Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 620 - 639)

THURSDAY 22 NOVEMBER 2001

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

  620. This is part of the contract.
  (Dr Prudo-Chlebosz) It was not part of the contract it was something we used to improve the working conditions and efficiency of the laboratory.

  621. So it was found to be something you wanted to add in.
  (Dr Prudo-Chlebosz) Yes.

  622. What drove that? Why did you do it?
  (Dr Prudo-Chlebosz) Because it is in everybody's interest to do that.

  623. No, I mean what brought it to your attention that there was a problem which needed solving?
  (Dr Prudo-Chlebosz) It was not being done before, we were doing it in the private sector, it seemed a sensible thing to introduce it.

  624. It was something which was common in the private sector, but was not being done.
  (Dr Prudo-Chlebosz) Whether it was common or not, it was prevalent in our laboratories. There is more room for that. Much more mundane issues are that a lot of re-testing is done simply because test results were not available.
  (Mr Spiller) I accept entirely what has been said about Ealing, but we are not really talking about a set of rules to which those in the pathology department and the scientists respond. We are looking very much there at clinical decisions being taken, by those who previously would not have taken clinical decisions and that is a difference here. We are looking at decisions which previously a consultant would have taken, not looking at a set of rules, but the subjective decisions which the consultant would have been taking.

Jim Dowd

  625. We are not looking at that. That is not what we are talking about. We are asking whether the procedures have changed since the provision and we have been assured they have not. If re-tests are necessary, re-tests are made. Clinicians were not making those decisions.
  (Mr Spiller) I am sorry, I am not referring to that. I am referring to the last point which was made about signing off. We are not just talking about signing off here, we are talking about treatment pattern for the patient being determined by a scientist.

Dr Naysmith

  626. We need to know what "signing off" means.
  (Mr Spiller) We are talking here about the scientist and I echo the point being made, that I have included clinical scientists in my position because we represent them as well. The distinction between the scientist and the MLSO is disappearing and increasingly the distinction between the scientist and MLSO and the consultant is disappearing. Treatment patterns, treatment determination are now starting to be taken by the scientist where previously that would have been taken by a consultant. We are not just talking about having done a test and giving the results and saying that these results are okay within the normal range or abnormal. We are not talking about that. What we are talking about is going to the next stage which is that because these tests are abnormal, what do we do about it? That is a decision which in the past has not been taken by the scientist, that has been a consultant pathologist decision.

Sandra Gidley

  627. Earlier you were saying it was a good thing.
  (Mr Spiller) Yes.

  628. Now you seem to be saying that is not a good thing. I am slightly confused. You seem to be approaching this from two different directions. Either it is a good thing that MSLOs and scientists are taking on far more responsibility and making decisions or it is not. You cannot have it both ways.
  (Mr Spiller) I am saying it is a good thing, but it is something we believe will be damaged if a barrier is put in between private and public sector so that it is difficult to see that process continuing. The retention of employment model is clear. It looks at people who have no clinical responsibility at all and that is why it may well be appropriate there. The point I have been trying to make—and clearly I have not explained well enough—is that we do not see that being appropriate in pathology because in pathology there is no longer any clear point at which you can say that this is a technical decision, that is a clinical decision. That barrier has gone so we have no natural break point in pathology. The argument therefore is that private sector involvement in pathology, if it is going to be there, should not include the staff.

Chairman

  629. It is a bit like the difference between health and social care.
  (Mr Spiller) Yes.

Mr Burns

  630. The arrangements described in your memorandum do seem to be rather complicated. Could you briefly tell us whether the contracting out to the private sector has led to an increase in management costs.
  (Ms Wannell) From our experience, the one thing I would say is that it did not lead to an increase in management costs. One of the things we learned in hindsight is that we under-estimated the amount of management involved. An issue raised before, which I would echo, is that having dedicated managers does help. Actually managing the contract itself, developing the protocols we have talked about, does take some dedicated time. Within the management structure—and this is common to many organisations—pathology is often lumped onto several other areas of management. The advantage of the future, if we are looking at bigger networks and organisations working together, is the opportunity of having dedicated managers. What we have learned through our experience is that within this next round, and by working with Ealing hospital, we shall have a dedicated pathology manager who will be able to manage the contract. By working together we have been able to get the efficiencies and been able to afford that. On our own we had not done that but it has been a learning process for us, both within the NHS and the private sector.

  631. One of the key factors in deciding whether pathology services should be kept in-house in the NHS or with the private sector is the value for money and whether it is cheaper or not. Could you tell us whether the average costs of a range of diagnostic tests in your organisation are less than in the NHS?
  (Ms Ward) It is probably very difficult to assess costs, certainly in the NHS, because there are many different ways of accounting for them. It is a problem which has been recognised by many people working in and with the NHS. I can only speak for Quest Diagnostics, I cannot speak for the suppliers, but it is true to say that the costs are more transparent because they are identified very clearly in our organisation. You could therefore say there is more accountability for those costs. In terms of value for money, there is a number of areas which I would probably highlight if we are looking at what a service actually costs. Recruitment and retention are very important to us. Our staff are very important to us. Having lots of staff pass through your hands is very wasteful. It is very important to us to recruit and retain the right staff and a supportive environment is key to that. In terms of procurement, where we add value, our turnover as an organisation is approximately equivalent to the pathology budget in the NHS and we use that purchasing power to develop very good relations with our suppliers. This is not just in terms of financial agreements, it is in terms of support for equipment and in terms of technology refreshment. We have some very good agreements with our suppliers and we take the same view with our suppliers as we do with our customers in that you need a long-term relationship, you need to build on trust you need to develop a relationship which benefits both parties. That is very much our approach to that. There are areas where it is certainly accepted that costs are lower if you get higher volumes of automated tests. If you are putting large volumes of automated tests through then it is fairly well accepted that costs come down and we probably have an advantage in that respect in that our network is large in the US. In other areas we probably spend more, for example in cytopathology. That is related to quality. When we started the contract with West Middlesex Hospital, the numbers of staff were quite low and the turnaround time was long, there were some concerns over quality and deliverability of the service. We have invested in that. Yes, it is difficult to recruit and retain staff in cytopathology, as I am sure everyone is aware, but we were determined that we would do that and we have an excellent cytopathology department which is fully accredited and all our staff are trained in the new liquid-based cytology techniques which are being investigated by NICE at the moment. We have invested in that and we train the staff and we train our own staff to come through that. There are probably areas where we spend more money than the NHS, where it related to certain quality issues, but there are efficiency gains by looking at work which can be automated and put together to get the benefits of the scale.

Dr Naysmith

  632. We have been talking this morning as though pathology were just pathology, but of course it is a whole series of specialties and sub-specialties. Are there any things, including cytology, haematology, biochemistry, clinical pathology, which the private sector does not touch either because they are too expensive or too complicated or too difficult?
  (Ms Ward) There is nothing that we do not touch.

  633. There is nothing at all that a NHS pathology service currently provides that you would not bid for.
  (Ms Ward) As far as I am aware; yes.

  634. I just wanted to check on that. Is that the case Professor Lilleyman?
  (Professor Lilleyman) I am not sure about autopsies. Do you do those?
  (Ms Ward) We have not been asked.

  635. You do not contract for autopsies.
  (Ms Ward) Everything we have been asked to do, we have been able to do.

Chairman

  636. Would you do autopsies if you were asked to do them?
  (Ms Ward) Personally? I am sure we could find a man who could.

Mr Burns

  637. When you said that your turnover is equivalent to that of the whole of the NHS, was that just in the UK or did it include your turnover in America?
  (Ms Ward) As a company as a whole; the whole of the company.

  638. So that is UK and US.
  (Ms Ward) Yes.
  (Dr Prudo-Chlebosz) We have had two NHS contracts which we won in open tender. We were asked contractually to deliver savings on both those contracts, to save and maintain over ten per cent of the previous spend in an environment in which there was already pressure on making considerable savings. We have been able to achieve that over many years. On the value for money issue, certainly in one of the current contracts, in terms of quality we were able to obtain accreditation for the hospital laboratory, we were able to achieve training status for staff of the laboratory, we were able to provide support for training programmes for the laboratory staff. Our experience has been that in an open tender situation we have been able to provide value for money, in both our major contracts we have improved the service levels to the hospital. I think there is in principle room for this kind of PPP.

Dr Taylor

  639. As one who has worked in bog standard DGHs for quite a long time, I have lots of concerns; one or two satisfactions but lots of concerns on the quality issue. One comment on managers before I come onto that. The standard of management throughout the NHS, as I am sure you are aware, varies tremendously. If you follow the Health Service Journal correspondence columns you will know that in the part of the country I come from we have two particular managers—whom I shall not actually name—who have been labelled doyens of the stonewall school of Health Service managers. Those sorts of people are not doing anything to help the NHS. I am sure we have here examples of superb managers and that is what we need. Coming back to the quality issues, the first one which concerns me tremendously is the contact between pathologists and clinicians. When I was working—and it is a few years ago—the regular meetings were relatively easy; lunchtime meetings were fairly easy. The difficulty was the ad hoc meetings where you did not really want just to telephone; you could telephone a biochemist—but you need a microbiologist to come onto the ward and see somebody. If you are a surgeon you need to go to talk to the histopathologist on an ad hoc basis. What sort of proportion of time are the actual pathologists on the DGH site or on your sites?
  (Ms Ward) The vast majority of consultants are on DGH sites for most of the time. We ask the consultant pathologist to attend regular quality reviews, which they do, but the vast majority of their work is still based at the DGH; certainly the histopathologists do the cut up on site, certainly the microbiologists come over to the laboratory at regular intervals, but the vast majority of time is spent on the hospital site. Our understanding is that the actual contact between the clinicians and pathologists has not changed. If you look at the way GPs have been used to getting in touch with the consultant pathologists, according to the evidence we have it is easier for them now; we have made it easier for them to get in touch them.


 
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