Modernising pathology services
145. The first indication of the Government's proposals
to modernise pathology funds came in an announcement of a £20
million modernisation fund in 1998-99, and the establishment of
a steering group to assess bids for funding.
A central instruction was issued to NHS Regional Offices to examine
their pathology services and produce a co-ordinated plan to bring
them up to date. These plans were returned by March 2001.
According to a Royal College of Pathologists' Discussion Paper,
"central thinking in the Department was being shaped by policy
makers in the Prime Minister's office and strategists from a variety
of sources, including a Canadian company with much experience
of configuring laboratory services in North America".
146. In the first two years of the Programme (1999-2000
and 2000-01), 400 expressions of interest were received and £20
million was invested in 35 projects, looking at the adoption of
advanced technologies in pathology and encouraging consolidation
or reconfiguration of services. In 2001-2, a further £8 million
is being spent supporting three or four larger reconfiguration
projects exploring the development of managed clinical networks
in NHS pathology services - moving from trust-based pathology
services to those serving whole Health Economies, up to strategic
health authority size (ie around 1.5 million). However, as Professor
Lilleyman of the Royal College of Pathologists has noted, the
modernisation programme has run into some difficulties.
"First, initial bids showed just how un-modern
some pathology services had become and that considerable investment
was needed simply to bring them up to date. Second, the notion
that capital might be more readily available from the private
sector has not been greeted with universal enthusiasm. This is
a disappointment to Government policy advisers who see public:private
partnerships as an important part of the modern NHS - particularly
in pathology. Finally, in late 2000, regional offices of the NHS
Executive were each charged with producing a local modernisation
strategy, and the perceived lack of consultation on this process
has produced professional indignation in some parts of the county."
147. We took evidence from two private sector pathology
providers, Quest Diagnostics Limited and The Doctors Healthcare
Company (TDHC), West Middlesex University Hospital (which had
contracted its pathology services to Quest) the Royal College
of Physicians and the MSF trade union.
We wanted to ascertain what the perceived advantages and disadvantages
were of the contracting out of pathology services.
148. All our witnesses were agreed that pathology
services in the UK were in need of reform and reorganization.
Ms Gail Wannel, Chief Executive of West Middlesex University Hospital
NHS Trust, told us that "economies of scale" were being
lost because of the fragmented nature of the current provision
Not only did larger networks of providers offer cost savings,
they also facilitated the presence of specialized pathology teams,
in contrast to the present situation where some senior technical
and clinical staff were engaged in a variety of functions, including
pathology. Professor Lilleyman for the Royal College of Pathologists
drew attention to the problems caused by "pockets of unsatisfactory
service due to chronic under investment" and workforce shortages.
He backed the calls for reform of pathology along the lines of
larger networks, which he felt should be managed at strategic
health authority level,
but was open-minded as to whether this required greater private
Ms Wannell too felt that there was an opportunity for "a
variety of models" but that the NHS could learn a lot from
the private sector in terms of the development of specialist services
and off-site laboratories for cold [non-urgent] testing.
149. We asked our witnesses whether private pathology
provision in the NHS gave good value for money. Ms Ward suggested
that it was difficult comparing the costs of private provision
with those obtaining in the NHS, owing to the complexity of accounting
procedures within the NHS.
What she felt was indisputable was that the costs of provision
by her company were more transparent and that this improved accountability.
West Middlesex recorded that the costs of its pathology services
had fallen by ten per cent since it had contracted out services.
Ms Ward told us that the purchasing power of the NHS would suggest
it might obtain more favourable rates than private clients.
150. We also wanted to establish how turn round times
in the private sector compared with those in the NHS. Ms Ward
of Quest cited the example of cervical cytology tests at West
Middlesex, where the turn round time had been reduced from 16
weeks to seven working days following substantial investment by
Quest. Dr Prudho-Chlebosz of TDHC assured us that there was no
discrimination in turn round times as between tests carried out
for NHS or private sector customers: "it is more expensive
to discriminate between private pathology and NHS pathology than
to ensure that the configuration of the department is such that
all work is put through quickly".
151. We were also concerned that quality might be
compromised in the search for efficiency, and that control over
procedures might move out of the hands of clinicians; West Middlesex
University Hospital NHS Trust assured us that its pathology service
Urgent tests are analysed in a small laboratory on the hospital
site while "cold" tests are conducted in an off-site
laboratory. West Middlesex had found quality systems to be "robust",
equipment was updated more frequently and pathologists were freed
from routine administrative tasks and able to focus on clinical
to Ms Wannell:
"The facility and environment are much 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 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."
152. Ms Wannell told us that a crucial aspect of
the contract was that it was "clinically led", and that
it had been clinicians who had determined the balance of tests
to be conducted on and off-site. Mr Spiller of MSF acknowledged
that his union's experience of the main private sector pathology
providers had been that they provided work to a high quality standard,
though he felt that similar improvements could be made within
the NHS with adequate investment.
153. Given the consensus over the need for substantial
restructuring of UK pathology we wondered why so little had been
done to date. West Middlesex recorded that a disadvantage of their
public private partnership with Quest had been that pathologists
valued the NHS ethos and wanted to remain in the mainstream of
Dr Prudo-Chlebosz of TDHC thought that the reason the NHS had
not moved more quickly to more rational structures in pathology
arose from the historical background of pathology, the fact that
it had traditionally been constituted as a number of small disciplinary
areas. People entered pathology out of an interest in providing
a clinical service to a local set of needs, not to institute structural
change. Mr Spiller
of MSF felt that the Pathology Modernisation Programme was severely
under-funded and that the debate was hampered by the almost automatic
assumption that rationalisation and reorganization entailed involving
the private sector.
154. All sides to the debate accept the need for
rationalisation and structural reorganization and we are attracted
to Professor Lilleyman's suggestion that the new strategic health
authorities are the appropriate level at which, or areas within
which, new pathology networks can be organized. The evidence we
have seen suggests that private sector providers have introduced
greater efficiency without compromising clinical standards. This,
we believe, is partly due to the fact that clinicians have been
closely involved at every stage of the reorganization. We especially
commend the model of having NHS consultant pathologists in charge
of on-site laboratories where "hot" testing takes place,
whilst off site laboratories are left to handle large volumes
of cold testing.
155. We would agree with Mr Spiller of MSF and
Ms Wannell of West Middlesex University Hospital Trust that a
variety of models need to be tested, and it seems to us that many
of the benefits being achieved by the private sector companies
could be achieved within mainstream NHS provision if sufficient
investment were made.