One of the biggest challenges facing our health service is how to reduce waiting lists. Aside from the obvious, increasing staffing levels and bed availability, what other measures can be taken to reduce the number of people referred by primary care to hospital specialists for diagnostic tests? Reducing the time that patients spend in hospital and early diagnosis would ultimately lead to a reduction in waiting times and faster, potentially more effective treatment times. Screening out those patients at lower risk is an important step; and reducing the need for invasive, time-consuming expensive test procedures is perhaps not the first step that comes to mind, for most hospital administrators and clinicians. This is however an increasingly valuable consideration, if waiting lists are to be tackled and costs reduced.
Keeping up to date with the latest technologies and innovative, published research is vital if outcomes are to be improved across a wide range of diseases and health conditions. In this article, I will focus on the potential application of two recent innovative approaches to removing the need for invasive testing.
Detection of Alzheimer’s need not be challenging
The diagnosis of Alzheimer’s disease currently involves the use of invasive tests such as brain scans (PET scans) and spinal taps, neither of which are an easy undertaking for patients or the health professionals responsible for their care. Both these procedures are time-consuming, expensive and require specialist skills.
Without a confirmed diagnosis of Alzheimer’s, sufferers will not have access to early intervention treatments now being considered for licensing in Scotland.
Another factor which contributes to delays in diagnosis and long waiting times for tests is the lack of availability of PET scanners in the UK, which has one of the lowest numbers of scanners per capita in the developed world.
Assuming an NHS target of an 18-week average waiting time, the investment needed to close the gap in the availability of PET scans between England and other G7 countries is estimated to be around £16 bn.
It is therefore imperative that simpler less invasive tests are made available if progress in the diagnosis and treatment of Alzheimer’s is to be available at lower cost.
Novel diagnostics to detect amyloid protein
A recent research study published in Nature Medicine has concluded that a blood test could replace the traditional cerebrospinal fluid test (CSF). The blood test has not only proven as accurate as a CSF test but due to its sensitivity, it can detect Alzheimer’s in patients that are not showing outward signs of the disease. This is of importance to those patients who may be genetically predisposed to the disease and allows early intervention in its treatment since disease-modifying therapies are now available which slow disease progression.
These blood-based tests are invaluable in the pre-screening and identification of individuals who have amyloid proteins associated with the development of the disease. Their adoption would reduce the need for more invasive tests such as PET scans, reduce the costs involved and reduce waiting lists and hospital stays. The tests are based on the detection of amyloid proteins which, in combination with another protein called tau, are deposited in and around brain cells, forming plaques which are a characteristic of Alzheimer’s.
How novel diagnostics can speed up treatment
It has been shown across Europe and the US that reduced access to diagnostic tests is potentially delaying and preventing effective treatment of patients, which could be transformative and life-enhancing. Alzheimer’s is most prevalent in the elderly – 90k suffering from dementia, half of those diagnosed in Scotland have Alzheimer’s and are over 70.
However, the disease can affect people in their 40s, and 50s and even younger according to Alzheimer Scotland. Dr Susan Kohlhaas, director of research at Alzheimer’s Research UK, said recently that fewer than two-thirds of sufferers receive any dementia diagnosis at all.
Costs of early intervention
Early treatment of Alzheimer’s with the antibodies donanemab and lecanemab which bind to amyloid protein and help our immune system clear it from the brain, is promising and costs around £20k per patient per year (according to US data). The Scottish Medicines Consortium are currently assessing the effectiveness of lecanemab and donanemab, and whether they represent value for money.
In Scotland, following referral to a specialist, an Alzheimer’s diagnosis is primarily accomplished using a PET Scan, which may involve a waiting time of weeks or several months.
Can we now start to look forward to the day when the significant numbers of people suffering from Alzheimer’s disease are reduced and the costs of social care and burden both economic and emotional, on sufferers and carers become lighter or removed altogether?
Sponge on a string diagnostic replacement for an endoscope
It is a major achievement that this particular innovation was successfully piloted during the pandemic when resources were stretched beyond their limits.
Barrett’s oesophagus is a condition which can be the precursor to oesophageal cancer in some patients. The standard diagnostic test used to detect Barrett’s oesophagus traditionally involves an upper endoscopy, which is an invasive test using a tiny camera delivered into the windpipe via an endoscope.
Upper endoscopy will still be the preferred diagnostic test for high-risk patients and is undertaken by a specialist practitioner, sometimes with the need for sedation. In contrast, the sponge on a string takes around 15 minutes and can be carried out on low-risk patients or as a screening tool to determine if an upper endoscopy is needed. The NHS pilot resulted in 80% of patients being discharged with no requirement for further testing. Its use reduces the demand for a traditional endoscopy, which ensures that higher-risk patients referred for urgent investigation for oesophageal cancer can be seen and treated earlier.
The new test, developed by Professor Rebecca Fitzgerald at the University of Cambridge, involves patients swallowing a small gelatine capsule which has a string attached. After 7.5 minutes have elapsed, the capsule dissolves, releasing a tiny sponge that collects cell samples for analysis from the oesophagus. A nurse or practitioner then extracts the sponge using the string.
The conclusions from the pilot were that the sponge test was highly cost-effective when compared to traditional upper endoscopy only for diagnosis which costs around £400 per patient.
Revision of diagnostic testing to cost effective novel alternatives
The pandemic-induced pressure on health services has resulted in much revision of diagnostic testing. There has been a distinct movement away from invasive tests to cost-effective novel alternatives. Since 2mn endoscopy tests per annum were performed pre-pandemic in the UK, the need to adapt and respond to high demand for novel diagnostics needs to be addressed.
Researchers have made a valuable contribution to making life more bearable for patients and healthcare professionals alike. They aim to provide the means to ensure our health service is equipped to make an impression on waiting lists and continue to provide the best service possible. This is welcome indeed and deserves our full support.
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