Pathology services will become strategically more, not less, important as we move into a world of preventive medicine. Paul Lindsell, from MindMetre Research, argues against the case for consolidation and calls for increased investment.
The massed voices of sensible commentators on healthcare in the UK (and Europe) now seem to agree that systemic change is needed. With various factors inexorably driving up healthcare consumption, radical reform is needed to make our healthcare system sustainable in the 21st century. The NHS Constitution notes that we as individuals must bear some responsibility for our own, and our family’s health. This notion is now being extended to an idea of creating more healthy societies through better information, public education, diagnosis, early intervention, accurate treatment and, ultimately, prevention.
Healthier societies require less treatment – attacking the problem of swelling healthcare demand at its root cause. Reaching this noble nirvana is, of course, a massive challenge. Nevertheless, most would agree that pathology services – which provide that all important diagnostic input – will become strategically more, not less, important as we move into a world of preventive medicine. So surely more important means more investment? Apparently not.
Lord Carter’s Pathology Report of February 20161 categorises pathology as a ‘backoffice’ function, not a strategic building block for the health service of the future. NHS Improvement issued a letter2 to all acute NHS Trusts indicating that pathology services should reach standard performance targets or face consolidation on a regional basis – with the deadline for early 2017. We can all agree that stringent demands for efficiency should continue. Nevertheless, this ‘guillotine’ approach to pathology services seems puzzling.
More efficiency or more investment?
There is constant pressure to find areas within the NHS where efficiency gains can be made. These ‘efficiency savings’ are the subject of some controversy, but they are a firm commitment from Government and central authorities,3 and as such cannot be swept under the carpet. Few nowadays would argue with the idea that there are efficiencies to be made – and any bombastic protest smacks of something between stubborn obduracy and protectionism, neither of which are in the interests of the patients that the health system serves, nor the taxpayers who ultimately fund the NHS.
It is also true that the NHS was not originally structured to deal with the healthcare demand that presents itself today, and so properly funded investment in structural reform has to be on the policymakers table. Efficiency must never undermine the quality of patient care and outcomes. At all events, there is an urgent need to find areas of healthcare where greater investment may help reduce the requirement for other (more expensive) therapies and interventions down the line.
Diagnostics must surely be a major focus of such initiatives to create earlier identification and intervention. Diagnostics is widely seen as an area where technological, process and performance improvements can have a disproportionately positive impact on patient outcomes, duration of treatment and overall cost.4 Specifically, there are three key benefits from such improvements: accuracy and reliability of testing; speed of results; and access to results by clinicians and care professionals. Logically, therefore, diagnostics and pathology should be one of the main focuses for additional spending, hand in hand with demands for efficiency. “Spend twice as much, but gain quadruple the benefit.
Some visionary NHS Trusts have found this logic to be so obvious that they are unilaterally investing in pathology services to produce better patient outcomes, help minimise the lifetime ‘amount of treatment’ each patient consumes, and help strategically contain and reduce costs in the long-term. To quote one Trust, “Getting faster, more accurate microbiology results saves lives, as it means we can provide the best treatment sooner.”5 Further recognition of the impact and return on investment from improved laboratory services is witnessed by the emergence of spin-off joint ventures between Trusts and commercial partners.6
The overly rapid, and possibly ineffective, demands by NHS Improvement to deliver cost and performance improvements or face the threat of consolidation, do not yet seem to be based on data. A Freedom of Information (FOI) enquiry was recently put to NHS Improvement7 asking which NHS Trusts do not currently meet the 1.6% cost of service to Trust operating expenditure target as set out by the Carter report. The answer, interestingly, stated that NHS Improvement did not hold the information requested, but that it was planned to collect this information in the future. On a positive note, though, the Pathology Modernisation Programme and the Carter Review8 both recognise the need for a change of scale for pathology services – albeit with reform of internal efficiency levels within the test production process. This does recognise the changing nature of the NHS towards better prevention; demand for pathology services is rising with overall increasing demand for healthcare, and improvements are needed simply to manage current requirements.9
Quite apart from the strategic issue of whether more funds should be put into pathology services, it is the contention of this article that far more effort should first be put into improving laboratory performance, before crude guillotine measures of enforced consolidation are imposed.
In order to shed light on just one aspect of the future of pathology services, MindMetre – an independent research organisation – reviewed test turnaround times (TAT). Although one of several factors, TAT is a fundamental enabler – providing more test results, more quickly, back into clinicians’ hands. As part of our research, we questioned laboratory and chemistry managers on the role played by turnaround time improvement in the overall improvement in pathology service performance.
Results from the study show that out of a list of 15 key aspects of laboratory services, ‘inpatient stat TAT’ is viewed as the most important service to clinicians. ‘Routine test TAT’ was also in the top five aspects of laboratory service considered by laboratory managers to be most important to clinicians, along with ‘critical value notification’, ‘quality/reliability of results’ and ‘accessibility of pathologists’.
Not only did the research ask respondents to rate different aspects of laboratory services, it also captured qualitative input from interviewees. The overwhelming majority of laboratory managers interviewed strongly emphasised the importance of test TAT to them, and the positive impact on the patient pathway of being able to reduce TAT.
Therefore, one of the main arguments emerging from the MindMetre study is that there is room for TAT improvement, without any loss of test result quality, through procedural and technological improvements in the laboratory network as it currently stands. Laboratory mergers and consolidation should not be considered before stand-alone TAT improvement initiatives have been exhausted. To this extent, the authors of this study agree with the response to Lord Carter by the Royal College of Pathologists.10
Carrot or stick?
If we look historically, we find (rather astonishingly) evidence from a previous phase of the Government review programme saying: “a small investment in pathology services can disproportionately improve the quality and lower the total cost of a healthcare encounter.” It remains unclear why this good sense has now given way to ‘guillotine’ measures. If standard improvements have not been delivered, then simply consolidating two or more supposedly inefficient laboratories is not the answer. It is clear that investment is required in order to significantly reduce test TAT, and hospital laboratories should be looking to the range of innovative new technologies now available to help them achieve the key performance indicators set by The Royal College of Pathologists.
Confusingly, the importance of embracing innovation is a key message of this earlier phase of government review, which makes it clear that “providing services which are swift to adopt innovative technology and practices, where effectiveness is proven” is a key aspect of the authors’ vision for NHS pathology putting patients first. The authors also “recommend that the Department of Health identifies ways to facilitate the adoption of innovation in pathology.”
Of course, turnaround time improvements require more than just the introduction of technological innovation. Laboratories need to review the full test process – from sample collection and transport, to pre-analytical preparation, to testing, to result delivery – in order to ensure that any new technologies or measures adopted are of maximum benefit. As one laboratory manager commented: “I agree with the notion that improved test turnaround times would have a big impact on effectiveness to serve people. However, rather than looking at the mere turnaround time of the tests in the laboratory, we are looking at improving the whole process.”
Little will be achieved in reforming and improving pathology services unless laboratory management and policymakers work hand in hand. Pathology has to embrace new technologies, process management and automation to achieve greater throughput without loss of quality. Policymakers need to urgently and intelligently address the question of pathology funding, which common sense suggests should be reviewed upwards given the strategic trend towards a health system where we try harder to prevent people needing healthcare, rather than struggle against the inexorably rising tide of demand for healthcare.
The discussion summarised in this short article underlines the fact that key improvements to laboratory processes can have a lasting impact on a patient’s acute care journey. Resorting to laboratory mergers should be the last, not the first, strategy – and only once initiatives to improve process and technology have been fully explored.
1 https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/499229/ Operational_productivity_A.pdf
2 https://www.rcpath.org/resourceLibrary/ 2016-06-28-letter-re-2016-17-financialpositions-to-chairs—-ceos-final-pdf.html
3 The Guardian, NHS ‘will miss £22bn efficiency savings target’, says thinktank, 23 Apr 2015
4 NHS England, National Pathology Programme: Digital First, Feb 2014.
5 Lewisham and Greenwich NHS Trust, Pathology Consolidation and tQuest Upgrade, 2016
6 UCLH, Ground breaking pathology partnership launched, 1 Apr 2015.
7 FOI request to NHS Improvement dated 16 June 2016 https://www.gov.uk/government/ uploads/system/uploads/attachment_data/ file/529840/FOI_Carter_Review_2016_ recommendations-trust_pathology _performance.pdf
8 Department of Health, Operational productivity and performance in English NHS acute hospitals: unwarranted variations, 5 Feb 2016.
9 NHS Improvement, NHS providers working hard, but still under pressure, 20 May 2016.
10 The Royal College of Pathologists’ response to Lord Carter’s report on operational productivity, February 2016.
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