Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 560 - 579)

THURSDAY 22 NOVEMBER 2001

KAREN WARD, PROFESSOR JOHN LILLEYMAN, MR ROGER SPILLER, DR RAY PRUDO-CHLEBOSZ AND GAIL WANNELL

Chairman

  560. You do know that Mr Burns was a Health Minister about five years ago, do you?
  (Professor Lilleyman) I think the problem arose at a level slightly below that actually.
  (Mr Spiller) I would not disagree with what has just been said. The feature of pay is critically important to recruitment in the first place; recruitment is important wherever we go in the country. the career development and progression beyond that is important wherever we are in the country and that is not based on high costs in the London area and the South East. As far as retention is concerned, which is the other big problem, pay clearly is more of a difficulty in areas of high costs. Thus we are firstly unable to recruit new staff into pathology because we are looking there at school leavers, some time before they leave school, having decided their career path. Then they have to go through their degree course before they even come in. We are looking at a lag of four, five or six years. Until we are able to build a career which is seen as being a beneficial one, then individuals are not going to go into it. It is a long-term process. We have started on that, there have been some substantial improvements in pay in the last year at the bottom end of the structure. At the top end of the structure there are some problems, but the recent move towards advanced practitioners who will be engaged in some clinical work has helped to extend the career path there and make it slightly more attractive.

Mr Burns

  561. What about the independent pay review body?
  (Mr Spiller) We believe that when the agenda for change programme is instituted—it looks at the moment to be late next year—certainly MLSOs, the staff in the laboratories, will be part of the pay review body. It is something we have been after for many years and it looks as though we shall be moving towards that. That does two things. Apart from ensuring generally better levels of pay increase, it also means that their professional work is going to receive that bit more respect and hopefully we have already managed to raise the profile of the laboratory scientist so that they are now taken notice of, particularly in the Department of Health. It is a very welcome change.

  562. One of the seeming criticisms of the system at the moment is that the services are on too small a scale and too fragmented across the country to be as efficient and as effective as possible. Would you think that is a fair criticism and would you agree with it, or do you think that is unfair?
  (Ms Wannell) I would have to agree on that. The aspect of being on a smaller scale is that you lose the economies of scale. Pathology is moving, like many other clinical services, almost to a network provision as we see in cancer and coronary heart disease. The emphasis now is moving towards a number of organisations working together to provide a better quality of care and efficiencies in service provision. The other aspect is that the larger units can actually have dedicated pathology and managers. In some of the smaller units, there are senior technical and clinical staff who are multi-tasking; it is not necessarily their area of expertise but a lot of management responsibility, sorting out transport. In bigger units there is dedicated management and that makes a big difference. Other aspects are in relation to the capital investment we talked about before, on building scales, on the IT aspect and on the equipment. We are talking about a specialty which has very specialised equipment. Smaller units and trust cannot always necessarily invest in that whereas larger units, whether it is private sector or a combination of NHS organisations, can pool resources and get better provision that way. The other element which was mentioned before was that with bigger organisations there is better training. There is a lot to do with larger organisations working together attracting staff. It does a lot on the recruitment and retention side.
  (Professor Lilleyman) You have to understand how we have got into the position we are in today. We have to look back to the 1970s, because we are kind of locked into the configuration of service which was developed in the 1960s and 1970s with the District General Hospital and the four sovereign departments of pathology and the main disciplines within it. Time has moved on and there are tremendous pressures on the configuration of acute clinical services other than pathology, but in pathology we now have to start looking at delivering the service on a bigger population base. We cannot sustain sovereign departments of that size any more. There are all sorts of reasons which we probably do not have time to go into and it probably does not matter. What we are really being pushed towards is more people working in fewer places and providing a more peripatetic sort of service, particularly in histopathology.

  563. Do you think it is possible for the service which is currently within the National Health Service to be reformed, enhanced and improved without private involvement? Can it be done from within on its own, or will it have to be done with private involvement?
  (Ms Wannell) I do not see any reason why the NHS cannot work in a network and cannot modernise. There is the potential for different models. We can have networks of NHS organisations working together in a large lab and emergency labs on the sites. That can be purely NHS. There may be potential for networks having private and NHS and the private sector providing either some capital or some different levels of IT support. There is an opportunity for a variety of models but there is absolutely no reason why the NHS, working together in a network covering a large population cannot modernise.

  564. Do you not think there is a danger, given that the service as it is at the moment is in one way exposed because of the variations in the quality of the work and the problems with staff shortages and everything, that here would be a service within the Health Service which is ripe for privatisation—to put it very crudely—if the Department of Health were so minded to rid itself of the potential financial costs of providing the investment, particularly the capital investment?
  (Ms Wannell) I think there is an opportunity for a variety of models. What the NHS could do on the modernising side is learn a lot from the private sector. The private sector has experience of working as specialist pathology services, off-site laboratories and on-site hot labs. If the NHS go down that line, which they are moving towards, there should be emphasis on the NHS learning from the private sector. There could be the opportunity of moving more towards pushing it to the private sector but I genuinely believe that there is room for both models and one should actually look at the local situation and what is right for the local population and the local service.

Chairman

  565. Mr Spiller and Professor Lilleyman have made the point about the issue of pay scales and pay levels. You may remember that some years ago the Health Committee looked at staffing levels and we particularly drew attention to our concerns about the starting salaries of people in your area of work. My recollection was that graduates were starting at round about £7,000 a year which seemed to us to be quite incredible for a highly responsible job. I am interested in your thoughts on the way in which in certain areas the service has, within the NHS, moved, modernised itself. You in your evidence mention Lincolnshire. I should be interested to learn a little bit more about what motivated the changes in Lincolnshire, if you are aware of it, and the kind of problems you identify which had occurred before this change. You mention consultants trying to protect their own empires. Can you say a little bit more about what the position was there and how it is improved by the changes which have occurred which you describe?
  (Mr Spiller) A number of changes took place simultaneously, some of which in the Path Links case are local and others are on a national scale. If I may deal with the national scale first of all, the issue of pay has not been resolved but there is movement towards it. In his evidence to you a few weeks ago the Secretary of State made it clear that there is still some way to go on that and we are looking forward to seeing that reflected in the pay results this year. There is clearly still a problem with technical staff being recruited on starting rates below £11,000 a year for graduates. That is a real difficulty which still needs to be overcome. Moving beyond that, the career path changes are beginning to take effect. At the moment in cytology we have the advanced practitioner where the practitioner will be a scientist but making clinical judgements and suggesting the treatment path to the patient. We are breaking that glass ceiling which has existed.

  566. When you say "to the patient", do you mean to the referring doctor?
  (Mr Spiller) No, directly with the patient. This has also happened in other areas in the professions allied to medicine and it is already happening as far as nurses are concerned, with nurse practitioners. We certainly want to see that go further and it is as a result of the pressures on staffing among consultants that that has arisen, as well as the knowledge that for much of the work the advanced practitioner with fairly limited additional training is perfectly capable of performing those roles. In the Path Links case, that has already had some impact as well because the process in Lincolnshire has been to set up a single pathology service, not a hub and spoke as might be more appropriate in an urban area but a distributed arrangement so that each of the laboratories within that area will have its own specialties and will perform those for the whole area. It is a means of increasing efficiency and managing the workload without requiring additional staff to do so.

  567. May I be clear? What you have in Lincolnshire is a number of hospitals which will have their own labs.
  (Mr Spiller) Yes.

  568. What has happened presumably is that these labs, as well as doing the core work for their own hospitals, have specialised within the Lincolnshire area, so that they would deal with certain specialisms within one lab instead of all of them doing it.
  (Mr Spiller) Yes; that is right. That is common practice anyway because the workload in some of the specialties is so low you cannot warrant doing that in all laboratories. The other important thing with Path Links is the IT system which has been established to bring them together. It is that which is perhaps the most crucial single element in being able to make the whole process more efficient. In North West London at the moment, their modernisation proposals are based largely around an IT system which will enable the number of tests done to be substantially reduced and the patients interfered with less than would otherwise be the case.

  569. What was meant by the consultants protecting their own empires in the previous system? How did this work and how did it impact on what was going on?
  (Mr Spiller) One of the difficulties we faced in Path Links was that the consultants sought to put up barriers around their own departments, both as far as the rest of the acute hospital was concerned and between units. It was a problem in the negotiations over Path Links to break down those barriers, to persuade consultants that they would have to share both the responsibility and "power" that they could exercise. That has been broken down to a substantial extent. That is a problem in a number of areas and that is why the advanced practitioner role is becoming so important. It is breaking that barrier between clinical and technical work which in some areas has been breaking down anyway of its own accord because of the shortage of clinicians. It is now gathering pace.

Andy Burnham

  570. I should like to direct a few questions to Ms Wannell, picking up on your general replies to Mr Burns a moment ago and look at your particular experience when you were contracting your services out to what were SmithKline Beecham Clinical (now Quest Diagnostics). Reading your memorandum, I got the impression that an in-house bid was never really a starter to be honest. Did you cost an in-house bid against the private sector bid and if so, why did it fail?
  (Ms Wannell) Regarding the in-house option for ourselves, we did look at that. Putting it into context, we had at that time four separate laboratories in different locations with different IT systems and very old equipment. When we look at the capital cost involved, it was too much as far as the health community was concerned at that time and the money was not available on the capital side.

  571. Would you have preferred to keep it in-house if the money had been there?
  (Ms Wannell) At that time the trust board were wanting to look at various options and were also looking at new models. The option for us was to look at potential for new ways of working on site and off site and we had linked in very much with the clinicians and identifying the model was something management and clinicians had to work together on. We were quite happy with options totally on site or a split site option. When we went out for bids, although we knew we did not have the money to provide an in-house service ourselves, we ensured that the bids went to both private and NHS providers as well, so there was a range of bidders. We were looking for quite an innovative approach.

  572. Why did the other NHS bidders fail?
  (Ms Wannell) At the first stage we had a number of bidders and to get it down to a short list of three we went through a detailed qualitative evaluation. We got down to three bidders and unfortunately the NHS bidders fell out at that stage of the process.

  573. Reading your evidence I was quite struck that you said the contracting out of the service had led to a ten per cent saving for the trust. That meant the pathology service was costing you ten per cent less. There was a strong impression that quality had improved, it allowed clinicians to be freed up from different tasks and generally an "enhanced level of service" was the phrase you used in your evidence. Then you went on to say that "there is a concern that tendering to the private sector is simply a means of reducing cost. Particular attention needs to be given to ensuring that this is not the case". There you seem to be suggesting the opposite, that the culture of the new service is perhaps a bit more penny-pinching, cost-cutting. There is a slight contradiction there. Can you explain that?
  (Ms Wannell) What I was trying to express there was that in terms of value for money for West Middlesex and our population, there is obviously the cost-effectiveness and value for money aspect. We also very much balance it with the quality of service. The two aspects have to be together. It is meeting all the quality criteria as well as value for money. That is the message we were trying to get across: cost is one aspect but the quality aspect is fairly key.

  574. Would you say that it is cheaper and it is better quality? That seems to be the crux of the matter here. You are getting a better service for less.
  (Ms Wannell) When we had the contract initially yes, there was a significant saving to us. The other aspect of cost saving is that it is not just the initial saving but the trust actually transferred quite a bit of risk. There was not the re-investment in capital, the IT side. It has been long-term saving as well and the quality has been maintained right the way through.

  575. Do you think staff in the trust would share your view? Is there any conflict between what clinicians and staff think?
  (Ms Wannell) From our perspective at West Middlesex, it has been absolutely crucial that we keep the pathologists on board. They are still our staff; all the clinicians as well. Many of the concerns people have about the concept of on-site/off-site testing moving towards the private sector is possibly about, people like the pathologists not being available for the multi-disciplinary team meetings. What we have been able to demonstrate is that communication is still there, there is still the level of quality, there is still the level of communication. We would say on the pre-analytical stage, the phlebotomy, the transport, the errors which potentially arise through labelling and specimen taking, those aspects have reduced dramatically. I would say it has been an enhancement for us.

  576. It seems as though it has been a good solution all round.
  (Ms Wannell) For us it was beneficial.

  577. Does that mean that when you come to re-tender the service next year there is no realistic proposition that it would be brought back in house?
  (Ms Wannell) I would not agree with you on that. We have very clear qualitative standards within our tender process and the value for money. We are at the stage of inviting bids from the private sector. We are looking at both options Public and Private and we would not be excluding anyone. We do have very clear criteria for the quality and value for money so we are testing all providers on that side.

Dr Naysmith

  578. What are the qualitative advantages for the clinical pathologists in your setup and are there any financial advantages for them?
  (Ms Wannell) If they were here today, I think they would say that the qualitative advantages are that the service is enhanced for them. Professor Lilleyman mentioned that there is a shortage of pathology staff. Previously they were very much involved in managing the MSLO staff, they were responsible for the phlebotomy, they were responsible for the transport system. A lot of their time was involved in managerial and sometimes administrative elements. Very often they were involved in their own IT; they became the pioneers in troubleshooting on IT. A lot of their clinical core time was on other duties. What the clinicians are able to do, now that we have dedicated managers who have taken on that responsibility, is devote more clinical time to their specialist area, where their expertise is.

  579. Were your clinical pathologists pushing for this change?
  (Ms Wannell) At the time there was a lot of concern, anxiety. It was a significant culture shift for us as an organisation to take this on board. The clincher for us was very much developing a consultant-led service. This was in agreement with the Royal College of Pathologists, Quest and West Middlesex. We now have pathologists who are very much the gatekeepers of the policy and they are very much on board.


 
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