The potential of pathology to improve healthcare is enormous but to untap it we must avoid a number of pitfalls, as Sasha Karakusevic explains
Reflecting on our recent pathology report, the words of Margaret Mead seem particularly relevant: “Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has”. We identified several teams making real progress and continuing to push the boundaries of practice.
But those small groups can only create change if every level of the system creates an environment that allows it. Our findings are not about picking winners and shaming losers: collective action has the potential to set new performance standards in pathology. Conversely, a collective failure to establish clear workforce plans that encourage young people to join the service has the potential to undermine best efforts in the field.
Our research – including an event for leaders in the field, interviews with senior managers and clinicians, and a literature review – showed us the scale of the risks and the rewards.
The first set of opportunities comes from rolling out standardised definitions for tests and procedures, and best practice in when and how to use them. “Choosing Wisely” is an international initiative backed in the UK by the Academy of Medical Royal Colleges and the Royal College of Pathologists. It aims to identify and eliminate the costs and patient concern and inconvenience that can result from overtreatment, widely recognised to be a particular issue in diagnostic procedures.
Radically improve performance
The National Catalogue of Laboratory Medicine will enable pathology data to be communicated and analysed across the service for the first time. We identified very interesting work under way in North Devon to put these principles in to action with pathologists working very closely with general practice and commissioners to radically improve performance.
The second comes from the centralisation of services, and the creation of networks with sites specialising in different services. In many fields evidence for this is limited. But with several projects and joint ventures now under way in pathology, we have seen that service redesigns can deliver 10-20 per cent savings over a three to five year period. Lord Carter first identified these opportunities in reports in 2006 and 2008: his latest review concludes that £200m of savings are still achievable.
That is not to dispute that consolidation and network working are difficult to get right. Local systems need to support clinical leaders and ensure that those who create the savings benefit through payment systems or re-investment. Without enough thought and clinical engagement, there is the risk of losing productive local relationships built up between pathologists and their colleagues in other fields over years.
Pathology deserves a place at the top of board agendas across the NHS. The opportunities are increasingly clear, and will grow
The ground-breaking 100,000 Genomes project has already created a national network of Genomic Medicine Centres. Teams are working together to tackle difficult practical, scientific and ethical questions at pace. Together with advances in Point of Care Testing, where laboratory tests on patients’ tissues are carried out where they are being treated, truly transformative improvements in personalised care are possible. The prize is faster, more certain diagnoses that save patients’ time and the health service’s money.
But the risks are also very real. Our report a month ago warned that there was a very real danger of these opportunities being overlooked. The core of the narrative around savings and transformation has grown from ideas about “integrated care”: shifting care out of hospital, prevention and population health, and facilitating easier discharges. Pathology can contribute to all of these goals, but it receives no focus in NHS England’s Five Year Forward View.
Another risk, one which can only be fully addressed nationally, is clear when we look at the signs of strain around the pathology workforce who will be needed to deliver these changes
Recent interventions from Lord Carter and NHS Improvement, reported by HSJ , put pathology much more clearly in the spotlight. The regulator’s recent note demanded specific plans for pathology consolidation by the end of this month. This brings another serious risk: a focus on efficiency savings at the expense of other opportunities.
There would be two problems with this. Firstly, some of the most promising developments will deliver savings in money and patient time beyond the laboratory, elsewhere in the system. Secondly, clinical leadership is critical to making these changes happen and getting the most from them, and this is often made difficult where there is a perception that immediate savings are all that matters.
Another risk, one which can only be fully addressed nationally, is clear when we look at the signs of strain around the pathology workforce who will be needed to deliver these changes. 40 per cent of pathologists are over the age of 55, and half of those plan to retire within five years.
At the other end of the pipeline, significant numbers of training posts went unfilled last year, including in histopathology, a major branch of the field. In chemical pathology, 12 out of 16 posts were not taken up. The changes in train will also mean continuing rising demand for bioinformaticians who process and analyse clinical data. We need to ensure that enough are being trained.
Pathology deserves a place at the top of board agendas across the NHS. The opportunities are increasingly clear, and will grow. But there are also real pitfalls: focusing too closely on narrow efficiencies, failing to plan consolidation properly, missed connections to the national genomic medicine programme and the potential for staff shortages. Careful leadership, and more consistent focus than we have seen so far, will be needed to get there successfully.
Sasha Karakusevic is a visiting senior fellow at the Nuffield Trust