Examination of Witnesses (Questions 620
THURSDAY 22 NOVEMBER 2001
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.
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
626. We need to know what "signing off"
(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.
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 makeand clearly I have not explained
well enoughis 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.
629. It is a bit like the difference between
health and social care.
(Mr Spiller) Yes.
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
structureand this is common to many organisationspathology
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
(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.
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.
636. Would you do autopsies if you were asked
to do them?
(Ms Ward) Personally? I am sure we could find a man
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
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
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
managerswhom I shall not actually namewho 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 workingand it is a few years
agothe 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 biochemistbut 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.