Sunday, June 17, 2007

Focus review: Care in the community

Healthcare provision in the community is taking shape. Kirsty Osei-Bempong asks how prepared laboratory medicine is for these changes.
The publication of the white paper: ‘Our health, our care, our say: a new direction for community services’ and news that a progress report on the Carter pilots will be available this autumn, serve as stark reminders that the government’s modernisation plan is continuing to take shape.

But how prepared are the clinical and medical laboratory professionals in adapting to these changes? Central to many of the topics discussed at Focus 2007 was the changing and potentially greater role patients could play in managing their health. Presentations from patients during one seminar session provided a novel approach to thrashing out such contentious issues as patient ownership of results, their right to information and the role of the high street in healthcare provision.

“The internet is the inevitable path that pathology is going down,” said Mary Ann Cameron, a lay member of the Royal College of Pathologists, who regularly sources her health information from the web. “And information is going to belong to the patient and be more easily accessible.”

But while this may be true, ensuring the information is of good quality is vital. It is up to clinical pathologists to control and disseminate this, urged Sir Muir Gray, programme director of the UK National Screening Committee and director of clinical knowledge, process and safety for the National Programme for IT, in his opening ACB address. “In the 21st century, knowledge is the key element to improving health. In the same way that people need clean, clear water, we also need clean, clear knowledge,” he said.

Cameron recalled an example of how misleading information impacted on her life. Although three home-kit pregnancy tests she performed came back negative, she later discovered she was pregnant with twins. Doris-Ann Williams, director-general of the British In Vitro Diagnostics Association agreed, expressing concerns over the proliferation of non-regulated tests that are being sold online – opening up potential risks to users. The plethora of misinformation around requires a collective effort by everyone within laboratory medicine to disseminate the right message. Sites such as Labs Tests Online provide an example of how information requests can be managed appropriately.

Even on a day-to-day level, laboratory staff have a unique role to play as knowledge providers. Brigid Stacey, nurse director and chief operator officer at Walsall Hospital NHS Trust, kicked off the patient’s view session by recounting the time when her daughter required medical assistance after exhibiting symptoms linked to cystic fibrosis.

Although it eventually turned out that her daughter did not have the condition, she urged laboratory staff to use their knowledge to help give patients greater understanding of what tests are being performed and why. “You perform these tests day in day out but you don’t realise what it means to us. It’s a really scary time. It’s not an everyday test – for us it’s the future of our lives,” she said.

For some patients like Catherine Goodyear, who spoke about living with Graves’ Disease, having knowledge about her condition helps her to have some control over how it is managed. She believes that patients have a role to play in sharing their experiences with doctors. “It’s not the results the matter so much for me but how I feel,” she said. “When I feel changes in my body, I know when my dose needs to be increased.”


Discussion also threw up issues of standardisation and concerns about the consequences of community healthcare if it is not regulated. One patient, Geoff Hayward, shared his findings from a comparative assessment of his cholesterol level results at a high street pharmacy and an NHS hospital laboratory over a three-year period. He found wide variation in results between the high street store and the NHS lab. On one occassion his high street result was 2.69mmol/l compared with 6.4mmol/l at the NHS. Hayward says the pharmacy claimed its kits were calibrated weekly to ensure accuracy.

“You’ve got to question the validity of the tests in the high street chemist,” he said. “It also raises concern about how other patients or clients are being affected by the mismatch of results.”

But session chair Dr Danielle Freedman, of Luton and Dunstable NHS Foundation Trust, believes the situation has the potential to become much worse. She raised her concerns about a government proposals that could see 80% of surgery conducted outside the laboratory setting. She said:“I think on the back of what we’ve seen from Geoff, it’s going to get much worse.”

And as more healthcare provision is channelled into the community, healthcare professionals will be faced with the mammoth task of responding to the varying needs of their patients. One histopathologist from the Wirrall pointed out that while there may be many patients that want details of their results, there will be those who are ambivalent and others that simply don’t want to know. “How do I decide which patient fits into which category?” he asked.

Similarly, it is all very well some patients requesting more information, but laboratory professionals will have to now tailor the information to suit the varying level of understanding a patient has on his or her condition.

“There is much to consider – what information to endorse; the cost implications; the need for training; the additional time needed to dedicate to patients; and if you can afford to spend that time deciding which patients to disclose that information to. These are the questions we need to discuss – and how we are going to react to this growing interference.”

And pathology managers have a strategic role to play in educating commissioners on the vital role diagnostics play within healthcare provision.

Professor David Whitney, a senior fellow at the Centre for Health Planning and Management at Keele University, urged pathology managers to put health, as a whole, on its clinical directorate agenda and take the lead when it comes to decision-making.

“When did you have health as opposed to health treatment services on your clinical directorate meeting? Talk about the health profile of their community, the health pathways, about how diabetes and cardiology fits into this framework. Focus on the wider care pathways and see how pathology might fit into that,” he asked.

Increasingly, diagnostics need to be seen as the 'front end of the hospital' because of the vital role it plays in informing GPs and clinicians in subsequent decision-making processes, Whitney explained. But this requires active communication with commissioners and a change in the way that pathology interacts with the rest of the NHS. .

“You have to understand where PCTs are coming from, invite the director of commissioning into your directorate to understand what their aspirations are and if they don't have any, inform and shape them. It's a fantastic opportunity at the moment and it's probably a one-off opportunity, given the changes that are around but pathology has a real opportunity nationally and locally to inform change and debate,” he said.

His discussion also centred on the white paper document Options for the future of Payment by Results: 2008/09 to 2010/11, which was launched on 15 March 2007 and is open for consultation. The paper puts forward proposals for future developments in PbR including tariff setting, coding and classification, expanding the scope of PbR, and supporting health policies through financial reform.

He says: “In the report, pathology is not mentioned once which could be a threat but also an opportunity.” He says, it is an opportunity for pathology managers to ask themselves what they want from PBR for pathology or if they want a separate tariffs.

“That with or without the help of the secondary care environment, PCTs will take control, so it is important for them to get involved. Change is being dictated by all sorts of intiatives. Pathology should be driving that now because if they don't drive it, PCTs will drive it in their own way and particularly when practice-based commissioners come on board.

Basically, the future is up to you. Focus 2007 with its theme 'beyond the laboratory', attempted to do more than just giving visitors an snapshot of the challenges they will be facing but also preparing them to be able to deal with them.

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