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Transforming ENT cancer pathways through outpatient biopsy: a Value-Based Healthcare approach at Manchester University NHS Foundation Trust

13 July 2026

Manchester University NHS Foundation Trust has demonstrated how a Value-Based Healthcare (VBH) approach can support meaningful pathway redesign to improve diagnostic performance, reduce costs and increase system capacity.

By shifting Ear, Nose and Throat (ENT) biopsies from a theatre based general anaesthetic pathway to an outpatient local anaesthetic model, the trust has significantly reduced diagnostic waiting times while maintaining high clinical effectiveness.

This approach directly supports key NHS priorities, including delivery of the Faster Diagnosis Standard (FDS), elective recovery, improved use of theatre capacity, and the ambition set out in the NHS Long Term Plan to increase outpatient-based diagnostics and deliver care closer to patients. It also aligns with Get it Right First Time (GIRFT) recommendations and the Diagnostics Recovery and Renewal programme, demonstrating how pathway redesign can unlock both clinical and operational value.

This case study highlights how a pathway led transformation rather than a product led intervention can enable trusts to improve patient outcomes while delivering greater value across the system.

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See our Useful Links section for our Care Pathway Team details. They can help you to map your current pathway, understand the potential clinical and financial benefits, and identify opportunities to pilot and outpatient biopsy model within your trust.

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The challenge

Manchester University NHS Foundation Trust, the UK’s largest NHS trust, faces sustained demand for timely diagnosis of suspected head and neck cancers. Within the traditional pathway, biopsies are typically carried out under general anaesthetic in theatre settings.

This approach introduces operational and clinical challenges. Theatre capacity is limited and must be prioritised for more complex or higher-risk procedures. The pathway itself requires multiple steps including preoperative assessment, scheduling and recovery, which can introduce delays.

As a result, diagnostic timelines can be extended, increasing the risk of not meeting FDS which requires diagnosis or exclusion of cancer within 28 days. This can also increase anxiety for patients waiting for results.

The pathway is also resource intensive. Patient level costing data from Manchester University NHS Foundation Trust (PLICS) shows the average cost of a biopsy under general anaesthetic is 1£1,380 per patient, alongside the use of valuable theatre capacity that could be used for more complex procedures.

The solution

Using a VBH approach, the trust redesigned its ENT diagnostic pathway to enable biopsies to be carried out in an outpatient setting under local anaesthetic.

A dedicated weekly clinic was introduced, allowing patients to undergo assessment and biopsy within a single visit where clinically appropriate. This removes the need for theatre-based intervention for many patients and reduces unnecessary steps in the pathway.

The outpatient model combines endoscopic visualisation and biopsy in a single procedure, supported by standard outpatient instruments and enhanced imaging.

This enables clinicians to deliver the same diagnostic outcome in a more efficient setting.

The transformation focuses on improving value by delivering better outcomes and experience for patients while reducing demand on constrained resources. The approach is centred on pathway redesign, demonstrating that significant improvements can be achieved through changing how care is delivered.

Process undertaken

The redesigned pathway was tested through a pilot delivered between April and October 2023, focusing on patients referred through urgent head and neck cancer pathways.

Patients were assessed for suitability for local anaesthetic biopsy based on clinical presentation and ability to tolerate the procedure. Those not suitable were safely escalated to the general anaesthetic pathway where required.

The outpatient clinic was delivered by a multidisciplinary team including an ENT clinician, physician assistant and nurse. The pathway enabled same day assessment and biopsy, with samples submitted immediately for urgent histological analysis.

During the pilot, 25 patients were listed and 21 successfully underwent biopsy under local anaesthetic. A small number of patients required escalation to theatre-based care, ensuring patient safety and maintaining clinical standards.

The results

Faster diagnosis (FDS performance improved) 50% reduction 30 Days 15 Days £204 saving per case (15%) Reduced cost per biopsy £1,380 £1,176 with outpatient biopsy High clinical effectiveness maintained 92% completion rate

The introduction of the outpatient biopsy pathway delivered significant improvements across diagnostic performance, cost efficiency and system capacity.

  • Diagnostic timeliness improved significantly, with average time to diagnosis reduced from 30 to 15 days.
  • This represents a 50% reduction in pathway time, supporting improved performance against the FDS.
  • Earlier diagnosis helps to reduce patient anxiety and enables faster clinical decision-making.

Clear financial savings achieved, with average cost per patient reduced from:

  • £1,380 (theatre-based pathway) to £1,176 (outpatient pathway)
  • This delivers a £204 saving per case (approximately 15% reduction.)
  • Demonstrates how pathway redesign can improve efficiency while maintaining quality of care.
  • Additional savings potential through full alignment to outpatient coding.
  • Clinical effectiveness remained high.
  • The outpatient pathway achieved a 92 percent completion rate, with all biopsy samples suitable for histological interpretation.
  • Only a small number of patients required escalation to general anaesthetic, indicating the pathway is appropriate for the majority of patients.
  • From a patient perspective, the benefits are clear. The pathway reduces the number of hospital visits, provides faster access to diagnosis and avoids the need for general anaesthetic. Patients are able to return to normal activities more quickly, improving overall experience.
  • The impact on system capacity is equally important. By moving suitable procedures out of theatre, the trust has released critical theatre capacity for more complex and urgent cases. This supports elective recovery and improves overall utilisation of hospital resources.
  • The pathway aligns with national priorities, including increasing outpatient diagnostics, improving productivity and delivering more care closer to home. Importantly, it was implemented using existing infrastructure, equipment and workforce, making it highly scalable across other NHS organisations.

Clinical perspective:

The transnasal endoscopy procedure in an outpatient setting enables fast, convenient and timely biopsies. It is well tolerated, supports earlier diagnosis and can also enable prompt progression to treatment. This pathway aligns with national guidance and is now well established at MFT.

Professor S Khwaja, Consultant ENT Surgeon, Manchester University NHS Foundation Trust

Patient perspective:

  • Patients highlighted the convenience of the outpatient approach, particularly the ability to return to normal daily activities quickly and avoid the risks associated with general anaesthetic.

Next steps

Following the success of the pilot, the trust is expanding its outpatient biopsy service and sharing learning across the wider system.

This case study demonstrates how a VBH approach to pathway redesign can deliver measurable improvements in outcomes, efficiency and patient experience.

Trusts interested in adopting a similar approach are encouraged to engage with our Care Pathway Team. The team can support organisations to map pathways, model benefits, engage stakeholders and deliver pilot implementations.

By taking a pathway led approach, trusts can improve diagnostic performance, release capacity and deliver greater value across their services.

Before: Traditional ENT Cancer Pathway (Theatre-Based Biopsy) After: Improved ENT Cancer Pathway (Outpatient Biopsy Model) Patient presents to GP with suspected symptoms Urgent referral to ENT (2WW pathway) Referral triaged by ENT team Wait for first outpatient appointment Initial ENT assessment Decision for biopsy Wait for theatre slot and pre-op assessment Follow-up appointment to review results Diagnosis confirmed Treatment planning begins Referral for biopsy under GA in theatre Biopsy performed in theatre Patient presents to GP with suspected symptoms Urgent referral to ENT (2WW pathway) Enhanced triage / patient selection Direct to one-stop outpatient clinic ENT assessment and biopsy in same visit (local anaesthetic) Immediate submission of sample of histology Rapid review of results Treatment plan agreed sooner Earlier diagnosis (supporting Faster Diagnosis Standard) Treatment begins earlier Resource intensive Multiple steps Enhanced Patient Experience Simplified Pathway

References

1 Manchester University NHS Foundation Trust patient-level information and costing system (PLICS) data, 2025 / 2026.

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