The media recently highlighted the fact that NHS England has announced:
“The NHS is set to radically overhaul the way MRI, CT and other diagnostic services are delivered for patients . . . . Community diagnostic hubs or ‘one stop shops’ should be created across the country, away from hospitals, so that patients can receive life-saving checks close to their homes. The centres could be set up in free space on the high street or retail parks.”
“The need for reform of NHS diagnostics was recognised in the Long Term Plan” – so begins the recent report by Professor Sir Mike Richards, ‘Diagnostics. Recovery and Renewal’.
The key recommendations are:
- Acute and elective diagnostics should be separated wherever possible to increase efficiency.
- Acute diagnostic services (for A&E and inpatient care) should be improved so that patients who require CT scanning or ultrasound from A&E can be imaged without delay. Inpatients needing CT or MRI should be able to be scanned on the day of request.
- Community diagnostic hubs should be established away from acute hospital sites and kept as clear of Covid-19 as possible.
- Diagnostic services should be organised so that as far as possible patients only have to attend once and, where appropriate, they should be tested for Covid-19 before diagnostic tests are undertaken.
- Community phlebotomy services should be improved, so that all patients can have blood samples taken close to their homes, at least six days a week, without needing to come to acute hospitals.
Motherhood and apple pie
On the surface of it, these are laudable aims that have been welcomed by hospital bosses. The COVID-19 pandemic has had a devastating effect on management of non-covid conditions with, for example, a 75% reduction in cancer referrals and a reduction in 210,000 imaging procedures each week. Before the pandemic there were 30,000 patients who had waited longer than 6 weeks for a diagnostic test, a figure that has now increased to 580,000. Urgent consideration must be given both to how the NHS is put back on its feet and how it addresses the huge backlog of problems as well as the ongoing pandemic. There is logic in separating acute and non-acute service provision into covid and covid free areas, and who could object to patients having convenient and rapid access to the best available technology? This does of course depend on many factors, not least having an efficient coronavirus testing system at some point in the future, but raises other crucial issues.
Where will the staff be found?
The plan as set out requires the recruitment of around 11,000 staff including 2000 radiologists, 500 Advanced Practitioner radiographers, 3,500 radiographers, 2,500 assistant practitioners, 2,670 administrative staff and 220 physicists. Bear in mind the current staffing crisis on the NHS, with around 140,000 vacancies across the board exacerbated by low pay and workplace stress. Cancer Research estimated that staff would need to double by 2027 to meet demand, with one in ten posts in diagnostics unfilled at the start of the pandemic. Furthermore, massive investment in equipment will be needed. The report points out that in relation to the 20 other countries making up the Organisation for Economic Cooperation and Development, the UK ranks bottom for CT and 3rd from last for MRI scanners. The Clinical Imaging Board claims that nearly 30 per cent of the UK’s MRI stock is at least ten years old, with no replacement plans for almost 40 per cent of systems more than seven years old.
All that’s left to find – money and staff
The last settlement for the NHS was £20.5 bn, which over a five year period amounted to an annual increase in budget of 3.4%. This did not include funding for training and employing the staff of the future. Most commentators thought a minimum 4% increase in funding was needed, and the Office for Budget Responsibility put the figure at 4.3% in order to meet increasing demand. COVID-19 has now blown all these estimates out of the water with the additional costs of restarting and sustaining the service, dealing with COVID-19 long term and developing and implementing a workforce transformation.
Private sector – the spectre lurking in the wings
In Simon Stevens’s letter to health care providers in July this year, he mandated:
“Ensuring that sufficient diagnostic capacity is in place in Covid19-secure environments, including through the use of independent sector facilities, and the development of Community Diagnostic Hubs and Rapid Diagnostic Centres”.
As pointed out in The Lowdown in a comment on diagnostic hubs:
“References . . . to high street and retail park sites are possibly of no real concern – perhaps they’re more about exploiting cheap-to-rent locations during the pandemic-driven economic recession than a push to link-up with high-profile brand sponsors – but the well-established presence of private sector interests operating in the diagnostic and pathology arena suggests there may be rich pickings on offer somewhere in the hub programme, if only until the backlog is cleared”.
In fact the privatisation of diagnostic and laboratory facilities is already well underway. There is no comfort here in Professor Richard’s report which even cites as a case study:
“The East Midlands Radiology Consortium (EMRAD) was launched in 2013 to create a common digital radiology system. Pioneering work led to the development of a Cloud-based image-sharing system through which the seven NHS trusts involved in the partnership could share diagnostic images, such as X-rays and scans. In 2018, EMRAD formed a partnership with two UK-based AI companies, Faculty and Kheiron Medical, to help develop and test AI tools in the breast cancer screening programme in the East Midlands.”
There is no mention of the fact that EMRAD paid £30m for the picture archiving and communication system from GE Healthcare but refused to pay full service costs until GE sorted out chronic problems causing a dangerous backlog of CT and MRI images.
Like many of the aspirational service developments contained within the Long Term Plan, ‘one stop shops’ could offer real value to patients. As the report by Professor Richards recognises:
“These new services will require major investment in facilities, equipment and workforce, alongside replacement of obsolete equipment. Training of additional highly skilled staff will take time but should start as soon as possible. International recruitment should be prioritized.”
This is no small ask and needs to be part of a generous new funding settlement for the NHS by government. This should be an investment in the NHS as a public service rather than a source of rich pickings for private companies.
This article was written by John Puntis for Keep Our NHS Public