Dr Michael Joffe
A commissioner-based national study of the fifteen key diagnostic tests published by the Department of Health in the United Kingdom on the 18 April 2007 indicate that there are currently 733,273 patients waiting for diagnostics with 141,000 waiting greater than thirteen weeks. The underlying causes for the increased waiting times are mainly due to the increased demand associated with the under-utilised resources within the NHS that provide these services. Adherence to NICE (National Institute for Health and Clinical Excellence) guidelines, together with the eighteen week target for treatment, have only increased the demand for diagnostics to be carried out within a structured time frame. Increasingly, the NHS is utilising external services to help meet this target.
Budgetary constraints, equipment availability or availability of professional and/or administrative staff all contribute to diminished provision within the NHS. To achieve the target of eighteen weeks, for example, there is a need for fifty MRI scans per thousand of the population to be performed, as opposed to the current figure of seventeen per thousand, which is soon to be bolstered by the second wave procurement from the independent sector to twenty three per thousand of the population per annum. The NHS is not as yet gearing up to meet this target.
What are the Government Doing?
The government has acknowledged the growing waiting lists and, in June 2004, the first wave of procurement was awarded to Alliance Medical, which won a £95million, five-year contract to provide and operate twelve mobile MRI scanners for the NHS. Following the first wave implementation and initiation, the government sent out to tender the second wave procurement, which launched in March 2005 to provide the NHS with an additional two million diagnostic procedures per year.
The department of health have implemented additional measures within the NHS to try to cut waiting lists, including:
• Improving efficiency within existing NHS units by cross-fertilising best practices and publishing guidelines for diagnostic departments. (www.radiologyimprovement.nhs.uk/View.aspx?page=/default.html)
• Encouraging appropriate direct referrals from GPs and allied health professionals, thereby speeding patient journey and saving the cost of unnecessary secondary/ specialist consultations.
• Enabling patients to choose between all available NHS facilities rather than just those within the patient’s geographic area.
Advantages of Outsourcing
There are clear advantages to be gained from outsourcing to the independent sector.
• Decreased waiting times naturally help the eighteen week target to be met.
• Mobile services enable patients in remote areas to access diagnostic treatment.
• Bulk negotiation in the private sector decreases the tariff for diagnostic services.
• Rapid access to diagnostic services improves clinical productivity in other areas of the NHS.
• The construction of new facilities, designed around the clinical flow of patients, also ensures greater productivity.
• The inclusion of independent sector providers means patient choice is widened, which will lead to a more responsive patient-centred service. Patient choice will, in turn, improve the productivity of existing NHS services, with the competitive challenge forcing existing providers to re-examine their processes to perform better than the new providers.
Regulating the Independent Sector
As patient safety is of paramount importance, the procurement process for diagnostics has also ensured adherence to the standards as set out by the recommendations of the Royal College of Radiology, the Medicines and Health Products Regulatory Agency, the department of health and the Healthcare Commission. The latter is currently in the process of determining its role in encompassing diagnostic radiological services under its auspices.
Lessons learnt from the first wave procurement have resulted in compliance with strict clinical governance, which encompasses stringent reporting policies (double reporting) and clinical audits. The independent sector contracts require collection and reporting on a wide range of performance indicators, which will undergo monthly assessment and annual publication. This naturally ensures a rapid recognition of, and immediate solutions to, any identified problems.
The development of independent sector clinical sites, concentrating on a single modality, ensures increased productivity, as well as assuring clinical excellence both in the hardware purchased and the quality of the reporting radiologist. The utilisation of UK-based radiography staff, with ties to academic centres both inside and outside the NHS, ensures a high standard of service provision.
In the table below it is clearly noted that, in keeping with technical development, there has been an incremental increase in the number of examinations taking place since 1995. However, the increase has been mainly due to a greater demand for CT and MRI scans. Although significant numbers of diagnostic scans are to be allocated to the independent sector, the NHS will still be doing the majority of the diagnostics.
Second wave procurement will bring some of the diagnostic modalities in line with the NHS eighteen week target. There will still be some shortfall, most probably in MRI provision and in PET/CT. There is also to be an expected growth in demand for diagnostics in the UK market as technological and medical advances progress. The growth may be gradual but alternatively, it may step up acutely if there is concurrent rapid technological or medical research development. As single modality centres hone their patient end-to-end process and start to provide significant throughput of cases, they will be able to reduce unit costs of diagnostics. The independent sector should become integral in the patient process and in patient choice and thus will ensure cost-effective high quality examinations, which will naturally lead to decreased patient morbidity.