Examination of Witnesses (Questions 560
THURSDAY 22 NOVEMBER 2001
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
561. What about the independent pay review body?
(Mr Spiller) We believe that when the agenda for change
programme is institutedit looks at the moment to be late
next yearcertainly 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
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
(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
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 privatisationto
put it very crudelyif 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.
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
(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
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.
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
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
(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
576. It seems as though it has been a good solution
(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.
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.