National Demand Optimisation Group (NDOG): demand optimisation in laboratory medicine - phase IV report

3 Introduction

3.1 Background

It has been widely accepted and demonstrated that there is considerable variation in the use of diagnostic tests across the NHS.^[1] While some of this variation may be attributed to clinical and demographic differences, the degree of variation suggests an element of over-requesting and under-requesting, or unnecessary repeat testing. This is amplified by lack of availability or awareness of certain tests within some NHS Boards.

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

The key areas to consider in targeting DO are:

• 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.

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^[2]; 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. Using evidence intelligently to continuously improve and challenge existing healthcare models, the approach taken by the NDOG is aligned with the principles of the National Performance Framework^[3], in particular contributing to the associated health outcomes as it aims to ensure appropriate diagnostic testing for the Scottish population.

It is also vital to acknowledge that diagnostics and patient pathways interact in complex ways that may not be immediately evident. There may be occasions where sub-optimal tests are used to triage patients to different treatment pathways. It is imperative therefore that national demand optimisation takes a whole systems approach, with open communication and collaboration between laboratories and referring clinicians, to ensure the end to end management of patients using diagnostics is appropriate and optimises NHS resource and patient outcomes.

3.2 Phase I-III Summary

Demand optimisation was determined a focus within the Scottish Government's 2015 Healthcare Science National Delivery Plan (NDP).^[4] The National Demand Optimisation Group (NDOG) was established to review and progress work against the third deliverable of the NDP.

"Demand Optimisation: Support healthcare science leads, managers and heads of service to work with the national healthcare science leads and diagnostic networks in collectively progressing this improvement work"

Under the auspices of NDOG, three distinct phases of work have been completed to date, as outlined below. All reports are published on the Scottish Government website and detail the key achievements realised in each phase as well as recommendations for future work.^{[fn],[fn],[fn]}

Phase I

2016

• Reviewed existing demand optimisation work
• Improvement plan to optimise diagnostic testing
• Published report

Phase II

2018

• Data collection of diagnostic test requesting activity
• Published report

Phase III

2019

• Launched Atlas of Variation prototype
• Published report

Due to the emerging COVID-19 pandemic, much non-essential work was paused, including work on the final stages of Phase III in early 2020. The NDOG resumed work for Phase IV in summer 2020 and the Phase III report was published in early 2021. This report contained an addendum highlighting initial progress made in Phase IV of the programme; collection of blood science and pathology data and initial development of interactive dashboards allowing interrogation of laboratory activity at NHS Board level.

3.3 Membership and Governance

The NDOG is commissioned by Scottish Government, with laboratories teams providing expertise, and National Service Scotland (NSS) providing programme management resource and support. See Annex A for the governance structure employed throughout Phase IV.

Since its establishment, NDOG membership has evolved to reflect the particular focus of each phase. However, there has always been consistent representation from:

• Scottish Government
• Biochemistry, Microbiology/Virology, Pathology, Haematology, Clinical Immunology
• Genetics/Molecular Pathology consortia

Full details of the Phase IV group membership can be found in Annex B. NDOG members continue to ensure that work is cascaded effectively through established formal and informal networks to laboratory users and other stakeholders.