HSJ Pathology Supplement - Health Service Journal

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oundtable: pathologyHow will we measure quality (from left)? RayPrudo; Peter Furness, who raised concerns overquality indicators; Martin Myers; Jill Rodney andAdrian Newland. Below (from top): Hemal Desaiand Michael Thomaswas going to be important in England butalready there were different models evolving.But he feared that these might evolvewithout people having a sufficientlysophisticated view of what comprises qualityin a pathology service. Having definedpathology as the end-to-end service, howthen was quality defined and measured?“How are you going to know which modelis working best?” he asked. Patientoutcomes are often looked at as measures ofquality but pathology comes at the start ofthe process, which can make it hard to relateto patient outcomes. Professor Furness saidthe Royal College of Pathologists had beenlooking at some key performance indicatorsthat could be used, such as the availability ofexpert advice.“If you have not got the measurementtools in place then you can’t know what thequality is,” he said.Dr Desai said he welcomed what the RCPwas doing. But he pointed out that whatquality was depended on what perspectiveyou had. He questioned whether laboratorybased quality markers were necessarily theright ones.“I completely agree with it being a clinicalservice,” he said. “Having the whole serviceprovided to a whole set of customers in thesame way does not meet the needs of allthose customers.”Pathology services in a hospital did nothave to be the same as a pathology service toa community, he said; the demands andrequirements were different.Richard Jones said the key to getting thisright was to give the NHS the financialbenefits from production economics withoutundermining the pre and post analysisadvice from the pathologist. But it wasimportant to get pathologists to work innetworks as well as laboratories. In manydistrict general hospitals, some specialist‘I don’t think we shouldbe blinkered – thatwe can only have a biglaboratory. In 10 years’time we will have adistributed system’pathologists were almost single-handedpractitioners and networks could help them.This could help avoid the position whereclinical staff were raising concerns aboutquality as production was consolidated.Dr Desai said: “For me as a GP, acommissioner, what happens in thelaboratory does not matter as long as I getthat service. I don’t really mind where thepathologist is as long as I can access them.”One service or two?Mr Sobanja posed the question of whetherthe clinical pathology service needed to becommissioned separately from theprocessing part of the service.Mr Jones said in London 50 per cent ofthe work done was direct access and 50 percent was part of the acute care package. “Formost pathology laboratories they do havethat 50/50 split,” he said. “If an acute trustlost 50 per cent of its activity it wouldgrievously undermine the financial viabilityof the rest of the work.”GPs might not be bothered about whathappened to that work but hospitals wouldbe very concerned. “If you lose yourmarginal activities you are left with fixedcosts. There lies the risk for a laboratory thatloses its direct access work.”Institute of Biomedical Science chiefexecutive Jill Rodney said: “I think weshould care what happens in the laboratory.The one thing that we know about the NHSis the degree of variability across variousproviders. If you commission for mediocritythen that it what you will get.”She warned they needed to be cautiousabout a market where providers couldstimulate demand and cost savings whichpeople hoped to squeeze out might notmaterialise.But Dr Desai said he had assumed thatlaboratories were providing a level of servicethat met a minimum standard and, beyondthat, operationally what happened in thelaboratories was “not my concern”.Professor Newland said the clinicalcomponent and the process could not beseparated.“If you pick and choose you end up losingthe staff that provide the service. What youmust not do is load the costs.”Association for Clinical Biochemistrypresident Dr Michael Thomas said pickingand choosing really concerned him. Hepointed out the vast range of services offeredby pathology – from very cheap tests tomuch more expensive and complex ones.But one underpinned the other and as soonas the cheap end was removed it started toundermine the ability of a laboratory toprovide the specialist tests.“Research and development is a key factorwhich needs to be costed into the overallservice of pathology,” he said.Professor Newland said that the Carterreport recognised that 30 per cent of thecosts were interpretation, research anddevelopment, and teaching and trainingcosts. And there was a need to cost thisproperly.Mr Sobanja asked the panel to describewhat pathology services might look like inEngland in 10 years’ time.Professor Furness said there would be4 Health Service Journal supplement 3 November 2011 hsj.co.uk
considerable consolidation of pathology asnormally defined – analysing samples, andproducing numbers. But the delivery of theother bits of the service needed to bedevolved as they involved closer cliniciancontact.“It is potentially tempting to suggest thatwe should commission the analysis andclinical bits separately,” he said.“As soon as you get into morecomplicated tests you need someone whocan span the bedside to the laboratory toensure that things don’t fall between thecracks. The biggest single cause of patientdamage is at the interface.”So how far will consolidation go?Professor Newland said: “I think we will see,in England, 20 to 30 hubs and I think it willbe closer to 20.” In some areas there werenot obvious hubs.“We have to have clinical pathologynetworks as well. You can’t abandon aclinical pathologist in a DGH with a smalllaboratory without proper support.“We have to have movement of staffwithin networks so we can keep them freshand up-to-date with what is going on andpart of the process.”Need for clinical networksMr Jones said it was relatively easy to getcompanies such as Roche to model what aredesigned service might look like – but nota lot of people seemed to have done thethinking around professional relationships.He had discussed this with non teachinghospitals around London and found thatclinicians liked the idea of clinical networks.He was concerned that the production sideof the transformation could run ahead of theclinical side and this could be a quality issue.KPMG associate director AdrianWoolmore said that, where clinicalleadership did not push change andrecognise the quality issues, there tended tobe stalemate, with cost driving change.“Taking 30 per cent out of pathologyservices would impact on people. Thequestion for me is how we get the clinicalleadership to take that decision,” he said.‘Phenomenal’ efficiency increaseProfessor Newland said that in hisorganisation over the past three or four yearsthe workload had increased by 20 per centbut the total budget had dropped by 4 or 5per cent; and they had 70 whole timeequivalent fewer staff through not replacingpeople when they left. This amounted to aphenomenal increase in efficiency within ashort period. Mr Sobanja commented thathe could not think of another part of thehealth service where technology had led toso much restructuring – and yet it was clearthis had not been enough.Dr Myers added: “Part of the problem isthat we see the costs as within pathology butthe costs are within the patient journey.”There was a need to look at how the costsof pathology affected the whole clinicaljourney. “I would say that pathology shouldbe delivered where we want it – if we want itnext to the patient then I think that can bedelivered.“I don’t think we should be blinkered –that we can only have a big laboratory. In 10years’ time we will have a distributedsystem.”Dr Ray Prudo, executive chairman of TheDoctors Laboratory, which offers pathologyservices, drew a comparison with othercountries. “We are 20 years behind what hashappened elsewhere. I spent 15 years inNorth America … what has happenedelsewhere is that you get what you pay for.”For example, pathologist input variedenormously and pathology providers couldbe focused on hospitals, the community orwilde FRyhsj.co.uk3 November 2011 Health Service Journal supplement 5
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