National Demand Optimisation Group (Ndog) – Phase 3 Report

2 Executive Summary

Demand Optimisation is 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 associated scarce NHS resources.

In 2015, Scottish Government funded the establishment of the National Demand Optimisation Group, in line with deliverable three of the Healthcare Science National Delivery Plan "Driving Improvement; Delivering Results"^[1]. Not only has the group been active in highlighting a variety of quality improvement activities associated with the promotion of appropriate laboratory test use, but has also led the design and delivery of an evidence based and strategic programme of work.

The group carried out its third Phase of operation during 2019 – 2020, concluding in May 2020. This document highlights the following key achievements in this Phase:

• The development of a Scottish Atlas of Variation for Laboratory tests that clearly demonstrates significant unwarranted variation in laboratory test use and availability. Phase III has further developed and refined the Atlas.
• Work with key individuals from primary care has informed development of the programme and the Atlas from the user's perspective and ensured meaningful dialogue can be established to lead to targeted improvement work.
• Pilot dashboard summary views have been created for both GP and Laboratory professional groups to interrogate and use as a basis to consider laboratory test use and availability.
• Data Collection to populate the Atlas has now stretched to cover three individual years (2017, 2018 and 2019). While manual collection of data remains the only option, this has been streamlined and has become routine work for NHS Board Laboratory Services. Data is now returned quarterly, meaning the impact of interventions and small tests of change can be observed more rapidly.
• NHS Board flash reports, focusing on requesting patterns for individual tests along with educational guidance on appropriate test use, were developed for some of the tests within the Atlas.
• A programme of quality improvement activity has continued, with work including:
  • Development of guidelines for a range of blood science tests
  • Discussion on the inclusion of samples for blood borne viruses, where the assumption is that the requesting rate may be too low in certain areas
  • Work with colleagues in sexual health to explore optimised swab submission
  • Optimising demand/workflow internally for a range of cellular pathology activity

Considerable stakeholder engagement around the work of the group continued throughout Phase III, notably with the Atlas of Variation, which has been very well received. A pilot within NHS Lothian Primary Care was planned for early 2020, with additional pilots planned for other areas later in the year.

The COVID-19 pandemic has had a major impact on the programme, which was largely paused in March 2020. Ongoing data collection, Atlas of Variation pilots and associated educational interventions, did not progress fully as planned.

In response to the changing healthcare landscape during the COVID-19 pandemic, focus of the programme transformed to monitor laboratory test use during the COVID-19 pandemic and recovery phases – this work has begun as Phase IV of the programme. It is anticipated that such data collection, analysis and subsequent dashboards can help identify healthcare gaps created during the pandemic and inform prioritisation decisions during remobilisation. In addition, identifying laboratory workflow issues, especially as remobilisation progresses, will enable laboratory resource pressures to be identified and addressed more easily.

To reflect the current status of the funded Phase IV COVID-19 pandemic monitoring project at the time of writing, an addendum has been added at the end of this report to reflect early progress with this work: Lab Activity as a Metric for Pandemic Healthcare Trends (see Section 11 Addendum).

With the return of conventional NHS services after the initial pandemic period is over, it is strongly recommended that the National Demand Optimisation work programme is re-commenced. The need for appropriate, targeted use of diagnostic tests will likely be even more important in the changed, new NHS of the future.

Unwarranted variation in the use and availability of laboratory tests will not be resolved rapidly and will require continual refinement and monitoring. It is vital that a National Demand Optimisation oversight is retained, both for the newly focused Phase IV pandemic monitoring programme and beyond, so that previous momentum and achievements can be built upon and the drive towards appropriate test use is supported to continue. Appropriate laboratory testing will be even more important in shaping prioritisation and driving recovery and remobilisation in a very changed healthcare landscape – ongoing funding of the programme is essential.