Welcome to PathUser ^TM Facilitating Demand Management and Best Practice in Pathology

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The Evidence

Problems of demand control are acknowledged privately by the Department of Health and the Pathology Modernisation Steering Group although no organised structure exists to address these. Most of the existing pathology modernisation funds have been directed towards re-organisation of service and service merger rather than use of service.

Laboratory activity is rising at around 6-10% annually ^5,6 and there is a real risk that pathology expenditure will escalate steeply in coming years. The fear being that changes in NHS contracting will mean that increased pathology expenditure must be ultimately paid for by reducing clinical activity even though this is not fully reflected at present because of block service contracting.

There are few conventional methods that control or modify user activity in pathology other than isolated interventions carried out in specific areas by individual laboratories. Several recent publications are available on the subject of the differences in laboratory testing and the need for a demand control agenda in primary care requesting of laboratory tests and methods of improving practice ^{5,6,7,8,9,10,11}

Large inequalities exist in testing activity between different general practices and between hospital laboratories. These are not explained by patient or practice factors (number of practitioners, age, sex distribution of patient list, deprivation index, etc) ^7,8,9 and inequalities in matching health care use to population needs is recognised by the Department of Health ¹²

This discrepancy of inappropriate test use between practices and PCTs is not a reflection of poor practice, but, more frequently, of failings in the health care system due to:

• Repetitions of tests by GPs and hospitals due to IT limitations and poor communication.
• Uncertainty about best practice for repeating monitoring tests in chronic illness.
• The absence of any best practice standards or evidence in test levels.
• The increase in the complexity of tests.
• Increased patient expectation for tests.

The inappropriate use of tests leads to unnecessary expenditure, avoidable further investigation and referrals. Conversely, the under-use of certain tests leaves patients with sub-optimal management and potentially missed diagnoses.^{5,6,9,13,14,15}

Advising on the optimal use of laboratory tests has always been a fundamental part of the pathologist’s remit, so there is nothing new in the concept of appropriateness. The need for a better evidence base, and for improvement in use of pathology tests, has been recognised for 20 years ¹⁶ although little progress has been made. This has been the subject of several recent reviews ^5,6,17-21

Primary care does not produce the most expensive pathology tests, but does produce a high and increasing volume of tests, constituting about 50% of laboratory activity in many district general hospitals. Both Bandolier and Health Trends have acknowledged that some 30% of these tests are inappropriate, an unnecessary public expenditure of £540 million per annum. Demand continues to outstrip resources and is forecast to continue to do so due to a number of factors:

• The shift from secondary to primary healthcare services puts additional strain on GPs who have limited specialist knowledge regarding pathology testing.
• Increasing involvement in nurse led clinics.
• Overall increase in demand on the NHS.
• An increase in the availability of complex and expensive tests.
• The shift towards the use of commercial reagents in pathology laboratories thus tying laboratories into long term contracts with a single reagent supplier.
• While reagent costs have fallen in recent years, there is no evidence to support the belief that they will continue to do so and, at the very least, they must level off.

There is good evidence that practice behaviour can be changed by a combination of educational and facilitating mechanisms, ^22,23,24 although these must begin with knowledge of what is best practice. Within this environment PathUser^TM will therefore provide a mechanism that allows the user firstly to address inappropriate testing and improve quality of patient care, secondly release funding for direct patient care and thirdly meet the requirements of standards in good practice awards.