CLINICAL MANAGEMENT

Published: 11/08/2005, Volume II5, No. 5967 Page 26 27 28

When Pennine Acute Hospitals trust had the opportunity to redesign its pathology service from scratch, flexibility was key. Alison Moore reports on a 'future proof' model

How would you set about providing a pathology service for close to a million people served by four main hospitals? How would you design it to cope with increases and changes in demand at each site and the possible move of some services into the community?

That is the challenge managers and clinicians at Pennine Acute Hospitals trust have been wrestling with. Despite the difficulties, they have had an unprecedented opportunity to design a service almost from scratch.

Pathology plays a part in diagnosing 60-70 per cent of patients and will have a vital role in delivering access targets over the next three years.

This is helping it escape its 'Cinderella service' tag. But like so much of the NHS, pathology needs to change if it is to deliver the service improvements being asked of it.

One of the drivers for change at Pennine Acute Hospitals trust was last year's Modernising Pathology Services document, which sets out the government's policy for modernising the service (see box, right). But while the Department of Health has put some additional central money into pathology, the£54m in capital spending, spread over several years, is not going to pay for all the changes needed across the country.

At Pennine trust, pathology is currently provided from six locations - two of which have to be vacated. With four district general hospitals within the trust, there is considerable duplication of services and differing practices between pathology departments.

The key to moving forward has been a£17.5m scheme to build a central laboratory at Royal Oldham Hospital, says senior service manager for pathology Deborah Ashton. At 4,700m¦, this will be the country's largest pathology laboratory and will accommodate work from all six existing units. The site will also take work coming from outpatients and GPs, and all microbiology, histopathology and cytology.

The scheme has been backed by Greater Manchester strategic health authority, which is providing much of the funding. But other services will be done locally at three essential service laboratories, which will be created at North Manchester General Hospital, Rochdale Infirmary and Fairfield General Hospital in Bury. This is deemed 'hot work' - tests that require a quick turnaround. Generally, urgent tests that cannot be done in under four hours at the central laboratory will be carried out locally.

Work at two of these sites is underway and should be completed by autumn. But the full reorganisation of the service will only come about when the central laboratory is finished in 2007.

However, the model of how the service will be delivered is already in place - and one of the key aims has been to make it 'future proof'. Not only is it not certain which clinical services will be provided, and where, but the pathology department will have to take on changes in demand and new tests that emerge. It could also take on work from outside the trust.

Because of this, the service is designed to be flexible, right down to the arrangement of rooms within the laboratories, with lots of open space and moveable benches. 'We have been careful not to put up physical boundaries, ' says Ms Ashton.

The trust is also hoping to become a cancer centre, with an outpost of the Christie Hospital, the specialist cancer trust based in Oldham. 'The cancer centre would be right opposite pathology - the consultants would literally walk across to histopathology to discuss individual cases, ' says major projects manager Ian Wilkinson.

Much of the routine work will be automated, and the trust is tendering for a private firm to provide equipment, consumables and training.

Automation, however, can be controversial.

Although well advanced in some areas, eg routine blood counts; it is less common in others such as cytology and microbiology. The idea is that it allows scarce biomedical staff to do more interesting work while the mundane part of the job is done by machines. In the long term this may help with recruitment.

The programme offers other opportunities for workforce redesign. While the trust is adamant that none of its plans involve job losses, Mr Wilkinson says there is 'a major opportunity for modernisation around workforce issues, including better use of skill mix and new ways of working'.

Staff are also more likely to work across different disciplines within pathology, and plans are being developed to provide a 24-hour service.

Working practices are being standardised; staff will work to the same protocols on tests and their results. When a shared patient record is eventually introduced, it will be important to have test results that clinicians in different hospitals can access, trust and interpret.

Accident and emergency departments will be given a 'recipe book' of tests, highlighting the ones which are most likely to aid diagnosis and treatment.

The centralisation of some pathology services will also encourage sub-specialisation, according to associate medical director and consultant haematologist Dr Vivek Sen. 'From a clinician's point of view it will provide the expertise under one roof, ' he says. 'There will be a critical mass which is needed to sub-specialise. At the moment, you have to be a generalist. It has to be better for the patient. With 15 experts under one roof you do not have to send a lot of stuff out for second, third and fourth opinions with the inherent delay in diagnosis.' This is very much in line with the DoH's desire for pathology networks, he points out.

Ms Ashton is also trying to get the implications for pathology considered every time the trust changes a service or introduces a new one.

Eventually, the new ways of working will offer some savings for the trust - especially as working with private sector partners will involve some sharing of risk. However, as with so many projects, costs have risen during planning - from£16.8m, including a£6.7m contingency fund, to£17.5m - partly because of the problems around decanting services while building work goes on.

'We expect to generate savings of over£1m a year by bringing work together, ' says Mr Wilkinson. Potentially, work from other trusts could also be dealt with at the site, although the first priority will be to bring in all the trust's own work, some of which is currently processed in central Manchester. 'Potentially people could contract with us - we could probably do it cheaper than they could do it in-house.' Working with primary care trusts is also going to be important, especially as discussion continues about how some diagnostics could move into the community. 'We have got a lot of expertise in the acute setting, but we recognise that there are some things which can be better done in the community', says Ms Ashton.

Gilbert Wieringa, consultant clinical scientist at Greater Manchester SHA, points out that some services involving hospital pathology are likely to move to point-of-care testing.

The SHA is piloting some diabetic and cholesterol testing in pharmacies, for example, and GP surgeries are likely to provide more diagnostic tests. Acute trusts will need to work closely with PCTs, and hospital-based staff can provide advice and expertise. 'Savings may well be realisable from secondary care-based services, but meeting such demands should be taken in the context of wider developments in enhanced primary care-based services, ' he says. 'Such developments will require wide stakeholder input.

The challenge for laboratory medicine everywhere is to reach outside local confines and take the lead.' Although the exact shape of how services will be provided between primary and secondary care has yet to be determined, this will be another factor which demands flexibility from the facilities and staff at Pennine. But some work currently done in tertiary care is likely to be carried out in the secondary sector instead.

Selling change to staff is never easy, and Ms Ashton is candid about the anxieties of some of the 360 staff involved in pathology, and the problems of closing units.

'It has been difficult. People came from different backgrounds, from different sites and with different working practices, ' she says.

'Our approach was that we do not do it the Oldham way or the North Manchester way - we do it the best way, ' and staff have the opportunity 'to influence how we decide that rather than anything being imposed'. But she concedes that even then not everyone will choose to become engaged with the process.

Choosing Oldham for the central laboratory site - where microbiology staff from five sites will eventually work together - was also controversial, even though it was proposed by independent research. One factor, says Mr Wilkinson, is that 'it had by far the newest pathology build, most suitable for expansion'.

Dr Sen says that many clinicians are supportive of the move and, although it could be argued that some sites will lose individual expertise, in the long term the trust will benefit.

And what of the patients? In many respects they should hardly notice the difference - and where there is a difference it may be that tests are dealt with more quickly and do not need to be sent off for a specialist opinion. One benefit should be that it will be easier for them to move between hospitals and test results to follow them - and be trusted by their clinicians.

Ms Ashton points out that the work will help the trust meet government targets 'but it is not all about achieving targets. Fundamentally, delivering targets is about improving care for patients.' But could the Pennine development provide a template for other areas, especially where trusts are running several laboratories?

'The development at Pennine seems eminently sensible, ' says Dr Mike Burrows, chief executive of Salford primary care trust and pathology lead for chief executives across Greater Manchester SHA.

'The learning that is generated from Pennine is something that we may want to look at within the Greater Manchester pathology network - ensuring that you have hot labs on site but where there are economies of scale ensuring that you can deliver those as well by centralising some services.' Pennine trust chief executive Chris Appleby says: 'The pathology modernisation project is of great importance in its own right, and a wide range of staff have made sustained efforts to bring us this far, laying the groundwork for a genuinely pioneering scheme. But the approval of the project is also an endorsement of the ability of the trust and its staff to handle major projects, and bodes well for the future.' .

MODERNISING PATHOLOGY SERVICES WHAT NEEDS TO BE DONE

The Pennine Acute trust project was designed with the government's Modernising Pathology Services policy in mind.

This called for:

The setting up of managed pathology networks. Like many trusts, Pennine is working with the developing Greater Manchester area network. But as a large acute trust it also wants to see its own pathology department working as an integrated whole rather than a series of sites with their own individual ways of doing things.

Examination of the skill-mix within pathology, with implications for workforce development and additional training.

Reviews of how services are delivered in each locality, whether capacity will meet the demands of NHS targets and the reduction of inappropriate variations between units.

Greater use of IT and technological developments, and for pathology to be effectively integrated into wider service developments.

Requirement for all pathology departments to be accredited.

IN PRACTICE: PUBLIC-PRIVATE PARTNERSHIP

A public-private partnership at North Middlesex University Hospital trust has enabled a redesign of pathology services and the transformation of less-thanideal laboratory space into a state-ofthe-art facility. It has released staff from routine tasks and is delivering one of the country's lowest benchmarked cost per tests.

Ninety-eight per cent of tests are now available, on screen, to accident and emergency within 40 minutes, helping to meet the four-hour A&E target.

The change happened five years ago.

The department won a modernisation grant for introducing pre-analytical sample processing in clinical biochemistry, but this was not sufficient for the desired service reconfiguration.

To boost purchasing power, several key decisions where made. The main chemistry and immunochemistry contracts were added to the tender. The specimen-processing pathway was reviewed. To realise the benefits of automation, we had to address the processes in sample reception - a recognised bottleneck. We borrowed process management techniques from industry to improve efficiency.

As part of the tendering we asked companies to examine the laboratory processes and provide solutions, with outcomes. Automation, coupled with changes in process, was going to revolutionise the way we worked. This would enable better use of well-trained staff, improve staff development opportunities and increase staff retention. It would also free staff to carry out point-of-care testing, and enable us to increase the repertoire of tests.

But what could we offer the private sector? Traditionally most contracts run for five to seven years. We were not simply replacing equipment, but reconfiguring a service. We decided to offer a 10-year deal with upgrades at seven years. This gave the companies income over a longer period, giving us a better deal and reduced test costs. It also meant we could avoid having to retender as soon as the changes were bedded in.

The biochemistry department also offered to provide a European show site for the company's products and help train staff without a pathology background coming into diagnostics. We provide speakers for conferences, with the proviso that we speak our mind and reserve the right to refuse the invitation.

We chose a joint bid between Olympus Diagnostics and Euro DPC. As a show site, we had one of the country's first Olympus laboratory automation robots, which sorts out and tracks samples for analysis. We also became a site for clinical implementation for the DPC sample management system which loads samples into analysers. We have also piloted IT solutions, and our technology is constantly updated.

Staff are freed to provide care on the wards and even go on the intensive care ward round so they can see the benefits to the patient. We came top in an international benchmarking system. The companies have also provided support for education and training. We have competitive prices, excellent service and offer a higher quality service to the patient.

David Ricketts is laboratory manager and Geoffrey Benge is head of pathology, clinical biochemistry department, North Middlesex University Hospital trust.

Find out more

Modernising pathology services DoH 2004

www. dh. gov. uk

Pathology - the essential service (draft guidance on modernising pathology services) DoH 2002

www. dh. gov. uk

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