Examination of Witnesses (Questions 680
THURSDAY 22 NOVEMBER 2001
680. In respect of the role of the Commission
for Health Improvement, you will probably be aware of any work
they have done which has related to your area of concern. Have
they produced any information which has looked, any work that
has looked at pathology services and the current concerns about
how they are organised? It is not something I have picked up in
reading. Are you aware of anything?
(Professor Lilleyman) The only investigation they
did was in Swindon following problems there with the employment
of an elderly locum histopathologist, you may recollect, a couple
of years ago. They came up with some recommendations on employment
of locums particularly. Several issues were thrown up in that
inquiry but it was in their early days and I think they were still
feeling their feet. They did not address the wider issues surrounding
pathology as far as I know and I do not think they have looked
at it specifically since then.
681. Have you done any survey? Have you measured
or surveyed any of the users, the GPs, the consultants the patients
even or the staff as to their view of whether matters are better
or worse or has nobody really noticed the change to the provision
of pathology services?
(Ms Wannell) We had not had a structured survey. What
we do have is a pathology operating group which consists of a
meeting which has Quest, has a pathologist, has a medical director
and representation from the users, both clinicians and the trust.
We have an opportunity for views about the service to be presented,
clinical issues to be raised, between Quest and the pathologist.
That is the forum. It has been very much something which has evolved
and we see it very much as a partnership. There has been two-way
feedback, not just feedback from ourselves. What we are learning
is that the private sector can assist us. They are expert in this
field and they can give us feedback on whether we are doing tests
unnecessarily. That is the way the system has been going. It is
more through the pathology operating group that we have got feedback
two ways on the service.
682. What about the general perception of it
in the trust?
(Ms Wannell) The general perception is much better.
The facility and the environment are significantly enhanced. We
were sited in four different laboratories, two of which were in
a dreadful state of repair. The equipment is enhanced and we have
IT systems significantly enhanced now. They link to the GPs so
there is rapid response. People are not hunting around for results,
it is a lot easier on that side. In the transport system we had,
we had a situation where sometimes pathology was being collected
in laundry vans. Now we have dedicated transport. The whole service
provision has been enhanced tremendously. I think the GPs would
say that as well.
683. Did you say you had samples being transported
in laundry vans? Do you mean it was a van normally used for laundry?
It was not with the laundry, was it?
(Ms Wannell) No; no.
684. Your perception is that things have improved.
That is widely held, is it?
(Ms Wannell) Yes, the perception is that the service
has been enhanced.
685. Do you do any monitoring of this Ms Ward?
(Ms Ward) Yes, we do regular surveys of our GPs. The
most interesting feedback was received from the consultant pathologists
because they have more dealings with their clinical colleagues.
They certainly felt that a lot of the mundane tasks they ended
up being called to account for but did not really have the power
to influence, such as transport and phlebotomy and this kind of
thing, was a great burden off their shoulders and they were able
to respond more to the clinical colleagues. The areas the GPs
are concerned with include having one number to ring and getting
to know people by name and developing a relationship with that
person so they know who they are talking to and they know they
are going to get the response back, they trust them. Certainly
when we first started to provide the service, the feedback we
got was very good but I would not say it was quantitative. It
was only in subsequent months and years that we have done regular
GP surveys. I can certainly provide that information and shall
be happy to.
686. Ms Wannell, your experience has been generally
positive but others do not appear to have followed you. Why do
you think that is?
(Ms Wannell) From our perspective, there has been
a huge cultural shift. There has been a lot of anxiety and discussion
here this morning about the aspects of on-site and off-site testing.
As an organisation we were in a situation where we could not maintain
our service, we could not carry on as we were and we were looking
at different ways of providing it. In other services, where they
had not necessarily had such a problem, there has not been the
driver for change. What we are finding now is that we are going
more towards bigger provision of pathology over a number of organisations
and there is a drive now and recognition from the College that
the on-site and off-site testing is not so much of an issue. There
are quality benefits and efficiency benefits. We shall see the
service moving forward in that direction both with the NHS and
with the private sector. My perception of the reservation was
more the reserve and anxiety about the on-site and off-site testing,
but I would hope people would look to West Middlesex as an example
of how it has worked.
687. To the two private companies: is it these
anxieties or are there other issues as to why you have in a sense
not got more business in the NHS?
(Dr Prudo-Chlebosz) You can take a top-down view and
a bottom-up view. The top-down view is that the sector has suffered
from strategic neglect. There is no shared vision.
688. That is really the point we started with
in a sense, that we have not been clear in the direction we have
(Dr Prudo-Chlebosz) Yes and CEOs generally in DGHs
do not have a feel for whether this is an appropriate direction
to go in. We say this because we have also acted for ten years
as management consultants to the NHS so we get a feel for this.
There is a lack of organisational focus on this as an issue. We
heard discussions earlier on management issues, bottom-up. You
have to remember what was said earlier that pathology departments
consist of a number of small disciplinary areas. You enter pathology
because you are interested in haematology, biochemistry, providing
a clinical service to a local set of clinical needs. You do not
join pathology services to have a strategic vision. You have very
few opportunities for change management. You do not get into re-engineering.
Consequently there is very little opportunity for staff to have
relevant background, relevant opportunity, relevant experience.
You asked why it is not happening and I think there is a strategic
neglect issue. There is a lack of management skills in order to
do that, not because of the people, but a lack of the opportunities
to do that. You have to ask where that strategic vision should
be coming from.
689. Ms Ward would you concur with that?
(Ms Ward) There has been a lot of uncertainty among
chief executives as to whether it is an appropriate move for them
690. Is that because of a lack of knowledge
of this area or is it because of a lack of a clear view at national
government levels as to the relationship between the NHS and the
(Ms Ward) Three contracts were let in 1996 to the
private sector; they were market tested and let in 1996-97. Since
then there has probably been the odd one. There is uncertainty
as to whether it is the right thing to do. There are also concerns
from the professional groups and the staff as to how they would
be involved in any kind of relationship with the private sector.
A large part of that is lack of understanding as to how partnerships
work. When people come and talk to us they go away much reassured
and say now they know it is like that they are not quite so concerned.
The process that a trust or group of trusts would have to go through
is quite a difficult one. The current procurement route hinders
progress rather than helps it because it does not allow the professional
groups and the partners to come together at an early enough stage
to have a good input into how a model could be developed.
(Mr Spiller) A number of issues arise here. The first
is that there is pressure for involvement with the private sector
coming from the Department of Health and regional offices in particular.
Karen spoke earlier of the situation in Lancashire and North Manchester
where Quest made a presentation to four trusts. That was as a
result of pressure from the regional office but in circumstances
where we had been involved in negotiation for some time to provide
a more central pathology service. In spite of what Karen said
earlier, there was huge opposition as far as the staff were concerned.
The difficulty was the twofold change simultaneously. One was
centralisation, one was private sector. When we made the presentation
to the joint trusts, they reversed their decision and took a view
that it should as far as possible be a public sector operation.
The pathology modernisation steering group has tried to influence
with a very small budget a real modernisation of pathology and
there are several instances there which one might start to use
as exemplars of what the public sector can do. Given the resources,
the public sector can do what the private sector can do. That
is the big difference. We would want to see more money put into
that modernisation process because £8 million or thereabouts
per year is really inadequate for even the four projects they
presently deal with. We want to go through that process and we
believe that there is the skill, the knowledge and indeed the
drive in the public sector to do it. That is sometimes held up
by some of those managers who fail to understand or accept that
change is needed, fail to understand or accept this needs to be
patient driven not organisationally driven. If we can remove some
of those barriers, then we are confident that pathology can modernise
in various ways, because we do not want to look at it in just
one format, we have dealt primarily in the debate and discussion
with centralisation of resources and that may be one important
way of dealing with it as a hub and spoke, but equally importantly
we must look at the distributed network which is another way of
dealing with the same problem. In Path Links it certainly seems
to be working. The real difficulty we have is that there are not
enough exemplars at the moment of how to do this. We are thrashing
around in the dark to some extent with only the three significant
private sector involvements which we have seen, but there is an
increasing number of public sector arrangements which we can look
at. Almost never is a private sector element not involved. Private
sector has been involved in the Health Service since its inception
one way or another and thus it is sometimes a misnomer to talk
about this as something new. On the other hand we can also see
elements of private sector involvement which do not interrupt,
do not interfere with career paths, career progression and the
standards and the new ways of working in the Health Service. It
is those we should be looking for.
Dr Naysmith: It is quite clear this morning
that we have had lots of evidence where we need modernisation
and change in pathology services. That has been quite clear. Whether
it has to be private or public is really a separate question and
Mr Spillar has answered the question I was going to put.
691. In the appendix you provided you were developing
a £48 million re-development at West Middlesex. Is that under
PFI or not?
(Ms Wannell) Yes, it is under PFI.
Chairman: Do any of my colleagues have further
Sandra Gidley: A quick blue skies, Devil's advocate
question. It has occurred to me from what I have heard today,
especially with the creeping move of staff out of the NHS and
clinical staff now being employed privately, if this catches on
there could be a very good case for contracting out the large-scale
testing in much the same way as primary care pharmaceutical services
are; they could be completely independent. Do you think that is
a possibility or is this completely out of the frame at the moment.
692. Professor Lilleyman, would you like to
answer that? I regard you, sitting in the middle, as reasonably
neutral on these issues.
(Professor Lilleyman) I am not totally neutral on
that. We should never lose sight of the fact that pathology in
all its branches is an essential clinical service; it is not like
the laundry, it is not like the gardening team, it is much, much
more important than that and if there were no good pathology service,
hospitals would grind to a halt very, very rapidly indeed. There
would be no diagnosis, there would be no treatment monitoring,
there would be no blood banking and so on and so forth. We must
never lose sight of the fact that it is a vital clinical service
and hiving some of it off into a factory environment, which I
think is what you are suggesting
693. Not quite a factory environment.
(Professor Lilleyman) It sounds very like it.
694. If you have 230 or whatever large units
which can put the tests through, the chances are if we do go down
a similar route to Middlesex, they will all be owned by two or
three companies. I can see it would be very tempting just to take
that part of the service off into the private sector.
(Ms Ward) The important thing about pathology is that
people in pathology, both the pathologists and the biomedical
scientists, work as part of a team. Roger is right in many respects
in that what is important is that they retain that team spirit
with the clinicians. I certainly do not think that is harmed in
any way by the kind of working relationship we have in our contract.
The staff themselves do not have any problems with where they
are located, they do feel very much part of the team. They are
as committed as anyone else is to treating patients and they get
quite upset and we do on their behalf when people refer to them
as people working in big factories. They see their patient focus
just as sharply as people working in NHS laboratories and they
are just as dedicated and they are just as committed to their
science as other people in other areas of pathology are. The important
thing is that pathology is part of a team. I take John's point
about it being more important than laundry, but if you have no
sheets you cannot look after patients. It is all part of the same
bigger picture and everyone has to do their bit in the overall
Chairman: If there are no further questions,
may I thank our witnesses. A number of you have said you will
come back to us with more information on certain points. We are
most grateful for your co-operation with this inquiry. Thank you