For NHS commissioners and providers alike it might feel like there’s insatiable public demand for diagnostic tests and the related outpatient consultations – and that costs are spiralling out of control.
But rather than limitless demand or over-referral for scans, the underlying issue for the UK is an under supply of the most common of these, the MRI (magnetic resonance imaging), used to look at the structure of the joints and soft tissues. In providing 34 scans per 1,000 of population, England lags behind other developed countries such as France (> 45 per 1,000), Belgium (>50), Greece (>95), and, despite the huge improvements in provision by the NHS since 2005, demand is continually outstripping supply.
Estimates of demand vary greatly depending on their source. A survey of strategic health authorities puts demand for MRI tests at 35 per 1,000 while consultant radiologists estimated clinical need to be at 70-90 per 1,000.
Whichever picture you believe, the fact is that demand is going to continue to rise. As the population profile ages, more tests are needed. Advances in hardware, software, research and medical evidence have turned the MRI into the preferred diagnostic test for an increasing list of symptoms and conditions. More groups of professionals, consultants and GPs are receiving MRI training and making use of their knowledge.
The abolition of Care Quality Commission targets on waiting lists means that attention has shifted away from the problem of a growing backlog. None of these developments in themselves is a problem – but the subsequent issue of cost certainly is.
Solutions are needed that will fit the current magic formula for the public sector: increased services at higher levels of quality and at lower cost. Without them, there is the potential for a return to the waiting list scandals of five years ago, and more importantly, many more patients with serious, undiagnosed and untreated conditions.
One of the answers would be to give direct access to diagnostics to GPs, another would be to make full use of existing capacity. Setting up GP direct access pathways will cut the need for an initial consultation at the outpatient clinic. A hospital outpatient appointment would then only be required if specialist management is needed. On the traditional pathway, four separate appointments are typically needed before reaching a confirmed diagnosis.
Evidence from work by InHealth in London has shown in practical terms that patients benefit from far fewer steps from referral to diagnosis; commissioners can benefit from around a 20% reduction in the cost of referral to diagnosis; acute trusts benefit from reduced pressure of demand on their MRI resources and outpatient consultations, leading to better service for patients.
There have been concerns among primary care trust commissioners that direct access for GPs leads to over referring. This isn't borne out by a clinical audit of a randomly selected sample of cases which shows 79% of MRI results were abnormal – suggesting a high level of appropriateness of referrals by GPs. Nearly half (45%) of patients went on to GP management subsequent to the MRI test – suggesting a significant reduction in both initial and follow-up consultations required at outpatient clinics.
Another answer lies in dealing with the major capacity issues. For many it is the availability of staff budget that defines equipment utilisation. Otherwise MRI scanners can and should be operational at least 12 continuous hours per day, seven days per week, 50 weeks per year, and performing on average 7,500 MRI tests – compared with a current average of 4,941. But there’s no need for acute trusts to be running imaging departments at only half their potential capacity – better management will deliver increased volumes.
Commissioners must demand transformational change from their providers, and now. That way, the looming waiting time problem can be dealt with. By making these demands now, waiting times will not have to grow, availability increases and the lower unit costs have the potential to grow into significant efficiency savings.
Patrick Carter is director of strategy at InHealth, which provides diagnostic and imaging services
