HSJ looks into the top issues facing CCGs in commissioning pathology services.

The NHS spends some £3bn on pathology a year – and around 30 per cent of this is on community and primary care work. It would not be unreasonable to expect that clinical commissioning groups will start to look at what they are getting for their money – and whether they could get more.

In December 2011, The Doctors Laboratory and Salix Consulting convened a round table debate to explore this dynamic. Are CCG leads really thinking about pathology? Do they have the expertise to commission services with new or different providers? Or the appetite to destabilise local NHS providers by doing so?

The short answer to all of these questions is not yet. The slightly longer one is that CCGs may soon start to demand the information they need on which to base decisions.

Pathology is undergoing enormous change at the moment. The drive to generate £500m in savings has prompted service reorganisations across England, with traditional pathology departments based in district general hospitals merging into centralised hubs with “hot labs” doing on site emergency work.

Meanwhile, primary and community care demand is rising, driven by rising patient expectations, the care closer to home agenda and new technology to support point of care testing. CCGs will be looking for end-to-end services that encompass not just the primary care element of their work but also the secondary care elements of integrated pathways including how to take services out of hospitals if they don’t need to be there.

As Dr Ishani Patel, a GP in London and a member of the North West London Cancer Network, said. “Pathology encompasses lots of different aspects of the care pathway.”

In addition to benchmarking practices for their own use of pathology in primary care, CCGs will have to start looking at pathology across the pathway. They will want to consider issues such as reducing the duplication of tests, the use of evidence based practice and training of junior doctors, she said.

Mo Girach, special adviser to the NHS Alliance, added to the list: key performance indicators for pathology, value for money and delivering of results directly to patients should all be in the ambit of CCGs, he suggested.

Yet, according to Dr Ray Prudo, chairman of The Doctors Laboratory, primary care and CCGs are not at the table as the reorganisation takes place.

“It’s pretty clear to me and to GPs that the community part of labs is seen as an appendage to the main action – the hospital,” he said. “We have yet to see the impact of clinical commissioners on our business.”

There are some exceptions to this. East of England SHA has, for example, worked closely with GPs in reconfiguring pathology regionally.

But the lack of engagement elsewhere is leading to some developments that CCGs with an eye on the future may find alarming.

As David Byrne, chief executive of The Doctors Laboratory, said: “Point of care testing is still relatively expensive - although we hope costs will come down. When we talk to hospital managers it is clear that they often do not have the funding to invest in it. No doubt the GP community will face the same challenge.”

Not only does that mean it is not available as an option for GPs using the service, but the debate around accreditation, validation and quality assurance as well as order communications is off the table. As Dr John Chisholm, clinical director of Concordia Health, pointed out, these issues are currently unclear to clinical commissioners.

That’s not the only knowledge gap. “Part of the problem for general practice is that we do not know what tests cost,” said Carol McPaul, operations director for Surrey Docks Healthcare. “If we had a pathology budget it might help us to think about what we are doing.”

CCGs may well start to demand more transparent pricing information, suggested Dr Michael Dixon, chair of the NHS Alliance.

But Dr William Tong, GP lead of the Bracknell and Ascot CCG, was more interested in the service offered than the price. “The issue for me about the budget is I wish it did not have to be financially oriented,” he said. “I am more interested in an end-to-end service with modern IT and led by consultants whom I can call and talk to face-to-face.”

Modernised IT was seen as crucial to GPs in their role as clinical commissioners. In Dr Tong’s locality, for example, there are three pathology providers based at different district general hospitals and patients moved between them. Yet none can talk to the other about test results.

In this scenario, CCGs would find it difficult to influence unnecessary duplication of tests, he pointed out.

Dr Dixon added: “In Exeter, my results go to the hospital but hospital results do not come to me.”

Dr Tong added: “There are things that IT can resolve for us.”

But all the GPs at this forum agreed they are a two to three years off tackling pathology. Dr Tong said: “Somewhere between now and 2013 we have got to get information about how pathology is being used and this information is not available at the moment. It is currently on our horizon but it is not a must do item right now.”

The willingness of GPs to change providers did vary by local circumstances. Dr Patel, for example, said that in London there were many options and CCGs might be willing to explore them.

But Dr Toby Davies, chair of Old Sarum CCG in Wiltshire, had little appetite to change providers. His CCG had already been approached by a pathology service in a neighbouring trust offering to do their bloods cheaper – but had turned it down.

“We have one trust locally and we do not want to destabilise it,” he said. “We cannot go in with big boots on demanding a better pathology deal.”

“Involvement in pathology is something of a Rubicon for us, as GPs, to cross,” added Dr Dixon. “We don’t know where we are and we are not absolutely sure where we are going. But what is clear is that CCGs need to be provoked and challenged and need some support to move forward.”