Nineteen more locations have been announced for Community Diagnostic Centres (CDCs) by the Health and social care secretary Steve Barclay, which takes the total approved to 127, but how will they operate in the face of staff shortages, is outsourcing inevitable?
By September 2022, there were 92 CDCs up and running and the government has a target of “160 CDCs to perform up to nine million additional tests a year by 2025”.
But are these centres going to have any impact on the 1.5 million people waiting for tests at the end of October 2022, 11.8% of which have been waiting 13 weeks or more from referral for one of the 15 key diagnostic tests?
Although Covid is cited by the government as a reason for the backlog, the problem is more long-standing as the ‘standard’ six week wait target for a diagnostic test has not been met since February 2017.
Diagnostics is a key component of many treatment pathways and any delay in tests can reduce patient survival. A lack of diagnostics is having a particularly devastating effect on cancer waiting times. In November 2022, NHS England reported the worst ever waiting times for cancer treatment.
The idea driving the CDCs is that they would reduce waiting times and clear the backlog of tests, as well as make access easier by being located at sites that are more convenient for patients, reducing visits to hospital sites.
CDCs have added much-needed physical space for diagnostics, but as with the rest of the NHS, the lack of a workforce plan means staff shortages will ultimately limit their ability to clear that backlog.
The NHS was already short of thousands of skilled staff in diagnostics even before the CDCs opened.
In July 2022, the RCR told the Health and Social Care parliamentary committee, that there was an estimated shortage of 1,939 whole-time equivalent consultant radiologists for the UK, which equates to a 33% shortage.
At the start of 2022, when the DHSC confirmed that the CDCs will need an extra 3,500 radiographers to carry out diagnostics tests and 2,000 radiologists to interpret the results, as well as 500 advanced practitioners, groups representing staff said that the staff did not currently exist for the CDCs and that recruitment by the CDCs would deplete departments elsewhere in the NHS.
Outsourcing
The shortage of staff has been ongoing for a number of years and NHS trusts are increasingly having to pay for staff to do overtime or outsource the analysis of scans to private companies. The RCR estimates that UK NHS trusts and health boards spent £122m on outsourcing radiology in 2021.
The upturn in business is clear from the accounts of the private companies involved. Two of the largest companies operating in the UK, Medica and 4Ways Healthcare, have reported big jumps in turnover in 2021. Medica, reported a £47.1m turnover in 2021 in the UK, up 33% on 2020. 4Ways Healthcare reported £34.5m turnover in the year to March 2022, up 70.5% on 2021, reportedly due to an increase in work from the NHS. The company’s profits jumped to £5.1m from £1.7m in 2021.
The shortage of staff has been made worse by the refusal of the government to make changes to the pension rules in the NHS. Many consultants are reluctant to do extra sessions because of the potential impact of the extra income on their pensions, with breaches of the lifetime and annual allowances incurring penalties.
Consultants have been turning to the formation of limited liability partnerships (LLP) as a way to carry out work that otherwise would have been given to private companies. Several of these have already been set up, with HSJ reporting that in the Buckinghamshire Healthcare Trust, where there is a backlog of 8,000 to 9,000 unread scans, an LLP has been set up and the consultants are waiting for the trust to contract with it, so they can carry out extra work.
In November 2022, HSJ reported that NHS England is assessing the viability of establishing an NHS-owned consortium to bring some of the diagnostic work currently being done for profit in the private sector back into the health service.
However, HSJ also reported that a meeting between NHSE and the private sector on joint venture arrangements was expected soon.
An investigation by The King’s Fund has also found that the claim that CDCs will be located in places that are more convenient for people to visit and away from hospital sites is not holding up. The Kings Fund found that 47 of the 92 centres up and running were on existing hospital or primary care sites, not “closer to home”, and not diverting people away from hospitals or more convenient as the NHSE has suggested they would be.
This trend appears to have continued – of the 19 recently announced new CDC sites, 10 appear to be at sites that are already hospitals or health centres, and it is unclear where the other nine are to be located within the city or town named.
The reason for this is that government guidance means that the CDCs have to be built within existing NHS estate and only on ‘an exceptional basis’ can building take place. Although some have been set up in shopping centres, unless a suitable site is available, then the CDC ends up being located with all the other NHS estate. The plan to target hard to reach populations to produce a diagnostic centre embedded in a community rather than at a distant hospital site, seems to be falling short of its goal.
In a report by The Kings Fund in October 2022, it notes that the ban on building work is also likely to have constrained the size of the centres, meaning not all tests can be carried out. It notes that although there are reports of 30,000 tests being performed weekly across the CDC, this equates to just 411 tests a week for each centre, “which suggests that not all centres are able to offer the full range or volume of tests that the Department of Health and Social Care expects the sites to meet.”
The CDC programme is now over halfway through, and although 92 are up and running, it does seem that they are having little impact on the waiting list for diagnostic procedures. And without solving the workforce issue, their initial promise of ending the diagnostic waiting list crisis is likely to remain unfulfilled.
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