Centralisation in the time of pandemic
Whilst the current coronavirus crisis has clearly highlighted many areas of our public health systems and indeed societies that will require permanent alteration and development, it has interestingly also shone a spotlight on testing centralisation. Or rather more accurately Debes Christiansen, a veterinary scientist from the Faroe Islands, has exemplified why rapid localised testing still remains so important in the management of infectious and indeed non-infectious diseases (1). The Faroe Islands with a population of approximately 50,000 currently has 187 confirmed cases of coronavirus, 178 of which have recovered with 0 deaths (as of the 26th of April 2020). This enormous effort so far to prevent the spread and spiralling death rate is being attributed to Mr Christiansen who in response to the virus quickly converted the local reference laboratory for fish diseases to a coronavirus testing facility. This enabled the rapid testing of 10% of the island’s population successfully identifying symptomatic and asymptomatic patients as well as allowing contact tracing to prevent the spread and thus far any deaths from the disease. Locally performed testing and rapid testing turn-around times (TATs) were therefore crucial to the Faroe Island’s subsequent responses. Another similar but equally extraordinary case involves the small completely isolate Italian village of Vo near Veneto. Here a local professor of clinical immunology Sergio Romagnani blanket tested the entire village of 3,000 people for this coronavirus. Through this extraordinary measure they were quickly able to identify the population that were positive (symptomatic and asymptomatic) reducing the number of cases by 90% in 10 days (2). This shows that quick, broad localised testing effectively identifies cases that would previously be missed, allowing these patients to be isolated to rapidly reduce the spread.
What can molecular testing centralisation learn from these examples? As discussed in our previous articles of the series, molecular testing centralisation in the UK has been steadily progressing since its 2018 announcement by NHS England. The main concern of centralisation thus far being slower TATs which in turn affects patient treatment options and outcomes. Indeed, clinicians have indicated that in some time-sensitive cancer cases, they have stopped sending samples to the central Genomic Laboratory Hubs (GLHs) in favour of running the tests in-house to prevent negative patient outcomes. When central funding for these tests is eventually cut-off, these clinicians will have to decide between incurring debt and patient outcomes. The heroic efforts of Mr Christiansen, Professor Romagnani and their associates neatly illustrate the great power and need for local expertise, facilities and rapid testing TATs to maximise patient benefit (if nothing else).
Whilst centrally performed testing often increases the range of detectable biomarkers due to equity of access to the latest machinery and patient enrolment to clinical trials, a certain degree of decentralisation could provide benefit to the patients and greater dynamism of treatment management. Thus far NHS England have indicated that individual GLH networks can decide to partner with local trusts to fulfil the network testing burden and in turn support more localised testing to a certain degree. Whilst this does go some way to addressing the issue of slow TATs for some, it still leaves the majority of trusts nationwide having to send samples away. Furthermore, these measures intrinsically increase the system’s layers of bureaucracy. As the coronavirus pandemic has shown, complex bureaucracy in medicine dramatically reduces the response time to a rapidly evolving situation. And whilst a rapid medical response for infectious diseases may not initially seem comparable to non-infectious diseases, the near exponential development rate of technology managing these conditions will require clinical care adaption.
Perhaps NHS England should revise their current strategy and support the repurposing of local laboratories instead of cutting funding completely, especially in cases when biomarker testing is time sensitive. As shown by the examples of the Faroe Islands and Vo, local capabilities have real power to improve patient outcomes.
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