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www.england.nhs.uk
Tony Newman-Sanders
MA FRCR FRCP
National Clinical Director -
Diagnostics
NHS England
Diagnostics: An
NHS England
Perspective
RIS PACS Conference. Monday 4th December 2017
www.england.nhs.uk
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
Overview
2
www.england.nhs.uk 3
Imaging /
Radiology
For example, X-
Ray, MRI and
Ultrasound
Determining body
structures using a
variety of non-
ionising 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
• 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.
The Five Diagnostic Pillars
www.england.nhs.uk 4
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
• The Atlas of Variation in NHS Diagnostic
Services in England brings together information
on geographical variation in diagnostic testing.
highlights wide geographical variation in levels of
service provision, efficiency and quality.
• Both the 1st (2013) and 2nd Atlas (Jan 2017)
highlight significant geographical variation and
inequality in access, which can be linked to poor
outcomes in some conditions. This is despite
recommendations for the investigations by NICE
and in other guidelines
.
• Many of the reasons for variation in service
provision are common to all disciplines across
diagnostic services, such as patterns of disease
prevalence, the availability of a trained workforce
and local custom and practices, whereas others
are different, arising from the differences in the
nature of the specific interventions and tests.
• Whilst the 2nd Atlas provides some key data on
variation, it was not possible to update data on
pathology and genetics services.
Five Year Forward View like.
• Delivering the Forward View –
Diagnostics is reflected in:
• NHS England Mandate 2016-17
• NHS planning guidance 2016/17 –
2020/21
• The NHS England’s business plan
for 2016/17
• NHS Operational Planning
• Contracting Guidance 2017-2019
• Diagnostics are key to the delivery of a
number of key priorities across the NHS:
• Cancer
• Mental health and dementia
• Learning disabilities
• Diabetes
• They are vital in:
• the drive towards Seven Day
Services
• Delivering the Urgent and
Emergency Care agenda.
• Accelerating innovation in new
ways of delivering care
Diagnostic landscape
www.england.nhs.uk 5
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
• Learning disabilities and mental health
• Personalised Medicine
Strategic importance
www.england.nhs.uk 6
The overarching vision is to align our approach to diagnostics to support the move towards personalised medicine
Vision – personalised medicine
Imaging Biochemical &
biomarker data
Tissue
samples
Physiological tests
Genomic sequence data
Multi-omics information
Eg metabolomics, epigenetics
Clinical, population, social,
economic data
Individualised
and integrated
diagnostic and
clinical
phenotype at
one point in
time and over
time
Leading to the best use
of medicines,
supporting better
patient outcomes and
efficiencies
www.england.nhs.uk 7
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 8
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
Test Actions to ensure delivery
CT Ensure weekend capacity meets weekend demand.
Microbiology None required, although be aware of new acute micro tests becoming available
in next few years to help reduce AMR.
Ultrasound Training and recruitment of more sonographers, and in some specialties such as
obstetrics and gynaecology, skill-sharing with other related acute professions.
Echocardiography 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.
Upper GI
endoscopy
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).
MRI Provide clarification for the survey of indications and encourage networked
provision (usually patient can travel by ambulance if necessary).
Haematology,
biochemistry
All basic acute tests already available. No action required.
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
www.england.nhs.uk
Cancer Diagnostics
10
• 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
Future models of Service Delivery;
What is the future for diagnostics?
11
FUTURE
DIAGNOSTIC
PROVISION
At home or in the
High Street
Tele-monitoring
of individuals
Local Diagnostic
Hubs
Tertiary Care
Tele-reporting & image/ data
sharing
Specialist Diagnostic
Centres
24/7 & 7day
www.england.nhs.uk
Emerging areas of focus
12
• 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
NCD wider role
13
• 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 14
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 May 2017§ 15
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.
Digital Imaging Data
www.england.nhs.uk May 2017 16
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 Ultrasound activity by number of
days from date of test request to
date of test, by source of referral,
2015-16
Average period
from date of test to
date test report
issued for Chest X-
ray, by provider,
2015-16
X-ray Ultrasound CT Scan MRI Fluoro-scopy
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
NHS Imaging by gender and age, 2015-16
Digital Imaging Dataset
www.england.nhs.uk May 2017 17
Diagnostic performance
0.7%
1.0%
0.3%
0.3%
0.1%
1.2%
2.5%
1.9%
0.8%
2.3%
8.6%
3.1%
2.8%
4.5%
2.2%
0% 3% 5% 8% 10%
MRI
CT
US
Barium Enema
Dexa Scan
Audiology…
Echocardiogra…
Electrophysiol…
Peripheral…
Sleep Studies
Urodynamics
Colonoscopy
Flexi-…
Cystoscopy
Gastroscopy
0.5%
2.0%
2.9%
Total Imaging
Total…
Total Endoscopy
Current Performance
Figure 1: Current performance of diagnostic tests
against the 1% standard – breakdown of tests
0%
1%
2%
3%
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Diagnostic Performance
Standard 2015/16 2016/17
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 2: Overall current performance of
diagnostic tests against the 1% standard
www.england.nhs.uk 18
Waiting lists
750,000
800,000
850,000
900,000
950,000
Ap
r
Ma
y
Ju
n
Ju
l
Au
g
Se
pt
Oct
No
v
De
c
Ja
n
Feb
Ma
r
Total Waiting List
2015/16 2016/17
• 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
• 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
19
The transformative power of
technology
www.england.nhs.uk
Key messages
20
• 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