. This delivers a requirement for an organisational structure that enables a Board and NHS wide focus.

Without a strong combination of local ownership and national oversight, Demand Optimisation Leads at an NHS Board level would be isolated and less likely to succeed. It is therefore crucial to ensure they can link in through a variety of existing structures.

Executive Leads

The "provider driven" approach to demand optimisation will afford shorter term gains in reduction of variation, waste and harm associated with the use of diagnostics. The return will depend on organisational buy in to the approach, however this will require authority and support from NHS Boards to drive change in culture and behaviours.

Patient facing staff place the demand on diagnostic services in the main. Their requesting behaviours deliver the variation in demand. The underlying reasons for this source of variation are many and need to be addressed. Service providers are also responsible for variation in demand as a consequence of the way in which they make test repertoires available to users in different locations. These issues need also to be addressed and executive-level support and scrutiny will be required to deliver sustainable whole-systems change.

Continuous Quality Improvement

Diagnostics service providers are best placed to identify sources of variation in demand for testing and to critically assess and address the impact of service configuration on demand. Variation in requesting can be presented to users in order to constructively challenge demand. The providers are also in a position to enable implementation of best practice around frequency of testing and to share demand optimisation initiatives from other centres made available by the Demand Optimisation Leads. This places a requirement on Diagnostics teams to have a focus on demand optimisation with a structure that enables them as providers to identify variation, waste and harm arising from user practice. A further focus should include ongoing critical appraisal of the value of existing service repertoires and configuration to enable optimal service delivery and development of ways of working with users to enable them to use services to best effect. The Fryer and Smellie toolkit for managing demand provides a useful reference guide for initial focus by diagnostics providers, as does the NDOG guidance in appendix C.

Boards are currently attempting to deliver the demand optimisation focus in different ways and the approaches are evolving. Delivery of optimised demand will remain challenging without a whole systems focus, but much can be delivered from a provider driven approach with appropriate positive support from the Boards. Ability of any Board to deliver the necessary focus on demand optimisation will vary according to availability of resource and organisational structures, but it is clear that there is a requirement for this focus as part of a standalone provider driven initiative or as an integrated part of a whole systems approach within the currently evolving health care delivery system. Some key characteristics of an organisational structure /infrastructure for delivery of demand optimisation are attached in Appendix G. These may be used to help define the Boards response to the required focus on demand optimisation and to inform discussion within the wider health care system.

Members of the national DOG have built a library of test cases, to promote quality improvement activity at a local level, where innovation is taking place or evidence is being built to determine best practice. The library contains a range of examples of innovation across all disciplines and will provide access to expertise to validate and promote initiatives.

This multi disciplinary, multi-professional library will continue to be built and will contribute to challenging variation in practice across Boards, providing a shop window for demand optimisation. As evidence is built for a change in practice, this can be used to engage with stakeholders at all levels to continue to build a culture focused on the optimisation of demand. The national networks, the Diagnostic Steering Group and the local leads should all contribute to ensuring spread, via annual workplans.

5.3 The Way Forward

Diagnostics demand optimisation delivers a challenging but necessary focus for Boards. Optimised demand is a requirement for good clinical care and outcomes. Under and over-production of diagnostics both carry patient safety issues and deliver impacts on the effectiveness of clinical pathways.

A patient pathway or "whole systems driven" approach will ultimately deliver optimal demand by default. This should be aspired to and measures should be taken to ensure involvement of Diagnostics specialist in their development. Organisations should begin to work towards this. In the interim a "provider driven" approach will address some of the issue.

An organisational infrastructure with an embedded focus on demand optimisation will be required, ensuring leadership at an executive and operational level. Recognised senior leads will then enable development of an organisationally embedded approach top down, bottom up and across local health care systems, ensuring interaction with both provider and user at each point in the journey.

Existing governance structures should be harnessed wherever possible to promote ownership and oversight. The role of the national managed diagnostic networks in brokering the provider/user interface should also be optimised.

Through promoting local ownership, whilst at the same time retaining national oversight and leadership, it will be possible to develop a culture of continuous quality improvement; focused on demand optimisation in diagnostics.

1. Stiefel M and Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. Institute for Healthcare Improvement, 2012.

2. http://www.qihub.scot.nhs.uk/media/581636/nhsscotland%20qi%20hub%20-%20triple%20aim%20final.pdf

3. Fryer A, Smellie W. Managing demand for laboratory tests: a laboratory toolkit. J Clin Path 2013; 66: 62-72

4. Promoting resources, promoting value: a doctor's guide to cutting waste in clinical care. Academy of Medical Royal Colleges 2014. http://www.aomrc.org.uk/wp-content/uploads/2016/05/Protecting_Resources_Promoting_Value_1114.pdf