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

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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,

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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

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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

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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

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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

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• 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

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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