Technological advances mean diagnostic services can move into community settings, say Lisa Hollins and colleagues.

Technological developments are opening up new possibilities for the way communities can access diagnostic services. The current model for diagnosis typically relies on the interaction between a GP and a hospital based consultant, who exchange referrals and information.

This model is being challenged by the need to provide a more integrated service coupled with a move towards more localised patient care. This has led to the consideration and development of community based diagnostic services.

There has been little research exploring the financial and clinical impact of locating diagnostic services outside of hospitals. A study by a team from University College London Hospitals Foundation Trust took an evidence based approach to reviewing the potential benefits of community based diagnostic services.

The study examined whether it would be financially and clinically viable to operate a new model of diagnosis and patient care, using a community based diagnostic testing centre.

The centre would use virtual reporting, linking information to the appropriate clinical setting for patient care, whether in a GP’s surgery, a community outreach clinic or a hospital.

This system would be supported by a network of named consultants and community based clinicians, covering all the professional groups involved in a particular community’s diagnostic and treatment pathways.

The proposed model for centres would allow for simple imaging modalities, such as X-ray and ultrasound, as well as non-imaging modalities like ambulatory ECG monitoring, including reporting capabilities for both. Centres would be staffed on rotas by the chosen tertiary provider to ensure adequate support and professional development.

Notes on the proposed model displayed top of page:

The patient would be referred by the GP to the diagnostic testing centre, where they would have their test performed by a member of staff appropriately trained for the specific test required – a radiographer or a healthcare science assistant. Reporting of tests would be carried out using virtual reporting links with an agreed provider. Once the test is reported, the patient may be referred by the GP to hospital for an outpatient appointment, referred to a community outreach clinic, or managed by the GP. The clinician network could be accessed at any point if the GP was uncertain or wished to consult with a specialist with regards to the most appropriate treatment plan.

The research looked at the feasibility of establishing four diagnostic “menus” for community based diagnostics: imaging, cardiology, respiratory and pathology, covering a mix of ultrasound, spirometry, ambulatory ECG and blood pressure, resting ECG and plain film X-ray.

The team looked at both the capital cost and IT infrastructure required to set up a centre in a chosen facility, whether bespoke or existing, coupled with a review of the recurrent costs that the service would incur, such as workforce, consumables, equipment maintenance and reporting.

The research had three stages:

  • the creation of an operational model for a new community diagnostic pathway;
  • the derivation of the associated financial model;
  • the review of the key assumptions about volume and the sensitivity of the operational model to variations, which involved the production of a “high” and “low” volume model.

The activity data used to underpin the assumptions on volume was based on a mix of historic evidence and estimated future GP requests. The financial model compared an estimation of current costs, based on Department of Health references, with the proposed bottom-up costs of the centres, which were calculated in collaboration with senior clinicians.

The findings indicated that the proposed diagnostic testing centre model could produce improvements in clinical quality, efficiency, access to diagnostic services and an improved patient experience (see table 1, below).

Table 1: Potential improvements

 Clinical quality gainEfficiency/access gainImproved patient experience
Diagnostic testing offered in thecommunity YesYes
Diagnostic testing co-located in one
facility
 YesYes
Tests carried out by appropriately
trained personnel
Yes  
Workforce provided on rotational
basis from partner provider
YesYes 
Improved turnaround of results
through virtual reporting
YesYesYes
Virtual access to raw data from all
diagnostic tests
 Yes 
Support for GPs to manage entire
pathways in primary care
YesYesYes
Improved community management of
long term conditions
YesYesYes
Reduced variation in healthcare
outcomes
YesYesYes

Cost savings

Based on the assumptions in table 2 (below) and assuming a region with activity driven by 50 GPs, the normal costs for current diagnostic models, when accounting for the modalities in the table, are approximately £2m per year. By comparison, the norm for the proposed model would cost around £500k per year less.

Table 2: Investment and capacity assumptions

ModalityEquipmentEnabling worksEstimated IT costsTotal CostsCapacity (per year)Assumptions
Plain film X-ray£150,000£100,000£20,000£270,0009,000-12,000253 working days per
year, operating 8 hours
per day, imaging 4-6
patients per hour
Ultrasound£150,000£10,000£20,000£180,0004,050253 working days per
year, operating 8 hours
per day with 2 patients
per hour
Spirometry£5,000 £1,000£6,0009,000253 working days per
year, operating 8 hours
per day with 4 patients
per hour
Ambulatory monitoring
(ECG)
£1,500
(1 monitor)
 £1,000£2,5002605 tests per week,
52 weeks per year
Ambulatory monitoring
(BP)
£1,500
(1 monitor)
 £1,000£2,500 5 tests per week,
52 weeks per year
Resting ECG£5,000 £1,000£6,000 253 working days per
year, operating 8 hours
per day with 4 patients
per hour

This disparity increases proportionally with the volume of GPs covered, so that diagnostic costs for a regional community covering 150 GPs would end up exceeding £6m per year with current practice, but just £4m per year with the proposed centre model.

Even allowing for variations in costs and volume of activity, the current diagnostic model only gets near to the cost-efficiencies of the proposed model in those areas that are in the bottom 5 per cent for costs; and only then on the assumption that the community based diagnostics are in the top 5 per cent for costs (see graph). The overall financial performance of community based diagnostics appears to be not only viable, but financially preferable compared with the existing model.

The overall conclusion of the research was that the proposed new model not only adds clinical value through improved access and support to patients and GPs,  but also its operational costs were significantly more cost-effective for most tests, particularly physiological measurement modalities where minimal up-front investment is required.

Specifically, the study discovered that the biggest cost-efficiencies could be found in community based spirometry, ambulatory blood pressure monitoring and resting ECG. The savings were less pronounced for ambulatory ECG and plain film X-ray. Having said this, there is some evidence to suggest that operating a plain film X-ray service may become more cost-efficient with greater volume.

For ultrasound specifically, it would be more expensive to operate in a community based structure.

Based on a region covering 150 GPs, the savings per tested modality associated with establishing a community based diagnostic testing centre, compared with the existing model, were calculated as shown in the box below:

Testing modalityPercentage saving (based on activity from 150 GPs)
Plain film X-Ray10
Ultrasound-7
Spirometry62
Ambulatory
monitoring
(ECG)
16
Ambulatory
monitoring
(BP)
58
Resting ECG56

Practical challenges

As with any study of this type, there are some limitations to consider. For example, the lack of centralised data on diagnostic testing as well as variations in GP request rates limits accuracy and the DH reference costs do not fully reflect actual spend.

Also, the indirect costs of transacting diagnostic requests, such as the administrative costs for handling them, are currently unclear and so reference costs are used as an approximate alternative.

There are also a number of practical challenges to overcome in order to establish community based diagnostic testing centres, such as planning of staff rotation and the cultural change needed to support what would represent a significant change to the way diagnostic services are both planned and accessed.

Other keys to success include establishing a centralised activity reporting system, establishing virtual reporting capabilities, and formalising the links between the various clinical partners.

However, despite these challenges, the testing modalities undertaken in the research suggest that, if enacted effectively and embraced culturally, community based diagnostic services could deliver significant savings and real improvements in the care provided to patients.

Thanks to Professor Stefan Scholtes, Dennis Gillings Professor of Health Management at Judge Business School, Markus Harder, PhD student at Judge Business School and Cambridge University.