The scope of perioperative medicine

Perioperative medicine describes the practice of patient-centred, multidisciplinary, and integrated medical care of patients from the moment of contemplation of surgery until full recovery (Reference Grocott and MythenGrocott & Mythen, 2015). This encompasses the three stages of surgical care: preoperative, intraoperative, and postoperative.

This definition covers a wide range of patients with many different conditions, ranging from a low-risk, young, healthy person undergoing minor surgery in an ambulatory care setting to a high-risk older person with multiple co-morbidities undergoing major and complex surgery.

Perioperative care also involves a range of settings and disciplines. For the purpose of this chapter, it is taken as encompassing the period after a person with a possible surgical condition is referred to hospital by a primary care provider or ambulatory specialist, through traditional perioperative care, most commonly undertaken within a hospital, to their discharge and full recovery, as shown in Figure 8.1.

Figure 8.1

Patient pathway for elective surgery

Source: Authors’ compilation

Historically, the care provided to the surgical patient has been focused on the type of procedure being undertaken and the immediate recovery period, under the responsibility of an individual practitioner, a surgeon. It has typically been viewed in isolation from other elements of the patient’s experience, with little coordination and communication either within or beyond the hospital setting. However, reflecting a number of emerging factors that will be explored in this chapter, this model of care is being transformed to one that is individualized, coordinated, and delivers high quality care centred on the needs of the patient. This is particularly the case for high-risk patients with complex medical and social needs, undergoing major elective or emergency surgery. A major driver of the evolving model of perioperative care is the fact that patients with significant co-morbidities are increasingly being referred for surgical treatment. In the past these people would have been considered too high risk, or would have had a shorter life expectancy as a result of their medical conditions.

Over the last 10 to 20 years there has been a paradigm shift in the way that surgical patients are managed, driven by a mix of wider societal and clinical factors. During this time demand for surgery has risen considerably. According to OECD data, for example, in Denmark the rate of hip replacements was 140 per 100 000 population in 1996 but rose to 215 per 100 000 population in 2010 (OECD, 2015). A similar increase was observed in other western European countries, such as the Netherlands, but the increase was more pronounced in some of the southern European countries such as Greece, where it rose from 33.6 per 100 000 population in 1996 to 152 per 100 000 population in 2010.

During this time productivity has increased, driven in part by the increase in day-case surgery. The average length of stay (ALOS) (all causes) decreased across many European countries between 2000 and 2010. For example, the decline in the Netherlands was from 8.5 to 5.6 days, in the United Kingdom from 9.5 to 7.4 days, and in Greece from 8 to 6.6 days.

There is, however, considerable inter-country variation in length of stay. For example, the ALOS (for all types of patient) in Sweden was 15% lower than in the United Kingdom in 2011, with France having an ALOS 20% lower and Norway 36% lower. There are many reasons for this, reflecting different health system structures, organizations and economic contexts; however, the variation suggests that there may be opportunities to reduce length of stay in some settings, thereby potentially increasing productivity and making better use of available capacity. For example, widespread uptake of enhanced recovery programmes which combine a range of techniques to facilitate early discharge, and improvements in surgical techniques and care pathways which allow ambulatory surgery to be performed, both have the potential to dramatically impact productivity and efficiency. The impact of these changes could be significant; if ALOS in England fell by 15% by 2023, for example, with no further reductions in beds and all other things being equal, the NHS could treat around 18% more acute patients than it did in 2013/14 – an average annual increase of around 1.6% (Reference AlderwickAlderwick et al., 2015). However, as the cost of a patient recovering in a hospital bed is much less than that of undertaking a surgical procedure, the total cost would increase, possibly substantially.

Currently about 10 million patients undergo a surgical procedure in the English NHS each year, with consistent rises year on year, with a 27% increase seen in the number of surgical admissions between 2003/4 and 2013/14 (Royal College of Surgeons of England, 2017). The cost of elective (non-emergency) surgical care to the system is £16 billion (€20 billion). Out of these, around 250 000 patients are characterized as high risk (see below for a discussion of risk), representing 15% of all those who require inpatient surgical care and 80% of post-operative deaths (Royal College of Anaesthetists, 2016). Much of this risk is due to pre-existing long-term conditions and complex care needs, with the number of people living with multiple long-term conditions increasing steeply with age (Reference BarnettBarnett et al., 2012) and thus growing with an ageing population. For example, the 1.25 million people in the United Kingdom aged 85 or older are expected to treble in number over the next 35 years, and across Europe to rise from 5.1% of the population in 2014 to 12.2% by 2070 (Reference WilkinsonWilkinson et al., 2012; Eurostat, 2017). In England the number of people with multiple long-term conditions was expected to reach 2.9 million out of a population of 53 million by 2018 (5.5%) (Department of Health, 2012).

Improvements in perioperative management and surgical techniques have increased the numbers of people with pre-existing conditions deemed eligible for surgery and have, paradoxically, also been driven by the need to reduce the risk of complications. However, in many countries there is evidence of implicit ageism, with older people less likely to receive surgical interventions (Reference MarguliesMargulies et al., 1993). For example, a 2014 report showed that in England there was a 37-fold difference in rates of breast excision in patients with breast cancer over the age of 65, depending on where they live (Royal College of Surgeons & Age UK, 2014). This has led to calls to focus on physiological rather than chronological age (Reference KowdleyKowdley et al., 2012). However, among those who do receive surgery, older physiological age may be associated with a greater risk of complications which, when superimposed upon their already compromised physical state, mean that they may experience significant reductions in survival in the medium and longer term, and in their ability to return to their pre-operative function. Consequently, it is increasingly important that the scope of perioperative care extends beyond the immediate period of recovery from the acute effects of surgery.

This calls for a model of care that extends across specialties and professional groups and over time. Although the concept of perioperative medicine has been in use for more than a decade, until recently it has been applied only in a few selected areas and, even then, often incompletely. One area where it has been used is in cardiac surgery, where many facilities have established mechanisms to deliver efficient, multidisciplinary, patient-centred care. In contrast, most surgical specialties lack a unified approach to the prevention and management of perioperative surgical, medical, psychological, and social complications.

This is changing, with new models of perioperative care that emphasize improvement and consistency of outcomes for patients after surgery (Reference Kehlet, Delaney and HillKehlet, Delaney & Hill, 2015). These are fundamentally multidisciplinary, led by professionals who can take a system-wide approach and who can be drawn from a range of medical specialties, but most often anaesthesia, surgery, geriatric or internal medicine. This chapter will explore these models in detail and suggest opportunities and barriers to their future development.

The role of perioperative care

Perioperative medicine aims to deliver the best, multidisciplinary, person-centred care before, during and after surgery. There is a natural tendency to focus on major surgical interventions for the highest risk patients; however, the evolving models of care can be of benefit to the entire surgical population. As the vignettes in Box 8.1 reveal, there is huge variation in the perioperative care provided.

Perioperative care is often poorly coordinated, with weak systems of communication, focused on the individual practitioner and existing organizational structures. At worst, vital information about the patient is not shared between practitioners, resulting in untimely or delayed care and errors. Also, patients may undergo procedures in circumstances where they have not been made fully aware of the implications, resulting in dissatisfaction, poor outcomes, and a worsening of their general health status. However, where good perioperative medicine exists, the care provided is focused on the needs of the patient, employing individualized care pathways. The care is well coordinated and timely, and patients share in the decision-making process. Models of care vary (as explored below) but have common themes:

• Multidisciplinary: involving doctors (both primary and secondary care), nurses, allied health care professionals, such as physiotherapists, occupational therapists, speech and language therapists and dieticians, social workers and administrative staff.

• Crossing organizational interfaces: particularly primary care, secondary care and social care (Reference JohnsonJohnson et al., 2013).

• Well led: this could be by doctors from different specialties, including anaesthesia, surgery, acute medicine, cardiology, geriatrics and others. Most commonly, anaesthetists lead perioperative teams since they are the most numerous hospital specialty and their current training model makes them natural candidates to do so. However, the interdisciplinary nature of good care means that there should be an emphasis on deploying the skills and expertise available in order to achieve optimal patient outcomes.

• Robust communication: through the provision of a single point of contact for patients, surgeons and primary care providers, facilitated where possible by technology that enables the secure collection and exchange of patient data.

• Evidenced-based with continual improvements in quality driven by robust audit data.

• Patient-centred: respecting patients’ autonomy, listening to and respecting their wishes, and keeping them informed and involved with their care are the key tenets of patient-centred care which is now widely seen as an essential component of gold standard practice (Reference Epstein and StreetEpstein & Street, 2011). This model of care is gradually superseding its antiquated predecessors – doctor- and disease-centred care – and represents a paradigm shift from the patriarchal style of medicine which was practised for much of the 20th century.

• Using appropriate technology: at present the majority of perioperative care is delivered in a visit-based system with the patients travelling to a hospital/clinic to be reviewed by the health professional who provided the index treatment. With the rise of digital health platforms and the ever-increasing availability of technology, there is potential for increasing amounts of perioperative care to be delivered remotely in a home-based system.

Multidisciplinary assessment and optimization – models of care

Care bundles – enhanced recovery

In recent years enhanced recovery programmes (ERP) have become increasingly popular, with a substantial body of evidence demonstrating their ability to improve post-operative outcomes and to reduce length of stay. Common components of ERP include pre-operative counselling, planning, and nutrition, usually delivered in an outpatient clinic setting, and after the patient has been admitted to hospital intra-operative management such as guided fluid therapy, maintenance of normothermia (a normal state of temperature) and use of minimally invasive approaches. Post-operatively, initiatives such as early mobilization, prompt resumption of normal diet, innovative analgesic techniques and proactive discharge planning are employed.

Enhanced recovery after surgery (ERAS) for colorectal surgery was first described by Professor Henrik Kehlet in Denmark during the 1990s (Reference FearonFearon et al., 2005). The principles of this programme are shown in Figure 8.2. Subsequently the same elements have been applied to other surgical specialties, including orthopaedics and gynaecology, and have developed into the international ERAS society with centres of excellence in Canada, Denmark, France, Spain, Sweden and the United Kingdom.

Figure 8.2

Components of enhanced recovery after surgery (ERAS) pathway

Note: NSAIDs: non-steroidal anti-inflammatory drugs

Source: Recreated from Dorcaratto, Grande & Pera, 2013

There have been several studies showing improved outcomes, such as length of stay and morbidity, when ERAS is used (Reference AdaminaAdamina et al., 2011). Despite this body of evidence, uptake of the programme and adherence to its principles have been relatively low; patient-, staff- and practice-related factors as well as a lack of resources have been suggested as potential barriers to entry which must be overcome if widespread implementation is to be achieved (Reference Segelman and NygrenSegelman & Nygren, 2014). Furthermore, there is a paucity of evidence on the effect of ERAS on patient-related outcomes such as quality of life and cost-effectiveness, and furtherresearch is indicated in these areas to quantify the true value of ERAS and other ERPs.

Research on post-operative outcomes in orthopaedic patients after use of ERPs has been promising; however, there is a wide variation in the components of the programmes evaluated, with substantial variations in results (Reference IbrahimIbrahim et al., 2013). Development and widespread implementation of a standardized enhanced recovery protocol would help in disseminating best practice. Reference StowersStowers et al. (2014) suggested a protocol for enhanced recovery after hip and knee arthroplasty described in Table 8.1 below, which shares many features and principles of the ERAS protocol for colorectal surgery while being tailored towards the needs of patients undergoing orthopaedic surgery.

Table 8.1A proposed enhanced recovery protocol for elective total hip and knee arthroplasty

Pre-operative care

Education, and expectation management Discharge planning by MDT, e.g. occupational therapist and social worker Nutrition screening using the Malnutrition Universal Screening Tool, with appropriate referral to dietician as required Premedication: cyclo-oxygenase-2 selective inhibitors, gabapentin, dexamethasone

Intra-operative care

Spinal anaesthesia + regional (femoral/saphenous) nerve block or high-volume local anaesthetic Liberal perioperative intravenous fluids Intravenous prophylactic antibiotics for 24 hours Tranexamic acid Avoidance of surgical drains

Post-operative care

Early ambulation Early intensive physiotherapy Aspirin, thromboembolic deterrent stockings, and intermittent pneumatic compression devices for venous thromboembolic prophylaxis (for those at low risk) Multimodal, opioid-sparing analgesia regimen

Source: Recreated from Reference StowersStowers et al., 2014

Ambulatory surgery

Over the past 20 years there has been a significant increase in productivity driven by the rise in proportion of operations performed as ambulatory cases. Since 2005 England has employed financial incentives to switch to ambulatory surgery, driven by the rollout of a system of payment by results (PbR) for all elective procedures. As day-case patients cost less to treat than patients who stay overnight as inpatients (in 2013/14 the average day-case cost was £698 (€872) and the average inpatient-case cost was £1367 (€1708)), the increasing number and proportion of day cases has helped to reduce overall costs per case. In effect, by treating more patients as day cases, by 2013/14 the NHS had saved around £2 billion (€2.5 billion), equivalent to an average saving over the 15 years since 1998/9 of around 1.4% per year of the total spend on elective day and inpatient care (Reference ApplebyAppleby, 2015).

Several other factors have facilitated the shift towards day surgery including: cultural change, availability of regional anaesthesia, faster-acting anaesthetic, analgesic (pain-killer) and antiemetic (anti-sickness) drugs, organizational improvements, i.e. day-case units, minimally invasive surgery, and changing patient expectations.

Workforce

Barriers to delivery of perioperative care

There is a projected shortfall of physician anaesthetists, as well as other specialties. In the United Kingdom changes to medical and nursing training has resulted in a deficit of applications for training posts, meaning that some roles within the perioperative team are left unfilled. This threatens the sustainability of the workforce and poses safety challenges in terms of rota gaps, unmet service need, and increased requirement for locum or ad-hoc positions. Recently, there has also been difficulty filling positions for higher training in anaesthesia (http://www.rcoa .ac.uk/news-and-bulletin/rcoa-news-and-statements/rcoa-links-low-fill-rates-inadequate-supply-of-trainees). However, this situation may offer an opportunity for the design and implementation of new models of care (as discussed below) and improved patient outcomes.

Good quality perioperative care transcends traditional organizational forms and systems. For example, patients will often be cared for by their primary surgical team in conjunction with other medical and non-medical specialists in primary and secondary care. This demands good communication. Due to difficulties sharing information in health systems, however, information is often not passed on or made available when it is required. This can lead to replication, waste and, at worst, error. In addition, further barriers to the provision of good quality care, as with other health care settings, include inter- and intra-provider variation, processes lacking reliability, and lack of standardization. Addressing these issues is best done using improvement science principles (see below).

The future

Health care systems are facing challenges from the ageing population with a greater prevalence of chronic co-morbid conditions, and the opportunities to intervene provided by advances in medicine. However, with these challenges comes the opportunity to innovate and implement transformational change to the way that we deliver perioperative care. Consideration also needs to be given to the appropriateness of costly, complex surgical therapies, and whether centrally funded health care systems should be expected to provide these with the possible consequence of less available resources for more established therapies with proven cost-effectiveness. Policy-makers have a responsibility to engage with the public in discussion, and as a society, in order to determine where each health care system’s priorities lie within a cost-constrained environment.

For the vast majority of patients undergoing a surgical procedure, the episode is uncomplicated with good outcomes. However, increasing numbers of patients are being exposed to greater risk through a combination of their pre-existing condition, the surgical treatment itself, or issues regarding the delivery of care. The development of the perioperative care model offers a solution that can optimize the chances of a good outcome, particularly for high-risk patients.

Excellent perioperative care is, in part, already being offered in an individualized manner with the ability to draw on expertise and resource, as and when the patient needs it. This is described in Figure 8.3.

Figure 8.3

Individual perioperative care pathway

Notes: CPET: cardiopulmonary exercise testing; MDT: multidisciplinary team; GDFT: goal directed fluid therapy; PACU: post-anaesthesia care unit; QI: quality improvement

Source: Authors’ compilation

There are a number of enablers to the provision of quality, coordinated perioperative care including: technology, research and improvement science, and improved models of care.

The scope of imaging

Radiology is constantly evolving in its clinical application, playing a central role in numerous patient pathways in health care. Advances in sophisticated technologies have extended the scope of its application to every organ, offering not only essential services in diagnosis, monitoring treatment, and predicting outcomes but more recently therapy in the form of interventional radiology. The result of these developments is that the volume of activity is continuing to grow in all imaging techniques (often referred to as imaging modalities).

The term “imaging” encompasses a number of diagnostic tests, some of which may be performed outside a radiology department. There is great variation among countries and by specialty in how these processes are undertaken and where.

Imaging was originally founded on the plain X-ray. Despite the development of newer techniques towards the latter part of the 20th century, the plain X-ray still plays an important role in diagnosis (although its role is often to rule out pathology, rather than for primary diagnosis) and its uses continue to grow. However, the newer modalities of ultrasound, CT and MRI are increasing at a more rapid rate. Figure 9.1 shows the increased activity in England in the last 20 years. This demonstrates a 3.6% compound growth in the last five years.

Figure 9.1

Total number of imaging and radiodiagnostic examinations or tests, by imaging modality, England, 1995–96 to 2013–14

Source: NHS England Annual Imaging and Radiodiagnostics Data, 2014

Major growth can be observed in the more complex cross-sectional imaging techniques, with compound annual growth rates (CAGR) in the last 10 years of 10% for CT and 12.3% for MRI (see Table 9.1). There is slightly less growth recorded in ultrasound at 5.3%, but this may be an underestimate as a significant amount of ultrasound is now performed outside imaging departments and would therefore not be recorded in these figures.

Although these figures are specific for England, a similar picture is seen throughout Europe and internationally. This growth is significantly in excess of that expected by demographic drivers and is predominantly due to the increased reliance on imaging particularly in areas such as cancer, vascular conditions (including stroke and cardiac disease), and trauma.

As well as the established diagnostic techniques, imaging continues to expand at pace particularly focusing on the concept of molecular imaging utilizing ultrastructural diagnostics, nanotechnology, and functional and quantitative diagnostics. The main example of this in current practice is the use of fusion imaging, which combines the structural information gained from CT (or MRI) with the functional information from positron-emitting radiopharmaceuticals in the form of positron emission tomography fused with computed tomography (better known as PET-CT). The result is the depiction of the spatial distribution of specific metabolic or biochemical activity with clear anatomical localization.

This improved image clarity and tissue differentiation in a number of situations has dramatically increased the range of diagnostic information, in many cases providing increased confidence in terms of underlying pathology. These fused images are vital tools in a number of clinical areas, notably cancer diagnosis and treatment, but they are also used in neuroimaging and cardiac imaging (Box 9.1).

One of the most significant changes in radiology in the last 20 years has not come from developments in imaging techniques. Rather, the technological advances in information technology (IT) have had a major impact on the way that radiology is currently practised. The days of viewing X-rays on sheets of film are in the past. These days, when images are acquired, they can be post-processed, manipulated and also transmitted rapidly not just within a hospital but also anywhere in the world as soon as they have been acquired. This technology, referred to as picture archiving and communication systems (PACS), has challenged the traditional model of patient, scanner and radiologist all located in the same site (Box 9.2). Images can now be reviewed and reported from remote locations, opening up options for different delivery models.

So far in this chapter, the emphasis has been on the diagnostic role of imaging. However, imaging can also be used to guide therapy, a specialty referred to as interventional radiology (IR) (Box 9.3). This is now established as an alternative to conventional surgery in numerous conditions, offering less invasive alternatives with improved outcomes, safety, and cost-effectiveness, as well as more patient-focused care. As such, IR is a vital component of hospital medicine, providing life-saving care, both in and out of hours. IR services have replaced or enhanced many surgical procedures as well as allowing new treatments for patients which were not previously feasible. Interventional radiologists are part of the multiprofessional teams treating a wide range of pathologies and working closely with surgical colleagues.

The interconnections of imaging in the hospital setting

Imaging plays a significant role in most hospital-based specialties. The exact workload of an imaging department depends, to a certain extent, on the clinical specialties available within the hospital (e.g. neurosurgery, oncology).

In UK hospitals, A&E and general practice (direct access) are the specialties with the highest radiology demand, followed by Trauma and Orthopaedics, and this makes up approximately 50% of the activity. There is further demand from other specialities such as general surgery, general medicine, obstetrics and gynaecology, rheumatology, geriatrics, gastroenterology, cardiology, thoracic medicine, vascular surgery, ophthalmology, ENT, neurosurgery, neurology, paediatrics, oncology, psychiatry and intensive care.

The model of imaging provision varies throughout Europe. In many countries the hospital-based imaging department remains the main provider of imaging for emergency and urgent care, as well as planned care and community services. As discussed in the next section, in some countries the demand from primary care and from office-based practice is met by imaging services based off-site from acute hospitals.

In looking at new models of delivery, it may be more useful to consider where imaging plays a role in patient pathways and at what stage in this pathway imaging is best accessed. Table 9.2 is not exhaustive but lists the more common pathways and presentations relying on imaging.

Diagnostic radiology does not just offer an image acquisition and reporting service. Radiologists work closely with their clinical colleagues to ensure that patients get the most appropriate investigation and that the interpretation of the report is understood in relation to the clinical context. In this role, the radiologist plays an important part in the MDT approach to patient care, which has been acknowledged as a significant factor in improving outcomes, particularly in cancer care (Reference MorrisMorris et al., 2006; Reference StephensStephens et al., 2006; Reference CooryCoory et al., 2008). This has led to the development of MDT meetings where clinical radiologists (who usually lead the meetings) with their diagnostic pathologist colleagues work alongside their clinical colleagues to decide the correct clinical plan for each patient. These diagnostic specialists aid surgeons and oncologists in developing appropriate care plans based on the staging of the cancer. In this function it is now common for the biopsy of the primary tumour to have been performed by a radiologist under imaging guidance aided by the pathologist’s interpretation. Figure 9.2 illustrates the extent of these MDT meetings in a typical large hospital.

Figure 9.2

Multidisciplinary team meeting (MDTM) participants

Source: Royal College of Radiologists, 2012

IR also interacts with a large range of clinical services, as illustrated in Figure 9.3. The patients treated by interventional radiologists may be inpatients on wards in the hospital, but more frequently are treated as day cases. Larger imaging departments may have their own day-case facilities, but if not, the IR service needs access to such a resource.

Figure 9.3

Interventional radiology interactions with hospital departments

Source: Royal College of Radiologists, 2014

Links with services outside hospitals

Patients access imaging services from a number of different situations, including:

• hospital inpatients

• outpatient services based in hospitals

• consulting rooms outside hospitals

• primary care doctors/health care professionals

• self-referral.

Imaging activity referrals from outside the hospital setting are increasing significantly. This is influenced by a number of factors including a drive to earlier diagnosis of conditions such as cancer and heart disease (Independent Cancer Task Force, 2015), as well as the increasing capability to support patients to manage their health care outside the hospital. In areas such as plain X-ray and ultrasound the workload from primary care can often amount to over 50% of the imaging activity.

Although imaging is usually thought of as a tool to confirm a diagnosis, it is important to emphasize the role of the negative test in excluding significant disease. In many pathways early access to imaging can avoid unnecessary hospital outpatient appointments and, more importantly, unnecessary hospital admissions.

In many European countries there is direct access to imaging from primary care for all main modalities (i.e. CT, MRI, ultrasound and plain X-ray). This applies particularly to the field of musculoskeletal problems where there is high demand for MRI in the management of back pain and joint pain.

There are varying delivery models across Europe to meet these demands. In some countries the hospital imaging service also provides imaging services for referrals from outside the hospital, while in other countries much of this activity is provided in centres located outside hospitals either linked to or independent of the hospital departments. These centres may also provide services for “outpatient” imaging from specialists who work in office practice, notably in insurance- or private-based health care systems.

Workforce

There are two main clinical professions that deliver imaging in Europe: radiologists and radiographers.

A radiologist is a doctor who is also an imaging expert with specialized training in obtaining and interpreting medical images. As mentioned already, radiologists can also treat diseases by minimally invasive, image-guided surgery (interventional radiology). Like other doctors, a radiologist must first qualify as a doctor from an accredited medical school and spend a variable period in clinical practice. Following this, they will undertake further postgraduate training before qualifying as a radiologist (usually for a further five years in most European countries).

A radiographer (or medical imaging technologist) is a trained health professional whose primary role is to produce medical images that assist radiologists and other doctors to diagnose or monitor a patient’s injury or illness. In most European countries they have undergone training at degree level or equivalent followed by in-post further subspecialization. Some radiographers extend their role beyond that of image acquisition. This practice is more common in the United Kingdom than in most other European countries. Such activities include interpretation of ultrasound tests, mammography screening, and trauma plain film reporting.

A smaller workforce of nurses, health care assistants, and physicists as well as administrative and clerical roles supports these two professional groups. The development of PACS is creating a key role for IT support.

The legislative and regulatory framework varies, particularly with ultrasound. For example, in many countries (including the United Kingdom), radiologists have little involvement in performing and interpreting obstetric ultrasound. The obstetric ultrasonographers may be radiographers who have trained specifically in this practice, but may also be obstetricians and midwives.

A similar picture can be seen, to varying degrees, in other specialties where clinicians have acquired their own ultrasound equipment and provide a focused ultrasound service to support their specialty interest, e.g. urology, orthopaedics, or vascular surgery. This practice is most advanced in cardiology, where the cardiologists have developed their own expertise to acquire and interpret images as well as carry out interventional procedures under radiological guidance. In the United Kingdom, for instance, the term echocardiography refers to ultrasound of the heart and is usually performed within the cardiology department by separately trained technicians under the supervision of cardiologists, while cardiologists, rather than radiologists, often report CT and MRI of the heart and great vessels. This may be carried out on separate dedicated scanners in large centres, but more commonly the radiographers in the main imaging department acquire the images.

Existing barriers to delivering optimal imaging services

As the role of imaging has gained greater importance in health care, there is a real challenge to respond to the increased demand due to a number of factors, which has led to significant variation in the use of radiology in Member States across Europe. Figure 9.4 illustrates the variation in CT and MRI activity across Europe.

Figure 9.4

MRI and CT exams per 1000 population, 2015 (or nearest year)

Source: OECD (2018)

The following challenges and barriers are thought to be the major influences on the current usage and effectiveness of imaging in Europe.

Workforce issues

The marked growth in imaging activity in the last 10 years has been met with differing degrees of workforce expansion across Europe, but in most countries the increase in radiologists and to a lesser extent radiographers has lagged behind the growth in activity. The situation is most acute in those countries that started from a low base of radiologist per head of population. Figure 9.5 illustrates the variation in a number of European countries.

Figure 9.5

Number of inhabitants per radiologist, 2011 (including residents in training)

Source: Kamalasekar, 2011

The situation with radiographers is not as acute, although in the United Kingdom, for instance, radiographers and ultrasonographers are included with radiologists on the government shortage occupational list for immigration purposes. This situation is mitigated somewhat by the United Kingdom approach to skill-mix, described earlier.

This shortage of radiologists is further compounded by the fact that they have developed additional roles, for instance in interventional radiology, the performance of biopsy techniques, and in their role in the MDT mentioned earlier. A recent survey from the European Society of Radiology found that 58% (out of 31 respondents) reported having too few radiologists for their current needs and 55% (out of 30 respondents) replied that they would not have enough radiologists in training to serve their respective nations.

In addition, there has been a drive to subspecialization with the increasing complexity of imaging techniques. This is creating a real challenge, particularly in smaller hospitals/services where it is proving increasingly difficult to provide an expert specialized opinion over seven days a week, throughout the year. Networking between hospitals is seen as a partial solution to this.

Equipment

There is also considerable variation in the equipment base across Europe. This is illustrated in Figure 9.6, which compares the provision of CT and MRI scanners in a number of European countries and international comparators.

Figure 9.6

Scanner equipment per million people in selected OECD countries, 2015 (or nearest year)

Source: OECD (2018)

The international economic crisis has coincided with the recent rapid increase of imaging activity described earlier. This has significantly constrained the previous regular turnover of imaging equipment, resulting in a higher than usual amount of aged equipment, at a time when technological developments continue. This is leading to increasing levels of obsolescence.

This slow-down in equipment replacement is not only the direct result of shrinking budgets, but also the consequence of adaptive strategies leading to better use of resources. Radiology, based on highly technical hardware and diagnostic pathways, offers a fertile ground for workflow standardization resulting in productivity gains. Efficiency plans focus on a variety of measures including: merging of departments/hospitals, sharing of equipment, closing down excess capacity, policies for equipment upgrade, patient throughput optimization, and extension of opening hours. New equipment often offers improved imaging quality and reduced radiation exposure, due to the improvement of X-ray technology or to the substitution of non-ionizing technologies (e.g. MRI).

The future of imaging services

There is no evidence that the current increase in demand for imaging services is likely to reduce in the next five years. Recent work commissioned by Cancer Research UK suggests that the current increase in demand for CT, MRI and ultrasound will continue at the current rates (Reference Cancer ResearchCancer Research UK, 2015). Although there is less reliance on plain X-rays in certain areas of medicine, trauma and orthopaedics will continue to rely on skeletal plain films while the chest X-ray is unlikely to reduce in usage.

Research into the effectiveness of screening in ovarian and lung cancer will shortly be published. It is likely that this will suggest the introduction of screening programmes for at-risk patients. In lung cancer this would result in a further marked increase in CT of the chest.

One of the limiting factors to the expansion of the use of CT has been the risk of repeated radiation exposure, but the new generation of scanners has markedly reduced radiation levels. This is one of the drivers behind calls to evaluate lung cancer screening programmes and is likely to increase the use of CT in other presentations.

The usage of PET-CT will further increase in the next five years, predominantly in the area of cancer management, but the role of fusion imaging is likely to expand beyond cancer. One such area of expansion appears to be in neurological conditions, particularly dementia. Other forms of molecular imaging are most likely to remain as research tools in the next five years with no immediate plans for widespread use in clinical practice.

The scope of interventional radiology continues to expand. A proportion of IR has focused in the area of vascular disease. This will continue to expand with further applications in areas such as thrombectomy in the treatment of acute stroke. There is also likely to be a further major expansion in the use of interventional image-guided therapy in cancer care. This will extend beyond its established use in symptomatic relief and palliation. There are already a number of indications for its primary use in treatment (e.g. neo-adjuvant embolization, image-guided ablation and brachytherapy, trans-arterial chemo-embolization (TACE), selective internal radiation therapy (SIRT), and isolated perfusion chemotherapy).

The implication of current and future developments in imaging for the organization, management and design of the hospital in the mid-21st century

Although some of the functions of hospitals may change in the future, the management of emergency and urgent care will remain their primary focus. Imaging will continue to play a vital role in supporting this activity, with an increasing reliance on CT particularly for trauma and the acutely ill patient.

It is therefore important that the planning of imaging facilities is part of any planning of new emergency and admission departments in order to deliver timely, safe and efficient services. Imaging will also be required in high dependency areas such as intensive therapy units, high dependency units and certain wards. Thus, great thought needs to be put into hospital design to avoid inappropriate siting or unnecessary duplication of imaging facilities with resultant unnecessary redundancies.

It is likely, therefore, that imaging will no longer be housed in one department and consideration will need to be made in terms of staffing, particularly in facilities that need to be accessible 24/7. With the challenges of workforce supply, described earlier, it is essential that the efficient flow of patients through imaging is a key consideration in hospital design.

The challenge that imaging departments face in balancing the demands of emergency and urgent care with planned care could be addressed, but this is dependent on two main factors. The first of these relates to the future role of the acute hospital in dealing with planned care, particularly in the form of outpatient facilities. If these remain on the main hospital site, then there will need to be imaging provision alongside them, particularly where the concept of the one-stop visit is to be achieved.

The second factor is the demand for access to imaging from primary care. In this situation there is no need for the patient to attend the hospital and in fact there are definite advantages both to the patient and to the hospital if such visits can be avoided. This could be achieved by further development of imaging services outside hospitals. To make these cost-effective, they may need to be centralized in diagnostic centres for modalities such as CT and MRI, while ultrasound could potentially be delivered in GP surgeries if there is appropriate demand.

If such diagnostic centres were to be developed, they would also have the potential to provide an alternative facility for hospital outpatients, particularly if the diagnostic centres had facilities for consultations and minor procedures.

All hospitals that deal with emergency and acutely ill patients need access to interventional radiology. As with radiology, this must be available 24/7. Although the emergency work will require inpatient beds with full clinical support, there will also be a demand for planned procedures which can be performed on a day-case basis. Consequently, a facility that can deliver this should be located adjacent to the interventional suite. Although all hospital emergency Should this be ‘hospital emergency departments’ or ‘hospital emergency patients’? and inpatients will need access to interventional radiology services, it is unlikely that all acute hospitals of the future will have enough demand for such work to justify their own comprehensive funded service. The solution to this will be the development of various forms of network where either the patient is transferred to the experts (or possibly the experts travel between hospitals).

For radiology to continue to play a key role in health care it must be able to respond to the workforce needs and therefore adequate provision must be made for education and training.

Likewise for imaging to continue to develop and support health care in the future, adequate provision and funding of research involving imaging is essential and this is likely to be concentrated in larger hospitals. The provision of imaging is essential to much of medical research, particularly in the monitoring of new therapies. However, there is a need to carry out primary imaging research if the true potential of new technologies is to be achieved.

At present the radiology department remains predominantly the domain of the radiologist, but this is changing and there is no specific reason why other clinical specialists trained in imaging should not use imaging facilities (if possessing appropriate skills). If the case for this is established, then a coordinated imaging resource is far preferable to the growth of isolated services often with unused capacity and challenges of equality of access.

The opportunities and barriers to making this vision of the future a reality

As imaging continues to develop, it will remain heavily dependent on appropriate levels of workforce and equipment, but IT solutions have the potential to improve the efficiency of services. There are already electronic requesting systems in existence that are linked to evidence-based resources to aid the clinician in requesting the most appropriate test first time and avoiding unnecessary investigations and delays.

There is considerable interest and research into the use of artificial intelligence (AI) in the interpretation of imaging investigations. Although this is not yet at the stage of routine practice, it is likely that this will prove significant and may eventually substitute for radiologists in certain investigations.

As radiology increases in its complexity, it will be even more challenging for every hospital imaging department to employ enough radiologists to provide a comprehensive service throughout the week. One partial solution to this is the provision of efficient comprehensive PACS systems. This opens up options for transferring images in real time to radiologists outside the acquiring hospital. If used appropriately, this can facilitate the development of networks of expertise, which will support smaller hospitals and enable them to provide appropriate comprehensive services in a timely fashion. This can be particularly effective in the emergency situation, avoiding onerous rotas for small numbers of radiologists. An example where PACS can be used to provide support to such hospitals is that commonly seen in neuroradiology where a hub and spoke model often exists, with neuroradiologists supporting local radiologists with second opinions. There are also examples of network solutions where a group of subspecialized radiologists provide a service across a number of hospitals. In the emergency situation services now exist that offer radiologist reporting “out of hours”, removing the need for onerous on-call rotas for the local radiologists.

These solutions will not overcome the need for a significant increase in the radiologist workforce, but will help to ensure the effective use of radiologists.

There is an obvious need for this subspecialization radiological expertise within the hospital setting to provide expertise to the various clinical specialties that imaging supports. However, a great deal of radiology provision to primary care is of a relatively general nature and it will be important that adequate expertise remains to deal with this relatively large workload in a timely manner. Thus it will be important that radiology departments ensure that the development of subspecialization does not leave this important element of their work under-provided for. This is an area where the extended role of the radiographer may be a solution in some areas, particularly in the interpretation of the plain X-ray and in the performing and reporting of general ultrasound by sonographers. Some of their current work may be replaced by non-radiographer technologists working under their supervision.

Another challenge already mentioned is appropriate levels of imaging equipment. As there will be an increase in competition for space in existing hospitals, PACS also offers the solution to consider locating imaging equipment off the main site. This equipment, if sited effectively, could give better access to patients who do not require hospital facilities (e.g. outpatients and primary care patients). By decanting this work off the main site, it could have the added benefit of improving efficiencies in delivering inpatient imaging support.

Another issue to be considered, particularly in cross-sectional imaging (CT and MRI), is the increase in obesity in the European population. This has added another challenge to manufacturers who now have to consider increasing both the size of the machines and their weight limitations to accommodate the increasing number of patients who would not physically fit in the traditional scanners.

Finally, whatever innovative solutions are explored, these will not be effective unless an appropriate funding system is in place. This is obviously challenging in the current economic climate; however, there is no doubt that inadequate or inappropriate funding mechanisms have the potential to significantly hold back the effective use of imaging in the hospital of the future. It has to be realized that in many circumstances effective imaging services will deliver higher quality health care with efficiency savings elsewhere in the system, for example in reduced length of stay, avoidance of hospital admission, and reduction of unnecessary outpatient appointments.

Thus, it is essential that imaging services are an integral part of the planning of the hospital of the future to ensure that resources are used effectively and the potential improvements in both quality and efficiency of patient care are realized.

Introduction

Advances in laboratory medicine are happening at an uneven rate. On the one hand there has been a rapid expansion in innovative rapid molecular diagnostic techniques, but on the other hand translation into clinical impact has often been slow. Pathology services in many parts of Europe are undergoing modernization and reform but in some places this can be slow and patchy.

In this chapter, the terms pathology and laboratory medicine are used as synonyms to indicate cellular pathology, microbiology, virology, chemical pathology, immunology and haematology, molecular pathology, genetics and histocompatibility, and other laboratory-based medical specialties. As important as it is diverse, pathology is poised to become a key medical specialty, central to the development of stratified and personalized medicine, but it needs to overcome several challenges, not least the huge increase in complexity of tests, demand for digital data, the expectation of ever-reducing test costs, and shortages of trained staff. These issues as they impact upon European pathology are outlined with some specific national case studies.

The points below illustrate some of the emerging trends:

• An unprecedented velocity of technological advance. Pathology services will continue to lead the transformation of medical care through, for example, genomics, proteomics, tandem mass spectrometry, and microarrays. These advances will have significant impact not only in the delivery of diagnostic and therapeutic services, but also in the workflow and ethos of patient care. Advances in technology, however, come at increased costs to organizations and health care consumers.

• Self-testing and near-patient testing will proliferate. In parallel with advances in large-scale technology within laboratories there will be a proliferation in self-testing and single use devices to perform pathology tests outside the laboratory. The accuracy and reliability of these devices need to be vigorously examined, and capturing and storing the data generated by these devices might be problematic. There is a need to coordinate results from self-testing and point-of-care devices with the results from formal laboratories. The increased use of “wearable IT” with a health care purpose will raise expectations for seamless transmission of information to and from patients, and primary and secondary care providers, including pathologists. However, these devices, part of the “Internet of things”, raise concerns about data security, including both unauthorized access and commercial exploitation by software providers. Resolution of the confidentiality, privacy and security concerns will be led by patient or consumer demand.

• Increasing collaboration and partnership is key. Greater interdisciplinary contact within medical specialties and subspecialties and between organizations is an inevitable consequence of the requirement to ensure high quality. For example, an integrated diagnostic service between pathologists and radiologists could speed up diagnoses, increase accuracy, and improve patient outcomes. Ensuring that pathology services are adjacent to clinical teams will be important to minimize risks to patients, but there is a need to understand better the options for remote working arising from videoconferencing and telepathology so that the right balance is achieved between clinical adjacencies, reducing unnecessary specimen transport, and achieving economies of scale.

• Digital pathology is a disruptive technology. This development has great potential to make pathologists’ working lives more efficient, facilitate intra- and inter-departmental consultations, improve the efficiency and documentation of research, and enhance education and training. However, the adoption of digital pathology requires resolution of some longstanding issues. The time taken to scan slides, the significant storage required for the images, the capital cost of slide scanners and the variable costs associated with storage space, and sufficient data security will all need to be addressed as a priority.

• The laboratory is a translational environment. For example, as clinical genomics moves from research to a routine diagnostic, prognostic and predictive method, this presents numerous challenges in terms of sample processing, quality control, and service developments in management and reporting. The knowledge base of pathologists trained and experienced in traditional methods will be tested by the need to provide and interpret the new reports. It is difficult for established pathologists, mostly based in traditional laboratories that do not provide the new tests, to add interpretation of these new tests to their repertoire. This may well require a new approach to learning which can integrate knowledge of clinical genomics into everyday practice. The implementation of new technologies tends to follow the Gartner Hype Cycle (Figure 10.1).

Figure 10.1

Gartner Hype Cycle

Source: Gartner, 2015

What do these advances mean for the role of the hospital in the future?

Laboratory medicine is the bridge between analysis and interpretation of clinical data and care delivery. Pathologists order, conduct, and interpret the results of hundreds of individual tests to support clinical decisions that enable good patient care. The laboratory’s role as a centre of diagnostics within the hospital of the future, however, may need to be redefined in the light of pressures for cost efficiencies, greater effectiveness and improved performance, and the impact of emerging technologies.

A common theme in European pathology is the quest for greater efficiency. In this respect, laboratories have looked towards increased automation to improve productivity and meet increased demand. Automation of the laboratory can lead to better task integration and quicker turnaround times. The argument follows that patients benefit as quicker clinical decisions can be made with the potential to shorten hospital stays.

Across Europe the modern laboratory environment is increasingly being organized to create networks based on large consolidated centres (hubs) and smaller local testing centres (spokes). A key driver for service reconfiguration has been cost pressures. In some countries laboratories face a bleak ultimatum: restructure or lose all your work. The key question, as Lord Carter put it in his Review of NHS Pathology Services in England (Reference CarterCarter et al., 2008), “What is the right level of consolidation?”

Another driver for change is the desire to reduce variation of diagnostic tests across countries both in test investigation costs and the over/under-requesting of tests. The United Kingdom Atlas of Variation, for example, shows that cancer patients who received an early-stage diagnosis – a critical factor in treatment outcome – ranged from 22.7% to 60.8% between the United Kingdom’s best- and worst-performing areas (Public Health Reference EnglandEngland, 2015).

Major advances in diagnostic laboratory medicine may be disruptive, as technical advances have the potential to provide a more efficient and cost-effective pathology service. For example, molecular diagnostic technologies are being utilized in a wide range of medical specialties including genetics, infectious disease, oncology and haematology. Their advantages have been well documented and allow for the simultaneous sequencing of many millions of individual DNA molecules. Using this technology, pathologists and researchers are provided with increased sensitivity and specificity for the detection of abnormal DNA in solid tissues and body fluids, as well as a wide range of metabolites and signalling molecules and immune system responses to drug therapies. Technological innovation in pathology appears to be accelerating the paradigm shift to precision or stratified medicine, an approach that takes into account individual variability in genes, environment, and lifestyle for each person.

A plethora of other technological advances are impacting on the pathology laboratory, including liquid and gas chromatography and plasma mass spectrometry, conventional and next-generation sequencing, point-of-care testing (POCT) and “lab-on-chip” devices prompted by miniaturization of molecular assay steps, biochips and microfluidics, and digital pathology systems which allow the scanning, imaging, and storage of histological slide data for analysis by pathologists.

The adoption of these emerging technologies across Europe, however, is varied and this is a fundamental challenge for pathology. The impact of new technologies on the hospital in the future will be difficult to predict but tough to ignore in terms of investment decisions. Technology has provided pathology with a unifying narrative and the vision of the laboratory as an aggregate of preventative, diagnostic, predictive, prognostic, and interpretative roles will become key to the development of the future hospital.

Some of the reasons for varied adoption or “technology diffusion” include: length of time the technology has been available; a hospital’s culture of embracing innovation (e.g. a large teaching hospital may find it easier to adopt new technologies because a translational research culture pervades); at national level there could be incentives and a supportive infrastructure to speed up the rate of adoption – or conversely nothing at all; it could be that some hospitals are simply better at measuring the impact of technology adoption in terms of patient health outcomes; in the case of POCT diagnostics, it is often the case that costs are accrued in a different area from the gains. The Review on Antimicrobial Resistance (2015) provides an example where a primary care facility may invest in a diagnostic device that could reduce the number of hospital admissions. While this is desirable, the costs saved are not only hard to quantify, but the money saved might not be passed on to the facility even though it has paid for the test.

Pathology departments are increasingly presented with opportunities to form translational research networks within hospitals, universities and biomedical research centres, and with industry. Several laboratories do not have the organizational resilience to translate research technologies to a clinical environment. In turn, this may prompt the need for new workforce capabilities aligned to the most desired patient outcomes within each European country.

As an endpoint, there is growing evidence to support the emergence of “population health systems” as a means of meeting future health care needs. A population health system is defined by the American-based Institute for Healthcare Improvement (2015) as a framework for improving patient experience, improving the health of populations, and reducing the costs of health care. Approaches to population health have long been enshrined in many tax-financed health care systems, forming the basis of the purchaser/provider split in the United Kingdom, Italy and some other countries since the 1990s, and in Scandinavian countries where health care is organized by local government, but are now gaining increased traction in other parts of Europe, as identified by the United Kingdom King’s Fund (Reference Alderwick, Ham and BuckAlderwick, Ham & Buck, 2015). The Kaiser Permanente model in America is often seen as a prime innovator in this regard. Making the shift towards effective population health commissioning will require collaboration across a range of sectors and wider communities and may intensify further change for the pathology laboratory in the hospital of the future.

Where does pathology sit within wider hospital activity?

Pathology is the largest diagnostic service in hospitals as measured by the number of requests it responds to annually, in expenditure, and in the proportion of clinical decisions it affects. For example, in the United Kingdom over 50% of biochemical tests are related to chronic disease management and pathology is involved in 70% of all diagnoses made in the NHS (Right Reference CareCare, 2011). Pathology is part of the clinical governance of public hospitals and the wider health system, playing an important role in monitoring and managing disease, infectious agents, and public health.

The development of subspecialties in pathology is well developed to meet the needs of patients: cytopathology, dermatopathology, chemical pathology, haematology, medical microbiology, virology, endocrine pathology, forensic pathology, immunology, cytogenetics, blood transfusion, neuropathology, ophthalmic pathology, to name but a few. However, these subspecialties are not uniform across Europe.

Depending on the urgency of tests, pathology investigations can take place in what are often termed “hot” or “cold” laboratories. Hot laboratories process pathology tests requiring a fast turnaround and clinical support. Cold laboratories process less-urgent high volumes of routine tests. Because there is less urgency to receive the results of these tests, cold laboratories can be located further away from the patient. As the technical complexity of test methods increases, so does the complexity of reporting.

Pathology services are closely integrated with other clinical services, to support patient care by providing information and expertise to facilitate diagnosis and treatment decision-making. This is particularly true with cancer, a disease process whose complexity is increasingly recognized, with a detailed understanding of the pathological characteristics essential for targeted treatment. The complex pathway undertaken by what might appear superficially to be the simple process of taking a tissue biopsy is set out graphically in an illustrated web page: http://www.journeyofatissuebiopsy.com

Adjacency to clinical teams is important if pathology is to be integrated as a valued “companion diagnostic” and to move away from having a passive service role to taking on an active one. Adjacency to molecular diagnostic centres will also become important in order to benefit from genomic (gene expression), proteomic (protein expression) and metabolomic (metabolite profile) data and to hasten the shift to personalized medicine.

Pathologists are core members of MDTs and provide essential inputs for patient management. Laboratories are used to working across primary and secondary care organizations and will often serve several secondary and tertiary care providers. Providers of pathology services in public hospitals also play a leading role in the education and training of pathologists, clinical scientists and researchers. They are increasingly required to provide specialist input for translational research including involvement with clinical trials and evaluation of new technologies.

The wider and extended role of pathology is demonstrated by the range of other clinical services provided, which includes:

• specialist information and advice to health care professionals in primary and secondary care as well as public health

• mandatory surveillance of disease

• infection prevention and control

• guidance and advice, quality assurance and support for POCT in a range of hospital settings (e.g. outpatient clinics)

• specialist advice on blood transfusion

• mortuary services, including post-mortem examinations.

How does pathology link with services located outside the hospital?

The interface between pathology and services located outside the hospital is well established but may not be well understood. The health care services based outside hospitals are described as primary and community care sectors, which lie between self-care and hospital care. Hospital pathology has a long history of working with outside services (i.e. primary care doctor practices and health clinics).

In Europe primary care differs considerably and several categories of organization exist. Reference MeadsMeads (2009) provides a valuable typology of primary care organizations in Europe. To add to the complexity, European countries will have different arrangements for registration with a primary care doctor or GP. This may be financially encouraged, compulsory, voluntary or free.

Pathology is a touch point across the patient’s lifecycle from pre-natal to post-mortem. The diagram below illustrates where pathology sits regarding screening, diagnostic, and monitoring functions.

Laboratories are often located in or near hospitals to meet demand for a 24/7 service. Many hospital departments are highly pathology-dependent and need to respond rapidly to the clinical needs of busy emergency medicine departments and intensive care units. This means that extensive networks of transport, IT and management links between laboratories have evolved outside the hospital to provide quick turnaround times for tests and equitable access to services over defined geographical areas.

There is also the wider reach of pathology services and diagnostic products into local populations. “Smart pathology” is emerging in the

Figure 10.2

Pathology touch points

Source: NHS England National Pathology Programme, 2014

form of new-generation POCT devices. The availability and use of these have steadily increased in Europe. They have been used in primary care, diabetic and sexual health clinics, and care homes for over 40 years, but are now being assimilated into high street retail outlets as well as the home. The rapid test turnaround time provided by POCT potentially allows for accelerated identification and classification of patients into high-risk and low-risk groups (Reference Larsson, Greig-Pylypczuk and HuismanLarsson, Greig-Pylypczuk & Huisman, 2015). There are, however, regulatory and quality assurance challenges which need to be overcome. The proliferation of so many additional users and devices in operation make the maintenance of acceptable quality levels problematic (Reference St John and PriceSt John & Price, 2014).

The future relationship between hospital pathology and primary care needs to be shaped by value expectations and whether value of service can be demonstrated through improved patient outcomes and managed costs. Insights could also be gleaned as to how a laboratory could better manage demand on its services and how this might benefit the local health community. Some examples could include the use of data for comparing testing rates to emergency admissions, number of tests requested, length of hospital stay, and cost of emergency readmissions for relevant conditions.

An example of this type of work was the INvestigation of ThE Root Causes of Excessive RepliCatE Pathology Testing (INTERCEPT) study, which involved over 115 000 patients from North Staffordshire, England, and aimed to reduce the burden of unnecessary pathology requesting. It used HbA1 c testing (a test for monitoring blood sugar control in people with diabetes) as a model by assessing adherence to national guidelines and recommendations for retesting intervals. Results from the study found over half of key blood test requests from doctors for patients with diabetes were inappropriate and that guidance on monitoring diabetes patients was not being followed by the majority of primary care and hospital doctors. Further work by this research team found major incentives to establish systems that provided timely HbA1 c tests in terms of fewer diabetes-related emergency admissions per 1000 patients, fewer hospital bed days, and reduced costs of emergency admissions for diabetes-related illnesses (Reference DriskellDriskell et al., 2012).

The key message for health commissioners and policy-makers is that primary care engagement with pathology professionals and wider use of this type of data can change requesting behaviour and produce better patient outcomes.

Barriers to optimal pathology services

Barriers impeding the delivery of an efficient and effective pathology service include those related to service configuration, demand management, workforce, finance, quality, attitude, IT, and innovation adoption. These are discussed in turn.

Service configuration barriers

In some European countries there are too many laboratories carrying out specialist tests on too small a scale. Reconfiguration can be seen as a way to optimize pathology and to attain economies. However, consolidation, such as joint ventures and mergers, must be compliant with national and European competition law, which can constrain reorganization, as well as the undesirability of creating commercial monopolies that can lead to higher costs, worse performance, and reduced innovation.

The impetus for transformation can be slowed or blocked because pathology is not high enough on hospitals’ priority lists. Many hospitals are evaluating options to develop new models of care within social, community, primary, and secondary care and this may push pathology modernization further down the chain of importance.

Demand management barriers

Most laboratories across Europe have experienced significant increases in workload year on year and the capacity of a service to manage demand is stretched, especially without a commensurate rise in staffing levels. Workload, measured in terms of crude sample numbers or test requests, is increasing and this probably belies actual workload because greater sophistication of diagnosis is now needed.

For example, increasing numbers of cases now require consensus reporting and referral for specialist opinion, demonstrating increasing sophistication of diagnostic processes and an increasingly risk-averse culture. Equally, more objective assessments are now required, whether it is a lead to provide reproducible assessments that determine patient treatment (e.g. quantitative immuno-histo-chemistry results which act as a threshold for breast cancer oncotherapy).

Where pathology is excluded from strategic planning processes and investment decisions, there is a risk that there will be unexpected, unplanned, and unfunded demands on those pathology services in the future.

Increased expectations will contribute to demand pressures in the following areas: providing ongoing clinical advice to doctors in training and primary care doctors, direct interpretative and advisory liaison work with patients who can access their test results directly, and provision of direct specialist outpatient care in diabetes, obesity, lipid disorders, and metabolic diseases.

Medical microbiology has seen an increased requirement for ward-based consultation with patients with suspected or proven infection, as a means to facilitate earlier discharge from hospital. Increasing antimicrobial resistance has placed greater emphasis on antimicrobial stewardship, with pathologists working alongside pharmacists specializing in antimicrobials.

There is a need for payment systems to take account of these rapid changes, with regular revisions that recognize new ways of delivering care. The regular reviews of the system for paying providers in Germany offers such an example.

Workforce barriers

Wider training issues, such as the trend in some countries to expand general medical training before specialization, could lead to a shorter time for pathologists to acquire specialist competencies. Recruitment to particular pathology specialties has been problematic. Outsourcing tests or using locum staff may alleviate workload but this only represents a short-term and expensive solution. There is uncertain capability to undertake some emerging techniques and technologies. The ability of pathologists, for example, to understand the disease phenotype (the detailed characteristics of the patient) is essential for interpretation of the current explosion in “-omics” data, i.e. genomics, proteomics, metabolomics, and transcriptomics.

Financial barriers

Traditionally, diagnostic tests in pathology have seemed cheaper than, for example, the costs of imaging. However, with many pathology services increasing their repertoire to include molecular testing, costs are increasing. A test costing €1000 could be perceived as being expensive but this has to be seen in context, such as whether the test is used to determine the use of a drug treatment which may cost more than 10 times as much. Unfortunately there can be a focus on the unit cost of pathology rather than looking more holistically at the “downstream” value for money that pathology contributes to the whole health care economy.

Establishing a transparent tariff for pathology tests could be beneficial, as is the case in many countries, such as Germany. Having tariff transparency would enable business cases for service transformation to be built up more easily.

Quality barriers

Many pre- and post-laboratory processes remain outside laboratory control, even though they impact significantly on the value of the service. End-to-end quality depends on others (e.g. requesting clinicians) over whom pathology has less control. The quality of the clinical pathology service will be impacted where there are areas of differential influence and control.

Appropriate ordering and commissioning of relevant laboratory tests and having timely access to the tests and test results are central to the provision of quality care for patients and patient flows through the hospital system. There is considerable variability in awareness and understanding, which leads to suboptimal and inappropriate use.

ISO 15189 accreditation may have value in assessment of laboratory quality management systems but is highly expensive to maintain and is entirely focused on processes within the laboratory and not on the end-to-end pathology contribution to health care.

Attitudinal barriers

Van Krieken, President of the European Society of Pathology, identified a lack of collaboration between pathologists and other stakeholders such as the pharmaceutical sector. His idea is to move towards a system in which tests and drugs are integrated, so that payment for a drug includes all necessary testing (Reference van Kriekenvan Krieken, 2015).

It is frequently observed that pathologists themselves need to take on more of a clinical leadership role and move out of the shadows. Risk-averse over-requesting of tests can prevail due to perceived threats of medico-legal liability and a monetary incentive may exist for over-requesting in some systems.

If testing is perceived as a cost-free service as far as requestors are concerned, there is little incentive to avoid waste and duplication. The most effective method of managing demand and promoting new technology is to ensure appropriate recovery of cost to the laboratory budget from other clinical budgets.

IT barriers

Within many European countries a wide range of IT systems are in use and this creates problems of interoperability between service users and pathology. In radiology the Digital Imaging and Communications in Medicine (DICOM) standard has achieved a near-universal level of acceptance among medical imaging equipment vendors and health care IT organizations but such a standard does not yet exist in pathology.

The lack of end-to-end IT connectivity in pathology limits the opportunity to achieve effective communications between laboratories and those ordering tests, as well as decision support, both of which minimize inappropriate or unnecessary repeat testing. There is a widely held perception that results data are not being fully leveraged by pathology service users and providers, and this is a key obstacle to cost and service improvement.

Innovation adoption barriers

At a national level delays in approval processes can constrain innovation. At a local level many test sites will be required by ISO 15189 to perform their own evaluation of a new test and duplicate many of the assurances already fulfilled by the test developer.

Aggressive national pathology cost saving plans may discourage adoption of new techniques. A complex cost–benefit relationship often underpins decisions to use new devices. Point-of-care devices are a good illustration and highlight how costs and benefits are often accrued in different areas. A primary care group may have funded a diagnostic device and reduced the need for patient hospital visits but may not receive the benefit of saving money for the health system because of opaque reimbursement mechanisms.

Investment in innovation for some pathology specialties has been limited. For example, many drug companies have no commercial interest in the development of rapid diagnostics for determining antibiotic sensitivity because of low commercial returns. The uptake and adoption of diagnostic tests across Europe shows significant variation. For example, C-reactive protein (CRP) tests have been used for some time in the Netherlands and Scandinavia to indicate whether an infection is bacterial or viral, and these countries have some of the lowest rates of prescribing antibiotics in Europe (Review on Antimicrobial Resistance, 2015).

In recent years there has been growing interest in using more accurate, efficient and reliable technologies such as mass spectrometry. Despite the important scientific advantages of such technologies, many clinical diagnostics services have continued to use traditional immunoassays, facing barriers such as the need for investment and expertise in mass spectrometry.

The future of pathology

Obsolete but not yet abandoned

Obsolete ways of working include: laboratory standard operating procedures existing in isolation from patient pathways, single-handed pathologists, and old methods and out-of-date technologies.

Figure 10.3

Quadrant highlighting pathology trajectories

Source: Authors’ compilation

Declining but not yet abandoned

Some aspects of hospital laboratory medicine are in decline but have not yet been abandoned. In some instances this is because there is a hope that the importance of these activities will be recognized. Notably, research capacity in pathology is in a steady decline and academic pathology is small scale and disjointed in all but a few major teaching centres where huge efforts are being made to keep up this aspect of the service.

In the United Kingdom there was such widespread concern about the loss of research capacity in 2015 that the National Cancer Research Institute, together with the ECMC Pathology Network Group, funded the Cellular Molecular Pathology initiative (CM-Path) – a five-year project which was awarded £635 k. It aims to reinvigorate pathology research by building the change needed to support academic cellular molecular pathology. A report on the Experimental Cancer Medicine Centre Initiative (2015) gives more details.

Also, most pathology services are making great efforts to retain the interpretive and clinical advice aspects they provide, which is threatened by low-cost, dumbed-down “results-only services” which sacrifice patient-centred care and close working relationships between pathologists and clinical requestors. Importantly, hospital autopsies are in decline all over Europe (Box 10.4).

Box 10.4Case Study – decline of consented autopsy following hospital death in Europe

Context

• Consented autopsy rates have fallen significantly in Europe over the past half century to the verge of extinction (Reference Turnbull, Osborn and NicholasTurnbull, Osborn & Nicholas, 2015).

• The benefits of autopsy are established and include: clinical audit, patient safety, public health in a time of global antibiotic resistance, epidemiology, research, education, improved mortality statistics, improved diagnostics, improved resource allocation, comfort and explanation to grieving families.

• The priority of the autopsy in modern health and social care is highlighted by the Francis report and in the United Kingdom will be crucial to the work of Medical Examiners of the Cause of Death due that was due to be implemented in England in 2018.

Challenges

• The main reasons for the decline are: perceived difficulties in obtaining consent; a limited role given current diagnostics (“autopsy is pointless in modern medicine – we know the diagnosis”); and religious objection.

• In some countries legislation is thought to have had an impact on hospital autopsies, such as the Human Tissue Act in the United Kingdom.

• A change in attitude is required so that autopsy is considered an altruistic act similar to organ donation.

Responses

• Most religions contain no objection to autopsy and most families would consent to autopsy if appropriately asked.

• The number of diagnostic discrepancies would decline with an increase in autopsies.

• Diagnostic discrepancies may be due to co-morbidities or atypical clinical presentation.

• Despite technological progress, autopsy still has an important role in the assessment and improvement of the quality of surgical practice.

Achievements to date

• The European Critical Care Foundation (ECCF) held a conference in 2015 on the decline of the hospital autopsy to raise awareness among health care professionals.

• The idea to establish a pan-European anonymized autopsy database (“Europsy”) was proposed at the ECCF meeting.

For the future hospital

• Autopsy should be offered to families across Europe upon the death of a relative to demonstrate willingness to discuss the patient’s last episodes of care.

• Pathologists need to clarify and simplify the consent process to design a simple, yet effective, autopsy consent form.

• Alternative autopsies such as digital autopsies could be encouraged but their limitations should be understood and they are currently expensive and do not allow tissue to be obtained for in-depth diagnostic and research purposes.

• Medical research requires accurate causes of death. Autopsy should be used as a gold standard end-point for any deaths occurring in clinical trials.

• Specialist hospital professionals could be trained in consent, such as a pathology liaison nurse whose role would be to gain consent, to provide feedback to clinicians and to families, and to teach hospital staff about death.

• Teaching opportunities should be exploited so that students and junior doctors gain greater exposure to autopsy practice.

Source: Reference Turnbull, Osborn and NicholasTurnbull, Osborn & Nicholas, 2015

Existing but not widely implemented

Exciting new ways of providing pathology testing are not always implemented widely. For example, expansion of POCT and self-testing into the high street and homes has begun but in some instances is limited by patient acceptability (for a more detailed exposition see Reference Larsson, Greig-Pylypczuk and HuismanLarsson, Greig-Pylypczuk & Huisman, 2015). There are many other barriers to take-up of these devices, including the test devices themselves, patients’ use of and interaction with the devices, providers’ understanding of their uses, and the health systems in which they are used. Successful uptake usually requires integration of knowledge at these levels, which in turn can lead to trust and confidence.

The implementation of digital autopsies is limited by the diagnostic limitations of the technique. Standardization of units of measurement, reference ranges, coding and methods is required to enable results data to be of benefit in monitoring long-term conditions and in disease prevention, and implementation is limited by failure to implement national developments such as the National Laboratory Medicine Category in the United Kingdom.

Pioneering and aspirational

Some aspects of pathology service provision are envisioned but not yet in place. A key reason for this may be the traditionally slow rate of uptake of new technologies in pathology. The following technological innovations are discussed:

Conclusion

The tree of medicine diagram below provides a reminder of the centrality of pathology in medicine, as the trunk of the tree that links all aspects together is pathology.

Pathology in European hospitals is at a crossroads, with the future contingent on a willingness to address the barriers discussed in this chapter. There are many opportunities for pathologists to play a central clinical role. Despite operating under unrelenting fiscal constraints in some countries, pathology is entering into the “genome era” and pathologists must acquire and demonstrate visionary leadership.

Figure 10.4

The tree of medicine (date of publication unknown)

Pathology services tend to be ignored by policy-makers and managers, and a key challenge will be to demonstrate how high quality pathology provision improves accuracy of diagnosis and effectiveness of monitoring or treatment, so creating better patient health outcomes. Quality in pathology reduces patient pathway costs as well as providing key health care data and impacting on all other health care interactions. The redesign of pathology so that it becomes part of an integrated patient pathway should be explored and communicated so that a clear demonstration of its value can be evidenced. This would enable pathology to be delivered where it is required while operating within an integrated quality framework (Reference MyersMyers, 2014).

Preparing for the future

In the following section, we look briefly at some of the examples of innovation that reflect themes in earlier chapters and the opportunities and challenges that they pose for the hospital now and in the future.

We begin with the multidisciplinary team. As noted above, the growth of multimorbidity and the complexity of the responses to it, involving different groups of professionals, require completely new ways of working. A typical patient aged 75 or above may have five or six different conditions, each requiring long-term medication or other forms of therapy, not all of which may necessarily be compatible. Yet they may still be able to lead a normal life with appropriate input from different professionals. This requires a high level of organization, with seamless transmission of information. These patients are on a journey, and the challenge for the health system is to make it as smooth as possible. Unfortunately, in practice, it can be more like an exploration of an unknown land, moving from point to point almost at random, often getting lost in the process. Advances in technology can improve this process, in particular by ensuring the timely sharing of information. However, much more is needed. In particular, such teams can only operate in a culture characterized by collaboration, with flat hierarchies and mutual respect among all those involved. Creating these teams is not easy and requires deliberate work to develop and maintain them. Research in health care suggests that the appearance of teamwork may often disguise a lack of clear purpose, poorly defined membership, leadership problems, unhelpful hierarchical behaviours, and a lack of support for the team (Reference West, Markiewicz, Ferlie, Montgomery and PedersenWest & Markiewicz, 2016).

MDTs in cancer care involve coordinated working among different professionals, which is required to synchronize the complex array of interventions and frequent patient contacts. Oncology MDTs can include a broad range of health professionals with different skills including in diagnostics, oncology, pathology, radiology, surgery, nursing, and palliative care, who must work together and also alongside other professionals in psychology and psychiatry. Also professionals involved in new models of perioperative care, which emphasize improvement and consistency of outcomes for patients after surgery, are fundamentally multidisciplinary. Health professionals are drawn from a range of medical specialties, including anaesthesia, surgery, geriatric, and internal medicine, and should be led by those who can take a system-wide approach.

A related issue is the tension between generalists and specialists among health professionals. Unfortunately, in many health systems the specialist occupies a privileged position in the medical or nursing hierarchy, making it difficult to attract and retain generalists. Patients with multimorbidity will from time to time require highly specialized inputs. For example, a patient with diabetes, among other conditions, may need laser treatment on their retinas. This is a highly skilled task. They may also have kidney failure requiring dialysis, again a task requiring considerable expertise. But at the same time, they need someone who can take a holistic view of their health problems, ensuring that a treatment initiated for one problem does not exacerbate another. The growth of multimorbidity and polypharmacy as populations age presents a significant challenge to the model of narrow specialism. Patients increasingly fail to fit neatly into the way that medical specialisms have been organized.

As a consequence the fastest-growing area in hospital medicine in the USA has been in the specialism known as “hospitalists” (Reference Wachter and GoldmanWachter & Goldman, 2016). These are often internal medicine specialists (although they can be drawn from other disciplines) and are now appearing in paediatrics and other areas. Their role is to act as coordinators of patient care within the hospital and to co-manage cases with some specialties. Social complexity and difficulty in discharging patients as a result are also problematic and the hospitalist movement has been criticized for not paying sufficient attention to these issues (Reference GundermanGunderman, 2016). The chapter on frailty offers a similar model of a general physician with specialist skills for managing complexity, but shows the importance of services that can cross the boundary between the hospital and other types of care and address patients’ wider needs. Although this has been focused on older people, these issues of complexity are not confined to the old. The question of the optimal balance between specialist and generalist care has not been answered.

In countries where primary care is the main provider of care for chronic diseases, the increasing levels of demand and the large and growing body of scientific knowledge involved in managing chronic conditions mean that there is a need to help primary care doctors, nurses, and other clinicians in their work and in keeping up to date. Hospital specialists in areas such as endocrinology, respiratory medicine, nephrology, cardiology, rheumatology, etc., have a key role in supporting the management of conditions such as diabetes, heart failure, and asthma, overseeing the administration of complex treatments and providing feedback and help with activities such as quality improvement and process redesign. This may require new skills, different approaches to patient consultations, and a change in the relationship between hospitals, primary care, and patients. The key aspects of this include:

• Rethinking the traditional outpatient model based on referral to a specialist.

• Improving case management skills of health professionals to ensure that the patient’s problem is dealt with or that the patient is quickly referred to another professional who can deal with that problem.

• Health professionals working proactively to identify risks for the patient and engaging with them to address these. Often these may require action to deal with non-medical problems in the patient’s life that are making compliance with treatment plans difficult.

• Considering and developing strategies for population health and prevention. This will include specialists taking a more direct interest in these areas, including secondary prevention for their existing patients and more active involvement in health promotion for the wider population.

• Specialists acting as consultants and overseers of networks of care and supporting other professionals. This means that the type of patient they deal with will often be more complex.

These challenges have led to a great deal of interest in the creation of various types of integrated care organizations that bring together primary and specialist care, and which potentially can deliver care that meets the characteristics described above. Many of these changes to the relationship between the hospital and its wider system will support integrated care but it is easy to underestimate the scale of the changes in work processes and operating models for hospitals and the staff who

work in them that the full development of these models will require. If integrated care systems can deliver on their promise of reducing the use of hospitals, then there are some major challenges as to how to reduce fixed costs if there are reductions in the use of hospital facilities.

The growth of specialism and the narrowing of many specialist fields mean that all but the largest hospitals will not be able to have the full range of expertise on site. The growth of digital technology means that laboratory and imaging expertise does not necessarily need to be in the same location, or even the same country, as the patient. The development of communications technology also offers the opportunity to spread expertise across distances. This can support the growth of specialist referral networks with escalation criteria and standardized protocols. These networks are increasingly common in cancer, neonatal care, neurosurgery, and many rare diseases where there is already a strong trend towards centralization because of a strong body of evidence that for certain types of care – particularly complex care, some types of surgery, and cancer care – higher volumes are associated with improved outcomes.

Referral networks are also found in high volume areas such as maternity services, where different parts of the network will have rules for accepting or transferring patients relating to the level of risk involved. Sometimes these may include retrieval services to ensure the safe transfer of critically ill patients. The organizational arrangements to allow for rapid transfer and return of patients need to be agreed across the network and properly managed or will be a cause of some tension.

The development of hospital networks run by groups such as Helios and Asklepios in Germany, and IHH, Apollo and Parkway in Asia, and which are also increasingly found in other European countries, partly reflects a growing idea that there are economies from both scale and standardization. Agreeing a common approach to a procedure, such as hip replacement, allows for procurement savings but also creates the potential for benchmarking and improvement across a wide network with managed processes to make this happen, as opposed to relying on hospitals joining such approaches voluntarily.

The growth of technology and a strong emphasis on efficiency have had the effect of shortening lengths of stay and increasing the intensity of work in hospitals. This trend will continue and will put increased demands on staff, facilities, and engineering and means that the proportion of beds run as critical or high dependency care is likely to rise.

A second effect has been to move work and specialists, who have been traditionally based in hospitals, to ambulatory settings, creating new ways of delivering care and requiring different approaches to giving specialist advice for inpatient care.

While advances in technology have brought many benefits, they have also created new challenges. One relates to the challenge of providing effective health care to people living in remote areas. As has been noted, the management of conditions such as myocardial infarction, gastrointestinal bleeding, stroke, and major trauma have been transformed by the introduction of new methods to intervene actively to tackle the fundamental problem, whether it be a blocked artery or catastrophic bleeding. Yet for this to be achieved, there is a need for rapid diagnosis, followed, equally rapidly, by definitive treatment. If these are delayed, the treatment is simply ineffective. Yet in some places, where the population density is low, it will never be possible to provide such definitive diagnosis and treatment sufficiently close to where people live. This will require new and imaginative solutions involving the training of multiskilled doctors and other clinical staff, technology for remote advice and support, and rapid transfer or retrieval services. Remote areas tend to be more explicit with their local population about the limits and capabilities of local services and what will happen in the event of a serious emergency than those in more populous areas.

There are challenges as well as opportunities from the increasing role played by information technology. There is a danger that feeding the system with data can take priority over interacting with the patient. Patients frequently complain that the health professional spent the encounter looking at a screen rather than at them. Health professionals complain that they spend so much time entering data that they are unable to engage in conversation with the patient. Yet in other sectors this challenge has been addressed. There are many new means of entering data, ranging from barcodes to the use of voice recognition software. Unfortunately, in the health sector these appear to be difficult to implement and are significantly under-exploited.

The way forward

We conclude with four recommendations. In producing this book, we have been struck by the lack of fora within which those working in hospitals, those responsible for their design and operation, and those responsible for the policy environment in which they operate can come together to exchange ideas. There are many innovative models of care around Europe but far too few have been evaluated and, where they have been, the findings are not easily available. There is now clear expectation that those responsible for introducing therapeutic innovations, such as new medicines or surgical procedures, should evaluate them and share the results. This is not the case with innovative models of care. There is a clear need to create mechanisms that would enable this to happen.

The second relates to the hospital workforce. The roles and responsibilities of health professionals have changed remarkably over the past few decades. They will continue to do so. In many cases these transitions are managed easily and effectively. Yet in others, they are not. There are sometimes legal and regulatory barriers to change, as well as financial incentives that act as barriers to effective working. There is a danger in sweeping all of these away, as they can provide much-needed protection for health workers, who in many countries are inadequately rewarded for their commitment and dedication. But on the other hand, there is a need for sufficient flexibility to allow them to develop as circumstances change.

The third relates to the hospital and its wider environment. It is abundantly clear that the hospital is only one part of the health system and for many patients the boundary between it and the rest of the health system can act as an impenetrable barrier. Many contemporary advances, in particular those that seek to bring sophisticated treatment to patients as quickly as possible, require models of care that reach beyond the hospital into the patient’s home. Similarly, there is a need to ensure that the process of being discharged from hospital is as smooth as possible, and is not seen simply as a means of emptying a bed for the next admission. This means that hospitals need to be planned as part of the wider system in which they sit, both in terms of the opportunities to work differently with primary care and community-based services, but also as a part of a wider network with other hospitals and specialist centres. This also means that traditional approaches that use beds as the currency for planning hospitals is now inadequate and potentially misleading or unhelpful.

The final recommendation relates to connectivity. This means connectivity within and beyond the hospital. It means connectivity through information technology but also in person. Indeed, it particularly means in person. Yet it is necessary to recognize that connectivity has a cost as well as benefits. Time spent in meetings is time not spent treating patients. Too often, meetings are organized where those attending see little point. They feel that their time is being wasted, little is relevant to them, and they spend most of the meeting on their tablets and smart phones, engaged not with those in the room but with those outside it. In time, they drift off, finding excuses to stop attending. There is a clear need to find new ways of communicating in which the benefits outweigh the costs.

It is impossible to know what the hospital of the future will look like, just as it was impossible to say what the future of travel would be before the Wright brothers took their first flight. All that can be said is that the future will be different from the present. What is important is that structures and systems are put in place that have sufficient flexibility and ability to learn as circumstances change.