Transforming Services Together

‘Appropriate Diagnostics’Launch Event

(N.B.includes important changes to pathology services)

Dear colleagues,

We would like to warmly invite you to the TST Appropriate Diagnostics launch eventto be held onWednesday 28th September at 6:30 – 8.30pm at Stratford Circus, E15 1BX.

Over the next five years, we believe that –by working together - we could save £20m of waste on unnecessary testing and, most importantly, do the right thing for our patients by reducing the negative impact of over-diagnosis. We will be positively seeking your feedback on our plans.

The evening will include a lecture outlining the evidence base and harms of over treatment, previous success stories and patient vignettes asshared by Dr Julian Treadwell, Co-Chair, National RCGP Over-diagnosis Group.

The programme of changes to diagnostic testing (pathology and radiology) being implemented in the next few months will also be outlined. Our first batch of changes include: ESR, Urea and Electrolytes, GGT and ALT testing, as well as links to iRefer (for radiology referral best practice).

CPD certificates will be awarded to attendees – please reserve your place as soon as possible here: We believe that this will prove to be a thought provoking agenda and really look forward to your input and discussion.

This is the first of our regular bulletins to inform you of the improvements that are underway to develop clinical guidelines and update requesting and reporting of results.

Please see the attachment for more information – if you have any questions or comments about the programme, please contact us or Babar Shafiq, our TST Programme Manager ().

Very best wishes,

Dr Stuart SuttonProf Finbarr CotterDr Matthew Matson

GP Board MemberClinical Director, PathologyClinical Director, Imaging

Newham CCGBarts HealthBarts Health

Co-Chairs, TST Diagnostics Working Group

The TST Diagnostics Working Group is clinically led and co-chaired by Professor Finbarr Cotter, (Barts Health Clinical Director for Pathology), Dr Matthew Matson (Barts Health Clinical Director for Imaging) and Dr Stuart Sutton (Newham CCG GP Board Member). Dr Dinesh Kapoor (Waltham Forest CCG GP Clinical Director) and Dr Shah Ali (Tower Hamlets CCG GP Board Member) are providing strategic Primary Care input to the group to ensure each TST borough is represented.Dr Ruth Ayling (Consultant Chemical Pathologist) is providing the group’s expert biochemistry advice.

Changes to Diagnostics & Associated Guidelines

ESR testing

  • ESR testing is one of the most frequently over used tests in clinical practice and has extremely poor sensitivity for ruling out serious disease
  • Measurement of more than one marker of inflammation is generally not indicated and CRP would, in most cases, be the appropriate first line test
  • Please find attached the Barts Health Guidelines for ESR testing as well as a BMJ article outlining the evidence base (or lack of!) for ESR in clinical practice
  • With the exception of a normal result being useful in ruling out myeloma and Giant Cell Arteritis, ESR isnot recommended
  • We have included population standardised ESR and CRP request graphs for each of the three boroughs to help you identify whether your practice could look at reducing the number of inappropriate ESR tests requested and/or the number of inflammatory markers requested overall

Changes to the LFT panel – removal of GGT

  • Gamma Glutamyl Transferase (GGT) has been removed from the standard panel of Liver Function Tests
  • GGT has limited clinical value other than for potentially identifying whether an isolated rise in ALP is related to liver disease
  • GGT has a high false-positive rate and the degree of abnormality is not indicative of severity of any hepatic disease
  • Please see the attached BALLETS (Birmingham and Lambeth Liver Evaluation Testing Strategies) paper for more information

Use of ALT for statin monitoring

  • Current guidance ( advises the testing of ALT only (not full LFTs) for statin monitoring – before, at 3 months and at 12 months after starting treatment
  • ALT is now available as a separate test and should be used alonefor monitoring patients who are taking a statin

Removal of Urea from U&Es panel

  • Creatinine is the key marker for identifying and monitoring chronic renal disease in primary care
  • Newham practices have not received Urea as part of their ‘U&Es’ panel for many years, whilst in Waltham Forest and Tower Hamlets this is still automatically added to every request
  • Urea is of little clinical value in addition to creatinine in the vast majority of primary care monitoring situations and therefore we plan to remove urea from the standard U&E panel
  • Please note that Urea will still be available as a separate test outside the U&E panel where it is clinically indicated
  • Please see the ‘Best Tests’ paper below which outlines the limited role for Urea testing in primary care

iRefer Radiology Software

  • iRefer has been developed by the Royal College of Radiologists to help primary and secondary care clinicians choose the most appropriate investigation for a given clinical problem
  • The guidelines are free and can be accessed from any NHS network. There is also an app (small charge) available for iOS devices.
  • Click here: to access the guidelines free from any NHS network

Use of Ultrasound in place of MRI as first line imaging in painful shoulder

  • iRefer (as well as consensus from Barts MSK imaging clinical lead) clearly reports that ‘US is the investigation of choice in the assessment of rotator cuff and surrounding soft tissues’
  • As well as being a less time consuming or distressing investigation for patients (especially for those with claustrophobia) ultrasound is £120 cheaper than an MRI
  • We would like to suggest that, whenever considering investigating a painful shoulder, colleagues should consider an US (+/- Xray if indicated) as the most appropriate first line investigation

Use of TQuest for pathology requesting

  • As the work of the Appropriate Diagnostics group continues, there will be significant changes to TQuest to support clinicians to easily identify the most appropriate first line tests – with plans for additional links to evidence based resources and prompts
  • The uptake of TQuest across Tower Hamlets is high but usage across Waltham Forest and Newham is more variable – as a result your local clinical leads will be working closely with practices to support you to implement TQuest requesting within your practice
  • Use of TQuest hugely reduces the administrative workload in the pathology laboratories and improves the accuracy of transfer of results to the correct clinician and is therefore a win-win for both primary care and Barts Health!