APPENDIX 1

Correspondence of 17 January 2002 from Mr Clive Gowdy, Accounting Officer of the Department of Health, Social Services and Public Safety

PUBLIC ACCOUNTS COMMITTEE EVIDENCE SESSION - 29 NOVEMBER 2001

During the above evidence session, I undertook to provide further information on a number of issues raised by the Committee. I am now writing to provide this information.

Common Protocols

We discussed with the Committee the issue of common protocols for laboratory tests. I agreed to provide further information on the extent of common protocols that are currently in place and the range of tests that they cover. The Committee also requested information on the progress being made with professionals in the implementation of common protocols.

A common protocol may be said to be in place when there is one common approach to conducting a test which is applied consistently when undertaking that test anywhere in Northern Ireland.Within each laboratory, each laboratory test carried out follows a clearly defined protocol (also called a standard operating procedure) and, for example, there will be numerous protocols covering clinical biochemistry, haematology and microbiology.

In Northern Ireland common protocols currently only exist for some regional specialties. Examples include:

Cervical screening - all cervical screening slides are examined in the same way by the cytology screeners across Northern Ireland. The number of slides processed are now over 100,000 per year.

Phenylketonuria - all babies in Northern Ireland have a heel prick blood sample taken during the first few days of life and this is tested for the disease phenylketonuria in the Link Labs laboratory. There will be 24,000 samples each year.

Cryptosporidium - in microbiology the Public Health Laboratory Service in Link Labs adheres to a common protocol which exists right across the UK, to comply with statutory requirements for cryptosporidium testing.

Xanthochromia - clinical biochemistry has agreed on a protocol for testing for xanthochromia right across the Province.

Haematology - in haematology the Regional Audit Group has developed common protocols for the diagnosis, investigation and treatment of certain diseases such as chronic lymphatic leukaemia, polycythaemia, thrombocytopaenia, anticoagulant management and the use of blood products.

Histopathology - in this speciality the Royal College of Pathologists has drawn up skeleton report proforma in the different specialty areas. These are used by histopathologists in reporting on biopsy specimens.

Before a wider range of common protocols can be put in place, further steps need to be taken to standardise equipment and processes across Northern Ireland. In each of our laboratories the standard operating procedure for carrying out a certain test may differ from that of another laboratory. This reflects the fact that laboratories may be using different types of analysers and different reagents to perform the same type of examination. Common protocols could be developed progressively, as opportunities come up for replacing major items of equipment and thus standardising the approach.

Impact of the Transfer of Laboratory Services from South Tyrone
The Committee was concerned about the impact on the timings of responses caused by the temporary move of laboratory services from South Tyrone to Craigavon Area Hospital. I promised to make enquiries and pass on the response to the Committee.

The Committee also requested information on the additional costs which have been incurred due to the temporary transfer of services from South Tyrone to Craigavon Area Hospital and information on whether these costs have been funded.

The temporary move of laboratory services from South Tyrone Hospital to Craigavon has imposed some additional pressure on the Craigavon laboratory, but the impact on service delivery has not been particularly significant.

General practitioners in Dungannon were able to access a very rapid turnaround of specimens in Dungannon laboratory, because of their proximity to it. Currently, if a specimen needs to be reported on urgently, it will be collected from South Tyrone Hospital reception and taken to Craigavon Area Hospital laboratory by taxi. Routine specimens are now collected by Craigavon laboratory from general practitioners, taken to the laboratory in the early afternoon and the results are available that evening.

Outpatient services for medical, surgical and haematology patients are carried out on the South Tyrone Hospital site. When results need to be available at the clinic on the day of the appointment, for example, in haematology clinics, the patients attend the hospital a few days earlier so that the result is back from Craigavon Area Hospital and available. For the anticoagulation clinic, a biomedical scientist from Craigavon Area Hospital attends South Tyrone Hospital and runs the tests while the clinic is taking place.

The South Tyrone Hospital wards have online access to the Craigavon laboratory and results are therefore available quickly to the clinicians at South Tyrone. Day procedures are carried out at South Tyrone Hospital. If a patient is unable to go home in the late afternoon he or she would be transferred to Craigavon Area Hospital for an overnight stay, and any laboratory tests required would be carried out there.

In summary, there has not been a significant increase in turnaround times of laboratory specimens with the move of work from South Tyrone Hospital to Craigavon Area Hospital. The large workload from general practice now arrives in the early afternoon and the laboratory has accommodated the extra demand in workload without a corresponding increase in time in reporting back the results.
The transfer of laboratory services from South Tyrone to Craigavon Area Hospital incurred additional one off costs of some £60,000 and ongoing additional costs of some £6,000 per annum for the transport of specimens. These excess costs have been funded by the Southern Health and Social Services Board.

Cross-subsidisation of Laboratory Services

The Committee explored the issue of cross subsidisation of laboratory services and sought assurances that Trusts have complied with the guidance when establishing the prices charged for laboratory tests.

All Trusts are required to set their prices as accurately as possible and Trust Chief Executives have confirmed that they are complying with the costing guidance. Nonetheless, it is also standard practice that laboratory prices are reviewed on a periodic basis. For example, Belfast Link Labs are currently undertaking a pricing review of their laboratory prices. Whilst the outcome of this review may lead to a change in the Belfast Link Labs' block contracts, it will not reduce the total laboratory costs for the HPSS, but may lead to a redistribution of costs between the various Trusts. This does not indicate cross subsidisation of laboratory services with other services and is simply a routine process to ensure that laboratory costs are fairly distributed between Trusts.

Cross Border Co-operation

We discussed with the Committee the potential for cross border co-operation in relation to laboratory services. Whilst there is a wide range of practical co-operation in relation to the delivery of patient services, I under-took to confirm whether any such cross border activity takes place in relation to the provision of laboratory services.

There is a small cross border element in the provision of laboratory services. Some hospitals in the Republic of Ireland access Belfast Link Labs for virology and specialised biochemistry testing (trace metals and toxicology). The Belfast Link Labs do not send specimens to Dublin but use some laboratories in Great Britain for specialised services.
The Western Area and Southern Area laboratories have confirmed that they are not aware of general practitioners accessing laboratory services on a cross border basis.