Only by using GPs to ration referrals can the NHS meet the insatiable demand for MRI scans, says Dr Mona Vaidya.
The MRI waiting list scandals have disappeared - due to the success of the NHS in doubling the provision of tests performed from 17 to 34 per 1,000 of the population since 2005 - but the future looks stark.
Funding restrictions, the abolition of CQC targets on waiting lists, a growing backlog, and an ageing population are all factors which will both put a huge strain on budgets as well as present risks of large numbers of patients remaining undiagnosed and untreated.
Advances in hardware, software, research and medical evidence have made MRI the preferred diagnostic test for an ever increasing list of symptoms and conditions. More groups of professionals, consultants and GPs, are receiving training on MRI and making use of their knowledge.
Basic undersupply of MRI scans means that demand appears insatiable. Any new capacity introduced to the system is instantly mopped up by the previously unmet demand. Estimates of demand vary greatly depending on their source. A survey of SHAs has estimated demand for MRI tests at 35 per 1,000 while consultant radiologists estimated clinical need to be at 70-90 per 1,000. But the big picture is that England is lagging behind other developed countries such as France (>45 per 1,000), Belgium (providing >50 MRI scans per 1,000), Greece (>95 per 1,000).
New ways of working will make the current demand for a magic formula - increased service delivery at lower cost - actually work in practice for MRI scans. Setting up GP direct access pathways will cut the need for an initial consultation at the outpatient clinic. A hospital outpatient appointment would then only be required if specialist management is needed. On the traditional pathway, four separate appointments are needed before reaching a confirmed diagnosis.
Evidence from work by an independent service provider InHealth in London has shown in practical terms, that patients benefit from far fewer steps from referral to diagnosis; based on current cost figures, commissioners can benefit from around an estimated 20% reduction in the cost of referral to diagnosis; acute trusts benefit from reduced pressure of demand on their MRI resources and outpatient consultations, leading to better service for patients.
Within CLH (Central London Healthcare - Westminster Consortium), to make sure that easy access to diagnostics provided by InHealth doesn't lead to increased demand due to inappropriate referrals, the service has been implemented by using the patient referral service already in place. The triagers are GPs themselves, working within the consortium. They review all the diagnostic referrals, redirecting and advising via telephone/email support from specialists (radiologists, orthopaedics etc.) when necessary. This process helps identify educational needs and also improves the quality of referrals, ultimately leading to speedier access for appropriate patients through the system.
Additionally, a large-scale clinical audit of a randomly selected sample of cases in London by InHealth showed 79% of MRI results were abnormal – suggesting a high level of appropriate referrals by GPs. Around 45% of patients went on to GP management subsequent to the MRI test – suggesting a significant reduction in both initial and follow up consultations required at outpatient clinics.
A key factor here is the level of support provided for GPs - a pilot study may not have involved the same degree of education as a long-standing arrangement. Direct access needs to be delivered with commitment and a framework of expertise.
The other major cost-saving issue is capacity. For many it is the availability of staff budget which restricts equipment utilisation. Otherwise MRI scanners can and should be operational at least 12 continuous hours per day, seven days per week, 50 weeks per year, and performing on average 7,500 MRI tests (allowing for case mix variations and unplanned equipment downtime) - compared with a current average of 4,941. But there's no need for acute trusts to be running imaging departments at only half their potential capacity - better management delivers increased volumes.
Commissioners must demand transformational change. By making these demands now, waiting times will not have to grow, availability increases and the lower unit costs have the potential to grow into significant efficiency savings.
Dr Mona Vaidya is a GP in Westminster
Dr Mona Vaidya
