Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 680 - 694)

THURSDAY 22 NOVEMBER 2001

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

Chairman

  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.

Jim Dowd

  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.

Chairman

  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 been going.
  (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 to make.

  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 private sector?
  (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.

Dr Taylor

  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 questions?

  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.

Chairman

  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—

Sandra Gidley

  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 service itself.

  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 very much.





 
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