A diagnostic test is a procedure used to identify a person's disease or condition, allowing a medical diagnosis to be made. Diagnostic tests are a crucial aspect of care for patients, leading to treatment, advice, and support across urgent and emergency care, cancer and elective care. Undertaking these procedures as early as possible means patients can get prompt reassurance if tests are negative and they do not have a particular illness or begin their treatment sooner, improving patient experience and in some cases patient outcomes.
Prior to the pandemic, the NHS was working towards the standard in the NHS constitution which stated that patients should wait no longer than six weeks for a diagnostic test from the request being sent; the target for this waiting time standard is set at 99%. This standard was introduced to ensure the attainment of the 18-week referral to treatment (RTT) target. The pandemic has caused huge disruption to both cancer and elective care pathways, and although these services were already struggling to meet these targets prior to March 2020, the situation has deteriorated significantly.
The delivery plan for tackling the backlog of elective care provides a new, updated diagnostic recovery trajectory with important milestones which reflect the ongoing operational challenges. The ambition is now for 95% of patients to receive a diagnostic test within six weeks by March 2025 and for 75% of patients who have been urgently referred by their GP for suspected cancer to either be diagnosed or have cancer ruled out within 28 days by March 2024. It is important to note that the NHS has consistently seen record levels of urgent suspected cancer referrals since March 2021.
The pandemic has also highlighted the need to invest in diagnostic services.Assistant Research Analyst
The pandemic has also highlighted the need to invest in diagnostic services. National plans to transform the diagnostic landscape involve establishing community diagnostic hubs and encouraging trusts to weigh up the benefits of separating emergency and elective diagnostics where possible, as recommended by Professor Sir Mike Richards in his independent review of the diagnostic services recovery. The hope is that by creating such hubs or 'one stop shops', patients will be able to access potentially lifesaving checks much more conveniently and promptly. Richards also argued that separating elective and emergency diagnostic activity enables services to operate more efficiently, removing the risk of elective care being deprioritised for urgent work.
To assess how far activity and performance need to improve, this blog outlines current trends, what happened during the pandemic, and the sector's performance against the long-standing national target.
Current trends in diagnostic activity
Prior to the coronavirus pandemic, although performance against the six-week standard had been slowly deteriorating, activity had been increasing. Therefore, although activity is recovering, there are still far too few diagnostic tests being carried out to match demand. This, coupled with the enormous decline in diagnostic tests throughout 2020/21 means a significantly greater number of tests are required to meet the increasing demand, to clear the backlog and to achieve the national recovery targets.
When the pandemic commenced in March 2020, diagnostic activity began to decline rapidly, from 1,911,462 diagnostic tests performed in February 2020 to 612,232 in April 2020 – a 68% drop and the lowest figure on record. To provide capacity for coronavirus patients, non-urgent elective care was put on hold, meaning fewer diagnostic tests were carried out. As detailed in Professor Sir Mike Richards' report – the public's fear of contracting the virus by coming into hospital is thought to be linked to the marked reduction in A&E attendances for conditions such as heart attacks and the sharp decline in urgent referrals for suspected cancer, another reason for the reduced diagnostic activity.
In addition, increased infection prevention and control measures had the effect of reducing capacity. This was particularly detrimental for aerosol generating procedures such as endoscopies. Due to concerns over the dangers of these procedures during the height of the pandemic, all types of endoscopy procedures almost ceased: in April 2020 3,484 colonoscopies took place, just 8% of the average activity over the preceding six months, whereas MRI and CT scans dropped to 30% and 54% of average activity, based on the six months prior.
Diagnostics waiting times
As of January 2022, there were 1.45 million people on the waiting list for diagnostic tests. The waiting list has been steadily increasing over the past 10 years, but since the pandemic it has risen dramatically, with levels currently 39% higher than in January 2020. Not only is the waiting list growing at a substantial rate, waiting times have increased, with the median wait time now between two and three weeks, whereas before the pandemic this was between one and two weeks. There are a considerable number of patients waiting over 13 weeks for diagnostic tests, currently making up 10% of the total waiting list. This is significantly higher than in previous years; in January 2020 and 2018 there were just 0.7% and 0.2% of patients on the waiting list for over 13 weeks.
The last time the six-week target was achieved was in February 2017. Prior to this, the target had not been met since 2013 when activity levels first began to fall. However, performance remained level, fluctuating just below the target around 95-98% until February 2020. By May 2020, performance plummeted reaching 41.5% while non-urgent elective care was put on hold due to the pandemic. Encouragingly, activity improved from June 2020 and has continued to increase, with the number of patients waiting less than six weeks for a diagnostic test currently fluctuating around 70-80% – although still significantly lower than the 99% target.
At provider level, just four acute trusts are currently meeting the 99% target, demonstrating the intense operational pressures that all trusts are experiencing. In April 2019, 42% of acute trusts were reaching the target, with some just below and a minority performing under 90%. Throughout 2020/21, increasing numbers of trusts failed to reach the 99% target; two thirds of acute trusts were performing under 50% and just 10 trusts above 70% in April 2020.
Based on the existing diagnostic data, it will evidently be a journey to recover performance to the standards that all trust leaders, and their staff, wish to provide.
The establishment of community diagnostic hubs should be a crucial driver of success, relocating/adding much needed capacity for certain diagnostics in the community. However, expanding capacity will still prove difficult for trusts and their system partners, with workforce shortages and capital constraints being two key limiting factors.
The government plans to provide over £5.9bn of capital investment for new beds, equipment, and technology. Of this capital investment, £2.3bn is allocated to increasing the volume of diagnostic activity, including the rollout of 100 community diagnostic centres. It is vital that this investment is distributed appropriately to maximise effect. But it will take time for these to be set up and it is still unclear how they will be staffed, with many trusts telling us they face pressing workforce shortages in key professions such as radiography.
It remains to be seen whether the plans and funding to increase diagnostic activity will be enough to deliver the recovery targets.Assistant Research Analyst
Going forward, trusts will focus on using digital innovation where possible on some pathways, continue to prioritise treatment by clinical urgency, and provide patients with the information and support they need while they wait for care. Innovative partnerships with the independent sector may also help support the NHS with this challenge, including to offer more independent sector staff the benefits of more blended career development opportunities, to provide a modern care environment for staff and patients and to access the latest technology.
It remains to be seen whether the plans and funding to increase diagnostic activity will be enough to deliver the recovery targets. However, transforming diagnostics is without doubt a key linchpin in the NHS commitment to tackling backlogs in elective and cancer care and in improving patient experience and outcomes.