Exploratory Workshop

Thursday 13th June 2019

Jeff Ace

Chair of the WoS Laboratory Medicine Delivery

Board

Chief Executive,

NHS Dumfries and Galloway

WiFi

◦ SSID: NHSConnect

◦ Password: Nh3ALTH$

Fire Alarms and Emergency Exits

Toilets

Our current model of healthcare will

not meet the most optimistic

forecasts of demography driven

demand.

Financial challenges

◦ Costs are rising faster than

available funding.

Workforce challenges

◦ Even if we could afford to we

can’t staff it.

Performance Thresholds

◦ Not always met

National Context – Some Inconvenient Truths

Strategy

Health and Social Care Delivery Plan

Realistic Medicine National Clinical Strategy Healthcare Quality Strategy Scottish Healthcare Science

National Delivery Plan (2015-2020)

Demographics Ageing Population and

increase in Long Term Conditions

Service Increasing demand Inequitable access and

quality outcomes Variation and duplication New and emerging

technologies Training, skill mix and

career Progression Financial pressures

Sustainability of the current model

Programme emerged from earlier work undertaken by the

NHSScotland Shared Services Programme

NHS National Services Scotland (NSS) delivering the programme

on behalf of the Scottish Chief Executives group

Laboratory Oversight Board (LOB) oversees delivery of the

National Labs Programme which includes:

Developing a Distributed Service Model (DSM) for labs’

Deploying IT Connectivity (NPEx) across Scotland

Delivering a National Labs Information and Intelligence Platform

Aligning national/regional plans for transformational change of

laboratory services and encouraging collaboration

Providing a focus on programme delivery to drive the pace of change

Increase direct engagement activity ◦ NHS Board Chief Executives

◦ Directors of Finance e.g. LIMS

◦ Scottish Government including Access Collaborative

NHSScotland Event

National Healthcare Science Event

Promote website to increase reach of stakeholders

Deliver workshops and events in each region

13th June 2019 Glasgow

To investigate and explore opportunities for service

redesign and potential future service models for each

discipline aligning to Distributed Service Model (DSM)

Identify a preferred future model of laboratory services

in the West of Scotland

Using the workshop outputs, start to build the key

elements for the implementation and action plans to

deliver the DSM

Purpose of the day

9

Work for the best interests

of all 2.7m people in the

West of Scotland

Show trust

Act collegiately

Act with principle

and integrity

Show respect

Sharon Adamson,

Director of Regional Planning,

West of Scotland

The West of Scotland:

· Population of circa 2.7m, covering a wide geographic area of 8,777

square miles, consisting of urban, rural and island communities.

· Has most of the most deprived council areas in Scotland in terms of

their summary Scottish Index of Multiple Deprivation.

· Population growth rates will be highest for the over 65’s over the

course of the next 20 years.

· Increases in the rates of circulatory disease, cancer, gastrointestinal

disease, alcohol consumption, and dementia (albeit to differing extents

in different areas).

Increasing challenge to continue to provide current

range of services in all Boards

The West of Scotland Context

C

A

S

E

F

O

R

C

H

A

N

G

E

COMMON PURPOSE

We will proactively engage people to have better lifestyles, develop independence and self-care.

Design and deliver care services me around population segments that are closer to home, particularly those that require joined-up care.

We will design our future hospital services around the new and expanded local services, with different levels of service provided in different hospitals.

Develop regional workforce strategy, which includes addressing key gaps and the ability to flex across region.

Create regional estates strategy that makes best use of existing estates to support out-of-hospital and hospital care models and determines investment needed.

We will design our care around the specific needs of individuals and different segments of our population rather than around existing organisations and services (Population Health Management).

We need to improve people’s health.

Hospital is not always the best place for care.

We want to provide the best possible hospital care.

We need to use our precious workforce effectively.

Our buildings are not fit for purpose.

Our population is changing and so are their care needs.

We will make better use of the technology we have already invested in and make more investments in technology that allow us to improve care and reduce the cost of the care services.

Develop comprehensive regional plan that addresses drivers of financial pressure (incl. balance of care, productivity, workforce, back-office, estates).

Technology has changed but we are not taking full advantage.

We need to make the best possible use of tax payers money.

12

Model of Care

We have created a model of care that places the individual at its heart, delivered by services across multiple settings and supported by enablers.

13

We should not expect all hospitals to offer the same services – but quality of outcomes must be consistent wherever a service is provided.

The services provided must objectively reflect both local demand and total regional demand.

The services provided must adhere to evidenced pathways to ensure consistently safe and effective care.

Must be sustainable having responsibly assessed necessary staff/skills availability, and effective use of resources to maximise outcomes for individuals, carers and families.

Networks of clinicians – shared responsibility across hospital sites and Health Board boundaries.

Fewer sites, but local access maintained including by strengthening interface with and role of primary care.

Optimise capacity and so address service pressures (particularly staffing and rotas).

Standardise clinical pathways and reduce variation in clinical practice, and so improving outcomes for low volume procedures.

14

Local Hospitals

Networked services for specific specialisms

Safe, Efficient, Effective and

Sustainable Services

15

West of Scotland Update (June 2019) Current Regional Work Programmes

• Major Trauma Programme

• Systemic Anti Cancer Therapy (SACT)

Regional service models developed

• Vascular Services

• Ophthalmic Services

• Urology Services

Emergent service models reviews

• Cardiac Services

• Networked Care

• Interventional Radiology Transformation

• Realistic Medicine

• Head and Neck (ENT/OMFS) Surgical Services

• Child & Adolescent Mental Health Service

In-progress service model reviews

• Laboratory Services

• Aseptic Pharmacy

• Clinical Engineering

Shared service reviews

Our Focus

When required, laboratory services will be provided in

the most appropriate setting to ensure the

best outcomes for patients

RIGHT TEST, RIGHT TIME RIGHT

PLACE

Our Drivers

Population demographics and increasing demand

National policy, strategy, targets and

standards

Clinical and Quality standards

Evidence base

Patient outcomes

Sustainability challenges

Our Approach

Whole system linkages

Understand requirements for service models

Networked services - capacity configured

to optimise productivity,

efficiency and effectiveness to improve patient

outcomes

Sustainable future proofed services

17

Histopathology provided on one site in all WoS

Boards except GJNH

Biochemistry provided on all acute hospital sites inc

GJNH

Microbiology provided on one site in D&G and FV,

two sites in A&A, two in GG&C and three in

Lanarkshire. Also provided by the GJNH

Laboratory Services - Current

Model

18

Challenges

Boards working in isolation

◦ Inefficient use of collective resource

◦ Variation and inequity

Culture

Finance

Opportunities

New models of service provision:

Collegiate working

Networked approach

Technology

Multi –use analytics – blurring of specialty boundaries

AI

Data availability and quality information

Challenges and Opportunities

for Laboratories

WoS Laboratory Medicine Delivery Board established

Benchmarking against the National DSM Blueprint

Developing a Work Plan ◦ Quality and Efficiency

◦ Workforce

◦ Infrastructure

◦ Point of Care Testing (POCT)

◦ IT/eHealth

19

20

• Design networked laboratory services across sites to

make best use of resources.

• Develop competency-based roles within and across

services that optimise and value the expertise of our multi-

disciplinary workforce.

• Make best use of our estate to support service redesign

opportunities

• Make best use of technology that allows us to improve

care and make best use of the “public pound”.

Workshop Opportunities

Towards a Distributed Service Model: West of Scotland Regional Workshop

www.labs.scot.nhs.uk

Dr Bill Bartlett. Clinical Lead

National Laboratories Programme NHS National Services Scotland

Right Test

Right Place

Right Time

Patient centric,

outcome focussed,

whole system wise

service

Scotland wide access to

state of the art services

through a distributed

service model (DSM)

The Value Proposition

The Vision for Lab

Services

Right Test

Right Place

Right Time

What are the DSM Objectives?

• A scalable configuration of facilities that can meet future

demand for Laboratory services

• Enhanced service resilience through minimising variation

and enabling cross border working

• A sustainable, resilient, adaptable workforce aligned to a

credible workforce plan

• Improved and equitable outcomes for patients

• Enhanced value

Right Test

Right Place

Right Time

DSM Driver Diagram: How will we measure success?

To provide high

quality fit for

purpose and

efficient form

follows function

DSM for

laboratory

services, able to

operate in new

and evolving

healthcare

environments,

maximising cost

utility (value).

1. Optimal use of skills and

knowledge: workforce

development across systems

2. Optimal use of space,

equipment and resources

4. Integrated support

functions

6. Infrastructure to enable

and support research and

development within and

outwith the services.

3. Realisation of benefits

from new and emerging

technologies and knowledge

5. Effective Clinical

Interface; Input & Output

1.1 Embed lean processes and thinking

1.2 Define and develop specialist/generic work concept

1.3 24/7 Service Design

1.4 Culture of staff engagement and involvement

1.5 Maintain and develop specialist/generic competencies

1.6 Alignment of staff profiles to work profiles

1.7 Enable cross border working

1.8 Effective training and CPD for laboratory staff.

1.9 Role development with six steps workforce planning

2.1 Embed lean processes and thinking

2.2 Assessment of current and future space requirements and exploit existing resource

2.3 Explore resource sharing between disciplines /localities

2.4 Effective management of resources.

2.5 Functional consolidation of services to ensure optimal patient flow, capacity and outcomes

2.6 Develop logistics and communications

2.7 Standardisation and convergence (methods, SOPs, nomenclatures, codes etc)

3.1 New technologies: automation, molecular, mass spec

3.2 Ensure appropriate degrees of automation and modern testing strategies.

3.3 Develop point of care testing where appropriate.

3.4 Digitisation

3.5 Artificial/augmented intelligence

3.6 Rapid translation of best evidence and new knowledge into practice

3.7 Develop do once and share capability

3.8 Make outcome based business cases that demonstrate whole system value the norm

4.1 Development of generic support functions to co-ordinate activities across traditional laboratory

discipline, professional and geographical boundaries.

5.1 Electronic interface with decision support to enable optimal service demand by an evolving user

base

5.2 Infrastructure to enable closer collaborative working with users to improve clinical effectiveness.

5.3 Support for clinical audit and development of clinical and laboratory based practice.

5.4 Development of laboratory based clinical informatics functionality

5.5 Development of whole system view of service with outcome KPI development

5.6 Engagement with evolving health care delivery initiatives/structures to enable shaping of service

and focus of resources (Triple Aim/realistic medicine/precision medicine)

6.1 Develop R & D programme for laboratory services.

6.2 Staff/systems support clinical research .

6.3 Sufficient resource to support medical education and R&D

Aim

Primary DriversSecondary DriversBlueprint Consistent

Driver Diagram for Development of

Laboratory Services V0.2

Right Test

Right Place

Right Time

DSM, designed with a focus on whole system value

=

• Raises profile of labs as a

value centre instead of a cost

centre.

• Delivers opportunities for

investment in new

technologies.

• Addresses issues re

resilience and sustainability.

• Puts labs on the front foot as

a clinical service, NOT BACK

ROOM

Diagnostics Services:

Patients:

Benefits Right Test

Right Place

Right Time

Functional Distribution v Centralisation

Focus Functional Distribution:

• Design focus is predominantly on what needs to be provided in each locality – whole system value focus

Benefits realisation:

predominantly viewed in terms of whole system impact

Centralisation:

• Design focus is predominantly on the economies of scale, cost reduction and improving efficiency of the service- service provider focus

Benefits realisation:

predominantly viewed in terms of impact on service providers resource envelope.

Benefits: Organisational

Right Test

Right Place

Right Time

Requires:

• New thinking

• Collective ownership of a shared vision

• Ambition

• Willingness to embrace change and to think whole system

Co-production

Service Providers

Service Users

(patients)

Service Planners

E-health

Diagnostics Industry

Professional Bodies

Maximising Value: We can’t do this alone.

• Histopathology – Green Group

• Micro Biology – Blue Group

• Blood Sciences – Red Group 1

• Blood Science – Yellow Group 2

NHS Improvement

Pathology Consolidation – State of the Nation

Presenters: David Wells, Head of Pathology Consolidation Date: 13/06/2019

NHS England and NHS Improvement

Networking – The case for change

Benefits of Consolidation

Results : The Carter review

• Report saw £5bn of value opportunity 2020-21, if unwarranted variation removed.

• New Operational Productivity Directorate in NHSI to deliver report’s recommendations09.16)

The opportunity

Benefits of Consolidation

Financial

Operational

Clinical

• Allows for Essential Services Laboratories to focus on what is clinically urgent for a patient and provides faster turn around times for these tests

• Allows for greater collaboration between pathologists, resulting in better quality diagnoses

• Increases the standardisation of service across the UK • The economies of scale benefits can lead to faster turn around time of

routine work and can enable the latest technology to be purchased

• Economies of scale benefits allow for better utilisation of expensive capital equipment

• Less duplication of functions across the network such as HR, finance, logistics, marketing etc

• Increased volume allows for greater negotiating power to drive down costs of equipment, IT, reagents and consumables

• Improves service resilience through backup sites and increased workforce • Networking across wider geographies provides a solution to localised

recruitment challenges • Economies of scale allows for centralisation of low volume, high expertise

testing • Allows for standardisation of IT systems, logistics and result delivery

Improving the quality and value of NHS pathology services

35

Data shows +£200m efficiency saving

NHS Improvement is working with trusts to move towards 29 pathology networks across England

122 Pathology providers

Workforce of 25

thousand

Processing 1.1 billion

tests per year

£2.1 billion delivery

cost

• Pathology is essential in over 70% of patient pathways.

• High quality services, delivering timely results for patients, will also support national priorities in genomics, cancer care and integrated healthcare

• Currently there is national excess capacity in equipment, yet we are seeing local workforce shortages

• Variation of non-pay costs in routine testing from 2p to £1.26 per test

• Networking at scale allows for better value, better utilisation of capital equipment, faster turn around times where required and more opportunities for the workforce to undertake extended roles.

• NHS Improvement is engaging with the sector, with strong support for the hub and spoke model

By next year, the networks need to be operational and starting to deliver these quality and efficiency improvements.

Pathology Under the Microscope

Variation In Use Of MLA And BMS Staff In Acute Teaching Trusts

Average Non-Pay Cost Per Blood Sciences Test For Large And Medium Acute Trusts

36

Modelling

Patient Flows

Population Size

STP Boundaries

Existing Partnerships

Analysis of 2015/16 Data

• 29 Networks • £200 million opportunity

Network & Methodology

Hub Shortlist

Networking – Not without Challenges

Consolidation process – Key Lessons

Lessons learned from TPP

Consolidation process – Key Ingredients

- Agree a common set of values from the outset - Ensure a strong governance system is in place that confirms

accountability - Establish a strong auditable baseline - Agree a robust business plan - Accept, expect and budget for transition costs - Develop a strong target operating model and plan for implementation

including IT, equipment and logistics - Ensure clinical engagement - Ensure executive engagement - Gain a thorough understanding of regulatory and accreditation

environment - Engage with regulators and accreditation bodies - Invest in operational transformation resources - Be pragmatic

Consolidation process – Key Decision Points

Commercial structure

Governance structure

Legal considerations

Due Diligence

Operational

• Collaboration • Alliance contracting • Arms length hosted joint venture • Joint venture – Limited Liability Partnership • Joint venture – Limited Company by Shares or

Guarantee • Community interest company • Outsourcing

• Board structure • Responsibility & accountability • Executive governance • Clinical governance including Quality Accreditation • Key commercial terms • Transformational governance

• Organisational Form • Governance – Heads of terms of reference • Finance • Competition • Workforce • Relationships with customers and suppliers

and existing contracts • Outsourcing

• Standardisation of activity • Standardisation of workforce • Agreement of inclusions and exclusions

• IT platform – single LIMS or middleware • Equipment platforms – break existing contracts or

await contract completion • Logistics – utilise trust logistics, outsource or create

new system controlled by entity • Location for each service and the scope for essential

service laboratories (spokes) • Standardisation of operating procedures • Future state workforce design

Consolidation process – Key Decision Points

Barrier to consolidation Toolkit

Business case is too cumbersome and Carter compliance needs defining.

• Strategic Outline Case Template • Full Business Case Template

What services can be safely consolidated and how should a spoke service run?

• Essential Services Laboratory Template

How is risk shared? How are saving dispersed? Who is responsible for capital investment? How should a network be created and who is responsible for the operation?

• Commercial Structure Options • Operational Governance Guide • Clinical Governance Guide • Due diligence guide

IT will need large investment and is a significant barrier.

• IT Procurement Guide

How do I outsource my pathology and ensure I am getting the best deal?

• Pathology Outsourcing Guide

How do I structure the project of consolidating pathology services and what steps are involved?

• Network consolidation Framework Project Plan

What are the legal decisions that need to be made?

• Legal Watchpoints Framework

Pathology Toolkit Offering

Outputs

Described and enabling 29 Pathology networks: To set out the direction and ambition.

Publication of clinical and operational advice in the form of toolkits: To share learning and provide consistent advice with

agreement of the professional bodies and other ALBs

Development of specialist testing networks: To ensure highly complex clinical services are sustainable and efficient, supporting

faster access to sub-specialist clinical expertise

Facilitating network workshops involving clinical and operational teams: To drive the pace of change to ensure local

empowerment and ownership of networks.

Development and launch of the National Pathology Quality Assurance Dashboard: To monitor and measure quality of

pathology services clinically and operationally. To ensure good practice in adoption of national guidance, accreditation, training and education

and also to ensure corporate good practice in monitoring supplier performance, quality of industry service delivery and provider interactions for

new models of care (e.g Point of care testing in primary care).

Identifying national funding and innovations: A Working with Office of Life Science to ensure innovation pipelines to digitise and

adopt AI where clinical appropriate at pace and scale. Working with industry to identify disruptive technologies – for example drone delivery for

blood samples, or point of care diagnostics to improve bed utilisation

Collecting system wide data….

Model Hospital – Cost per test

Spring 2018: NHS Improvement pathology networks

Networking – Supporting formation

Pathology

• Clinically lead service. Every result issued has been monitored, reviewed or commented upon by a medical clinician or state registered (via HCPC) Biomedical or Clinical Scientist.

• Integrated access to sub-specialty expertise available for community, primary, secondary and tertiary at a single touch point. Scientists all have a sub-speciality training, and have an active role in many specialist MDT meetings.

• Accreditation and quality assurance integral to service delivery. Pathology in the UK has lead the way in clinical accreditation for more than 20 years. UK system is the basis of the current international accreditation standard.

• Keen technology adopters. Moving academic and novel technologies into routine, safe, clinical practice.

Covers all healthcare across prevention, screening, monitoring and diagnosis from before conception until post mortem. All with appropriate clinical and scientific support for local clinical teams.

Networks & Consolidation with engagement

47

The benefits are: • Driving up clinical quality, better for patient outcomes

• Faster turnaround times • Right testing available at the right time. • Better access to sub-specialty expertise • Access to new technology

• Improving service resilience

• Efficient use of highly skilled staff. Right role, right person.

• Economies of scale and purchasing – linking into the current NHS Improvement

Procurement teams and Category Tower provider using the NPODG to set the clinical standard and requirements for national purchasing

• National excess equipment capacity, yet workforce shortages • Networking across wider geographies provides a solution to localised

recruitment challenges and development of advance scientific roles.

NPODG

Regulators

- UKAS

- CMA

- BIVDA

Clinical community

- RCPATH

- IBMS

Providers

- Trusts

- Private sector providers

Suppliers

- Equipment

- Private sector operators

Commissioners

- NHSE

- CCGs

Workforce

- Unions such as UNITE

- Health Education England

The programme is working in true partnership with the clinical and scientific community to deliver the right test, with the right advice at the right time – utilising the right approach and technology via the National Pathology Delivery group (NPODG) We are working with other colleagues in legal, procurement, finance. In addition with are also aligned and contributing to national programmes for example Genomics, AMR, sepsis and digital / AI with NHS England, Public Health, and Office of Life Science

Pathology Quality Assurance Dashboard

48

• This is a tool for individual Trusts to assess and manage

the benefit Pathology services can deliver.

• It is not a contractual tool to manage the service

• Timely collection of appropriate data.

• Board visibility of system wide metrics that Pathology

has an impact.

• Support national initiatives

• Collecting data in one place, once.

• Benchmarking for some metrics to continuously drive

improvement.

• Innovation and Training, a method to and report and

support long term sustainability of workforce and

adopting advance and innovative roles and technologies.

PQAD

Health check

- SIs

- Staff turnover / Sickness

- Activity

Operational performance

- TATs

- Logistics

Quality and clinical Governance

- Accreditation

- Adherence to national standards

People

- Training and Education

- Agency and locum use

Stakeholder engagement

- Clinicians and users

- Commissioners

Commercial / procurement /

Innovation

- Capital planning / Contractual meetings

- Innovation and adoption planning

Aspirational metrics

The first iteration of the PQAD was launched in response to the Dr Barnes’ Pathology Quality Assurance review.

Next steps for NHS Improvement

• NHS Improvement will continue to support and guide the development of these networks,

ensuring that services are safe, effective, caring, and responsive.

• We will work with trusts in networks yet to become operational to jointly agree milestones,

establish what extra support they need and ensure local leadership (across trusts and

commissioners) is in place to complete or network becoming operational.

• Support progress at pace.

• Continue data collection and providing insight support to providers and commissioners.

• Release Pathology Quality Assurance Dashboard

Networking – The state of the nation

National Programme Updates

Progress so far:

State of the Nation follow up: - All networks have been written to with

follow up timelines and actions. - 5 Networks working at the size and scale

described by NHSI. - 21 Networks have an approved Strategic

Outline Cases (SOC). - 18 Networks working up Outline Business

Cases (OBC) - Q3 and Q4 Data collections available.

Preparations for the next annual collection is underway

Work continuing…..

Sub- committees: - Pan UK Specialist Bone cancer group met. - Blood Transfusion group met. - Specialist testing and Digital and LIMS groups

convened. - Initial meetings will be to agree membership

and Terms of reference. - Broad agreement that these committees, via

NPODG, should be agreeing standards and specifications which NHS Improvement will mandate to providers and suppliers.

Co-signed COSD data standards letter - Cancer Outcomes and Services Dataset (COSD) will

support the monitoring of earlier diagnosis initiatives that are developed as part of the Long Term Plan.

- Trust are required to meet the data standards on reporting by September 2019

- Current adoption across England is poor.

Digital and LIMS data standards letter issued - Requirements for SNOWMET CT, Hl7 FHR messaging

Questions?

NHS England and NHS Improvement

Innovation in Laboratory Medicine: Intelligent Liver Function Testing (iLFT) Academic Health Science Partnership in Tayside University of Dundee and NHS Tayside Ninewells Hospital and Medical School, Dundee, Scotland

Ellie Dow, LRCP, MRCS, PhD, FRCPath Consultant in Biochemical Medicine, Blood Sciences, NHS Tayside

Liz Furrie, PhD, FRCPath Consultant Clinical Scientist, Immunology, Blood Sciences, NHS Tayside

54

BACKGROUND

• Significant investment in automation and IT

• Regrouping of specialties

• Getting the best out of investment in systems/what we have

• Novel ways of working

• Human factors: openness, honesty, don’t be defensive/territorial, willingness to work together

• Changed ethos

55

600

500

400

300

200

100 0

1970

1980

1990

2000

2010

Years

Pe

rce

nta

ge

Liver Circulatory Ischaemic heart Cerebrovascular Neoplasms Respiratory Endocrine/metabolic Diabetes

DISCOVERY UK age standardized mortality rates

https://www.bmj.com/content/352/bmj.i124

• 3rd most common cause of premature death

• Kills more people annually than diabetes and RTAs combined

56

THE SIZE OF THE PROBLEM

ALFIE project

• All Patients in NHS Tayside with LFTs 1989-2007

• Incident LFTs in 310,511 patients

• Incident LFT taken in primary care without obvious liver disease

– 95,977 patients

– 21.7% had at least one abnormal test

– Less than 50% investigated

• Liver failure presents late

• 20% die on first admission

• For 70% of patients first admission is first presentation/diagnosis of liver disease

• LFTs = Liver disease ?

• Why are things not better

57

• Variable responses to an abnormal result: 1. See the patient again 2. Repeat the LFTs

See the patient again 3. Arrange other tests (e.g. Abdo Ultrasound/“liver screen” bloods) 4. Refer the patient to Secondary Care 5. Not act on the result

• Patient may not attend for investigation/review

On average, 6 contacts are required, and 50% of patients are not followed-up in line with guidelines

CHALLENGES IN CURRENT PRACTICE

58

ABNORMAL LIVER FUNCTION TESTING PATHWAY ACCORDING TO GUIDELINES

59

STANDARD CARE LFT

• Bilirubin

• Alanine transaminase

• Gamma- glutamyltransferase

• Alkaline Phosphatase

REAL TIME

REPORT outlines

diagnostic and

management

plan

CLINICAL DETAILS • Alcohol consumption • BMI • Metabolic syndrome

• Viral serology • Liver

immunology • Iron studies

REFLEX TESTING • Alpha 1 anti-trypsin • Caeruloplasmin • Fibrosis staging

iLFT

ABNORMAL RESULTS

NORMAL RESULTS

HYPOTHESIS Intelligent Liver Function algorithm (iLFT) was developed using: • Minimum diagnostic criteria set forth by a professional consensus working group

convened by the Scottish Government Liver Care Pathway Advisory • Automated track analyzers • Liver fibrosis markers with high negative predictive values.

60

1. Advanced information technology • Order Communication System (eg. ICE), Laboratory Information

Management System (LIMS) (eg. LabCentre), Data Management System (eg. CentraLink)

• And/or Clinical Decision Support (CDS)

2. Advanced laboratory automation • Real-time, automated tracking and analysis

3. Multi-disciplinary approach • Hepatology, biochemistry, haematology, immunology, virology

and IT

4. Intelligent algorithms • To combine test results and minimum diagnostic criteria

REQUIREMENTS FOR ILFT TO WORK:

61

TESTED IN CLINICAL TRIAL (STEPPED WEDGE DESIGN) 6 GP PRACTICES >600 PATIENTS

CHANGE IN FINAL OUTCOME OVER 40% INCREASE IN LIVER DIAGNOSIS, 100% INVESTIGATION VERY POPULAR WITH GPS

20/06/2019

62

INCREASED LIKELIHOOD OF CORRECT DIAGNOSIS

Correct Patient Diagnosis

93% 41%

10,830 Patients per annum

with increased likelihood of diagnosis

at Dundee

63

INCREASED LENGTH AND QUALITY OF LIFE

2,350 Patients per annum with longer lifespan

and increased quality of life

Quality Lifespan

With

iLFT WITHOUT

iLFT

8.523 8.545

PATIENT

64 64

DECREASED TOTAL COST OF CARE

>£7 Million Lifetime Cost

Avoidance at Dundee for every 2,350

patients diagnosed by iLFT leading to clinical

intervention

Short-Term Long-Term

£3,216 COST

AVOIDANCE

-£284

Incremental Diagnostics

Ch

ange

in C

are

Co

st P

er

Pat

ien

t (£

) Payor REDUCED COSTS

65

1Dillon, et al. Intelligent Liver Function Testing (iLFT): A trial of reflex testing, automated diagnosis and staging of liver disease (In Press).

HOSPITAL ADMINISTRATION

RESOURCE OPTIMIZATION

85% number of avoidable visits to the GP reduced

Implementation of the iLFT pathway

75% Referral rate reduced to secondary care

Early and certain diagnosis using the iLFT pathway

– Neil Greig, PhD FRCPath, Clinical Lead, Clinical Biochemistry, NHS Fife

IMPROVED DOCUMENTATION Documentation of hepato-biliary diagnosis by General Practitioner increased from 16%

56%

1

to

66

SO FAR iLFT HAS IDENTIFIED...

• 95 NAFLD-NASH with fibrosis

• 76 ARLD with fibrosis

• 45 NAFLD + ARLD with fibrosis

• 17 HCV and 12 HBV cases

• 37 patients with haemochromatosis

• 64 carriers of A1AT mutations

• 3 patients with A1AT PiS variant (risk of liver/lung disease)

• 1 patient with PiSZ variant

• 3 patients with PBC

• 39 Gilbert’s syndrome

• 1 Wilson’s disease

...and several other patients with fibrosis awaiting clinical review

67

Key Partners:

• Hepatologists/gastroenterologists, laboratory medicine, general practitioners, strategic development teams and Information Technologists (IT)

Keys to Success:

• Evolve from traditional ownership of specific testing

• Automated algorithms are designed to amplify, not replace clinical judgement, particularly because individual patients may have extenuating and/or confounding factors for select abnormal results

• Familiarity with the system, further education about the reliability and increased use of iLFT is expected to advance adoption and reduce variation in clinical practice

• HUMAN FACTORS

PARTNERS AND KEYS TO SUCCESS

68

THE TEAM

Michael Miller PhD, MBChB

Consultant Hepatologist, Gastroenterology and Hepatology

NHS Tayside

Ellie Dow LRCP, MRCS, PhD, FRCPath

Consultant in Biochemical Medicine, Blood Sciences

NHS Tayside

John Dillon MB, BS, MD, FRCP (Edin), FRCP (Lond)

Professor of Hepatology and Gastroenterology, School of Medicine

University of Dundee

Elizabeth Furrie BSc, PhD, FRCPath

Consultant Clinical Scientist and Clinical Lead, Immunology Service, Blood Sciences

NHS Tayside

Ian Kennedy

Lab IT Manager, Blood Sciences

NHS Tayside

Dr Michael Miller, Dr Paul McIntyre, Prof Peter Donnan, Dr Mohsen, Dr Kathleen A Boyd, Dr David McLernon, Dr Ellie Dow, Dr Ron Neville, Prof Sara Marshall, Dr Liz Furrie, Dr Christopher Weatherburn, Dr Bill Bartlett

Dr Mohsen Rezaeihemami, Dr Adrian Hepca, Shirley Cleary, Linda Johnston, Ian Kennedy, Jim Flood and Sarah Inglis &TASC, The GPs and the patients. The CSO for funding

• Histopathology – Green Group

• Micro Biology – Blue Group

• Blood Sciences – Red Group 1

• Blood Science – Yellow Group 2

Sharon Adamson,

Director of Regional Planning,

West of Scotland

To obtain a shared understanding of the current state and

configuration of Labs in the West Region

To investigate opportunities for service redesign for each discipline

To explore potential future service models for each discipline

aligning to DSM

Make recommendations for future of Laboratories services in the

West

Using the workshop outputs for each discipline start to build the

key elements for the implementation and action plans to deliver

the DSM

Did We Do What We Said We Would Do?

Populate on the Day

Distil and share the Outputs from the day

Build the key elements for the implementation and action

plans to deliver the DSM

Develop the implementation and action plan/ roadmaps

with clear timelines

Identify owners to drive the WoS laboratory

implementation and action plans in alignment with

National Laboratories Programme

Make recommendations for approval by the West Chief

Executives and Regional Programme Board