Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 580 - 599)



  580. Were the senior pathologists actually looking to press ahead with this change or were they suspicious of it?
  (Ms Wannell) It would be fair to say that there were anxieties about the service and what it meant. The way forward for us was to define a consultant-led service where a lot of the qualitative aspects and management of the service on the qualitative aspect were retained by the pathologists.

  581. I am just getting at the politics behind it. Were the senior pathologists arguing for this as a good idea or were they suspicious as well?
  (Ms Wannell) They were suspicious as well. It has been quite a cultural shift but they are very much for it now.

  582. Is there any financial advantage now in getting use of labs they can use for other purposes?
  (Ms Wannell) It would be fair to say that the consultants are members of the trust, they have a consultant contract. It is no different from any contract of our physicians or surgeons and within that there is the aspect if any member of staff or consultant is doing private work, they drop one financial session. When we had the contract with SmithKline Beecham, our pathologists dropped one financial session to enable them to do private work. There has never been any compromise on NHS work. There has never been a conflict between the private sector work they do, which is in their own time, and the NHS time.

Andy Burnham

  583. This issue of cost and quality goes to the heart of the inquiry we are doing. It would be extremely helpful if you could give the Committee more evidence about quality gains and more analysis of this ten per cent saving and what you think it would be costing the trust to provide the service in house today, given that you may not have been able to maintain it and the investment and capital may not have been keeping pace if you had not gone down a private sector route. If you could give the Committee any further evidence on those points, that would be very useful. I understand that you are linking together with Ealing to tender for the service next year. What has prevented a bigger west London consortium coming together for that service? The NHS plan talked about developing regional services for pathology. How is that going to happen, if at the stage when you are tendering, somebody comes in and asks why you do not all get together?
  (Ms Wannell) We do have a west London pathology consortium. Effectively what that consists of is three networks: two outer London ones and one inner London network. One of the outer London ones consists of Ealing and ourselves. As you saw from the submission, we and Ealing are going through a re-tender process at the moment. What it is fair to say is that at the moment it is appropriate because of the way our contract is, we need to have a new contract for pathology services. What we are doing within the contract is not closing the door to extending the opportunity for more cold work coming in. There is a realistic assumption because you are going more towards a regional pathology service that the two outer London networks will in the future come together as one network. There will effectively be an inner London and an outer London network linking to the increased size of population. Hopefully what we shall see in time, and we are aiming to issue a contract next year, is flexibility within that contract to accept more work and hopefully in time with more volume enable us to bring costs down.

  584. A pathology service for the whole of London. Is that what you are saying?
  (Ms Wannell) We are starting first of all looking at Ealing and West Middlesex, then potentially we are looking at more outer London trusts joining that in time. We have to work that one through.

  585. I am trying to get at whether the Department is pushing you to go even bigger. There seems to be a desire for regional pathology services, yet trusts are forming their own alliances on an ad hoc basis. Where is this going to meet in the middle?
  (Ms Wannell) On the modernisation aspect, where we look to stop, the emphasis is more moving towards populations between one to two million and the cost of hospital reorganisation will focus around that to get the right level of economies of scale and also to maintain a local service which people can relate to.

Mr Burns

  586. Could you tell us with regard to West Middlesex and Ealing what the experience of your members working there has been?
  (Professor Lilleyman) Ms Wannell has just explained that the consultants who are working for West Middlesex, to the best of my knowledge and belief, are content with the arrangements there. It is fair to say that they have not managed to convert large numbers of their colleagues in the NHS to that way of thinking, nor do I think they have tried very hard so I am fairly neutral on that point. Without prejudice, one can say that they are content with what is happening there.
  (Mr Spiller) As far as our members are concerned, I suppose everybody is a little conservative when it comes to changing employer so there is a lot of opposition to private sector involvement. As far as Quest are concerned, our members seem to be reasonably happy with the way things are going there. They were not happy to go in the first place, but having got there, they are reasonably content. We are not quite as happy with the arrangements at Quest as we are with Doctors' Laboratory where our members seem to be rather more committed and to favour the way in which they have been dealt with. The laboratory there is still on site and it enables family-friendly policies to be operated, whereas the idea of moving to an off-site and even relatively distant laboratory makes it difficult for many of the staff. One should bear in mind that as far as pathology staff are concerned, two thirds are women and many of them are part time and have family responsibilities. As a result of that one needs to bear in mind the ability to move staff into centralised laboratories. That is a problem whether we are talking public or private sector, but the attitude sometimes in the private sector is less helpful. On the same point, the NHS plan and agenda for change and making the change, the document on health care scientists, really stresses the integrated nature of the work which is now done in hospitals and our worry is that where work is taken significantly distant from the hospital, it removes the ability for inter-departmental working of the kind that is being envisaged. At the same time it potentially creates a barrier for staff so that if they do move, it has to be between the private sector and the public sector or back again and there is no fairly smooth path for their career development. It makes life more difficult. It also puts in place this barrier between clinical and scientific work, which we are just in the process of breaking down. At the time we are trying to break down barriers, other barriers are replacing them.

Siobhain McDonagh

  587. I should like to ask Ms Ward and Dr Prudo a question. Both of your companies have both private and NHS clients. Is there any difference in pricing structure or turnaround time for both these sets of clients? If so, why?
  (Ms Ward) The service we provide to any of our clients is based on their particular needs. If we are looking at the contract we have with the NHS, then the clinical need is the single thing which determines how quickly a test is performed. If you are looking at the private sector, we contract with a number of different organisations who have very different needs. It is a question of making sure we can provide the service they are looking for. The single most important thing in determining turnaround time is the clinical need for that particular specimen.

  588. Generally would you say that you were quicker in the NHS or the private sector?
  (Ms Ward) You cannot say one or the other. It is the clinical need. In the contract we have with the West Middlesex Hospital, there is an on-site laboratory which is focused very much on the in-patient activity. It is able to work to the needs of the hospital without having the demands of general practitioners and other people who send in work. That work is directed to the off-site laboratory which is geared to deal with their needs more effectively. Certainly the on-site laboratory is there purely and simply to cater for the needs of the clinicians and the patients at the hospital. It has no distractions in terms of large volumes of work arriving from GPs; it is purely there for the inpatients.

  589. Would you say it is more expensive to the NHS or the private sector for doing the same test?
  (Ms Ward) It is very hard to generalise because we do not have a price list as such. Any contract we have is developed on the basis of what that particular client needs. The NHS, because of the volume, is more favourably priced, but it is very difficult to say on that basis, because we do not have a contract and say they will get a ten per cent discount or a 20 per cent discount. It is put together for that individual client.
  (Dr Prudo-Chlebosz) Turnaround times are usually set by the consultant, taking into account the clinical needs of the institution. For example, in a DGH where there is an accident and emergency department, clearly the turnaround times have to reflect that. Turnaround times are a key attribute of the service level agreements and it is something which is very much in the hands of clinical consultants, pathologists who are in charge of pathology departments. Perhaps there is more room for utilising outside experts from other areas, because my experience has been that pathologists in the private sector are usually more attentive to matters like turnaround times than in the NHS. There is no real reason for that. Perhaps it might be that private sector laboratories are more flexible in their working practices and allow for services which could not otherwise be provided. I am surmising that. What I am saying is that there is opportunity to have whatever turnaround time you like and with modern pathology systems, where you have integrated IT, where you have new technology, it is more expensive to discriminate between private pathology and NHS pathology than to ensure that the configuration of the department is such that all work is put through quickly. On pricing, pathology sounds as though it is a simple exercise, but in fact there is a large logistic element to it, to do with taking samples, transporting samples, making them available in electronic format and depending on the level of service, whether you want a courier to pick up samples every hour, every day all clearly affects the costs. It is difficult to make straight comparisons because some of the pricing element is to do with patient convenience. If you want a patient to have seven-day-a-week access to phlebotomy services there is a cost for that. Intrinsically I do not see any differences and certainly our company has no policy of charging one sector more than another but adjusts it to the needs of the particular institution.

  590. Ms Wannell stated that there is a joint interest between the trusts and the provider of pathology services to limit tests. Can you explain how this was addressed in your current contract and how it might be looked at in any future contracts? How different was this from your practice prior to contracting out?
  (Ms Wannell) When we mentioned limiting tests we were really talking about making sure that the service is provided on clinical quality and that we are doing best practice on that side. What we mean is that we want to make sure that a test is not repeated unnecessarily or that junior doctors are actually calling for tests which are not necessary. The idea is that we are developing more of a protocol approach. Within the contract we have started to work on that aspect of developing protocols for certain tests. There is an aspect that it is quite time consuming on all sides, Quest, the pathologists and the trust, but it is a way forward to enhance the quality on that side. That is the aspect on the limiting tests side.

  591. Would the clinicians in your hospital agree that there has been no interference as a result of the contracting-out of pathology services with their ability to treat and order tests on the basis of need?
  (Ms Wannell) Absolutely. The whole aspect for us is that the contract has been very much clinically led. The whole focus on the division of tests between on site and off site has very much been done with the pathologist and the clinicians involved. Karen Ward mentioned earlier the tests which are done on site for the inpatients. It is very much the urgent tests which are done on site, so clinical quality and clinical need is not detrimental and, working with the consultants, we have identified which tests are not needed straightaway; it has very much been done on clinical need.

  Dr Naysmith: We should look at staff issues a bit more closely. There is some unease at the management of pathology being contracted out whilst the scientific, technical and support staff remain as NHS employees. Do you have any views on this? Is it something which can be managed or is it something which is really very, very difficult to manage?


  592. Before you answer that, may I mention that according to the papers this morning some agreement was reached yesterday. It only mentioned Unison so I do not know whether your organisation was involved in that and whether this is relevant to answering that question.
  (Mr Spiller) The Unison question relates to three hospitals and the contracting out of the soft services. We are not involved in that process anywhere. Up until recently it was being argued that clinical services would not be involved in private sector. That clearly is no longer the case because we are not talking about clinical services and pathology involving the private sector. The retention of employment model which has been developed to cover these three pilot studies, which Unison signed up to yesterday, is one in which we have been involved, but we feel frankly that it is inappropriate as far as pathology is concerned because it identifies a level of supervision which would be contracted out, which would go to the private supplier, but the rest of the staff would not. A pathology laboratory is not supervised in that way. Almost everybody in a laboratory has some supervisory or managerial responsibility and indeed a clinical responsibility as well as you move through that structure. There is a continuum. There is no natural breakpoint. The natural breakpoint to date has been seen as the pathologist because everything has to go through the pathologist. That will increasingly not be the case, so there is no natural break point. Therefore any private sector involvement in pathology is likely to create an artificial break point and that concerns us greatly. It concerns the professional development of the staff, not that the private sector will not train or provide that, but that you are not in an environment in which there is an obvious process to go through. You have to change employer often in order to make changes. Within the NHS that is not a problem. You are effectively with the same employer, moving sites. Moving back and forth between the private and public sector creates enormous problems.

Dr Naysmith

  593. Can you give us some examples of the problems it produces?
  (Mr Spiller) Fortunately there has not been much opportunity yet to find good or bad examples.

  594. What sorts of things would you predict?
  (Mr Spiller) Pensions, for example. Pensions are the biggest single issue because of the different nature of pensions in the public and private sector. That is an area where we find there would be problems moving back and forth. There are nearly always losses to the employee when you move pension schemes. No two actuaries ever quite agree on what benefit you are bringing with you. There is a difficulty there and we spent four years developing agenda for change and a new salary structure and a lot is based around that in terms of professional development and recruitment and retention. Having gone through that route where we believe we shall be able to recruit into medical science, then we would be starting to break it up and reducing—not removing but reducing—the career opportunities. We do see difficulties there.

  595. Perhaps I could ask Karen Ward what her experience has been in Manchester with this kind of thing. Do you have any observations on the difficulties, if any?
  (Ms Ward) I presume you are referring to the various reports which have appeared in the Health Service Journal.

  596. Yes.
  (Ms Ward) When we visited Manchester we were asked by the four chief executives to make a presentation to the working group, which we did. That was purely and simply a presentation on what our approach was to developing partnerships. We had various discussions with the laboratory staff, the consultants, trust managers and certain union representatives. Whilst there was some vigorous debate about it, I would not say that we encountered out and out opposition, certainly from MSF. They were concerned about how partnerships would be developed, because obviously the unions, as is their role, are concerned about terms and conditions. It is fair to say that when people look at our terms and conditions, when people look at the culture in our organisation, I have not met anyone who has been to our facility who has not come away very, very impressed by the commitment of the staff, the general atmosphere of the place and the ethos of the place.

  597. How would the terms and conditions compare between National Health Service conditions and what you were offering?
  (Ms Ward) We tried very hard to keep the basic salary very comparable with the NHS. The difference is probably in areas such as training and development and opportunities for staff to develop their particular skills. As far as we are concerned, staff are a key resource. We cannot provide an excellent service unless we have excellent staff. We are prepared to put a lot of time and effort into developing excellent staff. Our voluntary turnover rate is probably the lowest in our particular industry. We work very hard because we have a very strong belief that we need to have that kind of environment to encourage staff to join us and to stay with us.

  598. You prefer that to the retained contract situation.
  (Ms Ward) We do not have a preference one way or the other. What is important is how the staff are managed and that they are given those opportunities, they are given the right training and development opportunities and that they feel part of a positive organisation That is what is important to them.

  599. Dr Prudo, do you have any views on this?
  (Dr Prudo-Chlebosz) There is room for all kinds of models. In the Ealing model the staff transferred to the Doctors' Laboratory contracts under TUPE and then were given a choice whether they stayed with their NHS contracts or came over to TDL contracts. There are differences and will continue to be. Pensions is one of them. What we do is provide a set of flexible benefits which the NHS does not provide and we allowed the staff to choose which contract they wanted to be employed under. It is interesting that after a period of a few years, most staff voluntarily chose to go to a TDL contract, even though the salaries are much the same.

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