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MINUTES OF EVIDENCE
Mr W Bell (Chairperson)
1.The Chairperson: You are all very welcome to the Committee.
2.The Committee had difficulties with the Depart-ment's response to our report on senior executives' pay in health trusts. The Committee discussed that report - 'Report on Health and Personal Social Services: Executive Directors' and Senior Managers' Pay, Contracts and Termination.' - with Dr Andrew McCormick, the Treasury Officer of Accounts, and we considered your subsequent helpful letter. The Committee will produce a short report on the matter, and it is to be hoped that that will enable us to put it behind us. The Committee will continue to develop its professional relationship with the Department of Health, Social Services and Public Safety.
3.The Committee will explore what the Department has done to ensure that the Health Service receives the best possible support with the organisation, quality and cost of its laboratory services. The Committee recognises the essential nature of front-line health services and the support that those receive, as well as the valuable work of those in the pathology service. At an Assembly debate - possibly last November - MLAs showed broad support for the work of pathology staff. Laboratory work is complex and might be difficult for the public to understand, but the laboratories provide a range of services that are dispersed throughout the Province. Those services involve a substantial amount of public money, and the Committee's interest lies there. This discussion is taking place at a time when there is much debate on the state of the Health Service and concern about the delivery of services.
4.Paragraph 1.15 of the report, 'A Review of Pathology Laboratories in Northern Ireland', states that the Department told one of its advisory committees in 1992 that "very little action had resulted" since it announced its policy on laboratories in 1983, and that "consequently" there were then too many laboratories." Paragraphs 2.1 and 2.3 of the report show that there was no overall reduction in the number of laboratory services between 1982 and 1999. What action did the Department take to ensure that its policy was implemented during that period? How many laboratories are there at present? What plans do you have to reduce further the number?
5.Mr Gowdy: There has been a reduction in the overall number since the report was published. We now have 56 services that operate from 14 sites, by comparison with the 61 that operated from 19 sites in April 1999 when the report was published. Several changes have been happening. Belfast City Hospital and the Royal Group of Hospitals have been rationalising services between their sites. There is now a clear distinction in the overall remit of the Belfast Link Laboratories as to where those services are sited.
6.Work such as clinical haematology is now centred on the Belfast City Hospital site. Haematology services have been transferred from Ards Hospital. As a consequence of what has been happening at the South Tyrone Hospital, all the laboratory services have been withdrawn from it and, for the large part, are now based at Craigavon Area Hospital. Rationalisation is ongoing.
7.The Chairperson: Attention is drawn in paragraph 1.25 to the acute hospitals review group, whose work has implications for the future profile of laboratory services. That group's report is complete. What were its findings in regard to the profile of laboratory services?
8.Mr Gowdy: The acute hospitals review group report is designed to advise the Minister. She established the group to provide her with an independent review of how hospital services are organised. That group completed its report in the summer. The Minister then felt that it was important to get a reaction from people in Northern Ireland to the recommendations of the report. A pre- consultation period finished at the end of October. We got a massive number of responses - well over 100,000. Those responses are currently being evaluated. The Minister is keen that she should discuss with all her colleagues in the Executive how people feel about the recommendations of the report and how we might go forward. She intends to produce proposals, to be published early in 2002.
9.The Chairperson: Would they, for instance, alter the Department's thinking on policy?
10.Mr Gowdy: It would certainly have a substantial impact on the profile of laboratory services. The linkage between laboratory services and acute hospital services is necessarily close. Laboratories provide essential services to deal with emergency and trauma cases, which need an immediate response. Laboratory provision must, therefore, be linked closely to where acute services are provided. Plans for acute hospitals are a major determinant of laboratory services provision.
11.The Chairperson: How would they impact on your Department's current review of pathology services?
12.Mr Gowdy: We are keen to ensure that we take two things in tandem: how laboratory services need to match the needs of acute hospitals, and the professional issues, including staffing, where the services are best brought together, and the development of new technology, computer applications, et cetera. We are trying to examine the matter as a whole, and to bring together those two aspects early in 2002.
13.The Chairperson: Paragraph 1.25 reminds us of the Department's proposals in 1998 to resite radiotherapy, chemotherapy and related laboratory services, from Belvoir Park Hospital to Belfast City Hospital. The implementation of those proposals was delayed, but what is the latest position? I have an interest to declare, because a family member of mine avails of those services.
14.Mr Gowdy: The intention is to create a cancer centre at Belfast City Hospital, which is to be supported by four cancer units throughout the Province. Work is well in hand to establish those units, and, in the last few days the unit at Craigavon got up and running. We are seeing things develop.
15.The transferral of services from Belvoir Park to the Belfast City Hospital creates the need for a new building and facilities. It will be a state-of-the-art cancer centre, which will improve the quality of service to cancer sufferers in the Province. We needed a business plan, and received an initial one from the trust at a cost of just under £30 million. They decided that they wanted to develop the project further. The cost has now almost doubled; it has increased substantially to some £56 million to £59 million.
16.As the Public Accounts Committee, you will readily understand my role as the accounting officer in ensuring that this jump in expenditure can be justified. We must look carefully at what this means and what it is all about. That creates the delay factor that you referred to, and we are trying to minimise that delay. We are examining the new business plan that we received recently from the Belfast City Hospital Trust, and are consulting on it with colleagues in the Department of Finance and Personnel. We hope to be able to progress quickly to the implementation stage.
17.The Chairperson: Why has there been no application for the accreditation of Belvoir Park Hospital's laboratories?
18.Mr Gowdy: After the decision was taken to move the cancer services from Belvoir Park Hospital to the Belfast City Hospital, staff at Belvoir Park were transferred to the Belfast City Hospital Trust. Arrangements were made to take over the assets of Belvoir Park Hospital by the Belfast City Hospital, and that applies also to the laboratories. Laboratory services at Belvoir Park Hospital are now part of the Belfast City Hospital's laboratory provision under Belfast Link Laboratories, which was established a few years ago.
19.The Chairperson: How does the delay in transferring laboratory services to the Belfast City Hospital impact on the quality of services at the accredited Belvoir Park Hospital laboratories?
20.Mr Gowdy: The new cancer centre will be a state-of-the-art, leading-edge development. The Belvoir Park site provides a high quality service; they do a tremendous job, but with ageing equipment. We hoped to plan the move so that as we built the new cancer centre at the Belfast City Hospital we would be able to furnish it with new equipment, and let the old equipment come to the end of its useful life at the Belvoir Park site. This slight delay in the timescale has meant that we will have to install new equipment at the Belvoir Park site and then transfer it to the Belfast City Hospital site when the new centre is completed.
21.Ms Ramsey:: The Chairperson mentioned briefly accreditation. Why are boards and GPs still using laboratories that are not accredited?
22.Mr Gowdy: The clinical pathology accreditation (CPA) is all-embracing, and covers both service quality and the wider issues of accommodation and staffing. With the uncertainties over the long-term future of acute hospitals, we are concerned that we have been unable to make the necessary rationalisation of the laboratory services. We have been holding off on investment in accommodation, but underfunding has also contributed to that difficulty. Several laboratories have less than perfect accommodation, and they would not meet the CPA standard. That would be counterproductive, because laboratory services could not then be provided, and we would lose the ability to respond to the needs of the hospitals.
23.The current arrangements protect everyone to a satisfactory level through the national external quality assessment (NEQA) scheme, and all our laboratory services are tested at one- to six-month intervals. We know that they are passing those tests, so our services are being accredited. However, the wider accreditation, through the CPA system, of the totality of the laboratories and their provision has not been addressed. We are satisfied that the GPs and hospitals are getting the laboratory services that they need, but we would be unable to meet the overall accreditation standards of the CPA.
24.Ms Ramsey:: You mentioned the quality of services. Why bother with accreditation at all? The lack of accreditation has a knock-on effect on public confidence.
25.Mr Gowdy: That is the important point. Accreditation provides a useful badge that allows everyone to feel satisfied that a rigorous test has been passed, or that services have been maintained at a satisfactory level. We want all our hospitals to apply themselves to those tests. NEQA is one important test for us. But it is also desirable that all the laboratories should be assessed under the CPA system. Only six laboratory services out of 56 have yet to apply for accreditation. That is due to accommodation issues and the fact that some laboratories do not have the number of staff needed to secure that accreditation. Accreditation is a useful guide and reassurance that standards are being maintained, but we have a technical difficulty with using the CPA method-ology at present.
26.Ms Ramsey:: Paragraph 1.6 refers to the review that was carried out in 1982, which you mentioned earlier. I have discovered that the service was affected by deficiencies in accommodation and medical manpower. Paragraph 3.6 states that some laboratories do not even have full- or part-time accreditation because of current accommodation inadequacies. You also mentioned staffing. Does the fact that those problems have persisted since 1982 not highlight the failure of the Department's policies to address the necessary issues over a long period?
27.Mr Gowdy: As we said earlier, one of our major problems is that the future of acute hospital provision has not yet been settled, therefore the laboratory services cannot be settled yet. That means that it would be a waste of resources to invest in accommodation if we thought that a short time later we would be moving them elsewhere. The standards of accommodation in some laboratories do not meet the required standards therefore they would not receive accreditation. Our key aim is to ensure that the provision of laboratory services continues, because access to those services is necessary for the effective operation of a hospital service. We do not want to shoot ourselves in the foot by applying a standard that does not deal with laboratory provision in terms of service to hospitals.
28.Ms Ramsey:: With respect, the problem dates back as far as 1982. I understand your point about the review of acute services, however that has only happened in recent years. The shortage of staff and the problem with accommodation were highlighted in 1982 and they still exist.
29.Mr Gowdy: There has been an ongoing problem. The policy that was set out in 1982 sought to reorganise the laboratory services onto six main sites. Work started and some progress has been made, but that has taken some time. For example, Belfast Link Laboratories, which encompasses the City Hospital and the Royal Group of Hospitals illustrates effectively how such rationalisation can take effect. Our problem was that, as we entered the early 1990s, the acute hospital issue began to arise. It has been an ongoing problem for 10 years.
30.Ms Ramsey:: The human organs inquiry, which was set up by the Minister earlier this year, is not part of the report, but it is relevant. We are aware that there have been problems with it. I know that the Department has given interviews and made statements on the issue, but why was it unaware of the practices that were adopted in the laboratories at that time?
31.Mr Gowdy: Post-mortem examinations have always resulted in the retention of some organs, and that was done for good reasons. The Department was unaware that some organs were being kept for reasons that were outside the remit. That only became apparent when the issue emerged in England and was investigated here. The Department had seen no need to investigate what was happening in pathology in respect of organ retention.
32.Dr Mock: To complete the post-mortem examination properly, some organs had to be preserved before they could be examined. Although the post-mortem consent form covered that, it was not explicit enough for people to understand the full meaning. We understand that deficiency, and it has been addressed. In certain situations, before examining the brain, for example, the organ has to be preserved for several weeks so that it can be carefully sliced and examined. We understand that the public did not appreciate how a post-mortem examination is performed and the practices that are necessary to make a complete examination.
33.Ms Ramsey:: You both mentioned consent, and that is the key. This practice took place often without the consent of the families. Can you assure the Committee that that is not happening in other aspects of pathology?
34.Mr Grzymek: On the issue of consent, the families signed consent forms in line with practice throughout the British Isles. However, the Alder Hay Hospital situation highlighted the rigour with which consent forms must be completed, and the fact that those who filled in the forms did not have an acceptable level of understanding. Once that became apparent, new consent forms were issued. All the trusts in Northern Ireland have reviewed their consent forms, and they have issued leaflets and guides to assist the families who must sign them. The forms have become more detailed, so that when small specimens, such as slides, are to be held, it is brought to people's attention. In cases where specimens that are necessary for the completion of a post-mortem examination must be retained, the families are advised of that, and they are asked whether they wish the organ to be disposed of or returned. We have learnt from the process; the practice has changed substantially here, and that has been reflected in other areas.
35.Mr Gowdy: The outcome of the current review will help us to understand what happened and what happens at present. It will allow us to make any changes that are necessary.
36.Ms Ramsey:: It seems that most hospitals would opt to have their facilities on site, if they were given the choice. However, paragraph 2.6 points out that Lagan Valley Hospital and Downe Hospital have had on-line access to the laboratory services of the larger Belfast City Hospital since the early 1980s. When reviewing policies in 1983 and 1997, and more recently, as recommended by the Auditor General in paragraph 2.10, what consideration did the Department give to the provision of off-site services such as exist at the Lagan Valley and Downe Hospitals?
37.Mr Gowdy: The key issue has always been the number of acute hospitals that we are going to have. An acute hospital that provides the full range of emergency service needs to have on-site laboratories and the full range of equipment so that it can respond quickly.
38.Hospitals that provide less immediate treatment have always been able to access laboratory services with a greater time delay. We have always wanted to ensure that that time delay is minimised. Lagan Valley Hospital is close to Belfast, and computer links will help to speed up the process, however the tissue or sample must still be taken from the patient to the laboratory. One development is that the response can be quickly telephoned or relayed via a computer link. In the future we may be able to put the sample into an on-site machine and deal with it through the computer link.
39.We are always conscious that technology is taking us forward. We hope that when we establish the full range of acute hospital services, according to the profile which the Minister will determine, that will allow us to concentrate the major laboratory sites next to the major hospitals. We can then deal with the linkages that must be made with the smaller hospitals. Our key point is what that future hospital profile will look like.
40.The Chairperson: Accommodation and staffing aside, are NEQA standards in respect of quality of service as rigorous as those applied by the CPA?
41.Mr Gowdy: Dr Mock knows the detail of those systems.
42.Dr Mock: The 25 NEQA schemes cover the range of laboratory testing. The laboratory sends samples away and makes sure that its own results are as they should be, according to another laboratory. All our laboratories take part in those schemes.
43.The CPA scheme operates at a higher level, therefore to apply for accreditation under that scheme all the standards of the NEQA schemes must be satisfied. We are certain that all our laboratories are meeting the requirements of the NEQA schemes. However, not all of them have achieved the CPA accreditation, which takes account of other factors such as accommodation, and whether a consultant pathologist is on-site at the time, which could be difficult for us.
44.Mr Dallat: This is a £41 million industry. There has been little progress in achieving accreditation, no performance benchmarking, and no competition, and precious little was said this morning that would instil in the public a great deal of confidence. Perhaps we should put aside money issues. I am sure that the availability of pathology services is often a matter of life and death: a diagnosis can often mean that a person will live. Surely, in an area the size of Yorkshire, there is no argument in favour of having 16 sites?
45.Mr Gowdy: I assure the Committee that the standard of laboratory services in respect of their ability to analyse and test samples is first class. They provide a very fast, responsive service and they do it at a top level. We know that that is the case because the service's quality is tested regularly under the NEQA scheme - either monthly or every four to five months. I would not want the Committee to feel that our service operates below the necessary standard, for that is not the case.
46.Mr Dallat: I am not suggesting that. However, I am aware of the well-publicised cases in the Kent and Canterbury Hospitals National Health Service Trust where things did go wrong. It is therefore proper that the Public Accounts Committee should express its concerns about what might happen in the future. I was certainly not implying that it was currently the case.
47.Perhaps I might return to the issue of value for money. If any other Government Department were to award a contract without the basic guidance principles being in place, there would be uproar. Yet we spent £41 million on a service which, by your own admission, does not comply with the guidance that you brought in nine years ago. We have already discussed the matter at some length, but it is important. Now you have said that you await a review. You also said that everything depended on acute hospitals, although there are sound arguments that the services are not necessarily linked to the hospitals, as Sue Ramsey pointed out.
48.Mr Gowdy: I should re-emphasise the point that I made earlier. The necessary on-site laboratory services are those which provide for acute hospitals' emergency treatment. When a hospital deals with someone admitted with a life-and-death situation, they must test for several things very quickly. Those services must be available on site, so the relationship between laboratory services and acute treatment is extremely powerful. The location of acute hospitals is therefore a very major factor in deciding where laboratory services should be sited. The relationship is absolutely critical.
49.We have a little more leeway in testing samples that are not of a life-and-death nature, in which case we can wait a little longer for them. Those laboratory services can be provided more remotely. The key issue is where the acute needs will be and where we must base the major laboratory services to provide an emergency response. We cannot make that decision yet, for we are still in the midst of a political debate regarding the siting of acute hospitals. It is not an easy issue, as I am sure everyone appreciates.
50.Mr Dallat: Perhaps I might move on to the issue of performance. The Northern Ireland Audit Office recommended in paragraphs 5.28 to 5.30 that Departments introduce performance measures providing benchmarks for a range of specialities. What is your view on the absence of that information for support services such as laboratories? Have you issued any guidance to or exerted any pressure on funding Departments to ensure that bodies for which they are responsible undertake benchmarking as recommend by the Northern Ireland Audit Office?
51.Mr Gowdy: Benchmarking is an important factor in ensuring that we secure value for money. Our spending on laboratory services is currently £54 million, so I can update the figure contained in the report. Of that sum, £36·5 million in spent on services to hospitals. The other element of expenditure is for GPs and work in the community, which has been a growing area. GPs ask for more tests nowadays, and that also has to be factored into the thinking.
52.At all times we wish to be sure that every laboratory benchmarks itself against others, both in Northern Ireland and elsewhere. During our work with trusts to develop service delivery plans providing for an annual plan of provision we said that benchmarking information should be included. We currently have an initiative to calculate comparative total costs or reference costs for each trust, ultimately covering all acute specialities. That will give us the information we need to benchmark within Northern Ireland and with Britain.
53.We are trying to get much more information out of them on the cost-per-test issue. We have moved away from the old cost-per-patient indicator, which was not giving us sufficiently accurate information on the volume of testing activity. We are now focusing on the cost-per-test, or the number of requests made for a test, which will provide more benchmarking information.
54.The Chairperson: Mr Delaney, do you want to comment on benchmarking in your Department?
55.Mr Delaney: Yes, the Minister announced in the Budget statement that the service delivery agreements would be produced early in 2002. As part of our new guidance on service delivery agreements, we have emphasised the importance of benchmarking as a performance measurement and monitoring tool that the Departments should consider, and they will take that on board.
56.Mr Dallat: Mr Gowdy, you will be aware that laboratory personnel expressed some concern about competition in the sector. Was the Department aware of that concern? If so, did your staff try to redress it? If not, why was the Department not informed of the concern?
57.Mr Gowdy: We were aware of the concern. We always operate within the context of the political philosophies that the Government of the day wants to put in place. When the Conservative Government were in power, they created the trusts and a competitive environment, because they believed that that was the way to drive down costs. That is why competition came into the health sector.
58.It is clear from the representations by staff, particularly in the laboratories but not exclusively, that competition was regarded as being unhelpful. It was not seen as having achieved its intended purpose. As we have moved from a Conservative Administration to a Labour one, and then into a devolved Government, it has become clear that we are moving firmly away from the competitive approach to one that is based on collaboration and, I hope, benchmarking as a test.
59.Mr Dallat: We can blame on the Conservatives for a good deal, but they did disappear quite a while ago.
60.Paragraph 3·6 of the report tells us that some laboratories do not have full accreditation due to their lack of consultant cover. I note in paragraphs 3·10 and 3·11 that the inadequacy of consultant cover was the main reason for failure in the Kent and Canterbury cases that I referred to earlier. Does an absence of consultant cover restrict the range of conditions that some hospitals can treat? I will listen carefully to your answer, because so far your argument for retaining the 14 sites has been based on the assertion that they must be attached to, or close to, hospitals.
61.Mr Gowdy: Are you referring to consultants operating in the laboratories or consultant-led services in the hospitals?
62.Mr Dallat: I refer to consultant cover. In the report, we discovered that some laboratories could not operate because no consultant was attached to the hospital to carry out the work.
63.Mr Gowdy: Dr Mock will discuss the professional issues.
64.We have been aware that consultant pathologists are something of a rare breed. We currently have 68 consultant pathologists, and there are 10 vacancies, some of which are at specific laboratory sites, and this has had an impact on those services. Our networked approach, which Dr Mock can explain, has allowed us to maintain those services, with consultants covering more than one site.
65.Dr Mock: We currently have several vacancies for consultant pathologists, because people get other jobs and move on. However, some laboratories outside Belfast are run on a board basis - in the Northern Board, the Western Board and the Southern Board the services are networked. For example, the consultant pathologist in Altnagelvin Hospital provides cover to the Sperrin Lakeland laboratories. The same applies to Daisy Hill Hospital and Craigavon Hospital.
66.The Kent and Canterbury Hospital case was specific to cervical screening. We do not have those problems in our cervical screening services in Northern Ireland because we have consultant pathologists with a special interest. Our system has developed over the years to become heavily quality assured. We have a regional committee that scrutinises the work continuously, and we are happy that our cover at that level is assured.
67.Mr Dallat: Would you describe the service at the moment as being comprehensive and adequate to meet people's needs?
68.Dr Mock: Yes. There is a shortage of consultant pathologists throughout the UK, especially in special fields such as histopathology, which involves less clinical contact, making it a less attractive option in recent years. Our service is running well, it is quality-assured, and we are proud of it.
69.Mr Carrick: Mr Gowdy, you commented on benchmarking and comparative figures. I wish to draw your attention to the comparative prices of tests in appendix 5, 6, and 7, pages 77 to 81. It is an interesting revelation that 80% of the prices quoted in appendix 7 are higher in Northern Ireland than in the NHS hospitals. I realise that that was based on a sample, but I understand that the Northern Ireland Audit Office selected an area in England that has many similarities to Northern Ireland. How do you account for the evidence that the price of carrying out what is presumably the same type of test in Northern Ireland is on average higher than in England? What are you doing about that?
70.Mr Gowdy: The figures must be examined, and I will return to that point. The prima facie view is that we must ensure that we are comparing like with like - that is a very important requirement and we are not sure that that is being met. Even if we were comparing like with like, there is a substantial difference between England and here. Many laboratory services in England are based around district general hospitals, which are major beasts, and are substantially greater than most of the hospitals here. They are able to get economies of scale in their laboratory services because they operate on that larger scale. That difference is therefore likely to have an impact on cost, and we are not necessarily surprised that it exists.
71.To be able to justify any difference, we need to examine whether the costs are of a justifiable magnitude. We are going to review the average cost per request in each laboratory to give us the necessary information. Our current initiative is aimed at providing detailed costs for all groups of hospital procedures, and that will include laboratory services. This specific review to compare the average cost per request will give us the hard information that we need in order to identify the relevant the factors. Other points might apply, for example, different laboratories use different equipment with different reagents that have different prices. Some laboratories are more manual, and therefore require more staff time than they do pieces of equipment. Therefore, much depends on what the different laboratories are using as the basis for making their test. Different factors can underlie the differences, but a review needs to be carried out.
72.Mr Carrick: I accept that you are anxious to compare like with like, and that is important. However, before the Audit Office produced its report comparing Northern Ireland with north-east England, you had no other samples to which you could have referred. Do you accept that before the publication of that report you were not engaged in the necessary benchmarking?
73.Mr Gowdy: No benchmarking exercise was carried out before that point.
74.Mr Carrick: On reflection, do you feel that there should have been such an exercise?
75.Mr Gowdy: Yes, we accept that a benchmarking exercise needs to be in place.
76.Mr Carrick: I welcome the statement in paragraph 5.20 of the report that the Belfast City Laboratory has started to develop common protocols for laboratory testing. How many protocols are in place? How many different tests do they cover?
77.Mr Gowdy: Different laboratories have different protocols in place. If varying types of equipment, reagents and procedures are being used, there will be different protocols.
78.Dr Mock: In the Eastern Health and Social Services Board the laboratories are working together to develop common protocols. However, because of the different starting points of the laboratories in respect of their equipment and reagents, it is a difficult exercise to achieve. Common protocols would exist in cervical screening, for example, because slides are examined in exactly the same way in every laboratory across the United Kingdom.
79.The chemical tests require the laboratories to proactively develop together their method of performing the detail of the tests and the reagents to use, and to apply a common protocol. You can be assured that, because of the laboratories' participation in the NEQA schemes, the quality of test results can be stood over. Work towards creating common protocols is ongoing, and that work was discussed at a recent meeting of the Laboratory Services Advisory Committee (LABSAC).
80.The clinical directors of the laboratories are moving out of the competitive mould towards having co-operation and discussions on that issue. It makes sense to establish commonality throughout the service. Because laboratories have developed differently, and support different hospitals, they have developed differing techniques. We can nevertheless be assured that the results will be the same.
81.Mr Carrick: I appreciate your general response to specific questions, but for the record I ask how many protocols are currently in place and how many tests do they cover at the moment? You might intend to introduce further protocols and more tests, but it would be useful for the Committee to have the current figures.
82.Mr Gowdy: We do not have that information to hand, but we can provide the figures to the Committee later.
83.Mr Carrick: What is the annual value of the tests?
84.Mr Gowdy: We have 5·9 million requests for tests every year, and that figure has been going up. The increase over the previous year was 2·6%. Over the last four to five years the figure has grown by 22%; demand for tests is rising dramatically.
85.Mr Carrick: What percentage of those tests are covered by the common protocols?
86.Dr Mock: The clinical biochemical tests, which are automated, are most susceptible to common protocols, since they depend on the same reagents. Those tests form a large part of the work and have increased by over 60% in the past five years. That is because diseases are now looked after in the community, and there has been a huge rise in testing on behalf of general practitioners.
87.Mr Carrick: Perhaps that sort of information could be factored into your response to the Committee. Has the Department taken any action to ensure that those protocols are subsequently used in other laboratories?
88.Mr Gowdy: We have taken the issue of building common protocols with professionals very seriously. As the report acknowledged, there are two specialist committees with professionals as members, and the issues have been taken up in those different forums. There is a clear acceptance by professionals that the development of common protocols is important, and we expect that to be taken forward fairly quickly.
89.Mr Carrick: Perhaps that might also be reflected in your response to the Committee. Paragraph 2.5 of the report tells us that Lagan Valley Hospital and Downe Hospital refer all their laboratory work to the Belfast Link Laboratories, to which you referred in an earlier submission. Figure 10 shows that the cost of that work is relatively low, even disregarding the six largest acute trusts. If Down Lisburn Trust is satisfied with the work it has received since the early 1980s, is that good evidence that other trusts might benefit from referring more of their work to outside laboratories?
90.Mr Gowdy: The Belfast Link Laboratories provide regional as well as common services. The nature of the work at the two hospitals concerned is more complex and involves the more difficult cases. The cost of providing services is therefore inevitably higher than elsewhere. That complexity explains the higher costs at both Belfast City Hospital and the Royal Victoria Hospital.
91.We wish to ensure the proper service at the right cost by undertaking a benchmarking exercise. That is the real test, and it would enable us to make the necessary like-for-like comparisons which the global figures do not allow. It is necessary to look beneath them, and we are committed to doing so.
92.We must also be careful that the speed of response is factored in. There is no point in having a cheap test if it takes a long time.
93.Mr Carrick: I come to a matter of interest to residents of my constituency, Upper Bann. As a result of the transfer of acute services, the South Tyrone Hospital laboratories have been closed, and most testing has been transferred to Craigavon Hospital. Have you yet determined whether this move is temporary or permanent?
94.Mr Gowdy: It is a temporary move. All the changes at South Tyrone Hospital were in response to an immediate and urgent need to ascertain the safety and clinical provenance of the services. All the decisions were taken temporarily, depending on the eventual profile of acute services across the Province. No final decisions have been taken on South Tyrone provision.
95.Mr Carrick: What impact has that move had on turnaround times for laboratory test results?
96.Mr Gowdy: I am not in a position to answer that. Perhaps my colleagues can do so.
97.Mr Carrick: If you do not have the information to hand, perhaps you might supply it later.
98.Dr Mock: Do you mean in respect of patients going to South Tyrone Hospital or the speed of the response?
99.Mr Carrick: Has there been an adverse effect on the timing and quality of the laboratory test results?
100.Mr Grzymek: There should not have been an adverse effect, since urgent response times most often relate to those admitted for in-patient care. Those patients will have been transferred to a hospital such as Craigavon following the changes in South Tyrone. Ultimately the laboratory services will have moved with the patient, and the timing should have been kept short. It may have an effect on out-patient or other diagnostics in the hospital, and that is an area on which we must concentrate. However, emergency testing relates primarily to emergency admissions. The patients would have gone to Craigavon Hospital, and the services would have followed them.
101.Mr Gowdy: I am happy to make enquiries and pass on the response to the Committee.
102.Mr Carrick: I should appreciate that. I am sure that you are aware of the degree of public interest engendered by this issue. What financial savings does the Department expect to achieve by the move?
103.Mr Gowdy: It is not about saving money; it is about ensuring that the Department is able to provide safe and effective services. We are determined that people in Northern Ireland should have the highest possible quality of services. One of the major underlying factors in the need to rationalise and reconfigure acute hospital services is the desire that the Department have the benefits of aggregating specialities in different places and bringing all the support services in round them.
104.Ultimately the key factor is to ensure that whatever is put in place provides high-quality, safe, accessible services. There are a few difficult issues arising from the Hayes review that must be resolved. The public has made many comments on its recommendations.
105.Mr Carrick: Considering the rationale and motivation for the move, I am sure that there was a financial consequence. Were savings or increased costs incurred?
106.Mr Gowdy: The present temporary arrangement is more costly than the previous. The Department has had to put money in to support the services. There will also be costs involved in the building that will eventually be needed to fulfil requirements in some areas. In future there may be some asset sales on the other side of the balance sheet. However, the temporary arrangements at South Tyrone and Craigavon have been more costly.
107.Mr Carrick: Have those costs been quantified?
108.Mr Gowdy: I shall send you details of how much additional funding the Department has provided over the past 12 to 18 months.
109.Mr Carrick: I should like to know the additional costs involved, for funding may have fallen short of expenditure, something which may in turn cause financial burdens elsewhere in the Health Service.
110.Mr Gowdy: That is true. The issue concerns not only the Southern Board area. Other boards are also accessing the service there, and the Department has made some provision for them too. I shall send you details of the total cost.
111.Mr Carrick: Paragraphs 5.18 and 5.19 of the report state that you issued guidance on the importance of recovering full costs in contracts and the need to ensure there is no cross-subsidy between contracts stretching as far back as 1991. Have you checked whether trusts have complied with that when establishing prices charged for laboratory tests? In the light of the wide range of costs per patient shown in figure 10 and the prices charged in appendix 5, are you happy that there has been no subsidy of certain laboratories by others?
112.Mr Gowdy: The Department has seen no evidence to suggest there has been any cross-subsidy between laboratories. However, there may have been cross- subsidy in laboratories where consultants provided an outreach service to others. That would need to be investigated if you wished details. However, we issue annual costing guidance to all trusts, and the chief executive of each trust must give me a statement each year saying that they have adhered to it. That costing guidance requires them to ensure that service costs are matched by expenditure and that they are not cross- subsidising or using one service's resources to fund another.
113.Mr Carrick: Have you checked that trusts have complied both in establishing prices for laboratory tests and with the guidance?
114.Mr Gowdy: Yes, in that I have issued annual costing guidelines to them and asked the chief executive each year to assure me that his trust has complied with them.
115.Mr Carrick: Have you always received that assurance from every trust?
116.Mr Gowdy: Yes.
117.Ms Ramsey:: More than once discussion has touched on the issue of laboratory accreditation. I should be interested to know if any laboratories have lost it.
118.Mr Gowdy: Yes. Some of them have lost accreditation.
119.Dr Mock: Recently Altnagelvin Hospital's haematology service lost its accreditation owing to the difficulties caused by two consultant haematologists leaving. The Mater Hospital had full accreditation, but that has now been withdrawn, mainly because of accommodation but also because of consultant cover. However, that illustrates how the accreditation process established in 1992 has itself become more rigorous. Accreditation has raised standards, which is why it has never been made a mandatory obligation, for we have no control over a consultant deciding to move to another job. That can mean the withdrawal of accreditation from that service.
120.Ms Ramsey:: Will they continue to provide the same services as previously?
121.Dr Mock: Yes. Haematologists in Belfast and across the whole clinical network support services provided to patients at Altnagelvin Hospital.
122.Ms Ramsey:: I understand what you are saying, but does that not bring us back to my first point? What is the point of having accreditation? Is it not a failure to the public if laboratories are not accredited?
123.Mr Gowdy: No. That is the point we discussed earlier. The NEQA scheme tests all services, including those at the Mater and Altnagelvin, very regularly - monthly or quarterly - to ensure that services are at the level required. None of our laboratories has had that accreditation removed. The accreditation in this case is the wider one provided by the clinical pathology accreditation scheme, which embraces consultant cover and accommodation as well as service quality.
124.Ms Ramsey:: Is it not then a waste of time? What is the point of having accreditation?
125.Dr Mock: I understand what you are saying. We should be aiming for clinical pathology accreditation, for it is the best standard available across the United Kingdom. You are saying that we could have opted out of the whole system.
126.Mr Gowdy: It is where the best becomes the enemy of the good. The key issue for us is to ensure that hospitals enjoy quality services from their laboratories. The further issue regarding accreditation as you describe it is whether we have accommodation which fully meets modern standards. We cannot say that, for we have not been funded enough to do anything about that accommodation.
127.We have also experienced the problem that staff find pathology a less attractive option, meaning we have difficulty recruiting. If we did not have the staff numbers the CPA scheme believed necessary, we should lose accreditation. If that were mandatory, we should lose the capacity to provide laboratory services. The key assurance to the public is that the quality of services provided by our laboratory staff is checked very frequently and has always met the required standard.
128.Ms Ramsey:: I take on board what you are saying, but I remain unconvinced. From your words I take there to be no need for accreditation. If a test is carried out regularly, meaning accreditation is unnecessary, why have it?
129.Mr Gowdy: It is important that everyone strive for accreditation. If we did not have some sort of standard, you could never be sure of getting a quality service. The key for us - the basic absolute - has to be whether services are being provided to the right quality standards. We are getting that assurance. The accreditation beyond that is striving to put the best in place. We should all like to have the best here, but we cannot afford it; that is the key difficulty for us. We are also having difficulty recruiting. We should like, in an ideal world, to meet those standards, but failing to meet them is not necessarily going to destroy public confidence, for we can say that we shall not provide any services that do not meet those basic professional standards.
130.The Chairperson: That supplementary question has been answered, and I do not wish to get bogged down in it.
131.Ms Morrice: I shall go over a few of the areas that we have touched on. I wish to talk about accreditation, the shortfall in consultants, the problem of data and testing and also costing. I also wish to tease out the issue of accreditation because public confidence is such a huge issue. It is amazing to hear you say that we want the best but cannot afford it. In other words, we have not got the best. That is an important statement. Does it instil confidence in the public?
132.Mr Gowdy: Perhaps I might clarify the issue. It is a matter of having the best modern facilities and modern buildings staffed to the ideal level. We are getting by on -
133.Ms Morrice: Is that good enough?
134.Mr Gowdy: It is not what I should like. I certainly want us to achieve the best, but we see our laboratories deliver services at the appropriate high-quality level. To assure the public, the laboratories are doing the job for which they have been put in place.
135.Ms Morrice: You are talking about delivering the service. There has been mention of cervical screening cases at the Kent and Canterbury Hospitals National Health Service Trust. We are also aware of more recent problems with the Royal Group of Hospitals Trust from the Minister's response to a written Assembly question in May 2001. Incorrect results were given to haemaphiliac patients when testing for hepatitis C. Are such examples not clear evidence of the need for compulsory accreditation? Sue Ramsey has been asking why it is needed, but at the other end of the scale, if you had compulsory accreditation and we had to adhere to that, no mistakes could be made.
136.Dr Mock: Our level of accreditation in Northern Ireland is exactly parallel to the level in England. Not every laboratory is able to achieve accreditation, but all of them are working towards it. It was never designed to be a compulsory system in the United Kingdom; it is not the only one, and there are also difficulties. If your accommodation is not deemed appropriate, you could lose accredition. If the scheme were mandatory, that laboratory would have to have to stop providing a service. We are all anxious for that not to happen. Even in the best system there can unfortunately still be errors.
137.Ms Morrice: What assurance can you give that the problems at the Royal Victoria Hospital were not in any way linked to the fact that haematology laboratories have not received full accreditation, according to figure 5 in the book?
138.Mr Gowdy: We can give an absolute assurance that it is not because of this accreditation problem. The national external quality assessment scheme operates on the basis that it sends samples to all the laboratories providing all the different services, asking them to test them and return their results. It then assesses the quality of the service. No laboratory has failed to meet those standards. That is the assurance that we can give you. That test happens frequently - in some cases it is monthly, in others every three or four months. There is constant checking that our standards are sufficient. CPA accreditation, however, deals with the wider issues to do with getting quality infrastructure in place, something which we do not have.
139.Ms Morrice: Part of the failure of that accreditation procedure relates to the 10% shortfall in the number of consultants.
140.Mr Gowdy: We have 10 vacancies - we should have 78 consultants, but we have only 68.
141.Ms Morrice: One reason you cannot get accreditation is that you do not have consultants in post. What are you doing to remedy the situation and train consultants?
142.Mr Gowdy: A substantial effort is being made to improve the number of medical students who specialise in pathology.
143.Ms Morrice: Are those numbers increasing, and is there encouragement for young student doctors to specialise in that area of interest?
144.Dr Mock: It is not confined to us. We have particular problems in Northern Ireland because of our geographic isolation, so in most specialities we are trying to train our own consultants. Histopathology, which is a branch of pathology dealing with tissues, biopsy specimens and performing post mortems, currently has four vacancies in Northern Ireland. A few years ago we had eight training posts in that speciality in Northern Ireland, but only two people came forward for training.
145.Ms Morrice: That is fascinating; the machinery to provide skills to match industry and needs is failing badly, and surely it is obvious what is needed. If there are eight training places available, what is being done to attract young students?
146.Mr Gowdy: An annual medical workforce plan is in place. It aims to review the number of posts we have and need and how many people are in them, along with a profile of predicted retirement ages and other wastage factors. That workforce review is conducted annually, and projections are made of the numbers of staff needed.
147.Ms Morrice: What will the cost of recruiting extra staff be, and is the Department prepared to pay?
148.Mr Gowdy: If we could get the extra 10 consultants, there would be no problem, for we have financial provision for 78. We have talked to the Department of Health in England, which is concerned with the output of medical schools throughout the UK. It is trying to increase the number of training places in pathology. In our most recent discussions with the Department of Health, it stated it was increasing the number of UK training places by 40, and we hope to benefit from that. Unfortunately, issues such as organ retention tend to put off young medical students, who view pathology as a less attractive option. Attracting people to the speciality is an uphill struggle for us.
149.Dr Mock: That issue was discussed at a meeting earlier this week. The Royal College of Pathologists recognises that there is a problem attracting trainees. We have 180 medical students, and there are 40 different medical specialities they can enter when they qualify. Histopathology is just one of those, and that must be taken in consideration. In the mid 1990s there were a great many people training in histopathology in Northern Ireland, so it was perceived that opportunities might not be available upon completion of training. In fact demand for histopathologists has outstripped supply because of factors such as the cancer plan, the ongoing cancer initiatives, and the increased number of specimens from each patient which must be examined by the consultant pathologist. Demand has increased, and we currently have vacant funded posts around the Province without any applicants.
150.Ms Morrice: It is a great pity that you are not shouting louder about it, for I am sure that there are people who would be interested.
151.I shall move on because of time constraints. I wish to talk about the testing and the data. Paragraph 5 on page 7 of the report's executive summary states that laboratories processed over 6·3 million requests for tests in 1998-99. Mr Gowdy, you stated that the figure was 5·9 million but I shall not question that. Please give more detail on any data the Department collects on the different laboratories' workloads. Do the data enable the Department to draw any conclusions about the relative workloads of staff in similar laboratories who specialise in the same areas?
152.Dr Mock: The Department keeps a record of the number of requests for work to be done in the various speciality areas. However, that does not accurately reflect consultants' workload. It is difficult to calculate workloads. For example, a request to one branch for the result of a biopsy specimen may simply require a consultant to examine something. A request for a certain biochemistry test, however, might require several other tests to be carried out.
153.All our laboratories have agreed to record the number of requests. It would be difficult to collect the information by recording numbers, since the number of tests carried out on just one sample can vary so much. Such bald figures do not accurately reflect the situation. The laboratory staff are being put under increasing pressure. The Belfast Link Laboratories have examined the number of requests and tests carried out per medical laboratory scientific officer. We know that the number is increasing rapidly every year because of the increasing number of patients in the system.
154.Ms Morrice: Let us talk about examples we can understand. There has been an increase in the interest in cholesterol levels and heart disease. Has that interest resulted in an increase in requests for cholesterol testing, and have you tried to accommodate that and ease the workload by sending all cholesterol tests to one laboratory, for example? Can it be done, and are you working towards it?
155.Dr Mock: There has been a rapid increase in interest in that area. General practice requests for cholesterol testing have increased. However, I am not sure how the laboratories have accommodated it.
156.Ms Morrice: If the testing were rationalised in such a way, would it improve the situation?
157.Mr Gowdy: The speciality advisory committees have not told us that certain laboratories are suffering from an overload that would require the kind of rationalisation or transfer of tests you suggest.
158.Dr Mock: No, they have not. The volume of tests increases at different rates in the different specialities. For example, it has increased by 60% over the past five years in biochemistry. That figure tends to be closer to 4% in the other specialities. Cholesterol testing, an area you suggest has seen a huge increase, would fall into one of those smaller categories.
159.Ms Morrice: We should think of that as example only because it is an issue of which we have been made aware. I am conscious of the time, so I shall move on.
160.I was astounded that a pregnancy test cost £14.20 in one hospital - I believe it was Altnagelvin Hospital - and £2.05 in another. That is an incredible difference in price for a pregnancy test. Do doctors realise that they can shop around? Do doctors in the Derry area realise that, if they sent tests to Bangor Hospital or the Ulster Hospital, for example, it would be cheaper? They might have to pay only a quarter of the price.
161.Mr Gowdy: This situation arose because of the competitive environment created when the trusts and GP fundholders were established. They were supposed to provide a marketplace where GPs could shop around and find the cheapest test.
162.Ms Morrice: What happened?
163.Mr Gowdy: The problem developed for the very reason that GP fundholders were able to shop around. Laboratories could not be certain of the level of activity with which they would be required to deal. To bring prices down, they risked finding themselves in a position where they were unable to cover their costs. Different laboratories tended to specialise or carry out a higher volume of particular types of test, and they were able to charge a lower price because the volume of requests was high.
164.Ms Morrice: The number of requests for pregnancy tests in the Derry area is quite high.
165.Mr Gowdy: If everybody drove their costs down in that way, there would be a danger that the total costs would not be covered in each laboratory. It was becoming a problem, and that is why we changed to block contracts. Movement from place to place meant that some laboratories were in danger of going out of business. To put it in the private sector -
166.Ms Morrice: However, you slap £14.20 on every test - not only pregnancy tests - whereas other prices range from £2 or £3 to £8.
167.Mr Gowdy: That was done because the laboratories were working on the basis that GPs wished to have a common tariff of charges for every type of test. There was a great deal of concern that competition would drive people from one place to another and back again as they swapped their costs. That is not the way to run a care service. The other issue was that, because the Department was telling them that they had to meet their costs, the laboratories were getting concerned that the competitive approach meant that their volume of activity was less predictable. That meant that they were unable to cover their full costs.
168.Ms Morrice: I have one final question regarding cross-border co-operation, which is important. What is the Department doing to try to collaborate with the same sort of laboratories in the South? For example, is it possible for a doctor in Derry to send pregnancy tests to a laboratory in Letterkenny and have them done cheaper?
169.Mr Gowdy: Most clinicians want a speedy response. The further they have to send the test, the slower the results will be, for the sample must be taken somewhere. If the sample has to travel a longer distance, it will take longer. There is cross-border co-operation, but I am not sure if it has reached the point where testing can be done.
170.Ms Morrice: A new health body has been set up; is that not cross-border?
171.Mr Gowdy: I could quote numerous examples of practical co-operation. It tends to occur in the delivery of services, where patients can get treatment, for example, in liver transplant and heart surgery. I am not sure if laboratory work lends itself to such co-operation.
172.Dr Mock: I have not heard of co-operation in laboratory services specifically. However, I should be surprised if it did not happen, especially given Derry's location.
173.Ms Morrice: Perhaps you could find out if it is cheaper?
174.Mr Gowdy: We can check if there is cross-border laboratory activity, and we shall let the Committee know. As you can see, we are unaware of it happening at present.
175.The Chairperson: Would it make any difference to the price charged?
176.Mr Gowdy: It could make a difference.
177.The Chairperson: We might get a great deal of business from them in euros.
178.Mr Grzymek: I agree that there may be tests which are not particularly urgent. However, it is necessary to carry out many of the tests in the hospital for ease of access and transfer. Those would not be suitable for movement across the border. Some rare or specialised tests may be sent outside Northern Ireland, either East or South, depending on where they can be done. That happens only for rare conditions. In a population of 1·7 million, there are certain conditions of which we might see only one or two cases at a time. We should go to the best possible place for testing.
179.The Chairperson: That concludes the questions. We aimed to finish the meeting at 12.00, and we have just made it. My thanks go to the Members for being concise and to Mr Gowdy and his team for answering in such an efficient way that there was no need to drag the meeting out.
180.I shall sum up. Pathology laboratories are an important part of the Health Service, and doctors' ability to treat patients depends on their work. The Committee does not wish the trusts to make economies that put patients at risk or create additional costs for the rest of the Health Service. However, it is important to know whether locally based laboratory services function as efficiently as possible. That is what the meeting is about. It is particularly important because of the great financial pressure the Health Service is under. To use your expression, we do not want the best to be the enemy of the good.
181.Thank you for coming. I shall not see you before the festive season, so
I wish you a happy Christmas
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