The Kings Fund on Better Value and Pathology Optimisation

For a number of years here in North Devon we have been working towards creation of a pathology optimisation capability. This will have the remit of working across patient pathways to improve the way we use diagnostic tests, from the decision to do the test all the way through to the way that results inform management. We have borrowed heavily from the thinking and structure behind Devon's medicines optimisation team, in which pharmacists help ensure that medicines are used to maximum effect. They aim to balance costs and benefits at all levels across the health system - from individual patient prescribing situations, to prescribing policy and formulary support.

So it is exciting that tomorrow we will launch a new pathway for DVT management in primary care, which has been arrived at through close collaborative working between pathology, pharmacy, physicians and primary care. And even more excitingly, we will also introduce the new optimisation team, which consists of two of our North Devon biomedical scientists, a pathologist, a GP, a GP trainee, and a public health doctor. We have also secured funding for link GPs in all practices who will work with the optimising team to a) understand demand b) study the gaps between demand and delivery and c) work towards closing this gap.

It is sometimes a little disconcerting to be doing things that few others see as possible. Although we have heard many good things about the work we have been doing, few others seem to be trying to replicate it. So it is reassuring to read the recently released Kings Fund report "Better Value In the NHS." This document is a call to arms for clinicians to lead the way on improving value in the NHS, and sees this as the way to ensure the future sustainability of the service. Many of the things it calls for are in our Pathology Optimisation service.

1. We need to tackle overuse and underuse of services. This is optimisation. Overuse, in particular, is hugely expensive. We have seen that this is not just financial, but also through opportunity cost. And in services that are stretched, where demand exceeds capacity (and this is almost everywhere, but particularly in primary care) it is this opportunity cost that is slowly killing the sort of healthcare that people actually want. The use of diagnostics has skyrocketed over the last decade. This has been associated with negligible benefits (as we have posted previously) but considerable harms, some physical, some mental. 5% of test results lie outside reference ranges. We have seen how this leads to activity that is usually of no benefit to patients, but that sucks the lifeblood from the NHS.

2. Teams delivering better care. We cannot design services in isolation. This is a traditional problem for pathology, which produces highly accurate results, but often throws up its hands in despair when asked to consider whether the tests were actually appropriate or results acted on appropiately. "These are not things we can control." "The standard of education these days is just not what it was." But we have shown that we can act on the pre- and post - analytical pathways; and that the only way to do this is through close engagement with all stakeholders, with the purpose of the pathway, as defined by the citizen through their stories, as the compass which keeps us on track.

Our latest work, on the DVT pathway, was blocked by silo thinking. We could see no way to get an urgent D-dimer test performed in primary care. We could see no way of dealing with anticoagulation in low risk (below knee) potential DVTs if an ultrasound was not available immediately. And yet we heard the patient stories of care that did not seem to care - patients shunted around the system being treated in ways that were certainly sub-optimal at best (such as having to travel 40 miles to have a blood thinning injection that was not actually necessary).

These problems were unblocked when we got together as a team and understood the problems from others' perspectives, challenging the limits of what was possible. For our pathway, the key enablers came when the laboratory showed that a D-dimer was stable in a refrigerated citrated blood for 24 hours; and the physicians said it was safe to wait 24 hours before making a treatment decision on a low risk (below knee) DVT. We must not be complacent that we have 'got it right', and the optimisation team will be important players in embedding this pathway into practice, and monitoring its efficacy.

I will leave the last words to the Kings Fund, :

"The challenge facing the NHS over the coming years is fundamentally about improving value rather than reducing costs. Framing the debate in these terms emphasises the role of quality and outcomes in meeting the challenges facing the health system, as well as providing the right language to engage clinicians and frontline staff in making change happen."

Pathology supporting chronic disease management: It's not all about the numbers!

I like numbers and I like words and stories, and I like them both the same.

The drive to prove the good practice of medicine through numbers and targets has almost lost us the art of words and stories. We can’t measure the healing powers of words; does this mean they don’t count?

Pathology can provide us with a number. We can make sure we test for that number and ensure that we move that number to target. Here we have someone with ischaemic heart disease; they have a cholesterol of 3, that’s great! That’s well in target. But what’s the story?

The story is not the story we think, and it starts from the very outset. When we started talking to patients about their annual chronic disease reviews, we found this....

Patients are called into their GP practice to have their annual heart disease monitoring review. They are asked to make an appointment for a blood test. No-one has told them what blood tests they will have done. They have their bloods taken. ‘I had loads of bloods taken’, ‘they test for everything don’t they?’, ‘I think they even pick up cancer’

Patients aren't really sure what the blood tests are for, and they start making up their own stories....

Not knowing what the bloods are for, or what they mean, creates stories that can make their health worse; or distract them from important health issues.... ‘My cholesterol is 3, that means my fat is good doesn't it?That means I don’t need to lose any weight...’

For pathology, ensuring that a number leads to good conversations and good stories that can help patients on the path to good health is as important as generating a correct and accurate number.

Supporting patients to know what blood tests they are having. Supporting patients to understand what the blood tests are for and the meaning of the result starts the story off on the right footing. And if the story starts off on the right footing, everything downstream has a chance of success. What chance is there of supporting a patient to lose weight, when their cholesterol is so good!

Supporting users to consent patients for blood tests every time: What test? Why? What it could mean? What it does mean. Supporting users to embed this into written information at annual review- recall letters, consent and reporting.

Stories count as much as numbers.