Diagnostics: An NHS England Perspective Tony Newman-Sanders MA FRCR FRCP National Clinical Director - Diagnostics NHS England RIS PACS Conference. Monday 4 th December 2017 www.england.nhs.uk
Overview 1. NHS England Strategic objectives and policy drivers 2. NCD wider role and relations 3. Digital Diagnostics 4. The transformative role of technology 5. Summary www.england.nhs.uk 2
The Five Diagnostic Pillars Approximately 1 billion diagnostic tests undertaken each year, circa 8 billion on NHS spend. Diagnostic services are currently categorized into 5 pillars based on similarities in primary function or measurement techniques. Within this there are over 100 discrete areas of service provision which are often viewed and treated as separate service entities despite common cross-cutting issues and involvement of multiple diagnostic services in care pathways. Imaging / Radiology For example, X- Ray, MRI and Ultrasound Determining body structures using a variety of nonionising and ionising radiation Mainly delivered in hospitals, including for primary care, and in delivering some therapeutic interventions, some private provision for NHS Pathology Services For example, biochemistry, and histopathology testing Assessment of body composition, microbial assessment and therapeutic markers through blood, cellular and tissue samples Mainly delivered by hospital labs, including for primary care - some near-patient testing Genetics & Genomics Analysing the genetic code. From single gene testing and arrays to full genomes, and other functional genomic investigations, for example RNA and transcriptomics. Primarily delivered through regional genetic laboratories Physiology For example, audiology, respiratory and cardiac Measuring the performance of aspects of the body s function and the restoration of function Mainly delivered in hospitals, some directly in primary care, by 8 different clinical specialities Endoscopy For example, bronchoscopy and colonoscopy Optical examination of the inside of the body, sometimes linked to therapeutic procedures Primarily delivered in hospitals www.england.nhs.uk 3
Diagnostic landscape The strategic importance of diagnostics: The Five Year Forward View sets out the aim of accelerating useful health innovation and taking steps to speed up innovation in diagnostics. However, the 2nd Atlas of Variation in NHS Diagnostic Services in England highlights significant geographical variation and inequality in access to diagnostic tests and investigations (in some tests up to a [50 fold] difference), which can be linked to poor outcomes in some conditions including cancer in local populations Five Year Forward View like. The Atlas of Variation in NHS Diagnostic Delivering the Forward View Services in England brings together information Diagnostics is reflected in: on geographical variation in diagnostic testing. NHS England Mandate 2016-17 highlights wide geographical variation in levels of NHS planning guidance 2016/17 service provision, efficiency and quality. 2020/21 The NHS England s business plan Both the 1 st (2013) and 2 nd Atlas (Jan 2017) for 2016/17 highlight significant geographical variation and NHS Operational Planning inequality in access, which can be linked to poor Contracting Guidance 2017-2019 outcomes in some conditions. This is despite Diagnostics are key to the delivery of a recommendations for the investigations by NICE number of key priorities across the NHS: and in other guidelines Cancer. Mental health and dementia Many of the reasons for variation in service Learning disabilities provision are common to all disciplines across Diabetes diagnostic services, such as patterns of disease They are vital in: prevalence, the availability of a trained workforce the drive towards Seven Day and local custom and practices, whereas others Services are different, arising from the differences in the Delivering the Urgent and nature of the specific interventions and tests. Emergency Care agenda. Accelerating innovation in new Whilst the 2 nd Atlas provides some key data on ways of delivering care variation, it was not possible to update data on www.england.nhs.uk pathology and genetics services. 4
Strategic importance The importance of diagnostics in addressing wider issues: Several reviews of the NHS and the health care system more widely have identified national and global issues and opportunities, that can only be tackled with concerted improvement of our diagnostic services Achieving World Class Cancer Outcomes - The Independent Cancer Taskforce noted that science has advanced to a point where we can increasingly predict the risk of developing cancer, the response to treatment and the overall prognoses for cancer patients using molecular diagnostics. It called for an increase in molecular diagnostic provision. Carter s Review of Operational productivity and performance in English NHS acute hospitals - Estimated that unwarranted variation in non-specialist acute hospitals is worth 5bn in efficiency opportunities and variation in diagnostic efficiency and productivity is contributing to this (~ 200m in pathology). Review on Antimicrobial Resistance, O Neill- New rapid diagnostics are needed to identify whether a patient will benefit from an antimicrobial and whether clinicians are dealing with a resistant strain. Building our Industrial Strategy and Accelerated Access Review - Recommendations on how to accelerate access for NHS patients to innovative medicines, medical technologies, diagnostics. NHS England Priorities : Urgent and Emergency Care Review Seven Day Services Referral to Treat / waiting times Early diagnosis www.england.nhs.uk Learning disabilities and mental health Personalised Medicine 5
Vision personalised medicine The overarching vision is to align our approach to diagnostics to support the move towards personalised medicine Imaging Biochemical & biomarker data Tissue samples Physiological tests Genomic sequence data Individualised and integrated diagnostic and clinical phenotype at one point in time and over time Multi-omics information Eg metabolomics, epigenetics Clinical, population, social, economic data Leading to the best use of medicines, supporting better patient outcomes and efficiencies www.england.nhs.uk 6
Diagnostic Policy Areas Quality Accreditation Point of Care AMR. Response to O Neill Report 7 Day Services with focus on USS, MRI, echocardiography and interventional radiology Cancer. 28 day referral to diagnosis/exclusion Referral to treatment; 62 day Identifying optimal pathway e.g. Lung CT Straight to Test Colonoscopy / Colorectal CT scan Senior Clinical Triage Digital Diagnostics Models of Service provision and underpinning Commissioning models. www.england.nhs.uk 7
Accreditation ISAS is a patient-focused assessment and accreditation program designed to help diagnostic imaging services ensure that their patients consistently receive high quality services, delivered by competent staff working in safe environments. NHS England has outlined its strong position towards accreditation of diagnostic services by publishing a position statement. It remains committed to, and strongly endorses participation of diagnostic services in the ISAS scheme. UKAS assesses imaging services against the ISAS Standard and ensures that required standards are maintained through regular monitoring. An enhanced package of pre-application support is available to all services, as well as an optional staged pathway to accreditation during the initial assessment. CQC explicitly recognises the assurance of ISAS as part of their inspections www.england.nhs.uk 8
The 7DS Programme has a priority clinical standard to ensure that key diagnostic tests are available to all patients admitted to hospital in an emergency by 2020 Standard 5 Timely access to diagnostics: Hospital inpatients must have scheduled seven-day access to diagnostic services. Consultant-directed diagnostic tests and completed reporting will be available seven days a week within 1 hour for critical patients, 12 hours for urgent patients and 24 hours for non-urgent patients CT Test Microbiology Ultrasound Echocardiography Upper GI endoscopy MRI Haematology, biochemistry www.england.nhs.uk Actions to ensure delivery Ensure weekend capacity meets weekend demand. None required, although be aware of new acute micro tests becoming available in next few years to help reduce AMR. Training and recruitment of more sonographers, and in some specialties such as obstetrics and gynaecology, skill-sharing with other related acute professions. HEE plans to train appropriate acute staff, including cardiology trainees as part of their sub-specialty training, to use echo as part of their range of skills, but it will take longer than two years for staff with these skills to be in place across all hospitals. Separate work also needed to ensure that all hospitals with on-site cardiology services have echo-trained cardiologists on site over weekends. Encourage trust to build in weekend emergency capacity locally or via a network (noting that the emergency endoscopy capacity must be on same site as the acutely bleeding patient). Provide clarification for the survey of indications and encourage networked provision (usually patient can travel by ambulance if necessary). All basic acute tests already available. No action required.
Cancer Diagnostics National Cancer Programme Clinical Steering Group Optimal diagnostic pathway design e.g. Lung, Colon, Breast Prostate Clinical Expert Group Straight to test; Colon cancer. Referral to treat; 62 day target. Remains a key priority Earlier diagnostics New delivery models; Sustainability and transformation fund Primary care and increased awareness Networked diagnostics Multi disciplinary Diagnostic Centres Pilot of 28 day standard; Referral to diagnosis www.england.nhs.uk 10
Future models of Service Delivery; What is the future for diagnostics? Specialist Diagnostic Centres 24/7 & 7day Telereporting & image/ data sharing At home or in the High Street FUTURE DIAGNOSTIC PROVISION Tertiary Care Telemonitoring of individuals Local Diagnostic Hubs www.england.nhs.uk 11
Emerging areas of focus Sepsis Implications for interventional radiology Artificial intelligence Electronic decision support systems Several well known companies providing differing perspectives; CAD Structured and unstructured data www.england.nhs.uk 12
NCD wider role Expert advice to NHSE; Royal Colleges Radiologists Anaesthetists, Surgeon, Emergency Medicine etc SoR Health Education England NHS Digital and National Imaging Board SCRG NHS Improvement GIRFT Imaging Transformation Connecting to regional teams www.england.nhs.uk 13
Digital Diagnostics New Programme Board Chaired by Chief Scientific Officer Clarity about roles of NHSE, NHS Digital and Genomics England Architecture to support future vision and current needs for interoperability National Information Board Strategic Clinical Reference Group Information and Digital Technologies Clinical Requirements 2020, www.england.nhs.uk 14
Digital Imaging Data The DID compiles record-level data from NHS Radiology Information Systems (RIS) relating to diagnostic imaging activity in hospitals in England. It fulfils a requirement from the Government s 2011 Improving Outcomes: A Strategy for Cancer to collect data on GP usage of key tests for cancer, to benchmark and improve access for early diagnosis. The data are collected by NHS Digital on a monthly basis. They are linked to Hospital Episodes Statistics for fuller analysis of acute secondary care pathways. NHS users may apply for access to the DID via NHS Digital s iview reporting tool. Details of this and the collection are at: http://www.hscic.gov.uk/did Results are analysed and published by NHS England in provisional monthly summary reports and a final annual release, at: http://www.england.nhs.uk/statistics/statistical-work-areas/diagnostic-imaging-dataset/ The DID captures information about the: Test, including type of test and body site (using NICIP and/or SNOMED CT coding schemes); Patient, including demographics and identifiers for linkage to other datasets; Referral source, eg GP direct access, outpatient, A&E and referrer details; Waits, eg from date of request to date of test and period from test to the report being issued; Organisation, the hospital provider, GP practice and commissioner. www.england.nhs.uk May 2017 15
Digital Imaging Dataset What tests are covered? All imaging activity is coded, but the grouped modalities commonly reported are: X-ray MRI PET scans Ultrasound Fluoroscopy SPECT scans CT scan Nuclear Medicine Medical photography Although we don t know which actual tests were used to diagnose or rule out Cancer, we report on the following tests that could contribute to the early diagnosis of cancer: MRI of Brain X-ray of Chest Ultrasound of Kidney or bladder Ultrasound of Abdomen and/or pelvis CT of Chest and/or abdomen What statistics are produced? Eg Volumes and trends; Wait times; Turnaround times NHS Imaging by gender and age, 2015-16 Ultrasound activity by number of days from date of test request to date of test, by source of referral, 2015-16 X-ray Ultrasound CT Scan MRI Fluoroscopy Female 11,982,320 6,352,960 2,189,130 1,631,900 506,045 Male 10,187,900 2,394,195 2,207,880 1,415,245 523,480 Not known / specified 404,375 181,775 64,565 39,070 11,030 0-14 1,998,165 409,560 52,610 131,490 54,020 15-44 5,261,755 4,385,080 734,230 962,430 186,900 45-59 4,542,165 1,697,510 893,380 856,845 238,430 60-74 5,368,395 1,374,265 1,328,970 750,830 316,505 75+ 5,087,755 954,020 1,393,935 358,135 233,175 Not Known 316,365 108,495 58,455 26,475 11,535 Average period from date of test to date test report issued for Chest X- ray, by provider, 2015-16 www.england.nhs.uk May 2017 16
Diagnostic performance Current Performance Total Imaging Total Total Endoscopy MRI CT US Barium Enema Dexa Scan Audiology Echocardiogra Electrophysiol Peripheral Sleep Studies Urodynamics Colonoscopy Flexi- Cystoscopy Gastroscopy 0.5% 2.0% 0.7% 1.0% 0.3% 0.3% 0.1% 1.2% 2.5% 1.9% 0.8% 2.9% 2.3% 3.1% 2.8% 2.2% 4.5% 8.6% 0% 3% 5% 8% 10% 3% 2% 1% 0% Apr May Jun Diagnostic Performance Jul Aug Sept Oct Nov Dec Jan Feb Mar Standard 2015/16 2016/17 Figure 2: Overall current performance of diagnostic tests against the 1% standard Overall, diagnostic performance decreased to 1.1% in March 17, from 1.% in February 17 but is better than March 16 (1.7%). However the national standard of 1.0% was not met. Overall the 1% standard has not been met since December 2013. Figure 1: Current performance of diagnostic tests against the 1% standard breakdown of tests www.england.nhs.uk May 2017
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Waiting lists 950,000 900,000 Total Waiting List 2015/16 2016/17 850,000 800,000 750,000 The total waiting list is 934,010, up 47,000 from February 17. Compared to the same month last year it has increased. This trend has been consistent historically Demand is therefore outstripping capacity with waiting lists increasing www.england.nhs.uk 18
The transformative power of technology Right test, right time, right patient Decision Support Links with EPR Meeting the challenge of turning the data tsunami into timely actionable intelligence Sustainable future Productivity, Clinician retention; Mobile technology; Point of Care imaging; Clinician interpretation Creating learning systems Computer assisted diagnosis The role of Artificial Intelligence and data lakes Networks and Academies www.england.nhs.uk 19
Key messages Importance of Diagnostics has never been more widely recognised Vision of truly personalised medicine will have a major impact on the way we think about diagnostic imaging Maximum value from treatments especially medicines There are significant and growing challenges to meeting the expectations of colleagues and patients Key policy drivers will help meet some of these Need to work creatively together to articulate and meet some of the others NCD doesn t have all the solutions but is uniquely placed to work across the system to try and find solutions www.england.nhs.uk 20