Healthcare Science National Delivery Plan for Healthcare Science Professionals in Scotland 2014-2017

4. REDUCING UNNECESSARY TESTS AND INTERVENTIONS

The recently published atlas of variation in diagnostic services in NHS England^[4] highlights wide variation in the availability and use of diagnostics across the country. Some of this variation is extreme (170-fold variation in the usage of rheumatoid factor testing, for instance) and suggests that both under- and over-testing are common. While these data are from NHS England, it is not unreasonable to assume that the picture in Scotland would be somewhat similar.

Demand for pathology testing increases every year, with a 74% increase in laboratory activity seen in NHS Scotland between 2003/04 and 2010/11. Laboratory services cost £275 million in 2010/11, including £56.4 million spent on testing more than 10 million blood samples. While this growth is to be expected, given the demographic changes in the population and health screening initiatives in primary care, the Carter Review of pathology services in England^[5] estimated that 25% of pathology requests are inappropriate.

A culture that views inappropriate testing as inevitable and something that can be absorbed within costs by the ever-increasing capacity of automated analysers has emerged within laboratory medicine. This does not address the fundamental issue of the very large number of otherwise well patients who will have an abnormal result from an inappropriate test, prompting either further testing or referral to secondary care. The statistical definition of reference ranges determines that for any given test, 5% of a 'normal' unselected population will be outwith the reference range: The laboratories in Greater Glasgow and Clyde, Lothian, Tayside and Highland together perform in excess of 60 million tests per year, equating to more than 3 Million 'abnormal' results being identified annually. Taking the Carter Review's estimate, this workload will generate 750,000 abnormal results per year (more than 2000 per day) on patients who should not have been tested in the first place. Such unnecessary patient anxiety and healthcare costs need to be minimised.

Reasons for 'inappropriate' testing are many. Laboratories may perform tests that have not been requested through reflex testing or applying inappropriate test panels. Healthcare professionals may request tests for non-evidence-based medicine reasons, through uncertainty and lack of training or experience, as a consequence of protocol-based requesting or by lacking awareness of recommended repeat-testing intervals. Failure of patient record availability may also contribute to unnecessary repeat testing. A robust demand-management strategy must address each of these aspects.

While each NHS board recognises the problem and has tried various approaches to mitigate the situation, a consistent integrated approach to demand management is lacking.

HCSs have in-depth knowledge and expertise in the use and limitations of tests. They are ideally placed to influence choice of tests, advise on their suitability in a given diagnostic pathway and recommend the frequency of repeat testing. HCSs working across NHS board boundaries and with service users in primary and secondary care are uniquely placed to develop a national strategy for demand optimisation.

Our question is - how might the involvement of HCS demand-optimisation measures be improved to reduce unnecessary test and interventions, while ensuring that the most appropriate tests are performed in all NHS boards?

Our proposals are set out below. Are these the right actions? What else could we do?

4.1 Proposals

• The CHPO will appoint an HCS national lead for service-demand optimisation, with a remit to identify and share aspects of good practice, test the effects of introducing new demand-control measures and develop a national strategy for demand control.
• Each NHS board should work with the HCS lead and pathology services managers to identify demand-control measures that have been effective locally.
• The national lead will work with NHS board HCS leads, networks and service managers to develop and introduce a definition and measurement framework for inappropriate testing and collect baseline data.
• The national lead for pathology service demand optimisation will produce a plan to halve inappropriate testing by 2016.
• The national lead will also help to coordinate communication among diagnostic networks and clinical services to establish agreed national testing strategies for common diagnostic pathways.