Diagnostic services in the NHS are vital to recovery and renewal – Sir Mike Richards
In the face of skyrocketing service demand, the UK must rapidly rethink diagnostic service delivery and quickly increase capacity.
Accurate and timely diagnosis is a prerequisite for selection of appropriate treatment and care and thus for improving outcomes in any health service. Diagnostic tests are critical to this for a very wide range of conditions. Unfortunately, many patients in the UK are diagnosed later than they should be, leading to poor outcomes in cancer, stroke, respiratory, cardiac and other conditions.
I was asked to undertake a review of diagnostic services in the NHS as part of the NHS Long Term Plan (2019). Much of the work had been undertaken prior to the pandemic, but publication was deliberately postponed so that account could be taken of the impact of Covid-19 on diagnostic services. All the pre-pandemic conclusions remain true, but with increased urgency due to Covid-19. Diagnostics: Recovery and Renewal was published in October 2020.
The review was deliberately broad in scope covering imaging, endoscopy, pathology, and physiological measurements, with a focus on those relating to cardiac and respiratory disease. To develop the report, I had extensive discussions with experts in a wide range of relevant fields, including NHS clinicians and managers in hospitals and the community, charities that had close contact with the voice of patients and relevant royal colleges and professional societies.
The tipping point
The case for change is strong. Demand is rising for almost all diagnostic tests and at a faster pace than attendances at A&E, outpatients and numbers of emergency admissions. The UK has much lower diagnostic capacity than almost all other OECD countries. For example, the UK would need to double its CT scanning capacity to match the OECD average.
Even before the pandemic we were reaching a tipping point, with waiting lists increasing and outsourcing of work to independent sector providers. The pressures on diagnostic services have increased even further because of the pandemic, as throughput is slower to comply with infection prevention and control measures. There is an additional need to recover from the backlog in testing this has caused.
Furthermore, demand for diagnostics is set to increase further in coming years – and needs to do so if commitments in the NHS Long Term Plan are to be achieved. Taking cancer as an example, the commitment is to diagnose 75 per cent of patients at stages one or two by 2028, against a current figure of about 55 per cent. This will undoubtedly need more and more timely access to CT and MRI scans and endoscopy, in turn leading to more samples requiring examination by pathologists. If lung cancer screening is approved, this will require a significant increase in capacity. In addition, as the use of systemic treatments increases year on year, so too will the need for scans to monitor progress. Demand for imaging is also rising rapidly for patients with heart diseases, for example in CT coronary angiography for stable angina and echocardiography for heart failure.
Endoscopy demand has been increasing year on year and is likely to increase further as the age range for bowel screening is extended and the threshold for investigation is lowered.
In A&E departments, about one in 10 patients now need a CT scan, but this is not always available as quickly as it should be. Stroke patients should be scanned within an hour, but this standard is only achieved in about half of cases. Before the pandemic, about one quarter of all CT scans were performed on patients admitted to hospital as an emergency. However, about 40 per cent of these scans were not able to be undertaken on the day of request, inevitably leading to increases in overall lengths of stay – bad for patients and wasteful of scarce NHS resources.
More and different
So, what needs to be done? First, we must expand capacity – more equipment, new facilities and expansion of the diagnostic workforce will be critical. I based estimates of requirements over the next five years on a combination of trends over the years prior to the pandemic, assessment of new uses of individual tests and international comparisons (conservatively only aiming to reach international averages). Once additional activity had been projected, the needs for equipment and workforce could be estimated, taking account of the need to drive efficiencies and the potential roles in diagnostics of artificial intelligence.
Second, services must be delivered differently. Unlike many other countries, our diagnostic services are largely concentrated in acute hospitals. Patients presenting as emergencies often compete with routine patients for the use of diagnostic testing capacity – to the detriment of both. I heard widespread agreement that ‘acute’ and ‘elective’ diagnostics should be streamed separately wherever possible.
To achieve this separation, my report strongly advocates the establishment of community diagnostic hubs (CDHs) across the country. Over time, these could take on almost all the diagnostic tests requested by GPs and many of the tests requested from hospital outpatient services. Work involving both national and local teams is now under way to offer guidance on the design and implementation of CDHs.
CDHs will be expected to offer a range of diagnostic tests and to provide one-stop services where this is feasible. Integration of CDHs into seamless pathways of care will be vital. Some CDHs may be provided directly by the NHS, others in partnership with independent sector providers. Whatever the delivery mechanism, joint workforce planning and ongoing training will be essential. Overall, CDHs need to play their part in improving health outcomes, delivering more diagnostic capacity, improving efficiency, reducing health inequalities and improving patient experience.
A range of other developments will also be critical to the delivery of high-quality diagnostic services. Digital connectivity will be of paramount importance. NHS trusts and primary care also need to work together in networks to plan and monitor service delivery, to avoid duplication of tests and to share workloads. Leadership on diagnostics at national, regional and local level needs to be strengthened.
The recommendations in my report were approved by the NHS England and NHS Improvement Board, and have been widely welcomed by NHS clinicians and managers. Structures are being put in place to oversee implementation and funding has been secured to start on implementation in the coming year. However, I am well aware that writing a report is the easy part. Driving implementation is much harder.