The last year’s article introduced the idea that Pathology, as an essential component of practically every pathway and an episode of care is ideally placed to join up thinking across the services, specialties, organisations, and segments of care about optimising and personalising prevention, surveillance, diagnosis, monitoring and treatment that are currently more often than not addressed in isolation. My colleagues from the other side of the Atlantic have already emphasised that due to its unique position in the healthcare ecosystem, a vast amount of longitudinal and low-latency data, laboratory services should be instrumental in supporting the healthcare to manage risks, access, and costs. Some beautiful examples of this approach have been tested or implemented locally, but none have yet been scaled-up or endorsed by the whole system.
In addition to an exceptional burst of creativity and dedication in all domains of healthcare, the pandemic has also exposed a number of our strategic debts, for which we do not have quick fixes. The response to the pandemic and the design of healthcare in its aftermath is a wicked strategic problem. As H. Rittel and M. Webber described in their 1973 Policy Sciences article, wicked problems are different because the current processes cannot resolve them. There are many interdependent, changing, and ambiguous variables within and beyond the healthcare sector. Therefore, there are no off-shelf solutions to mitigate the demand on clinical services or to address yet unforeseen and far-reaching consequences of the pandemic and its socio-economic sequellae on the health of the population.
Reflecting on a painful experience from almost three decades ago, I believe that our ambition should not be limited to survive the crisis and potential downturn but to emerge differentially stronger. Ahead of hard times, businesses would proactively take care of performance and balance sheets. Those more pragmatic would also focus on the size and scope of their portfolios; understanding that they cannot be everything to everyone. The organisations with the best chance to get out of the crisis with differential advantage would also purposefully invest in talent, skills, and technology that would enable growth. Cumulatively, these measures would ensure step-change in operating costs, proactive mitigation of risks, and optimisation of the value proposition to better match the future needs and access for their customers.
Pathology has the potential to be one of the principal catalysts of this type of healthcare transformation. However, we need to start at the system level, with the programmatic integration of laboratory services throughout the fabric of our fragmented healthcare ecosystem. “Programmatic”, because its purpose is to drive the development of new service models, not only to refine the existing ones by the accumulation of marginal gains. I often think about it as programmatic integration along six dimensions: horizontal, vertical, interdisciplinary, upstream, societal, and workforce.
The integration of laboratory services across more comprehensive geography has always been around. This includes highly specialised or niche referral practices. In many parts of the world, this is left to market forces. Systems leveraging economies of scale and scope, robust and financially effective supply chain, logistics, standardised technology, processes, and workforce can provide top-quality, resilient, and cost-effective service to the users. Also, the larger laboratory systems usually find it easier to adopt and mainstream new science and technology and have easier access to resources required for development and growth.
I will not elaborate on the on-going programmes in England. Twenty-nine Pathology Networks and Genomic Medicine Services gained the momentum before the pandemic and will hopefully continue at an accelerated pace. There is a number of questions, and I am sure a range of opinions on this topic. How to continue to support integrations having in mind the pandemic and other co-dependencies? Is twenty-nine too many or too few? Further consolidation of highly-specialised services or technologies? Alignment with the boundaries of the Integrated Care Systems? A distributed service model? We have recently seen the potential of high-throughput laboratories and decoupling of analytical and distributed reporting functions supported by technology across the range of pathology specialties. A system-wide approach to the procurement of analytical technology, IT infrastructure, Laboratory Information Management Systems, OrderComms, or digital pathology? What are the impacts of all these decisions on cumulative resilience, responsiveness to adverse events, equitability of care, or the bottom line? How to leverage the benefits of the emerging Genomic Medicine Services to fully mainstream standardised, equitable, timely, and cost-effective uptake of personalised medicine and safeguard the methodological consistency and continuity of development across multiple omics? How to do it at pace, so one of our relatively quick wins can be the implementation of clinically effective, equitable, and financially prudent management of pharmaceuticals?
I believe that the essence of integrated care needs to be reducing fragmentation and improving coordination of care around the needs of individual patients, carers and service users. In that respect, it focuses on care pathways end-to-end not only on traditional clinical domains. One of the aims on this journey is to improve quality and access to healthcare by enabling it at locations and by means that are most convenient for the patients, families and communities. In principle, it usually means closer to home. With the recent insights, we need to add considerations regarded the safety of the patients, their families, public and caregivers. The aspirations need to be to keep the hospital, diagnostic centre, outpatient clinic, pharmacy, and even primary care surgery visits only for as and when required and use telehealth channels as the preferred medium for consultations, monitoring, follow-up and self-support.
This is not a futuristic statement; we should look at results of Medical Homes (Mexico), Clalit (Israel), Tonic (Bangladesh), Appolo (India), Kaiser Permanente (California), to name a few. Pathology is ideally suited to help to accelerate the transition to this, currently unequally distributed future. If sitting at the table with other stakeholders, it can pay a significant contribution to co-creating and co-producing value often by introducing simple solutions for complex, multifaceted problems.
We have previously mentioned a significant current focus on preanalytics. Strategically located, walk-in or drive-through phlebotomy services, self-sampling or home visit arrangements will improve convenience, safety, sample quality, and turnaround times. With the phlebotomy in the integrated preanalytical chain, laboratory services can coordinate the monitoring of long-term conditions. Strategically engaged pathology services should provide dynamic and stratified safety gateways at the entry and transfer points to help with the management of the safe environment in acute hospitals, diagnostic centers, and care facilities, and keep awareness of the emerging threats in the community. These are only a couple of examples, more to follow.
This is not only the exercise in quality and access. There are tangible financial benefits, as well. The current cost-centre and organisation-centric accounting practices act as unintended firewalls to the economic evaluation of these interventions. Nevertheless, on first principles, a coproduction of value with service users drives down costs – we have learned that much from the experience of on-line line banks and retailers.
The unintended consequence of the growing knowledge and skills base and specialisation in healthcare are specialty and domain silos. The effective transition to the healthcare model that utilises the advantage of working and thinking holistically along care pathways cannot afford domain or specialty-centred insulation. It requires effective multidisciplinary teams, seamlessly and proactively cooperating end-to-end. All laboratory disciplines have a role to play in this process and at different stages of care pathways. In short to medium term, the ability to do so will be the make-or-break of a successful drive to optimise flow across diagnostic pathways. Histopathology, with its current challenges, will need to up the game quickly so it can support the immediate demand for cancer services. This will require two key developments: transition to the digital pathology platform and functional integration with genomic services. Also, it will need an effective, data-driven interface with other diagnostic modalities, such as imaging, endoscopy as well as more proximal and upstream parts of the diagnostic pathways. The latter is key to assist with preventive interventions, screening, and early diagnosis, to stratify risk, optimise access, flow, and productivity. Interdisciplinary integration of all laboratory disciplines will be discussed in future articles.
A critical proposition that can accelerate the transformation is that every patient who requires intervention in a hospital may represent a missed opportunity to detect, diagnose, and prevent the problem on time. With an upstream looking mindset, our value proposition should focus on improving lives, health, and wellbeing rather than ‘repairing what’s broken’. The upstream integration of pathology and laboratory medicine is relying on its fundamental ability to join its low-latency and longitudinal data streams with other sources of patient data, including the emerging home monitoring, public health, and data on relevant social determinants. This opens opportunities to leverage advanced data analytics and artificial intelligence to ensure personalised, preventive and effective care, best use of resources, risk management bespoke to point-of-care, and locality. On the whole-system level, it enables the development and refinement of healthcare standards. As a relatively quick win, trends from longitudinal laboratory datasets could be used for initiating timely interventions and preventing complications of long-term conditions. We have recently described the pilot in Scotland. Upstream integration will be the subject of future articles.
The integrative potential of pathology does not end within the walls of the healthcare; nor should the ambition. Pathology has a long tradition of collaboration with academia and industry. The routine business of pathology and genomics is the generation and collection of vast sets of multidisciplinary data. The structural position within the NHS enables its contribution to a unique national knowledge base and development of the value proposition for the patients and the public to contribute to the cutting edge research and development programmes.
In the immediate future, pathology will also be in a position to assist the academia to recover from the shutdown by introducing mutually beneficial joint ventures and co-development. I also envisage pathology further diversifying its R&D interests from the traditional biomedical domain to that of data sciences, computer sciences, artificial intelligence, and advanced engineering.
There is also a broader societal call. In addition to its contribution to health and wellbeing, pathology and laboratory medicine can contribute to cohesion and greener society. Young people are facing the worst career prospects since the Great Depression. With its multifaceted data-driven proposition, it can support educational and training efforts for the benefit of the whole society and become an agent of economic growth.
The staffing shortages affecting specific professional segments of pathology are widely publicised. However, less is published about the workforce development and knowledge/ skills gap that needs to be closed. In the previous post, I have alluded to the more cohesive integration of the existing and new professional grades, supported by clinical-grade computational pathology as advanced diagnostic power teams. Apart from a traditional set of medical and scientific professions, advanced power teams may require skills in bioinformatics, health informatics, data science, software engineering, etc. The existing clinical roles will also evolve. Instead of pathologists, geneticists, and radiologists, we may start seeing integrated diagnosticians. This tide is not limited to histopathology, new ways of organising staff to deliver clinical care are going to be equally relevant in the near future for diagnostic haematology, genetics, microbiology, virology, immunology and biochemistry.
Inevitably, horizontal and vertical integration of care is going to promote distributed work. Right expertise can be delivered with focus and on-time across a wide geography and with increased productivity. Interpretative expertise can be delivered at scale, irrespective of where the analytical processes are. This may be an exceptionally attractive proposition for highly-specialised or niche domains of expertise. This is not dissimilar to the knowledge work trends in other sectors of the economy. To succeed, we will need technology, training, governance framework, and the right culture.
We will also need multi-dimensional transformational leadership to navigate the dire straits of established professional cultures, changing healthcare, and fluid society. Programmatic integrations across multiple domains are outward-looking transformative processes that challenge existing organisational, professional, or domain-specific walls. Integration is an adaptive change that relies on collaboration between teams with different professional and organisational backgrounds, ideas, and places in the care pathways, healthcare economy, or society. The pathology leaders will need to go out of labs proactively. They will have to earn the key-partner seat at the table and act as catalysts of change and an effective conduit of information and ideas between laboratory teams and other partners in the healthcare ecosystem.