Pathologists and pathology labs play a critical role in diagnosis and the ongoing monitoring of myeloma patients. Like many areas of the NHS, they have been under increasing pressure to provide a consistent, high standard service over the years.
To help alleviate some of the pressure in pathology services and provide good practice recommendations that benefit both patients and clinicians, NHS England has initiated a deep dive review of pathology services in England as part of the Getting it Right First Time (GIRFT) programme.
It is hoped that by identifying variation in the way services are delivered across the NHS and by sharing best practice between trusts, the GIRFT team can help labs to address issues and implement improvements. Issues may include delays in providing results, inappropriate requesting, communications with users; addressing these can release capacity and resource.
Senior Healthcare Professional Projects Officer, Hannah Parkin caught up with Marion Wood, Joint Clinical Lead of the Pathology GIRFT team to find out more about this important project.
What is the Getting it Right First Time (GIRFT) programme?
GIRFT is an improvement programme developed through a partnership between NHS England, NHS Improvement and the Royal National Orthopaedic Hospital NHS Trust (RNOH). It aims to improve patient care and deliver best value by identifying and reducing unwarranted variation between trusts.
GIRFT differs from other improvement programmes as it combines compelling comparative data with a clinically led review process, to identify changes that will help improve care and patient outcomes, as well as delivering efficiencies and cost savings. Adoption of the first GRIFT recommendations published for orthopaedic surgery led to savings of up to £30m across 70 Trusts.
Prof Tim Briggs, an orthopaedic surgeon, led this first GIRFT project. He used nationally reported data to look at variation in practice and discussed findings face to face with colleagues, to identify ways to share best practices and reduce the variation, benefitting patients and producing potential cost savings. Since his first report published in 2015, the programme has been expanded to look for ways to improve many other clinical areas – including mental health, radiology and pathology.
The GIRFT methodology is structured in the following way:
- Analysts gather information from questionnaires, HES data and other sources which is used by clinical leads to inform a ‘deep dive’ visit at all Trusts delivering that particular specialty
- Good practice and suggested improvements are identified and regional hubs support hospitals to help implement these improvements
- A national report is produced which makes recommendations for the specialty as a whole
What does the GIRFT pathology review involve?
The pathology review will use the GIRFT methodology to identify issues along the pathology investigation pathway. The team are reviewing the process across three phases of the pathway: pre-analytical, analytical and post-analytical, identifying variation between service providers such as:
– Is requesting electronic or still paper based?
– How are specimens transported to the laboratory, how long this takes, is it temperature controlled?
– How quickly results are released – focussing on the emergency department and primary care
– How significant abnormal results (for primary care – potassium) are handled out of hours
– What “normal range” is used for certain analytes
– Is there a local standard for the repeat frequency of some more specialised tests?
– What is the “turnaround” time for certain investigations e.g.: molecular/cellular pathology?
– How are blood cultures handled in the local lab – in and out of hours?
How is the review progressing and how easy was it to adapt the methodology to pathology services?
Setting up the pathology project has not been without challenges – the breadth of the sub-specialties and the paucity of good quality national data being two important issues that the team have had to address. It was eventually agreed to start with the basics; a questionnaire was drawn up and sent out to all trusts with pathology departments, including those being run by third parties or in collaboration with private sector providers.
So far, data received from over 90% of trusts has been pooled by analysts and used to generate specific reports (“data pack”) for each trust, showing their responses against the national picture and local organisations. These packs form the basis for discussion at a “deep dive” visit to which the local pathologists, senior management team and primary care pathology rep are invited.
Having completed the data collection phase of the review, the face-to-face deep dive visits are now starting.
At the visits the pathology GIRFT team hope to understand what influences the variation in performance (good or bad), what can be learned from this and how the learning can be shared. For example, there are many potential reasons for rejected blood/urine samples. These samples often need repeating which leads to delays and inconvenience for many, especially the patient. If an organisation has fewer rejected samples, it is important to ask: how have they achieved this? Could it be implemented elsewhere? The “deep dives” commenced in the autumn and are already identifying plenty of variation and some interesting ways in which laboratories are addressing this.
On average a GIRFT round for any given specialty can take around 2-3 years. In the absence of a haematology GIRFT being planned at this time, it is hoped that some of the challenges faced by clinicians treating myeloma patients will be captured in the pathology GIRFT project. Correct testing, reporting and interpretation of blood results is a crucial part of myeloma diagnosis and ongoing management. The national report for the pathology GIRFT project is anticipated to be published in early 2021.
The pathology GIRFT clinical team is led by Dr Marion Wood, Dr Tom Lewis (Consultant Microbiologist & co-lead) and Dr Martin Myers (Consultant Clinical Biochemist & Clinical Advisor).
The Myeloma UK Early Diagnosis Steering Committee is a panel of experts dedicated to identifying and tackling the major issues preventing early diagnosis in myeloma. One of these issues is trying to better understand the inconsistencies in laboratory testing for myeloma patients at diagnosis. The Committee are asking haematologists to complete this short questionnaire which explores the interaction between the laboratory and primary/secondary care. Earlier work by the Committee showed that only 26% of laboratories provide comment on the possible underlying condition and only 45% recommend a referral to haematology. This survey will be hugely valuable to the Committee in its work to better support primary care physicians in diagnosing myeloma. Thank you.