Based on an article previously published on Healthmanagement.org
The Greater Manchester Rapid Diagnostic Centre (RDC) Programme offers a new model of rapid assessment that aims to improve patient outcomes across Greater Manchester, UK. The centre offers a new way of rapidly investigating patients with suspected, (often non-specifc) cancer symptoms, so that they can receive appropriate diagnosis and subsequent follow-up as soon as possible.
There are opportunities to make major inroads in both the speed of diagnosis of cancer and the reduction of multiple presentations to healthcare professionals prior to diagnosis..
NHS England published its Long Term Plan for Cancer in 2019, citing the Rapid Diagnostic Centre model as a way to support the ambition to increase the numbers of patients diagnosed with cancer at an early stage, to improve both their long term outcomes and experiences.
Read the article to learn more about this initiative, its goals, vision and performance from Barney Schofield, Director of Planning and Delivery, Northern Care Alliance and Roger Prudham, Clinical Director of Northern Care Alliance Rapid Diagnostic Centre.
Can you tell us a bit more about this initiative and what it entails?
Our Rapid Diagnostic Centre is one of the most developed examples in the country of this new model of assessment and we continue to take this forward at an accelerated pace. The aim is to develop and deliver a very rapid pathway where general practitioners can refer patients with vague symptoms of cancer into one place. Those symptoms will be investigated rapidly within a pathway where patients have both a single point of access and a single point of contact right from the point of referral. They are supported along their journey by clinical nurse specialists and care navigators.
This is a new type of service model - previously, at the point of referral, primary care physicians had to decide which specialist pathway to refer their patient into - whether it be a lung pathway or an upper GI, lower GI pathway or urology pathway. Sometimes it's not clear what the exact underlying cause of the symptoms is, but symptoms must be investigated. Hence, this is a pathway that's based on symptoms rather than body parts or specialist teams.
What are the goals of these rapid investigation centres?
The goal is to diagnose cancer at an earlier stage and give a definitive diagnosis of cancer (or rule out cancer) in an expedited way. For this, the cohort of people that we've initially targeted includes patients with vague symptoms, which could have any number of different causes. There is plenty of published evidence that these patients usually wait longer for a diagnosis, longer for treatment and visit their general practitioner more frequently before they're referred onwards. They also have comparatively poorer outcomes compared to patients who've got more specific symptoms.
Our aim is to deliver a model that gets patients into that first diagnostic test within no longer than seven days of referral from their general practitioner and, where possible to get the diagnosis on the same day.
Are there any specific types of cancers that are prioritised, or is this rapid diagnosis focused on all types of cancers?
There is a diverse range of cancers that we're diagnosing through the RDC. We've currently diagnosed lung cancers, urological cancers, haematological cancers, upper GI and lower GI cancers. This goes to show how difficult it is to place these patients into very specific pathways before they've been through an RDC type process, otherwise, they can end up in the wrong pathway being investigated by clinical teams trying to look for a cancer that they don't have.
What type of digital technology is being used to improve diagnosis, make it faster and more accurate and to improve patient experience?
At the moment, we're only scratching the surface of the long-term digital potential of the RDC. There is a whole range of enabling and digital technologies without which the RDC couldn't exist. Amongst those is digital radiology, which allows us to access the radiologists that we need to provide a reported scan within two hours of the scan. That is what we're currently piloting within the Centre, and we want to roll that out for many more cancer patients as we go forward. The development of a single system-wide radiology picture and archiving system is critical to the development of rapid diagnostic centres. Alongside that is the development of digital pathology applying the same principles.
In terms of patient experience, what has been the feedback?
This is not just about patient outcomes; it's about patient experience and how they are supported throughout their diagnosis of cancer. The Rapid Diagnostic Centre model is designed to address and acknowledge deficiencies in the patient pathway and the poor patient experiences as they go through their diagnostic journey.
One of the most gratifying things which really encourages us that we're doing the right thing is through patient feedback. We are told by our patients how much they appreciate the rapid nature of the service and subsequent result, the associated reduction in anxiety and also how much people appreciate the personal touch and support from the team.
Do you have personalised procedures, or do the patients have to go through a standardised process?
That is a good question. It's absolutely not a conveyor belt. One of the most important things that happen within the Rapid Diagnostic Centre is a clinical triage of the referral backed up by a telephone call so that we can make sure that we have access to the best intelligence from the patient themselves. Referrals arrive with a battery of blood tests already having been requested and carried out by primary care. At that point, we would look for any previous scans that the patient has had and any clinical history available on our digital information systems. Based on that, we form a view about the right sequence of diagnostic tests to get to the bottom of the presenting symptoms.
What we're seeing is, for most patients, the first diagnostic test is a contrast CT scan of the thorax, abdomen and pelvis, but the Centre has access to many other tests as well, including MRI, ultrasound, gastroscopy, colonoscopy, amongst others.
What are the main drivers for this initiative, and what are the key performance indicators?
We want to transform the patient experience, create a simpler model of diagnosing cancer, reduce delays and make better use of the scarce specialist workforce that we have. Many current models rely on medically-led service models, whereas our RDC maximises the use of specialist nurses and advanced nursing practice, delivering a service model which ought to, over time, demonstrate high levels of value and financial sustainability.
What challenges have you faced when implementing the Rapid Diagnostic Centre?
One hurdle that we certainly incurred was COVID-19. During the first peak of the pandemic, many of the nursing staff that we recruited to work in the RDChad critical care skills and were required to work in COVID-19 escalated areas. That delayed the implementation by several weeks, but as soon as we were in the post-peak period, we went live with the RDC pathway. We implemented the RDC at the right time in the post-peak COVID-19 period.
Which type of diagnostic solutions are being used to facilitate the goal of rapid diagnosis?
We use several concise tests that are available to general practitioners that could give us an indication of where a problem might be before the patient arrives in our clinic. That would include a basic blood count and biochemistry test, thyroid function tests in case an overactive thyroid was a cause of weight loss, serological tests that can be specific to cancer such as CA-199 in case of a carcinogen of the pancreas, CA-125 for carcinoma of the ovary and CEA for bowel cancer.
The primary diagnostic modality on which we rely, to give both the patient and the primary care practitioner the assurance that it is unlikely to be cancer, is a CT scan of the thorax, abdomen and pelvis. We worked with radiology partners over several months to identify protected capacity that would give reliable access to CT scan and report within a day of the patient presented to us. Therefore, we have screening blood tests done in primary care so that they are already available to us when the patient presents. The patient comes and has a pre-booked CT slot, so there's no stress involved with cancellation or delay. We have pre-booked reporting time, so within a day, we have the result for the patient.
What role has GE Healthcare played, and how has it helped this initiative?
We have been partners with GE Healthcare since the very early stage of this journey in providing thought leadership alongside our clinical and managerial expertise in the hospital group to generate the idea and the potential in this model. We live in a world where technology leads, and then applications and ethics follow.
Industry partners like GE Healthcare have a responsibility to let us see what is possible technically both in terms of the way that we acquire data and the way that we may use data in the way that we share data. That is where innovation comes in from industry partners in terms of managing patients in a streamlined and rapid way.
There is a lot of data within different systems and having the awareness of that and having applications and solutions that can bring all that together to help it make sense is another area where the industry can help. It's the global nature of GE Healthcare and their access to global insights and experience of international delivery models, which have been really useful for us right at the outset. GE Healthcare is a key partner with the Northern Care Alliance radiology and in many other clinical areas. We have a range of GE technology and infrastructure in use right across the hospital group.
What has worked well with these Rapid Diagnostic Centres and what could be improved?
We need to be able to widen the focus of activity in order to benefit more patients, and be able to reliably predict how we can pace that. It's the balance between risk and benefit when we considering widening our scope. There are very mixed cancer pathways. We want to take our methodology and apply it to other more traditional tumour groups. Thinking longer term, we can think beyond cancer to other conditions, which can cause as much mobility and mortality as cancer. We are diagnosing probably 10 to 15% of patients who come through the Centre with non-cancerous, but other serious pathologies, which we then refer on - so the benefit of the RDC is felt in other areas of disease detection and diagnosis.
We could think about how we would design a suspected airway disease pathway or a suspected heart failure pathway or a suspected vascular disease pathway, for example. That is still a good few years off, but that is the ambition in the long term. Also, leveraging the benefit of technology is a key part of the vision and understanding the potential of Artificial Intelligence (AI) and decision support tools to provide greater precision and targeted diagnostics.