HSJ Pathology Supplement - Health Service Journal

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oundtable: pathologysomewhere in the middle. The need toreduce costs was the driver in many cases, hesaid: in Ontario, the number of laboratorieshad been reduced from dozens to just threeor four.The UK was likely to end up adopting oneof these models and the question then waswho could run them best. “My answer tothat is very simple – whoever can deliver.What we have heard is that pathology is avery complex set of services, it is not oneservice. In pathology we have all thesecomplexities within one organisation.”He said the UK did not have muchexperience with re-engineering. ButProfessor Furness pointed out that theCarter report had said that the UK systemwas one of the most cost-effective in theworld. And Dr Myers asked: “If they havebeen doing it for 20 years then why are theystill the same cost base as us?”Standardised testsBut Dr Prudo said the US system was plural:“In America you see every single model youcan think of. Within that there are somewhich are very successful and some whichare not.”Professor Newland said that the UK hadproved itself on quality but suggested the preand post analysis side was whereperformance was “pretty poor”. “We arepretty bad at getting the specimens to thelaboratory and getting them out – we are aceat looking at the samples,” he said. MrSobanja, however, pointed out there hadbeen some “horror stories” around cytology.Professor Newland said: “There is anirreducible minimum of errors – around 3 to4 per cent. It is the mechanisms we have inplace to ensure they don’t get out – thechecks and so on.”Dr Desai pointed out that simple thingswhich might be assumed to happen – such‘It is cheaper atthe moment to dothe test than to argueabout whether it isnecessary or not. Wehave to change that’as standardised tests and ways ofcommunicating – did not happen acrosspathology services. “There are technicalstandards which you would expect to existwithin pathology,” he said, adding thereshould be a body that set standards.Professor Newland said there had beenprogress on such issues and a meeting wasplanned for the end of October which wouldlook at them. The current system oflaboratory accreditation had served themwell but now needed to change. They wouldlook at ways of using all the informationabout quality from the different perspectivesof people who wanted different things – forexample, the patient and GP.Dr Myers agreed there was a need forstandardisation and the minimising ofvariation. “We have got that wrong inpathology,” he said.Mr Sobanja suggested there was adifference between how you regulated andwhat quality was. He suggested thatregulation by multiple bodies could result infailure, whereas with a single regulatorybody it was obvious where the buck stopped.Professor Newland pointed to the amountof work the National Institute for ClinicalExcellence was doing around diagnostics.“In pathology we have sometimes been ourown worst enemy,” he said, explaining thathe knew of tests done by three differenttrusts which resulted in three differentresults.He suggested that there was value indefining what tests should be done and whatshould not.Dr Desai raised the issue of how intenselylaboratory equipment was used and whethera system that had equipment not being usedfor much of the time could be an efficientmodel.The Carter report suggested thathaematological analysers were only used 25per cent of the time, Professor Newland said.Dr Myers pointed out that UKbenchmarking had shown that in clinicalbiochemistry the cost had gone down inboth absolute and real terms over the past 10years. “If your entire costs have gone downdoes it matter how much redundantequipment there is?” Dr Desai said: “Itmatters to me because it shows that it hasnot reduced enough.”But was it always right to send all “cold”work to a central laboratory? Dr Thomasdoubted it because there would always be aneed to provide some core services within ahospital and that “sweating the assets” onsite might be a cheaper option.What will be done on site?But Professor Newland said that dependedon what equipment there was on site. About20 per cent of work needed to be done onsite, he said. “You fill up your machine timewith some of that work,” he said. “It’s aquestion of how much machinery you haveand how hard you work it.”So what will be the characteristics of asuccessful pathology service as we moveforward? Mr Sobanja suggested that aquality service would be one that knew itscustomers and their needs, and tried to meetthem: “One that could demonstrate that itsquality is as high as it could be. One that6 Health Service Journal supplement 3 November 2011 hsj.co.uk
Keeping up with the science (from left): Adrian Woolmore; Mike Sobanja; and RichardJones, who said pathology services would need to innovate in response to scientificadvances. Below: Peter Furness (top) and Adrian Newlandcould demonstrate that it was operating atan appropriate cost within a tax fundedmodel.”From a taxpayers’ perspective he said:“There is something about demonstratingcosts and, even more, a pathology servicethat is able to demonstrate its value in termsof the difference it makes to outcomes forpatients.”Personalised medicineRichard Jones said it was necessary toinclude something on innovation to the listof characteristics and highlighted the impactof molecular diagnostics, which opened upopportunities for pathology services thatorganisations needed to grasp. “We need totake advantage of scientific and medicaladvances,” he said.Professor Newland added thatpersonalised medicine would be important.An example of this was where testing coulddetermine which patients would benefitfrom new drugs so that money was notwasted treating those who would notrespond. “The problem we have inlaboratories is funding the introduction oftests that enable us to do that – to identifythe patients who can benefit from particulardrugs,” he said.Dr Prudo said there was a need to havepathology support for individuals. “We don’thave people trained in this kind of activity.It’s very doctor intensive.” Pathologistsmight have to pull together lots of differentinformation “We are going to require moreand more medical expertise to identify this.”Professor Furness called for decisionmakingbodies to say what should andshould not be used.“We can’t reasonably expect every singlelocal laboratory to be physically able to dothat job. It has to be more centralised. NICEis the obvious candidate for most of the stuffbut it is getting more complex.”Advice could extend to what is and isn’tworthwhile using in particularcircumstances. This could offer a way ofrelating the cost of tests to budgets – as itwould be clear that savings were made bynot doing things the patient would notbenefit from.“It is cheaper at the moment to do the testthan [to] argue about whether it is necessaryor not. We have to change that,” he addedProfessor Newland mentioned patientaccess to results, especially as where tests aredone diversifies – “the patient has to be incharge of that”.But while there was acknowledgementthat a diversity of providers is likely to beinvolved, Mr Jones pointed out some of theissues that held back the private sector. Hesaid: “There are issues around tariff andtransaction management, aroundprocurement rules and competition, and alsoaround TUPE and the impact on theworkforce of moving people around. Theyare massive issues preventing the marketplaying the part it can in this.”Jill Rodney said that people were vital tomaking change happen and they had notbeen talked about; clinical leadership wascrucial in all of this.Dr Prudo said there had been a lot ofdiscussion around cost but not what thebenchmarks for costs were. He highlightedthe very different costs between hospitals.Bringing the debate to an end, MrSobanja drew a series of key points out ofthe wide-ranging discussion. Theseincluded:l What do we mean by pathology? Was it anend-to-end service or simply a diagnostictesting service?l Variation was a critical issue. Reducingunwarranted variation is one of the mostproductive things we can do in the NHS, hesaid.l There is no “one size fits all” system.l Key performance indicators would beimportant for the service as wouldregulation/accreditation.l There was a distinction between the dataprocessing side of pathology services and thepathologist service – which raised questionsabout how they should be commissionedand whether different commissioningmechanisms were needed for these differentparts of the service.l 20-30 hubs for pathology services hadbeen proposed as a model with possibly amore “distributed” focus.l The role of the private sector would beimportant – “whoever can delivereffectively”.l Issues around workforce needs in thisnew world should not be forgotten. lwilde FRyhsj.co.uk3 November 2011 Health Service Journal supplement 7
Page 3 and 4: e better?Joining the debate (from l
Page 5: considerable consolidation of patho

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