National Demand Optimisation Group (Ndog) – Phase 3 Report

9 Recommendations

Unwarranted variation in the use and availability of laboratory tests remains an important issue. It is vital that national Demand Optimisation oversight is retained throughout Phase IV and beyond, so that previous momentum and achievements can be built upon and the drive towards appropriate test use is supported to continue.

The COVID-19 pandemic has had a significant impact on the programme. With the return of conventional NHS services at this point, including the re-introduction of more regular testing, it is strongly recommended that the Demand Optimisation work is prioritised to continue. The need for appropriate, targeted use of diagnostic tests will likely be even more important in the post pandemic Scottish NHS of the future.

The following recommendations are made: -

1. A National Oversight for Demand Optimisation of Laboratory testing is retained, further promoted and supported in all NHS Boards.

2. Data collection of laboratory test requesting and use continues as a priority in all NHS Boards; it is pivotal to the identification of unwarranted variation and it allows the effectiveness of interventions aimed at promoting appropriate testing to be addressed. It is therefore essential that appropriate dedicated resource for IT support is immediately identified and utilised within the NHS Boards where data extraction is currently a challenge.

3. Interactive dashboards within the Atlas of Variation and the production of regular focussed reports need to be further refined, promoted and actively utilised within Primary Care and Laboratory Services across all NHS Boards.

4. An expanded set of educational materials must be developed, published and widely disseminated to Primary Care and Laboratory colleagues so as to provide relevant guidance to reduce unwarranted variation.

5. Quality Improvement initiatives are actively championed in NHS Boards. New QI proposals are to be monitored and targeted work undertaken to facilitate the implementation of proposals.

6. Ongoing Demand Optimisation work must continue to uphold alignment with the values of the Realistic Medicine Programme and contribute to the Scottish Government's vision for the future of Primary Care and diagnostic services.

Funding was agreed for Phase IV of the National Demand Optimisation work, based on the following objectives:

• Data collection of laboratory test use/availability is continued on a quarterly basis as initiated during Phase III – where possible.
• Exploration of the possibility of embedding the Atlas in the existing QI landscape for GPs on iHub; alongside gaining support for the Atlas from the Royal College of GPs.
• Development and refinement of the user interface based on feedback of continued roll out of interactive Atlas dashboards.
• Continued engagement with National Managed Diagnostic Networks (NMDNs) and laboratories to develop educational materials to support the Atlas.
• Ongoing development of an electronic, automated method for extracting relevant data specific for a GP practice and sending practice specific reports.
• Engagement with relevant stakeholders to promote and refine the programme.
• Expanding stakeholder engagement with LIST to develop quality improvement initiatives.
• Where applicable, undertaking internal demand optimisation within laboratories to review and standardise methodologies.
• Monitoring and reporting on QI programmes being delivered.
• Promoting Demand Optimisation and the Realistic Medicine agenda at conferences, in reports to professional bodies and in newsletters.

Phase IV commenced in summer 2020 with the following re-focussed objectives relating to the COVID-19 pandemic:

Additional COVID-19 Pandemic monitoring objectives

• A re-focus on data collection to monitor laboratory test use trends related to the impact of the COVID-19 pandemic and the effect on healthcare flows.
• Development of COVID-19 pandemic monitoring dashboards for both pathology and blood sciences.
• Ongoing monitoring through remobilisation to track healthcare recovery and the impact on laboratory services.
• Additional lab IT support should urgently be provided in order to assist the manual extraction of this data from lab information systems – especially in the boards that currently have limited Lab IT capacity.
• Source data and observations from all boards/networks on the changes in healthcare infrastructure and provision as a result of the COVID-19 pandemic.
• Collect discipline specific laboratory activity data for the main sources – Primary care, Secondary care and out-patients.
• Estimate the "gap" in testing for different areas/disciplines – this is likely to relate to healthcare provision that was missed, delayed or postponed.
• Histopathology – expected that workload will increase as catch up is attempted – needs monitoring and prioritised given the fixed capacity of services. Specimen type, volume of work and complexity needs tracking to assist prioritisation decisions.
• Development of educational guidance as a matter of urgency, mainly via the networks, to roll out across healthcare settings – this needs to focus on avoiding samples as well as tests
• – the limitations are largely with patient interaction/phlebotomy, not with laboratory capacity (for blood sciences).
• Atlas of Variation – needs a re-think – both to acknowledge and track the new post COVID-19 metrics, but also to allow peer comparison across boards, regions, clusters and nations. Such comparisons are likely to be single use rather than looking chronologically at what came before COVID-19. A Post-COVID-19 dashboard needs developing.
• Focus on key areas such as cancer and diabetes where reduced testing during the pandemic is likely to have had a negative effect on individuals. Identification of specific requesting patterns that have failed to catch up.