Diagnostic Stewardship in NHS Laboratories

Diagnostic Stewardship in NHS Laboratories: Building Smarter Testing Pathways

June 30, 2026

Why diagnostic stewardship matters more than ever

In an NHS under sustained financial pressure, every test ordered carries a cost—and every unnecessary test carries two: the direct spend and the clinical risk of acting on the wrong result. As demand on pathology services continues to grow, diagnostic stewardship is becoming increasingly important in helping laboratories optimise testing pathways, reduce unnecessary investigations and support better patient care. This article explores the evidence behind diagnostic stewardship and what it means for today’s laboratories.

Diagnostic testing underpins almost every clinical decision made across the NHS. In fact, around 85% of all clinical pathways rely on laboratory results, placing pathology services at the centre of modern healthcare.³

As healthcare services continue to balance increasing demand with finite resources, laboratories are uniquely positioned to improve both clinical outcomes and operational efficiency. Every investigation requested consumes reagents, laboratory time, analyser capacity and clinical resource. When a test is unnecessary—or the wrong test is selected—the consequences extend well beyond cost, leading to delayed diagnosis, repeat investigations, inappropriate treatment and avoidable pressure on already stretched services.

Diagnostic stewardship provides a practical framework for addressing these challenges by ensuring every test contributes meaningful clinical value.

Diagnostic stewardship at a glance

£89 million potential annual NHS savings on antibiotics through diagnostic stewardship.¹

10.2% reduction in inappropriate urine samples following a stewardship intervention at one NHS trust – in just three months.²

85% of NHS clinical pathways rely on laboratory results, placing laboratories at the heart of effective stewardship.³

What is diagnostic stewardship?

Diagnostic stewardship is the discipline of ensuring that diagnostic tests are ordered appropriately, performed correctly and interpreted accurately so that results genuinely improve patient care rather than generating unnecessary cost, clinical uncertainty or inappropriate treatment.

The framework is built around five principles:

  • The right test
  • The right patient
  • The right time
  • The right interpretation
  • The right clinical action.⁴

Although straightforward in principle, consistently achieving these five “rights” requires robust governance, evidence-based requesting pathways and collaboration between laboratories and clinical teams.

The importance of diagnostic stewardship continues to grow.

The 2025/26 NHS Operational Planning Guidance calls on trusts to minimise unwarranted diagnostic referrals and optimise clinical processes.⁵ At the same time, the Getting It Right First Time (GIRFT) programme has identified persistent unwarranted variation in diagnostic requesting across NHS organisations, highlighting opportunities to improve both efficiency and patient outcomes.⁶

For laboratory managers and biomedical scientists, stewardship is no longer a peripheral consideration. Pathology services sit at the centre of the diagnostic pathway and are uniquely placed to lead improvements across the testing cycle.

The cost of getting diagnostics wrong

The cost of inappropriate testing extends far beyond the tariff of an individual assay.

Unnecessary antibiotic use

Without appropriate diagnostic evidence, clinicians often have little choice but to prescribe empirically.

The NHS currently spends more than £326 million each year on antibiotics, while targeted diagnostic stewardship programmes have the potential to save between £36 million and £99 million annually through more appropriate prescribing.¹

Accurate diagnostics enable clinicians to prescribe with greater confidence while supporting wider antimicrobial stewardship initiatives.

Sample contamination and false positives

Specimen quality remains one of the greatest opportunities for improving laboratory efficiency.

Approximately 65 million urine specimens are collected across the UK each year, with contamination commonly reported at around 25%.⁷

At Lancashire Teaching Hospitals NHS Foundation Trust, 25% of superficial wound swabs and 10% of urine samples grew mixed faecal organisms following submission without appropriate clinical indication.²

Reducing contamination before samples reach the laboratory not only improves diagnostic accuracy but also reduces repeat testing, unnecessary antibiotic prescribing and delays to patient care.

Clinical evaluations have shown that improved collection methods, including Peezy Midstream, can reduce contamination rates to as low as 0–5%.⁸

Preserving laboratory capacity

Every unnecessary investigation consumes valuable laboratory resources, including reagents, analyser time and biomedical scientist capacity.

Repeat urine testing resulting from contaminated specimens alone is estimated to cost UK laboratories approximately £70 million every year.⁷

Even relatively small stewardship interventions can have measurable impact. One NHS initiative achieved a 10.2% reduction in urine submissions within just three months, freeing capacity for clinically appropriate testing while also reducing environmental impact.²

Accurate diagnostics enable clinicians to prescribe with greater confidence while supporting wider antimicrobial stewardship initiatives.

Tackling antimicrobial resistance

Without accurate pathogen identification, treatment decisions become increasingly empirical. This contributes to unnecessary antimicrobial exposure and the continued growth of antimicrobial resistance (AMR).

Current evidence indicates that half of the global increase in AMR over the past five years has originated from urinary sources, while 92% of urinary tract infection bacteria are already resistant to at least one commonly used antibiotic.⁷

Accurate diagnostics remain one of the most effective tools available to support responsible antimicrobial prescribing.

Optimising every stage of the diagnostic pathway

Diagnostic stewardship interventions operate across the three phases of the testing cycle recognised by UKAS under ISO 15189: the pre-analytical, analytical and post-analytical stages.¹⁰

Each stage offers opportunities to improve quality, efficiency and patient outcomes.

1. Pre-analytical

Ordering appropriately and collecting cleanly

Many of the greatest opportunities for improvement occur before a specimen even reaches the laboratory.

Computerised clinical decision support tools can encourage clinicians to confirm the clinical indication before requesting investigations.

At Lancashire Teaching Hospitals NHS Foundation Trust, introducing these measures resulted in:

– a 10.2% reduction in urine submissions, and

– 190.5 kg CO₂e carbon savings over a three-month period.²

GIRFT also recommends wider adoption of clinical decision support tools to reduce unwarranted variation in requesting practices across pathology services.⁶

Equally important is specimen quality.

NHS service evaluations have demonstrated that improved midstream collection devices reduced mixed bacterial growth from 23% to 1.5%, significantly reducing repeat testing and laboratory workload.⁹

2. Analytical

Selecting the right diagnostic technology

Choosing the most appropriate diagnostic technology depends on the clinical question being asked.

For respiratory infections, rapid antigen testing provides timely results for patients with high viral loads who are likely to be infectious, while molecular testing offers greater analytical sensitivity and remains essential for immunocompromised patients or situations where missing an infection would have significant clinical consequences.

A similar principle applies to bacterial infections.

Rapid urinary antigen testing supports timely treatment decisions for pathogens such as Streptococcus pneumoniae and Legionella pneumophila, while culture and molecular diagnostics remain essential for confirming organism identity, determining antimicrobial susceptibility and excluding infection in higher-risk patients.

Across respiratory, enteric, fungal and virology pathways, selecting the most appropriate testing methodology remains fundamental to both effective patient care and responsible resource utilisation.

3. Post-analytical

Ensuring results lead to the right action

Producing an accurate laboratory result is only part of the diagnostic pathway.


Diagnostic stewardship continues after analysis through:


– antimicrobial cascade reporting

– reflex testing protocols

– structured communication between laboratories and clinicians

– electronic patient record integration

– audit trails that support governance and UKAS compliance


Ultimately, the value of any diagnostic test depends on whether it leads to the correct clinical action.

    Supporting diagnostic stewardship in practice

    Effective stewardship relies on having access to the right diagnostic tools throughout the testing pathway.

    Improving sample quality

    Stewardship begins before a specimen reaches the laboratory.

    Devices such as Peezy Midstream support cleaner urine collection, helping reduce contamination, minimise repeat testing and improve laboratory efficiency.

    Read more

    Detecting enteric pathogens accurately

    Accurate identification before treatment decisions are made is fundamental to antimicrobial stewardship.

    The TECHLAB® enteric testing portfolio supports gold-standard detection of clinically significant pathogens including Clostridioides difficile, Helicobacter pylori and intestinal parasites, helping laboratories support targeted treatment while avoiding unnecessary broad-spectrum antibiotic use.

    Read more

    Guiding antiviral treatment

    Accurate HCV genotyping supports selection of the most appropriate direct-acting antiviral (DAA) regimen, helping clinicians avoid unnecessary drug exposure while supporting responsible antiviral stewardship.

    Read more

    Supporting rapid respiratory diagnosis

    Urinary antigen

    Rapid urinary antigen testing enables earlier identification of important respiratory pathogens without waiting for culture. The ImmuView® portfolio includes assays for Streptococcus pneumoniae, Legionella pneumophila and Legionella longbeachae.

    L. pneumophila and L. longbeachae
    S. pneumoniae and L. pneumophila
    S. pneumoniae

    Supporting rapid respiratory diagnosis

    Lateral Flow Testing

    For acutely symptomatic patients with high viral loads, multiplex rapid antigen testing also plays an important role in first-line respiratory triage. Solutions such as the Beright COVID-19/Influenza A+B/RSV Antigen Combo Test provide rapid detection of four respiratory viruses from a single swab.

    Read more

    Standardising laboratory workflows

    Automation strengthens stewardship by improving consistency, reducing manual variation and supporting standardised laboratory workflows. Automated ELISA systems such as the DS2® Automated ELISA System help laboratories improve efficiency while maintaining analytical quality.

    Read more

    Looking ahead

    Diagnostic stewardship is about much more than reducing unnecessary testing.

    It is about ensuring every diagnostic decision delivers meaningful value—for patients, clinicians and laboratories alike.

    By improving test requesting, specimen quality, technology selection and result interpretation, pathology services can reduce waste, preserve laboratory capacity, support antimicrobial stewardship and improve patient outcomes.

    As healthcare continues to evolve, laboratories remain uniquely positioned to lead smarter, evidence-based testing pathways that benefit both patients and the wider NHS.

    Stay informed on the latest developments in laboratory diagnostics

    Clinical guidance, published evidence and diagnostic technologies continue to evolve, making it increasingly important for laboratory professionals to stay up to date with the latest developments.

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    References

    1. Schneider A. NHS could save £89m a year on antibiotics with diagnostic tests. Health Europa. 2020. Available at: https://www.healtheuropa.com/nhs-could-save-89m-a-year-on-antibiotics-with-diagnostic-tests/99253/ [Accessed June 2026].
    2. Montague E et al. The implementation of electronic clinical decision tools to reduce inappropriate urine and swab requests. PubMed. 2026. PMID: 41769725.
    3. Institute of Biomedical Science (IBMS). IBMS Response: NHS England’s 2025 Priorities. 2025. Available at: https://www.ibms.org/resources/news/ibms-response-nhs-englands-2025/ [Accessed June 2026].
    4. Hueth KD, Prinzi AM, Timbrook TT. Diagnostic Stewardship as a Team Sport. Antibiotics. 2022;11(2):250. doi:10.3390/antibiotics11020250.
    5. NHS Confederation. 2025/26 NHS Priorities and Operational Planning Guidance. 2025. Available at: https://www.nhsconfed.org/publications/202526-nhs-priorities-and-operational-planning-guidance-what-you-need-know [Accessed June 2026].
    6. GIRFT. Summary of Diagnostics Findings and Recommendations. NHS England; 2025. Available at: https://gettingitrightfirsttime.co.uk [Accessed June 2026].
    7. NIHR (National Institute for Health and Care Research). How traditional urine collection methods are fuelling AMR. 2024. Available at: https://www.nihr.ac.uk/blog/how-traditional-urine-collection-methods-are-fuelling-amr [Accessed June 2026].
    8. Forte Medical. Clinical evidence. n.d. Available at: https://forte-medical.co.uk/clinical-evidence/ [Accessed June 2026].
    9. Forte Medical. Barts Health NHS evidence. 2016. Available at: https://forte-medical.co.uk/wp-content/uploads/2025/10/2016_Barts_Health_NHS_Evidence.jpg [Accessed June 2026].

    10. United Kingdom Accreditation Service (UKAS). Medical Laboratory Accreditation — ISO 15189. Available at: https://www.ukas.com/accreditation/standards/medical-laboratory-accreditation/ [Accessed June 2026]. UK NHS microbiology and virology laboratories are routinely accredited by UKAS against ISO 15189, which formally defines the pre-analytical, analytical and post-analytical phases of the laboratory testing process.