Healthcare science national delivery plan 2015 to 2020: final report

4. Summary of Achievements

The NDP provided an ambitious programme of work for the Healthcare Science profession and brought together a range of professionals to jointly deliver on key policy priorities for the people of Scotland. Since publication, we have seen continued progress in improved services and delivery of safe, effective and person-centred care.

Innovation Fund

The Healthcare Science Innovation Fund formed part of the Scottish Government's investment to test and develop innovative ideas aligned to deliverables 1, 2, 4 and 5 of the NDP and 3 NHS Boards were awarded funding in September 2018 to progress three projects testing new approaches to drive improvement and deliver results. The focus was on learning of national significance which could, potentially, inform future services across Scotland. Although delivery of projects was impacted by the COVID-19 pandemic response, key learning from projects is discussed below.

• The fund supported NHS Greater Glasgow and Clyde in the development of a Physiologist led 3D Echo service whereby echocardiographers were trained to perform the acquisition and rendering of 3D cardiac ultra sound images. This pilot funding supported the development of referral criteria and pathway for 3D Echo services and transformed a service previously led by Cardiology Consultants.
• NHS Greater Glasgow and Clyde also worked to establish a continuous Innovation Programme in a Clinical Physiology Sleep and Breathing Support Service. This funding validated point-of-care testing, supported the transforming roles agenda and demonstrated value in emerging wearable technologies. Overall, this funding has provided insight into user experience and digital service models and enabled delivery of digital consultations through NHS “Attend Anywhere.” With increased demand during the COVID-19 pandemic, there has been clear applicability of this digital service model.
• NHS Lothian set out to implement Next Generation Sequencing (NGS) of lymphoid malignancies in Scotland using a custom designed panel. The overarching aim was to aid diagnosis, streamline therapy stratification and improve the patient pathway. A short life working group (SLWG) was established to select genes of clinical significance for testing and test 50 patient samples to complete clinical audit. The lymphoid NGS panel has been approved by the Molecular Pathology consortium and the Molecular Pathology steering group to be implemented for routine diagnostics of patient with lymphoid malignancies in Scotland.

The NDP has demonstrated the appetite for innovation and the potential to scale up successful projects, using ongoing work where needed to accelerate progress in these areas.

4.1 Deliverable 1 - Streamlining health technology management

Introduction

Medical devices and equipment are critical in many areas of healthcare, including intensive care and neonatal units. The management of health technology equipment often involves a range of healthcare professionals and systems and processes vary across NHS Boards and localities and can impact on quality and potentially patient safety.

The NDP recognised the opportunity for innovation and developments in portable and wireless networking technology to deepen and widen the range of Healthcare Science-supported technology in the community for improved patient safety and outcomes.

What we set out to do

• Reduce the risk of harm to patients and staff
• Reduce unnecessary variation
• Improve resilience and sustainability
• Reduce equipment replacement and repair costs.

Progress made

Funding NHS Forth Valley to use Radio-Frequency Identification (RFID) tagging in routine service provision demonstrated that utilising RFID technology can improve the management of medical equipment and have a positive impact on patient care, safety and team working. This investment allowed the project to develop with NHS Forth Valley being the first NHS Board in Scotland to test this approach and successfully learn how to improve the management of mobile medical devices and maximise their use in a clinical setting.

The Forth Valley RFID work has demonstrated a number of immediate benefits including the ability to locate mobile devices quickly when needed for clinical use and maintenance. It has improved the utilisation of existing devices and demonstrated immediate and long term financial savings. This includes the ability to inventory control 350 devices in a theatre recovery area in less than 3 minutes. In the past this would have taken significantly longer, and can now be done without disturbing patients. The time saved means that Forth Valley has now rolled out planned maintenance to its community hospitals when before they were only able to undertake repairs.

The learning from this work has been influential in developing interest amongst other NHS Boards in using the same technology.

The development of a national Medical Equipment Management system and the adoption of Global Standards Initiative (GSI) global standards, are being progressed as part of the NHS Scotland Scan for Safety Programme and will be key enablers to achieving a ‘Once for Scotland’ service to provide a joined up data view for the operational and strategic management of the medical equipment inventory across Scotland. The system will support decision making at local and national level in terms of equipment management, business intelligence, strategic and financial planning. Work is underway with NHS Boards to create the specification to enable the procurement of a system later in 2022.

Impact

Medical devices and equipment represent a substantial asset – and risk – for NHS Boards. Their effective management is vital to ensuring safe and high-quality care that minimises the risks of adverse events and unnecessary treatment delays.

The NDP has acted as a key enabler in prioritising the development of this specific policy area at a national level. It is recognised that technological developments will continue to impact on the use and management of medical devices and equipment and Scottish Government investment has provided learning around technological developments and their effective use.

4.2 Deliverable 2 - Point of Care Testing

Introduction

Near patient, or point of care, testing (NPT/POCT) is defined by the MHRA as ‘any analytical test performed for a patient by a healthcare professional outside the conventional laboratory setting’ and has the potential to expedite test results, treatment and patient experience and care.

What we set out to do

• Reduce unnecessary variation within and across NHS Boards
• Improve patient experience by reducing unnecessary secondary referrals
• Reduce repeat testing and associated costs
• Improve patient flow, access and monitoring

Progress made

The Scottish Medical Advisor's Scientific Advisory Group (SMASAC) recommendations for the safe and effective use of POCT were published in 2011 and acted as the driver for the NDP to work towards enhancing point of care (POC) governance across our NHS Boards in Scotland.

This included the formation of a Short Life Working Group which highlighted variable governance across NHS Boards and in particular further variation in primary and community care settings as opposed to secondary care settings. The NDP has been influential in ensuring that more NHS Boards establish local POC committees within their governance structures through its effective stakeholder engagement. National Diagnostic Networks also now have numerous POC projects within their own work plans.

In the context of the COVID-19 pandemic the need for further national governance policy on POCT was also identified, which resulted in the Scottish Government issuing its Governance Policy for the role of Point of Care and Rapid Testing of COVID-19 in Clinical Management; https://www.gov.scot/publications/governance-policy-role-point-care-rapid-testing-covid-19-clinical-management/pages/1/. This was approved for publication by the Cabinet Secretary for Health and Sport in 2020 and set out further recommendations around the use of POCT in the diagnosis and management of disease manifestations linked to SARS-CoV-2.

Further work is under development to establish a Near Patient Testing Programme Executive Board (NPTEB) to take forward the aims and ambitions of our national clinical policies and strategies around enhancing values-based healthcare and improving access to care through the safe and effective use of near patient testing solutions.

Impact

The ability to embed the use of Near Patient Testing NPT into patient pathways aligns with our policy ambition for values-based healthcare with a strong emphasis on shared decision-making and person centred care.

With such an approach there is the opportunity to diagnose, treat, and long-term manage a range of conditions without the individual ever having to leave their home. If applied appropriately near patient testing has the potential to enhance the patient’s interaction with our health and social settings, as well as reducing attendances and admissions at secondary care establishments.

4.3 Deliverable 3 - National Demand Optimisation

Introduction

Demand Optimisation is defined as the process by which diagnostic test use is optimised to maximise clinical utility, which in turn optimises patient clinical care and drives more efficient use of associated scarce NHS resources.

What we set out to do

The following key patient-centred outcomes were agreed to target action around Demand Optimisation:

• Minimising over-requesting and under-requesting, both of which can be damaging to patient care.
• Reducing unnecessary repeat requesting.
• Ensuring appropriate and useful test repertoires, are universally available across the healthcare system.
• Standardisation of test naming and coding to reduce unnecessary variation and allow automated data monitoring systems to extract laboratory test usage information in an efficient, consistent and timely manner.
• Internal standardisation of laboratory practice – to ensure the optimal processes, procedures and testing protocols are monitored and adhered to.

Progress made

The National Demand Optimisation Group (NDOG) was nationally commissioned in 2016 to review the third deliverable of the NDP and inform future improvement work around diagnostic test optimisation.

The design and delivery of four distinct phases of work have been completed to date, each building on momentum and success achieved in the previous phase. Work throughout Phases I- has highlighted ways to reduce unwarranted variation in laboratory diagnostic testing, contributing to improved patient outcomes.

Reports from Phase I- are published on the Scottish Government website and detail the key achievements realised in each phase as well as recommendations for future work.

The report for Phase https://www.gov.scot/publications/national-demand-optimisation-group-ndog-demand-optimisation-laboratory-medicine-phase-iv-report/ was published on 11 October 2021 and work on Phase V is underway.

Phase focused on supporting the implementation of the key recommendations identified from the Phase I report. This included regular collection of data that captured diagnostic test requesting activity, presenting it in an easy accessible format, and coordinating with laboratory network clinical leads to initiate and progress quality improvement initiatives. Building on this work, Phase saw the launch of the refined Atlas of Variation for Laboratory Diagnostics tests, extensive ongoing data collection and quality improvement initiatives within the diagnostic and primary care community. This prototype Atlas of Variation allowed professional groups to interrogate data to use as a basis to consider appropriate test use and availability.

National Demand Optimisation Delivery Phases:

Diagram 2: National Demand Optimisation Delivery Phases.

• Phase I 2016
  • Reviewed existing demand optimisation work
  • Improvement plan to optimise diagnostic testing
  • Published report
• Phase 2018
  • Data collection of diagnostic test requesting activity
  • Published report
• Phase 2019
  • Launched Atlas of Variation prototype
  • Published report
• Phase 2020-21
  • Recovery monitoring dashboards
  • Report has now been published

Phase scope was adapted in response to the COVID-19 pandemic, producing interactive recovery monitoring dashboards, tracking diagnostic activity across Scotland during the pandemic and into recovery. This data acts as a direct surrogate metric for associated clinical activity, to be used to identify healthcare gaps, monitor recovery and enable evidence-informed decisions regarding the resumption and prioritisation of tests and pathways across NHS Boards.

Impact

In addition to more efficient use of resources within diagnostics, optimisation of diagnostic testing is associated with more effective patient care pathways, driving appropriate and timely patient diagnoses and impacting patient flow and treatment.

The work of the National Demand Optimisation Group (NDOG) aligns with the ethos of the Realistic Medicine approach; strengthening the relationships between those who provide and receive care, and ensuring that people receive appropriate and beneficial care that is evidence-based and in line with their preferences.

4.4 Deliverable 4 - Developing Sustainable Services

Introduction

It was recognised that our NHS requires sustainable multi-disciplinary teams to ensure effective, safe and quality driven services and healthcare scientists have the potential to lead scientific teams and care pathways and work in advanced practice roles.

Some areas of our NHS workforce have significant service pressures and the ability to be adaptive and flexible with our workforce has the opportunity to relieve and support workforce pressure points by creating additional capacity and therefore improve patient outcomes.

What we set out to do

• Create sustainable teams
• Improve patient pathways and experience
• Free-up medical capacity

• Reduce diagnostic turnaround times.

Progress made

Our ambition was to create sustainable teams; improve patient pathways and experience; free up medical capacity and reduce diagnostic turnaround times. To achieve our ambitions, NHS Board Healthcare Science Leads worked with stakeholders to explore new and developing Healthcare Science roles that support areas of service pressure and have the potential to free-up medical capacity.

At the time of publication, we said healthcare scientists should work to “role extension appropriate to task” and that this should be “applied across all diagnostic specialties.”

The NDP highlighted that healthcare scientists can be trained to undertake tasks traditionally performed by medically qualified Histopathologists. In particular, expanding the role of Biomedical Scientists (BMS) has been a key step towards the ambition to develop a sustainable service in histopathology.

The Scottish Pathology Network has developed a Scottish training school for BMS, to enable scientists to become tissue dissectors. Enabling BMS to undertake what has historically been a medical role has the potential to release medical time from tissue dissection work to diagnostic reporting or other clinical work, this also impacts positively on overall turnaround times. BMS Dissection – Scottish Pathology Network

Our scientific workforce has numerous examples of other HCS advanced roles that the NDP has promoted such as Clinical Physiologist-led sleep clinics, Cardiac Scientist Led Implantable devices advanced cardiac imaging and direct access audiology clinics. Several NHS Boards have developed their Physiological Scientists to implant cardiac loop recorders, this extended role of the Physiologist, has released Physician time and improved the overall waiting times for these procedures.

Impact

We are aware that advanced practice roles have freed up medical capacity and there is ample opportunity to build on this work and use learning to inform what we do next.

4.5 Deliverable 5 - Clinical Physiology Integrated Service Models

Introduction

Clinical Physiology is a highly specialised modality within Healthcare Science, with significant direct patient contact and working across various settings, such as hospitals, clinics, wards, theatres and also within our community environment. Changing demographics, individuals living longer with long term conditions have impacted on the demand for our Clinical Physiology services, this impact has been experienced across diagnosis, treatment and monitoring of our patients.

What we set out to do

• strengthen integrated local leadership infrastructure to underpin service change and improvement, leading to long-term sustainability of Clinical Physiology services
• ensure senior Clinical Physiologists expand their interpretative role in clinical services as part of multi-disciplinary teams
• support direct referrals from primary care to utilise the group’s potential, releasing medical capacity in the system
• explore the development of a Clinical Physiology network to promote a collaborative approach to improvement

• develop a community of practice to support service sustainability, creating quality improvements across patient pathways.

Progress made

The NDP has brought our Clinical Physiology workforce together across Scotland across all specialities. The creation of the Clinical Physiology Executive Board (CPEB), accountable to the Diagnostics in Scotland Strategic Group (DiSSG), has delegated authority in relation to physiology services. The purpose of the Clinical Physiology Executive Board, is to agree and own the vision for service transformation, development and quality improvement in Scotland.

The CPEB will also provide a vehicle for service-led improvements. This will involve bringing a multi-disciplinary focus as well as national and regional perspectives to discussions and that the benefits for Clinical Physiology services as a whole in Scotland are realised and any risks managed.

4.6 Impact of COVID-19 on the NDP

In response to the COVID-19 pandemic and associated infection control measures, some of the NDP actions were paused and some were of necessity delayed. The need for different virtual ways of working was also noted and the need to address unnecessary testing across primary and secondary care meant that there was increased opportunity for some areas of work such as Demand Optimisation. Addressing the challenges that COVID-19 has put on the NHS has also accelerated the requirements to embed near patient testing into our service delivery.