Supplementary evidence by West Middlesex
University Hospital NHS Trust (PS 56A)
RESPONSE TO COMMONS SELECT HEALTH COMMITTEE:
22 November 2001
Q538 "This issue of cost and quality
goes to the heart of the inquiry we are doing. It would be extremely
helpful if you could give the Committee more evidence about the
quality gains and more analysis of this 10 per cent saving and
what you think it would be costing the Trust to provide the service
in house today, given that you may not have been able to maintain
it and the investment and capital may not have been keeping pace
if you had not gone down a private sector route"
Following an extensive option appraisal process
in 1995, SmithKline Beecham Clinical Laboratories (SBCL) emerged
as the preferred provider of pathology services for the West Middlesex
University Hospital in 1996. (SCBL were acquired by Quest Laboratories
in 1999). This document describes the quality systems before and
after this date.
The pathology was split into four departments:
biochemistry, haematology, microbiology and histology (including
Each department was housed in separate
premisesBiochemistry and Microbiology in purpose built
accommodation; Haematology and Histopathology in converted wards.
The conversions were suboptimal in respect of space and layout
and were expected to attract criticism from accreditation inspectors
The departments did not share a common
computer system. To retrieve complete patient test results, requests
were made to reception staff in each discipline. This was time
consuming and could lead to errors as different conventions were
used to record patient demographic details. Junior medical staff
complained because a disproportionate amount of their time was
devoted to "chasing up" hard copy results.
Quality processes concentrated on
Internal Quality Control (IQC) and participation in External Quality
Assurance (EQA). There were insufficient staff to engage in Quality
Assurance (anticipation/avoidance of errors) and Quality Improvement
Initiatives (continuous improvement of standard working procedures).
Departments differed in the manner
in which they captured and documented errors.
User satisfaction surveys were not
carried out because of insufficient resources.
Accommodation was reconfigured. An emergency
laboratory was established on the hospital premises. A large,
new offsite laboratory (30,000 sq ft) was built in Heston, five
miles from the hospital. Each facility housed all pathology disciplines.
The new premises provided optimal
accommodation for personnel and machines. The pathology department
now holds dual accreditation [CPA Ltd (UK) and CAPCollege
of American Pathologists].
All pathology disciplines and services
now share a common computer system. Patient lookup is reliable
because standard rules apply to all entries. The laboratory system
is interfaced to the hospital system permitting lookup of results
on the ward by junior staff who no longer waste time engaged in
protracted searches of paper based systems.
A Quality Assurance (QA) Officer
was appointed. She has worked collaboratively with the consultant
pathologists in creating a new Quality System suited to the requirements
of a major NHS district general hospital.
The QA Officer is supported by
a dedicated group of experts in laboratory quality systems. These
personnel are employees of the company (Quest) and generally work
in corporate headquarters. Some are international experts in their
respective fields. Their advice is available to the consultant
pathologists and to the clinical scientists.
The QA Officer has established
a Quality Action Team (QAT) which directs the strategy and operations
of all quality processes within the pathology department. The
QAT is chaired by a NHS consultant pathologist.
The QAT implements and monitors
Quality Assurance activities and Quality Improvement initiatives.
The QAT designed and implemented a formal system to monitor, record
and resolve errors.
Since 1996, the pathology department
has carried out surveys among users drawn from the hospital and
from general practice. This has led to changes and enhancements
of the service eg patient reports were completely redesigned because
of comments and suggestions from users.
Quality is an ongoing and expensive process.
Before 1996, there were good intentions but delivery was constrained
by inadequate budgets and therefore resources. The service to
the hospital and surrounding GP's has since benefited from the
introduction of a well-resourced and comprehensive quality system.
In 1996-97 the Trust had a pathology budget
of £2,731,528. The baseline contract signed with SBCL in
September 1996 was for a base contract value of £2,451,000.
This represents a saving of £280,528 or 10.27 per cent on
the base budget.
This saving was achieved mainly from the following
Rationalisation of the use of Trust
estate and facilities for the provision of a pathology service
to the hospital. In particular, the laboratory was centralised
into occupying one building, rather than the several prior to
the contract. This generated savings to the Trust in terms of
overhead costs such as cleaning, estate maintenance, rates and
The Trust also realised savings in
capital costs related to depreciation on equipment which was transferred
to SBCL and Capital Charges on the vacated premises.
Savings from reduction in management
costs from vacant post and reduction of consultant sessions to
Additional savings in processing
costs for payroll, purchasing, general ledger and accounts payable.
On the question of what we believe it would
cost the Trust to provide the service in-house today, this is
not readily easy to quantify. No specific analysis of the comparison
between the current service provision and the in-house option
has been undertaken during the period of the contract. It is true
to state that the cost of pathology has risen over and above the
rate of inflation since 1996. This is mainly due to increased
volumes of test being performed which are in line with the increases
seen nationally through NHS laboratories. It is also difficult
to evaluate in retrospect what additional capital and revenue
costs the Trust would have incurred in investing in equipment
and additional staffing resource to meet the levels of quality
and service currently provided by Quest. However, these aspects
are being tested and evaluated as part of the current retender
of pathology services which the Trust is engaged in with Ealing