A need for diagnostic medicine specialists in primary care

Pathology laboratories across the UK are in a state of upheaval. Ever since the publication of the Carter report there has been pressure to remove costs from laboratory medicine. The debate is polarised – on one side a group of ‘modernisers’ who look at the unit cost of pathology, note the disparity with benchmark costs on a range of national or international comparisons, and project savings from reorganising and consolidating existing services. On the other side is a group who emphasise the hidden costs of pathology that are often not taken into account in unit cost analyses, point to low total pathology costs in the UK, and strive to protect the status quo of local laboratories linked to local hospitals.

This debate somewhat misses the point – both sides are effectively arguing over the same data - how to minimise unit costs. Although quality is often thrown into the mix, it is at a rather low level of laboratory accreditation, or via the rather poorly defined concept of patient safety. There is, however, a clear opportunity to use this crisis in pathology to reinvent the specialty as one that is fit for the 21st century.
What are the challenges facing modern healthcare? Management of a rapidly growing population living with long term conditions and support of the frail elderly are the two issues that feature at the top of most commissioners lists. How does diagnostic medicine currently support these? For LTC, we tend to provide a reactive service. Order sets from different practices may be wildly different. Every unnecessary test adds to workload and generates the risk of iatrogenic harm. This leads to an additional workload that sits on top of a system that is already under strain. The problem is even worse when one considers how the laboratory supports the frail elderly in the community. There is enormous variation in how clinicians use tests to support their management – this must go beyond the personal preference of individual clinicians, and represents a real quality issue that must be addressed. It is no longer sufficient for laboratories to blindly accept these requests without understanding the behaviours and beliefs that sit behind requesting patterns.

Over the last couple of decades pharmacy has seen similar upheavals, with the role of the traditional pharmacist disappearing in the community. A few far sighted pharmacists realised that they sat in a privileged position to provide a degree of governance to prescribers. They could monitor prescribing patterns, challenge variance, introduce best practice, and control costs. These small teams have now grown substantially as their worth is recognised. GPs highly value this specialist input embedded into their practice, and this is now an accepted part of all practice governance. The parallels with diagnostic medicine are obvious. We can see variation in requesting patterns, and knowledge of diagnostic best practice is a highly valued skill. The increasing recognition that testing adds to workload is now a major driver for most practices to get on top of their laboratory usage. It is not clear whether current laboratory staff have the skills to provide this service, but there is almost certainly something to be learned from talking with pharmacists about their experiences.