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While the need for reforming diagnostic provision and introducing a new service model to provide safe, patient-centred pathways has been an area of priority for some time, the impact on Covid-19 on diagnostic activity has highlighted the urgency with which this needs to be delivered.
A need for reforming diagnostics and the separation of pathways between acute and elective care was outlined in a report released by NHS England in October, which followed on from the long-term plan.
The Covid-19 pandemic has highlighted a number of weaknesses affecting the resilience of our healthcare system. What we have learned from Covid-19 is that, while having a clear separation of pathways between acute and elective care can minimise knock-on effects on the healthcare system as a whole; it is also necessary to be able to effectively deal with the next pandemic.
Covid-19 has exacerbated the situation
While UK hospitals have coped relatively well with the Covid-19 outbreak, given the pressure it was under before the pandemic hit, it has had undesired effects on most non-acute parts of the healthcare system. Appointments have been cancelled, diagnostic procedures have been postponed; and actions taken to free up beds in hospitals have impacted negatively on community health provision and reduced the number of beds available in hospitals for non-urgent patients.
One of the most visible effects have been the marked increase in the number of people waiting for diagnostic tests and treatments. While activity has risen since the first lockdown it has not yet recovered to pre-pandemic levels, and the throughput of patients is lower, in particular for CT scanning and endoscopy, due to measures aimed at reducing Covid-19 infection risk.
The impact has been the highest on those waiting the longest. By September, despite activity increasing substantially, a third of patients on the list had waited more than six weeks for a scan or other diagnostic test, and for endoscopy that figure was over 50%. The number of patients waiting more than 13 weeks for an endoscopy has come down from its peak in June, but the most recent wave of Covid-19 is expected to cause further disruption to services.
What is also causing concern is the ‘hidden backlog’ of deferred referrals, as waiting times for getting an appointment with a consultant have also become longer. In a consultant-led system with reduced patient flows, the wait to see a consultant becomes a bottleneck.
Reforming diagnostic services
However, the pandemic has also provided an opportunity for change. As it has progressed, the focus has shifted from looking for solutions to the immediate crisis, using short-term temporary solutions such as the Nightingale hospitals, towards adapting to living with Covid-19 risk in the longer term. There is a renewed emphasis on looking for greater built-in resilience for the future.
The need for radical improvement to the way diagnostic services are delivered was widely acknowledged before the pandemic, with demand having risen rapidly over the past five years in particular, leading to an increase in breaches of the six-week diagnostic standard in recent years.
Access to endoscopy equipment and facilities were already under considerable strain before the pandemic, in particular for colonoscopy. Estimates based on the Get it Right First Time (GIRFT) programme indicate that around 20 NHS Trusts are likely to require a complete rebuild of their endoscopy facilities, with others needing improvement.
While there is no national asset register for endoscopy facilities, a report published by Public Policy Projects in partnership with Vanguard two years ago showed that around 25% of hospitals have endoscopy decontamination suites & equipment that are more than ten years old.
Clearly, it is not just about investing in buildings and equipment. Alongside increased capacity, the workforce will need to be expanded and new service models will need to deliver a full set of diagnostic services outside of hospital settings.
Diagnostics: Recovery and Renewal
A proposed solution was outlined in the recent report, based on a review of diagnostic services commissioned by NHS England as part of the Long Term Plan. It advocates the separation of acute and elective diagnostics wherever possible, and under the proposal, stand-alone diagnostic hubs would be set up in the community, away from acute hospital sites to provide ‘one-stop shops’ for diagnostic assessments.
The report emphasises the need for increasing capacity, and states an estimated 200 new endoscopy rooms are needed in NHS Trusts to cover current demand growth and to enable the planned extension to the bowel screening programme. A need to replace all existing imaging equipment older than 10 years was also identified, along with a need to expand CT scanning capacity by 100% over the next five years. CT scanner provision per population in the UK is much lower than in other developed countries.
The approach would bring a significant reduction in the number of patients attending an acute hospital setting and create efficiencies across the healthcare system as a whole. Since its release, the report has been universally welcomed, and if the recommendations are fully implemented, will herald substantial investment in workforce, equipment and facilities.
A more flexible approach
The £2.3 billion rise in capital spending in 2021/22 announced as part of the latest spending review, which includes £325 million for diagnostic machines such as MRI and CT scanners and to replace old imaging equipment, will go some way towards covering the cost.
The question is whether it will be enough, and whether we will see the impact soon enough, to make a real difference to waiting times and patient outcomes in the short to medium term. The recommendations in the report will take time to implement - but with the backlog growing each month, is waiting an option?
A clear separation of pathways is already possible to achieve using existing flexible healthcare infrastructure, which can be set up closer to patients as an integral part of an integrated care network. Mobile and modular imaging and endoscopy units can be set up in almost any location to create a stand-alone, Covid-free diagnostic facility within a very short space of time.
While mobile units are often used to provide greater flexibility as part of the hospital estate, they are also ideal for bringing services closer to patients. As part of an integrated care system, mobile infrastructure, which is available for a range of specialist and general procedures, can be situated at a local GP surgery, a community hospital, a dental practice or other healthcare facility.
The benefits of mobile healthcare units in this context are clear. Their flexible and relocatable nature has meant that some types of mobile units already play an important part in the delivery of patient services in the community. Mobile infrastructure can evolve and change as needs change, and can quickly be adapted to respond to an emergency.
Delivering community healthcare
To deliver integrated care, it is necessary to adopt a whole system perspective. A vital component of a flexible and resilient healthcare system is the ability to pool resources across a wider area, enabling services to be provided when and where they are needed the most. This has always been true, but the Covid-19 pandemic has heightened the need for robust integrated care systems, and this cannot happen unless we have an estate that flexible enough to meet the broad scope of needs of an ICS.
The key to making this approach work is developing collaborative networks, as new diagnostic equipment such as scanners and endoscopes is costly, and the usage of any new facility will need to be maximised. For practical and financial reasons, there are going to be a limited number of locations that can house an MRI scanner or an endoscopy facility, meaning many patients will still need to travel some distance to a central location.
With mobile infrastructure, however, the facility can be moved between locations to provide services closer to patients. The flexibility offered by mobile healthcare units means a network can be created within which primary care facilities, community hospitals and other healthcare settings share central diagnostic resources using a ‘hub-and-spoke’ system.
This could be delivered using a combination of a receiving facility, or ‘docking unit’, and a range of mobile healthcare facilities. The docking unit is set up with the appropriate connections, such as utilities and connecting corridors, in preparation for receiving a mobile facility, allowing mobile facilities to be connected easily and quickly.
Such a system gives providers near-instant access to fully-equipped diagnostic facilities. Mobile facilities can then easily be moved around within the network and quickly be installed in another location. Within the collaborative network, a range of clinical services can be selected that match demand and healthcare needs in the local area or offer different specialist facilities on rotation.
Among the key benefits of increasing access to services using flexible infrastructure are that it provides a low-risk and less capital intensive solution, with flexible pricing structures. It also offers low operational risk, since maintenance and repair is taken care of by the supplier of the facility. With a flexible solution like this, the cost of contracting, staffing and equipping the facility, as well as its benefits, could be shared between providers.
Alternatively, mobile and modular units can be combined to create a stand-alone fixed diagnostic hub in almost any layout, containing patient waiting areas, consultation rooms, scanning and procedure rooms, all specialist equipment, recovery bays, and staff and patient facilities.
A patient centric solution
Ultimately, the aim of a reform, as outlined in the NHS’s report, is to reduce both acute and elective waiting times, and help drive improved patient outcomes. However, the plan will take time to deliver and to achieve key targets, including early stage diagnosis of cancer patients, a solution is needed urgently.
Using a partnership approach and insourcing capacity from providers that can support and work with the health system can bring substantial benefits. Solutions already exist that can be implemented without the need to wait for specialists to be trained and recruited, capital budgets to be approved, large scale equipment purchases to be made and buildings to constructed, meaning benefits can be passed on to patients much more quickly.
As ICSs accelerate their evolution in the coming years, flexible healthcare infrastructure will play an increasingly important role in enhancing the accessibility of diagnostic services. As well as improving patients’ experiences, increasing access to services locally can also drive uptake for screening and diagnostic procedures. And if we continue to see clinicians streamline referrals and use virtual consultations on similar scale to now for the foreseeable future, these benefits will only increase over time.
This article first appeared in the fourth edition of the Hospital Times magazine.