Insight

Overcoming the barriers to developing future-ready community diagnostic services

Even before the pandemic began, demand for diagnostic services of all types were rising and, in some cases, outstripping capacity. Covid-19 has exacerbated this problem, deepening the diagnostic backlog with knock-on effects for cancer and elective care.

However, it has also demonstrated what is possible. Seemingly complex changes were implemented at a pace not seen before, transforming services within a matter of weeks to ensure they continued during lockdowns, whilst incorporating Covid-minimisation measures.

Although the challenge of catching up with the diagnostic backlog is a steep one, it presents similar opportunities to deliver much-needed long-term change in diagnostic services.

Reshaping diagnostics for the new normal

The challenges created by Covid-19 are ongoing and require new and sustainable solutions. Standard diagnostic pathways have remained the same for many years, despite the fact they are often inefficient both for the NHS and its patients.

But the drive to develop a system that harnesses new ways of working and new technology has already begun. This includes more than 40 new community diagnostic centres that are currently being rolled out by NHS England and set to provide around 2.8m scans in their first full year of operation. Situated in a range of settings from local shopping centres to football stadiums, they are designed to give patients more direct access to the full range of diagnostic tests closer to home.

Crucial to the success of many of these initiatives, will be the relationship between the community and acute services. The transition to integrated care systems (ICS) will help to create this, but a truly interconnected system will still require wider change.

An independent review of diagnostics services for NHS England recently outlined the key components of a new service delivery model. This article explores some of its recommendations and the barriers Trusts need to overcome to achieve them.

What could the future of community diagnostic services look like?

There are three key models to transforming community diagnostic services.

Optimal care pathways

Building on established pathways through existing community support, such as pharmacists, opticians, and phlebotomy services, is one model of delivery that realises the benefits of a greater separation of acute and elective diagnostics.

This provides patients with quicker and more convenient access to care closer to home or work, whilst relieving pressure on acute sites. Telephone and virtual consultations are also expected to play a much larger role in diagnostic services in the near future.

Optimising these established pathways brings a range of challenges which Trusts need to consider, including:

  • Financial arrangements – Ensuring the commercial arrangements are cost-effective and attractive for the commissioner and the service provider, is important in order for services to run smoothly. A comprehensive activity forecast and tested commercial model is critical.
  • Care boundaries – Optimising care pathways should involve eliminating the boundaries that still exist in the care system. The transition to an ICS model will play a key role here. As will an effective commercial arrangement that gives the patient true flexibility and choice on where they receive their care in the community.
  • Collaborative working – Integrated care requires collaboration on all fronts. Often parity of esteem or an assumption of vested interest builds barriers between professionals. Ensuring clinical professionals are engaged and introduced at an early stage will help alleviate this.
  • Public perception – With the introduction of any new service model, comes the requirement for change management. Fear of a patient backlash often deters Trusts from doing this, but regular patient engagement and feedback is vital.
  • Social value – An area of increasing priority, the service provider should demonstrate how they will aid recovery of the local community and economy through employment and training, as well as community support.

Community diagnostic hubs

There is an opportunity to develop new diagnostic service models outside the existing Healthcare landscape that are more responsive and innovative, such as community (or remote) diagnostic hubs (CDHs).

They provide a one-stop shop for patients requiring potentially life-saving diagnostic tests closer to home. As noted earlier, centres that deliver this kind of service are already being rolled out and have begun combatting the impacts of Covid-19.

Their numbers and the services they offer are set to grow over the next five years in a bid to reduce the pressure on acute care. In the near term, non-invasive diagnostics are the most viable, but with developments in technology and practice, there will be an increase in more time-consuming, invasive diagnostics in the community.

As part of this initiative, Akeso supported leading specialist Trusts to implement CDHs. There are several key challenges to consider during this process to ensure a successful implementation:

  • Strategic vision and scope – Fully define the strategic objectives for the hub before implementation. This will inform the scope and operating model as well as support timely decision making and evaluation.
  • Patient need – Identify who the hub’s patients will be and what their needs are. Every aspect of the service model and patient pathway must be built around this.
  • Project management office (PMO) – Robust planning from the outset is critical to the success of the project implementation. With involvement from multiple stakeholders, capturing dependencies at each stage will not only ensure the Project is delivered on budget, but also prevent surprises further down the line.
  • Resourcing – Identify and engage with the right people early on. Collaborating with clinical and operational people across the organisation, who have the right expertise and experience to implement a new service model will avoid potential setbacks.
  • Capacity modelling – Model patient activity across the whole patient pathway. Capacity within the CDH must align with the Trust’s internal capacity. This may be dependent on the capacity to book patients’ assessments and follow-up consultations.
  • Service resilience – In light of Covid-19 ensure the safety of patients and service resilience by reviewing patient flow and infection control.

New diagnostic technologies

Innovation is advancing rapidly in areas such as genomic testing, point-of-care testing and the use of artificial intelligence for imaging, endoscopy, and wearable devices. These have the potential to transform the service diagnostic hubs can offer.

Historically Healthcare providers have been slow to adopt new technological innovations. That is why it is important to explore the most effective way to introduce them. Here are some considerations to bear in mind:

  • Clinician uptake – Clinicians need to be encouraged to trust the integrity of new technology and move away from established processes.
  • Patient awareness – Patients must be supported to understand and adopt new technology. Striking the right balance between a face-to-face and digital service is vital.
  • System interoperability – New systems and equipment will need to exchange information seamlessly. Clinical data comes in a variety of formats and terminology, which means standardised catalogues will need to be developed for complete interoperability.
  • Safety – Safeguards must be put in place to ensure data compliance, and Healthcare workers are given the time and knowledge to implement them.

Combining these elements will create community diagnostics services that can rise to the challenges created by the pandemic, while also improving patient care.

By considering the key factors mentioned here at the outset, Trusts will be able to successfully implement and operate each element successfully.

As experts in delivering high quality solutions to the Healthcare sector, Akeso has a track record of supporting Trusts to do this in a way that develops the effective diagnostic services of tomorrow. To find out what we offer, get in touch at enquiries@akeso.co.uk

Contact our experts

Chris Robson

Chris Robson

Managing Director
Case studies – newspapers
Case Study

Optometry / Ophthalmology Digitalisation PMO

Akeso were engaged by a London ICS to provide programme management expertise for a NHSx national pilot programme supporting the delivery of an Electronic Eyecare Referral System between community optometry and secondary care ophthalmology

INSIGHT

The Electronic Eyecare Referral System (EeRS) pilot, jointly commissioned by NHS England and NHS Improvement and NHSx in November 2020 was a pilot programme that sought to achieve:

  • Electronic referral management between primary and secondary care
  • The ability to share complex diagnostic images (e.g., Optical Coherence Tomography Scan (OCT scan)

ACTIONS

With EeRS being procured and managed on a regional basis, Akeso were engaged by a London ICS to support the roll-out of EeRS within the region.

Responsible for Programme Management, Akeso were responsible for end-to-end programme implementation accountable to the Programme Board and reporting back into NHSx.z

The Akeso project team were responsible for maintaining oversight of the budget, supplier and contract compliance, and working with a diverse stakeholder group from independent, private and NHS sectors.

With 6 workstreams including Information Governance, Communications, Clinical Safety, Digital Integration, Commissioning and Evaluation, Akeso ensured the project progressed to timeline, with the London region being a national exemplar, with the highest level of optometry engagement as well as being first-movers in implementing a technical integration into secondary care and resolving IG issues.

RESULTS

Owing to Akeso’s programme management support, the proof-of-concept EeRS programme in London was successfully evaluated at the end of Year 1, with a board decision to continue the programme.

The Akeso team facilitated an efficient project roll-off following a short-term extension into Year 2, with the Programme Management moving into BAU activity.

Contact our experts

Olivia Jeffery

Olivia Jeffery

Manager
Insight

Discharge to Assess: Where the rubber hits the road

There are seven key steps to generating traction and improving the discharge-to-assess pathways. These are a mix of technical development in respect of discharge-to-assess (such as the establishment of agreed patient strata) and the generic challenges of change management (such as engagement, communication, and skills building). The first 3 phases (which are the planning phases) will be broadly sequential but the delivery phases can be run in parallel, as the figure below indicates:

  1. Establish a core guiding coalition: build a small group with representation from the acute, community, and social care teams who will act as the core accountable team.  This team will guide the program to ensure time and resources are well spent.
  2. Understand where you are and why, in order to build the local case for change, including:
    1. Maturity model completion:  complete the self-assessment complete the self-assessment of the Akeso discharge-to-assess maturity model to show where the current system is already fit-for-purpose and where changes need to be made
    2. Internal analysis on “no right to reside” and other key metrics (such as risk adjected length of stay, and elective and cancer waitlist variation) to give additional local relevance
  3. Define the overall model of discharge-to-assess which best suits your location, given the NHS England guidance, known exemplar case studies, and the results from the maturity assessment, including:
    1. Patient stratification: be clear on which patients fall under the category of relevant for discharge-to-assess and how/when they are highlighted
    2. Workforce models: with community and social care partners, develop a sustainable workforce model which meets local population health needs and is achievable with local resources
    3. High-level process: agree what the high-level discharge-to-assess process is which balances discharge efficacy with clinical risk
    4. Technology aspirations: be clear on where technology will help (with both current and potential future systems)
  4. Launch the program of change: take the time to engage with a broad range of stakeholders to lay out the overall aims of the discharge-to-assess program and how it contributes to the aims of the organisation, including:
    1. Vision expected outcomes, and expected timelines: establish what success looks like from an outcome perspective (for example, number of patients remaining in the acute setting with no right to reside; 7-day re-admission rate
    2. Leadership team & resource: ensure that there is sufficient resource ring-fenced to deliver and manage the work, and that senior leaders are actively supportive
    3. Govern and track effectively: embed discharge-to-assess governance within the existing board and directorate mechanisms to ensure its visibility
    4. Communicate plans and progress
      Healthcare team working
    5. Establish portfolio of work: the maturity matrix and case study examples will suggest a wide range of work to be done. It’s important that any portfolio and phasing is chosen which reflects the need and resources available, including:
      1. Pilot and refine: choose 1-2 specific patient groups or services on which to pilot the design where there is both a clear need and support for discharge-to-assess; learn from these pilots and moderate the initial designs as necessary and remember that “getting it right first time” doesn’t apply in this situation! Learning and adapting is part of the process. To aid this, you may want to instigate regular learning cycles (such as Plan-Do-Study-Act) and daily management meetings
      2. Embed and roll-out: broaden the scope of patients and services for whom discharge-to-assess is available, building on the learnings from the pilots (in 1 or 2 further phases)
      3. Business case development: when investment is necessary, put together a robust business case (using recognised approaches such as the HM Treasury 5-case model)N.B. when engaging in technology-driven change, it is very important to ensure that practices are “digital-ready” before they become digitised so take the time to improve ways of working before the technology is available. It is value destroying to embed poor current practice within a new system. Many organisations, therefore, go through two phases of transformation: pre-tech and post-tech availability
    6. Train, support and reward those involved in delivering this new way of working. The pilots will establish local standard methods and learnings. These should be documented and shared with groups involved in subsequent phases of roll-out. The pioneers who drive the change should be given the reward and profile that it deserves.
    7. Communication progress, learnings, and successes, including regular broad updates and particular highlights. Appreciation of the efforts of everyone involved could be included within monthly and annual recognition systems. 

Keeping people healthy and returning them to their usual home after a hospital spell is a key ambition for all those involved in health and social care. There is an even greater imperative to do so given the pressures on the system now (be they workforce, elective backlog or capacity constraints). Discharge-to-assess, enabled by technology is one of the ways in which we can work together to ease this problem. Many organisations are already making this work. We hope that these four articles can encourage more progress for the benefit of citizens and health and social care workers alike.

For a free Discharge-to-assess consultation, please contact us for an initial conversation with our consultants.