The Challenges and

Improvements in Diagnostic

Services across 7 Day Services

Prof Erika Denton, National Clinical Director for Diagnostics

West Midlands

June 11th 2014

• The NHS and diagnostics

• National data

• Geographical variation

• 7 day & 24/7 working

• Diagnostic service improvement work

The aim for all healthcare…..

To deliver appropriate, good quality, cost effective care

co-ordinated across primary and secondary care

The five pillars of diagnostics

10% of NHS spend, £8 billion

1 billion tests pa

Ge

net

ics

Cyt

o &

mo

loec

ula

r ge

net

ics

Imag

ing

eg x

-Ray

, CT,

MR

I, u

ltra

sou

nd

End

osc

op

y in

c co

lon

osc

op

y

Ph

ysio

logy

Eg

Au

dio

logy

, Res

p, C

ard

iac

Pat

ho

logy

B

loo

d, C

ellu

lar,

Infe

ctio

n

The five pillars of diagnostics

Why does diagnostics matter?

Key examples:

• Pathology, imaging & endoscopy for cancer diagnosis

• Timely brain imaging enables thrombolysis and doubles number of stroke patients who walk, from 1/3 to 2/3

• Interventional radiology for post partum haemorrhage vs hysterectomy, in limb ischemia vs amputation

• Sleep studies initiate treatment to prevent morbidity & mortality

• Genetic testing enables monitoring or intervention to avoid early death & hereditary transmission

• Long term condition management of diabetes, rheumatological disorders etc

NHS Outcomes Framework

Commissioning to support delivery of 5 domains:

• Domain 1 To prevent people from dying prematurely

• Domain 2 To enhance the quality of life for people with long term conditions

• Domain 3 To help people recover from episodes of ill health or following injury

• Domain 4 To ensure that people have a positive experience of care

• Domain 5 To treat and care for people in a safe environment and protect them

from avoidable harm

Sounds simple for a CCG….?

1-3 large acute

contracts, value

>£50million

10 - 30 smaller

inpatient and

community contracts

c. £1million

100s of single

provider

contracts or

individual patient

placements

<£100k

Cataracts

General surgery

A&E

Trauma

Maternity

Comorbidities

Dementia

Neurology

Weight management

Cancer

Depression

Respiratory

Long Term conditions

Rehab

Deprivation

Disadvantaged

groups

Specialised Commissioning

• 5 groups of Service Specific CRGs

• Specialised is for popn >1m, rare conditions

• Directly commissioned by NHSE

• Standardised structure for all CRGs

The NHS Funding Gap…

Projected Rate Of Population Growth

By Age Last Birthday Graph showing projected rate of growth of Projected populations at mid-years by

age last birthday (under 60 years and over 60 years) over the next 8 years.

Source: Government's actuarial department

0%

2%

4%

6%

8%

10%

12%

14%

16%

Year

Projected Population

Increase from 2004 %

Under 60 (% increase from 2004)

Over 60 (% increase from 2004)

Under 60 (% increase from 2004) 0.0% 0.5% 0.8% 0.8% 0.7% 0.9% 1.0% 1.3% 1.5%

Over 60 (% increase from 2004) 0.0% 1.4% 2.8% 5.6% 7.9% 9.8% 11.5% 13.1% 14.6%

2004 2005 2006 2007 2008 2009 2010 2011 2012

The vast majority of increase in population over the next 6 years is predicted to be in

the 60+ age bracket.

The vast majority of increase in population over the next 6 years is predicted to be in

the 60+ age bracket.

(Source: Government’s actuarial

department).

Causes Of Death, over 60s

Respiratory Diseases

GI Disease

Mental/Behavioural

CNS Disease

Abnormal Findngs

All Others

Circulatory Diseases

Neoplasms 80% of death of

the over 60s

attributed to 3

underlying

causes

Why do we have a Challenge?

Because the equation…

Demographics + Patient / Public Expectations + Quality

Money

Rising to the Challenge?

Demographics + Patient / Public Expectations + Quality

Money

Solution = transformational change to the current way of delivering health care

‘Old’ vs ‘New’ change methodology

Transactional change:

Doing things better

Transformational change:

Doing better things

‘You can’t solve a problem by using

the same thinking that created it’

Albert Einstein

National Data

• Equipment

• DMO1

• Intervention Rates

• DID

• The Atlas of Variation

National Audit Office Report 2011

Managing high value capital

equipment in the NHS in England

• MR, CT, RT linacs

• Poor VFM in purchase & maintenance

• Variable utilisation

• Poor cost & performance data

NHS Supply chain currently reviewing existing equipment in NHS to baseline & evidence benefit of modernisation

1 – Data include equipment in hospital

only.

1 – Data include equipment in hospital

only.

20

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

All 15 key tests

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

Pro

po

rtio

n w

aiti

ng

6+

we

eks

6+ Wait %

Operational Standard

0.0

0.5

1.0

1.5

2.0

2.5

Me

dia

n W

aiti

ng

Tim

e (

we

eks

)

-

5,000

10,000

15,000

20,000

25,000

30,000

Gastroscopy

24

0

10000

20000

30000

40000

50000

60000

Gastroscopy

1 – Data refer to exams in hospital only.

2 – Data refer to exams outside hospital only.

1 – Data refer to exams in hospital only.

2 – Data refer to exams outside hospital only.

The Diagnostic Imaging Dataset: DID

• Monthly

• Direct from RIS

• Every imaging event: requester, demographics, code of test etc

• Report turnaround & waiting times

• Link to outcomes via HES & Cancer registries?

• Extending to include all diagnostics?

Aim: to establish “optimum” intervention rates

DID: Chest x-ray usage by CCG

Chart 1 – Rate per 1000 GP Registered Population

GP Direct Access activity

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00

0 50 100 150 200 250

Median Mean NHS Airedale, Wharfdale And Craven CCG Low er Quartile Upper Quartile

DID: Ultrasound usage by CCG

GP Direct Access activity

0.00

5.00

10.00

15.00

20.00

25.00

0 50 100 150 200 250

Median Mean of CCGs NHS Barking And Dagenham CCG Low er Quartile Upper Quartile

Life across the NHS?

Just do more!!

The NHS Atlas of Variation

Looking at rate of healthcare interventions undertaken per

population

eg. For sleep studies 2010/11

60 fold variation between the highest PCT and lowest PCT

still a 27-fold variation, when you don’t consider the top 5

and bottom 5 PCTs

Similar pattern across diagnostic services

Rate of magnetic resonance imaging (MRI)

activity per weighted population by PCT, 4

fold variation

2010/11

Rate of dual-energy X-ray (DEXA) scan

activity per weighted population by PCT, 13

fold variation

2010/11

Rate of PET/CT activity per population,

by PCT, 25 fold variation

2010/11

• Benchmarking

• NHS diagnostic service improvement

• Pathology

• Endoscopy

• Interventional radiology

• 7 day services

NHS | Presentation to [XXXX Company] | [Type Date] 34

NHS Service Improvement

Founded in 1996

in house, by and for the NHS

Over 320 member organisations

Sector based reference groups

Hosted by East London NHSFT

Non-profit making – all membership fees

support the work programme

NHS Benchmarking

• “benchmarking is the use of structured comparisons to help

define and implement best practice”

Community services

Community hospitals

Urgent Care

Integrated Care (new) –

including older people’s

commissioning

Medicines Management

(new)

Theatres

Corporate functions

Benchmarking project reports & good practice guidance

Mental health inpatients &

community

CAMHS

Learning Disability (new)

Acute therapies OT/Physio

& SLT/Dietetics

Emergency Care

Radiology

Older People (new)

Intermediate Care

• Recurrent revenue

costs per 100,000

outpatient

attendances.

• Median £2.57m per

100,000 OP

attendances

• report turnaround

times for CT vary,

median 2 days,

range from same

day - 9 days.

Benchmarking examples

37

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

R033

R090

R026

R074

R040

R028

R016

R047

R068

R079

R024

R086

R051

R007

R052

R073

R025

R046

R017

R065

R015

R011

R088

R078

R083

R042

R014

R013

R036

R050

R009

R045

R030

R082

R085

R092

R010

R072

R031

R005

R071

R021

R076

R038

R075

R041

R060

R012

R054

R067

R056

R070

R003

R080

R032

R087

R059

R062

R066

R058

R069

R081

R091

R044

R027

R089

R064

R084

Reve

nue

Cost

s

Total Revenue Costs for Radiology 2012/13 per 100,000 Outpatient Attendances

Teaching Large Non-Teaching Medium Non-Teaching Small Non-Teaching Community Mean Lower Quartile Median Upper Quartile

0

1

2

3

4

5

6

7

8

9

10

R082

R065

R091

R017

R044

R021

R059

R087

R070

R052

R064

R016

R036

R058

R056

R013

R041

R062

R066

R072

R075

R077

R024

R028

R045

R032

R078

R009

R010

R043

R083

R092

R076

R027

R007

R042

R048

R067

R073

R090

R003

R033

R012

R054

R081

R038

R030

R060

R015

R069

R074

R005

R031

R050

R051

R080

R085

R086

R088

R046

R025

R068

R071

R047

R079

R049

Num

ber o

f Day

s

Average Report Turnaround Time in Days - CT

Teaching Large Non-Teaching Medium Non-Teaching Small Non-Teaching Community Mean Lower Quartile Median Upper Quartile

Reporting using Voice Recognition

Average 62% of examinations reported with VR

38

0%

20%

40%

60%

80%

100%

120%

R011

R028

R052

R070

R084

R090

R013

R033

R060

R058

R003

R009

R093

R048

R077

R017

R043

R045

R078

R064

R074

R068

R007

R038

R066

R079

R082

R050

R010

R015

R005

R046

R080

R030

R031

R092

R065

R054

R069

R044

R016

R083

R073

R025

R071

R036

R059

R027

R081

R087

R047

R072

R062

R075

R056

R021

R014

R088

R042

R076

R012

R085

% o

f Exa

min

atio

ns R

epor

ted

Usi

ng V

oice

Rec

ogni

tion

Sof

twar

e

% of Total Examination Reported Using Voice Recognition Software

Teaching Large Non-Teaching Medium Non-Teaching Small Non-Teaching Community Mean Lower Quartile Median Upper Quartile

CT most extended

hours availability

(78%)

Fluoroscopy, MRI, and

Cath Lab all have

availability levels at

more than 50% of

weekly available hours.

PET, DEXA, Nuclear

Medicine and

Mammography have

lowest hours of

availability.

Equipment Utilisation Rates by Modality

39

58%

51%

27%

26%

50%

25%

22%

44%

51%

78%

66%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Average % Utilisation Across All Trusts

Plain film X-Ray - total

CT

MRI

Ultrasound

DEXA

Nuclear Medicine

Fluoroscopy

PET

Mammography

Catheter Laboratory / Interventional Cardiology

Other

Pathology Improvement Programme

From 2008

• Cytology

• Histopathology

• Blood Sciences

• Microbiology

• Phlebotomy

• SHA based approach

0102030405060708090

100

Oct-

09

Nov-0

9

Dec-0

9

Jan-1

0

Feb-1

0

Mar-

10

Apr-

10

May-1

0

Jun-1

0

Jul-10

Aug-1

0

Sep-1

0

Oct-

10

Nov-1

0

Perc

en

tag

e (

%)

Histopathology- Average TAT in 7 & 3 days

7day TAT 3day TAT

Lessons learned

• In house improvements in pathology impacted positively on whole patient pathways

• Quality was improved

• Turnaround times were reduced

• Sustainment of the improved processes was variable

• The ability of Managers and Leaders was variable

Second Phase for National Pathology

Improvement

• ‘Influencing the future-leadership in action’

Leadership Development Programme

first in pathology now for MDTs with radiology

• Exemplar site development

Organisation development programme learning from those with sustained best practice and

continuing to innovate and improve

Interventional Radiology:

the evidence for change

the evidence for change • NCEPOD on Trauma, Renal, IR & Neuro IR, AAA

• NICE: UAE, NAI etc

• Northwick Park Maternity Services HCC report

• Birmingham Children’s Services HCC report

• National Imaging Board’s reports:

‘Interventional Radiology: Improving Quality and Outcome for Patients’

‘Interventional Radiology: Guidance for Service Delivery’

DH involvement with

Interventional Radiology

• Interventional Radiology (IR):

‘Improving Quality and Outcomes

for Patients’ (DH, National Imaging

Board 2009)

• Interventional Radiology: Guidance

for Service Delivery (DH 2010)

• Delivering the Service:

Interventional Radiology for Major

Trauma Networks (DH 2010)

• Towards best practice in IR – (NHS

Improvement 2012)

College Guidelines: RCR (2009):Standards

for providing a 24-hour radiology service

Acute intervention including damage control surgery, . . . .

. . . . . interventional radiology, haemorrhage control, and blood transfusion.

Interventional suites should be co-located with operating rooms &/or resuscitation areas.

Interventional radiology (IR) taking place within an MTC should be available 24 hours a day.

Patients requiring acute intervention for haemorrhage control should be in a definitive management area (operating room or IR suite) within 60 mins of arrival.

IR Programme 2011-12:

Trauma & IR

Aim: 24/7 Interventional Radiology services in all Major Trauma centres

• National Survey

• Visits to 24 Major Trauma Centres

• Publication of Learning Document

• 2 National Workshops to launch the document and share good practice

Aim: Provide access to IR services for all, 24/7

Focus on core procedures- embolisation for haemorrhage (general and PPH), endovascular intervention, nephrostomy

• Promoting Networks

• East Midlands and South West (Interviews and visits)

• Other possible networks (telephone interviews)

• Workshops East Midlands and Southwest

• 3rd IR Survey 2013

IR work in 2013 IR work in 2013: access to IR

Red: No core service

provision and no network

pathways - includes

adhoc rotas.

Amber: Some core

services available on a

formal rota, limited formal

network provision

Green: Core service

provision or partial

service provision with a

formal rota and formal

network pathways to an

agreed recipient trust.

White : No data received

NHS Improvement Survey

2011, MTCs

2012

Survey

2011 Survey

2012

Survey

2011 Survey

Total IR RAG status

(as at 16/05/2012)

51.1%

44.8%

28.2%

26.9%

20.6%

28.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 Survey 2

Staffing (Actuals)

0

50

100

150

200

250

300

350

North East North West Yorkshire

and

Humberside

East

Midlands

West

Midlands

East of

England

London South East

Coast

South

Central

South West

WTE Radiologists IR Radiologists Radiographers IR Nurses

Nephrostomy - Interventions per Radiologist

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

Nor

th E

ast

Nor

th W

est

Yor

kshire

and

Hum

berside

Eas

t Midla

nds

West

Mid

land

s

Eas

t of E

ngland

Lond

on

Sou

th E

ast C

oast

Sou

th C

entra

l

Sou

th W

est

# In

terv

en

tio

ns

Uterine Fibroid Emolization - Interventions per

Radiologist

0.001.002.003.004.005.006.007.008.009.00

10.00

Nor

th E

ast

Nor

th W

est

Yor

kshire

and

Hum

bers

ide

Eas

t Midla

nds

Wes

t Mid

land

s

Eas

t of E

ngland

Lond

on

Sou

th E

ast C

oast

Sou

th C

entra

l

Sou

th W

est

# In

terv

en

tio

ns

Two key issues remain

1. Lack of network approaches

2. Lack of IR Radiologists

WEST HERTFORDSHIRE HOSPITALS

NHS TRUST

ROYAL BERKSHIRE NHS FOUNDATION

TRUST

OXFORD RADCLIFFE HOSPITALS NHS

TRUST

BUCKINGHAMSHIRE HEALTHCARE

NHS TRUST

MILTON KEYNES HOSPITAL NHS

FOUNDATION TRUST

HEATHERWOOD AND WEXHAM PARK

HOSPITALS NHS FOUNDATION TRUST

NUFFIELD ORTHOPAEDIC CENTRE NHS

TRUST

BEDFORD HOSPITAL NHS

TRUST

LUTON AND DUNSTABLE

HOSPITAL NHS FOUNDATION

TRUST

IR Consultant IR Radiographers IR Nurses

Nuffield 4 4 7

H Wood & W Pk 5 5 2

W Hearts 2 6 4

R Berks 4 4 9

Bucks health 2 8 3

Bedford 1 5 4

Luton 2 7 2

Oxford 6 7 10

M Keynes 2 2 2

Total 28 48 44

WESTON AREA HEALTH NHST

NORTH BRISTOL NHS TRUST

UNIVERSITY HOSPITALS COVENTRY AND

WARWICKSHIRE NHS TRUST

WYE VALLEY NHS TRUST

SOUTH WARWICKSHIRE

UNIVERSITY HOSPITALS BRISTOL NHS

FOUNDATION TRUST

ROYAL UNITED HOSPITAL BATH NHS

TRUST

GREAT WESTERN HOSPITALS NHS

FOUNDATION TRUST

GLOUCESTERSHIRE

HOSPITALS NHS

FOUNDATION TRUST

WORCESTERSHIRE ACUTE HOSPITALS

NHS TRUST

IR Consultants/Consultant

Radiologists

IR Radiographers IR Nurses

RUH Bath 3/16 5 4

UH Bristol 7/29 4 3

Gloucester 3/12 4 6

S Warwickshire 4/9 0 0

Great Western Hospitals 3/11 5 4

Worcester 3/14 8 3

Wye Valley 1/8 3 1

Coventry and Warwick 4/25 3 8

North Bristol 6/24 6 12

Weston Area Health 1/6 1 0

Total 35/154 39 41

South West

• Interventional Radiology

• On site

Yes 84 64%

No 48 36%

Endoscopy: what looks good?

• An accredited endoscopy service that participates in

• Global Rating System (GRS)

• National audit

• 24/7 service for GI bleeding, networked or in-house

• Access to flexi-sig or colonoscopy in <4 wks for all patients >40 with recent onset rectal bleeding and/or persistent (>3 weeks) diarrhoea.

• Compliant with NICE standards

NHS England

‘‘Hospital services should be commissioned to provide:

24 hr 7 day endoscopy service for GI bleeding’’

‘‘Average GI bleeding mortality rate = 10% is ↓ by

access to 24/7 endoscopy, IR & surgery as an MDT’’

GI bleeding toolkit:

http://aomrc.org.uk/projects/upper-gastrointestinal-bleeding-toolkit.html

• 132 of 156 85% responded

• Self reported RAG status of OOH AUGIB service

Green 81 61%

Amber 32 24%

Red 19 14%

Survey of acute

service providers

• NICE Quality Standard 2 – Timing of endoscopy (immediate for haemodynamically unstable)

Yes 100 76%

No 32 24%

• NICE quality standard 3 – People with AUGIB who are haemodynamically stable are offered endoscopy within 24 hrs of admission

Yes 72 55%

No 60 45%

• Interventional Radiology

• On site

Yes 84 64%

No 48 36%

NHS | Presentation to [XXXX Company] | [Type Date] 67

• Network

Yes 61 46%

No 71 54%

• Barriers currently or envisaged to providing 24/7 therapeutic endoscopy

• Rota’s

Open 24 hours?

Why the variation across the week?

Patients at weekends

• Fewer discharges to alternative place of rehab or death

• People wait longer before seeking help, admission thresholds raised

Staff at weekends

• Fewer

• Less experienced

• More exhausted

Available services

• Diagnostics

• Specialist interventions

• Discharge support

24/7

Extended Day +/- 7/7

Diagnostics

Tertiary Care

In Patient

A&E

Stroke Strategy

Primary Care Increased Access

Patient Choice

Secondary Care delivery – Out Patient

Specialist Care

Service delivery model

Anaesthesia Monitoring Ventilation ECG Echo/Contrast Catheter Scan

one cardiac patient . . . 10-day hospital stay . . .

…….six departments . . . 105 healthcare professionals

Hidden diagnostic services

“Be ambitious – you can’t

take two steps over a gap”

David Lloyd George