Pathology services in England are still working through the changes triggered by the Carter Review in 2016. Since it was published, NHS Improvement has been working with the 105 hospitals that provide pathology services to create 29 networks.
In an update to the conference at The Belfry, Andrea Clark, NHS Improvement’s regional diagnostics lead for the Midlands and East, said five are now “working at the scale that we envisaged” while others are “working, but with some hospitals still to come on board”.
However, some networks are small, and in response to questions she said their number may reduce “organically” over time. She also urged her audience to remember why they were being set up: not just to deliver savings but to “create sustainable services” in the face of “staff difficulties” and “demand challenges”.
In another presentation, Dr Rachael Liebmann, a vice president of The Royal College of Pathologists, laid out the sheer scale of those “staff difficulties” by discussing a survey it had conducted. It found that just 3% of histopathology departments are fully staffed with consultants, and almost half are using locums to meet demand or are sending work away for reporting.
Addressing variability with GIRFT
Another driver for change is Getting It Right First Time (GIRFT), a clinically-led programme to improve the quality and reduce the cost of hospital services by tackling unwarranted variation. Three joint clinical leads and a clinical advisor were appointed for the GIRFT review of pathology last March; one of them, Dr Marion Wood, told the conference that they had developed a “clean” framework for their work.
Hospitals have been sent a questionnaire that explores different aspects of “clean into the laboratory environment, clean through the laboratory environment, and clean back to the user of the service”; and a first, pilot visit to Frimley Health, part of Berkshire and Surrey Pathology Services, is about to take place.
Dr Wood said a programme of ‘deep dive’ visits to all laboratories/networks will explore the results of the questionnaire and draw up action plans starting in the autumn, with a national report next year. “We are collecting evidence because we want to show what good looks like, so that we can, with your help, make sure that everybody does that to help patients,” she said. “We also want to show, with your help, how important pathology is to clinical pathways and to almost every patient interaction.”
Data and standardisation
The evidence that the two programmes are looking for will mean a lot more work for pathology services. Andrea Clark outlined a ‘pathology quality assurance dashboard’ (PQAD) that has seven sections.
NHS England/Improvement is looking at collecting these data quarterly; yet the PQAD is going to make minimal use of previous national data collections, and differs from the GRIFT questionnaire; which is, at least, a one-off.
In response to questions about why both programmes needed new data collections, Dr Wood said GIRFT had looked at existing data “but we were not convinced that it told us what we needed to know”; while Andrea Clark said there were problems getting existing data into a consistent format for comparison.
More standardisation of IT systems or the data they hold would help to address the second issue. But, as conference delegates pointed out, the idea of a national catalogue for pathology tests has been discussed for years; and NHS Digital has made only limited progress on creating one. NHS England and NHS Improvement have recently issued a letter to all trust CEOs stating that all new IT systems purchased must support the SNOMED-CT nomenclature standard.
Will Smart, the NHS chief information officer, who was at the conference to give a keynote speech on digital health policy, urged delegates to come to the centre with solutions.
Smart digital policy
In his presentation, Smart outlined the role of NHSX, the new unit being set up to coordinate NHS IT policy and address a wide range of digital health issues, from standards to procurement to security. He told the conference that it was important because “it will bring IT decision-makers together” and create “a coherent view of what we want to do at the centre”. But he emphasised that it would not “reinvent the wheel” or set out to build new systems.
Instead, Smart said NHSX will be looking to build platforms and to agree and enforce standards that suppliers and innovators can use so that systems can interoperate with each other and data can flow around the service. This means the NHS is unlikely to undertake a national pathology procurement on the model of New South Wales in Australia, which has created a single, managed service supported by a single IT system. “I do not like central IT contracts because, necessarily, as soon as I buy something for you, you will say ‘that is not what I wanted’,” Smart said. Also, he added, it was important to have a “plural and competitive market” for systems of all kinds.
Working in partnership with pathology
At the start of the event, Michael Simpson, the chairman and chief executive of CliniSys Group, outlined some of his plans for moving the company and its culture forward. He outlined a set of values that he wants to see embodied in the company’s work, and promised a stronger focus on customers and on getting any issues that they had with their systems resolved quickly. He also promised investment in key systems, including ICE and WinPath Enterprise, the next-generation laboratory information system that has been built to support pathology networks.
“They (networks) are a big development. They are different. And we want to sit down with our big customers and talk about how we can help,” he said. “If you are not coming down the line until 2021–22, it should be a lot easier for you.”
Of course, networks are not the only change that pathology services are facing. Digital pathology is on the near-horizon, and Dr Liebmann told her audience that it was a change that pathology needed to embrace, if it was going to overcome that staff and demand challenge.
Artificial intelligence (AI) should also automate some tasks and help clinicians to work at the “top of their licence", she added, quoting Professor Geraint Rees from University College London, who has argued that “AI will not replace doctors, but doctors who use IT will replace doctors who do not”.
Adopting innovation: The challenge
Digital pathology has been slower to take-off than some predicted. Simpson argued that three reasons for this were the problems of storing the huge amounts of data generated by digitising slides, the additional time that it takes to prepare those slides, and the difficulties of sharing slide images.
“Picture archiving and communications (ie digital imaging in radiology) took off because people could share images,” he said. “We need to crack the same issue for digital pathology, and make sure you get the benefit out of that investment.”
The barriers to change are not just technical or financial, though. Jonathan Bloor, the medical director of System C Healthcare, and developer of its CareFlow Connect product, suggested that the uptake of innovation requires leadership, time, money, evidence and trust.
The ‘move fast and break things’ culture of Silicon Valley is, rightly, not the culture of healthcare, he pointed out; but sometimes the evidence bar for change can be set a lot higher than the evidence bar for doing things the way they have always been done.
Hype curves and pain cycles
Professor Jonathan Kay, the vice-chair of the Faculty of Clinical Informatics, used a slide of the Gartner hype cycle to show that some innovations move quite rapidly from expectation to dip to widespread uptake, while others do not.
Perhaps surprisingly, there are many virtual intensive care units around the world, in which very sick patients are monitored remotely. But there are remarkably few patient decision aids in use, despite press excitement about them; and some well-attested innovations, such as positive patient identification for blood transfusion, never make it out of their pilot organisations.
Both external factors (expert reports, national roll-out programmes, payment and incentive schemes) and human factors (interest, leadership, ownership) affect take-up, he suggested, and the policy-makers and practitioners need to work out which levers they need to pull.
In an entertaining presentation on the second day, Dr Nigel Oakes, Pathology Manager at Royal Cornwall Hospitals NHS Trust, backed this up when he used his own version of the cycle to explain how he had got local
GPs through the denial, shock, anger, fear and uncertainty, understanding and finally commitment and enthusiasm phases of a project to use CliniSys ICE for electronic requesting.
Frequent repetition of messages, frequent visits to surgeries (particularly those that were struggling), a quick response to any (and every) query or problem, and “the personal touch” were the keys to success, he explained; concluding that the project had been so successful that imaging now wants to use ICE.
Innovation: A challenge for networks?
Professor Rachel McKendry, from the London Centre for Nanotechnology and Division of Medicine, University College London, also stressed the need to overcome both technical and human challenges in an inspiring presentation about a project that it has been involved with piloting mHealth technologies for point-of-care testing for HIV in KwaZulu Natal, South Africa. The research programme called i-sense is exploring the use of mobile phone-connected rapid self-tests and online care pathways for fast access to treatments, without the need for a physical appointment with a doctor.
A range of challenges were highlighted, including the digital divide, data privacy challenges of shared phones, and the cost of data in low and middle-income countries. Yet some ‘pain points’ in UK pathology seem resistant to change (e.g. transport). With some frustration, Professor Kay pointed out that “our laboratories have all sorts of automated tracks, yet we cannot get a van to run twice a day with refrigeration in it”.
Or, results reporting. Getting test results back to the people who ordered them or need to see them remains a significant challenge. Addressing these issues, Professor Kay suggested it would take a combination of national pressure from regulators and commissioners, dissemination of good practice, and local champions who could actually take control of the problem.
Somewhat controversially, he wondered what role pathology networks would play. “Will the networks make things better or worse?” he mused. They are the big change underway in laboratory medicine at the moment: “but are they focused on innovation?”