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SIXTH REPORT PATHOLOGY LABORATORIES IN NORTHERN IRELAND INTRODUCTION 1. The Public Accounts Committee met on 29 November 2001 to consider the Comptroller
and Auditor General's Report on his "Review of Pathology Laboratories in
Northern Ireland" (NIA 31/00, Session 2000-01). Our witnesses were:
2. The Committee also took Written Evidence from Mr Gowdy (Appendix 1). 3. The Department of Health, Social Services and Public Safety is responsible for providing or ensuring the provision of health and social care for the population of Northern Ireland. It is therefore responsible for ensuring that pathology laboratory services, which play an essential part in such provision, are organised and managed in such a way that they are able to provide that support, efficiently, effectively and making the best use of resources. 4. Expenditure on laboratories is approximately £54 million annually. The service is provided by a workforce of around 870 people who process some 6½ million tests each year. 5. In taking evidence, the Committee focused on four main issues:
OUR PRINCIPAL CONCLUSIONS AND RECOMMENDATIONS ARE AS FOLLOWS: 6.1 In view of the considerable problems being faced by the health service,
this Committee would urge the Depart-ment to set out its proposals for the future
organisation of pathology services as soon as possible. Uncertainty brings with
it a lowering of morale and the potential for inefficiency and waste. The Committee
would also be interested to see the recommendations of the Department's own
Review of the Pathology Service when it is completed. 6.2 We fully accept that it doesn't make sense to rationalise laboratories
until the acute service is rationalised. What is disappointing, however, is
that it is clear from the C&AG's report that the need for rationalisation
was accepted in 1983, yet no progress was made in reducing the overall number
of laboratory services until the late 1990s and only slow progress has been
made since then. This is inexcusable. It also seemed to us that, in an area
the size of Yorkshire, yet with a much smaller population, there is no argument
in favour of having 14 laboratory sites. 6.3 We are not satisfied that we have been given an adequate response to our
questions about the sending of tests by the Lagan Valley and Downe Hospitals
to Belfast laboratories and the use of on-line access facilities. If the Lagan
Valley and Downe Hospitals have been able to manage effectively, over a lengthy
period, without on-site laboratory facilities, it is essential that the Department
give full consideration to incorporating off-site testing in the options reviewed.
The Committee expects to be assured that, following the reorganisation of acute
hospitals, all such options will be reviewed. 6.4 There has already been a considerable delay since the date that the proposals
were made to move services from the Belvoir Park Hospital to the Belfast City
Hospital and it is clear that the opening of the new facility is still some
years off. 6.5 We are concerned at the lapsed time taken to implement these proposals,
which were generated to improve the arrangements for care and treatment of patients.
We view this delay as wholly unacceptable. Delay in implementation will inevitably
adversely affect overall patient care. We therefore urge the Department to ensure
that future delays are minimised. 6.6 We will be monitoring developments in the future organisation of services
both at the Belfast City and Craigavon Area Hospitals. Although we welcome the
movement, albeit slow, towards rationalising the service where improved efficiency
is the intended outcome, we would like the Department's assurance that the care
of patients still attending the Belvoir Park Hospital and those previously attending
the South Tyrone Hospital is in no way compromised by the decisions to move. 6.7 The Department's policy, over many years, has been that quality and safety
of care should have primacy over the geographical accessibility of services.
We were concerned to note, from the C&AG's Report, that in June 2000, only
45 per cent of the pathology services throughout Northern Ireland had been unconditionally
accredited and 18 per cent had been conditionally accredited. 6.8 We see from the C&AG's Report that the conclusions and recommendations
emanating from the 1995 NHS Strategic Review of Pathology Services in Great
Britain were endorsed by the Department in 1997 and that these included the
requirement for purchasers and providers of health services to incorporate accreditation
or a commitment to obtain accreditation as a condition of any pathology contract.
We also noted that the absence or non-involvement of consultants and the absence
of accreditation were key points raised by the review, in 1997, into the failures
of the Kent and Canterbury Hospitals Trust histopathology department. 6.9 The Department blames accommodation problems and a shortage of consultant
staff. While we recognise that the health service has undergone considerable
organisational change over the last ten years, we must point out that these
problems were highlighted as long ago as 1982. In referring to the Clinical
Pathology Accreditation (CPA) system, the Accounting Officer talked of the best
becoming the enemy of the good and he placed reliance on the External Quality
Assessment (EQA) scheme, where the quality of services is checked frequently
and has always met the scheme's standard. However, he also told us that the
wider accreditation, through the CPA Scheme, of the totality of the laboratories
and their provision had not been addressed. 6.10 We are not satisfied that sufficient emphasis has been placed by the
Department on the need to ensure that services are fully accredited. Although
the Accounting Officer was able to tell us that more laboratories had achieved
complete or partial accreditation since the C&AG's report, he also admitted
to us that the Altnagelvin Hospital's haematology service and the laboratories
at the Mater Hospital had had their accreditation withdrawn because they did
not have the requisite consultant cover. He told us that the same services would
continue to be provided, which leads us to speculate on the Department's whole
attitude. 6.11 We are unconvinced of the sufficiency of how this policy is being implemented,
particularly as the Accounting Officer accepted that everyone should strive
for accreditation. When pressed on this issue, he acknowledged that the service
was getting by, but it was not what he would like it to be. 6.12 It is of vital importance that any delay experienced in the transfer
of services from Belvoir Park to Belfast City Hospitals does not lead to a reduction
in the high quality of service provided at present. Although the laboratories
at the Belfast City Hospital are fully accredited, we do not see how those at
Belvoir can automatically be assumed to be incorporated within that assessment
rating, merely because of an ownership transfer. We are aware of the problems
of ageing equipment at Belvoir and we impress on the Department the importance
of keeping standards of care for patients at the highest level during this interim
period. We agree with the Department's decision to go ahead with the replacement
of equipment and urge it to implement this as soon as possible. 6.13 We asked the Accounting Officer about the retention of human organs inquiry,
which was set up by the Minister in 2001. While we accept the response that
the issue only became apparent when it emerged in England and was then investigated
in Northern Ireland, it is our view that this issue is, nevertheless, disturbing.
It underlines the extent to which the Department is remote from the actual practice
for which it is supposed to be responsible in the health service. We don't think
it unreasonable to expect the Department to be more conversant with these matters. 6.14 We would urge the Department to complete its review regarding the retention
of organs as soon as possible. We would also like the Department to recognise
that it has a prime responsibility for safeguarding the interests of the public
at large, and particularly the sick and their relatives. 6.15 The Committee noted, from the C&AG's report, that a number of consultant
pathologist posts throughout Northern Ireland were vacant and the Accounting
Officer acknowledged that, of the 78 consultant posts in pathology, only 68
posts were currently filled. 6.16 We find it difficult to understand or accept the Accounting Officer's
view that the service, at present, is comprehensive and adequate to meet people's
needs. The Department has established that it needs a complement of 78 consultant
pathologists to operate an efficient and effective service. Whilst the Committee
appreciates that there is a very high standard of service being given by the
staff who are in post, it is inconceivable that the service is able to operate
to the required level of efficiency and effectiveness with understaffing approaching
13 per cent. An absence of permanent on-site consultant cover at major centres
of acute hospital care, such as Altnagelvin Hospital, is unacceptable. 6.17 We recognise that there are difficulties in recruiting people to pathology,
but we impress on the Department the need to explore every option to encourage
suitable applicants to come forward. We consider it a great pity that the Department
had not done more to bring this problem into the public arena. 6.18 We endorse the recommendation of the C&AG that there needs to be
an objective reappraisal of how the technical staff grading and payment system
is applied, to ensure that future placements and regrading are made on an equitable
basis across the service and that discretionary payments are only awarded for
the purposes for which they were intended. The Committee is totally behind the
principle that pay must be seen to be sufficient to attract appropriately qualified
staff and it should be applied equitably throughout the service, recognising
the value of experience and skills. 6.19 We noted the Accounting Officer's acknowledgement that his Department
was not engaged in benchmarking prior to the C&AG's Report. While this is
surprising, given that the value of benchmarking had been recognised, we welcome
the fact that the Accounting Officer is now committed to introducing suitable
measurements. 6.20 The Committee is also encouraged by the statement from the Treasury Officer
of Accounts that the new guidance to be issued by the Department of Finance
and Personnel on service delivery agreements would emphasise the importance
of benchmarking as a performance measurement and monitoring tool. 6.21 The Committee asked the Accounting Officer about the comparative prices
charged for undertaking tests in different hospitals in Northern Ireland and
between Northern Ireland and in the sample of NHS hospitals listed in the C&AG's
Report. 80 per cent of the prices quoted were higher in Northern Ireland. We
expressed our astonishment at some of the wide price variations shown. 6.22 It cannot be acceptable that, as an example, the price of a pregnancy
test is £14.20 in one place in Northern Ireland and only £2.05 in
another. Similarly, it cannot be a measure of consistency in costing that one
Trust charges the same price for all tests within a specialism, yet other Trusts
cost each test individually. Any attempt to measure cost effectiveness in these
circumstances must be meaningless. Moreover, there is a significant point of
accounting principle concerned with the recovery of costs at laboratories. We
welcome the fact that the Department has stipulated the importance of recovering
full costs in contracts and the need to ensure that there is no cross-subsidy
between contracts. 6.23 We also welcome the fact that work is progressing in the development
of common protocols for carrying out tests. The Department must not place reliance
solely on the participation of laboratories in accreditation schemes. While
these might give assurance on the quality of testing, the Department must also
take into account the efficiency of the process. To measure that efficiency,
it is important to be comparing activity performed in the same way in all laboratories. 6.24 We therefore urge the Department to do all it can to promote the wide-spread
use of common protocols throughout the pathology service, beginning with the
adoption of those that are in place elsewhere. We also expect the Department
to monitor progress in this area 6.25 The Department needs to review how workload is measured, so that it can
properly benchmark activity at different locations. This should be acceptable
to all laboratories. We would expect the Department to be able to satisfy us
that it has taken action to resolve this difficulty within a reasonable timescale. GENERAL FINDINGS 7. To us as public representatives, the health service presents a particularly worrying problem because it combines both an urgent need for additional funding, with disturbing evidence of poor value for money in many areas* but particularly in the two areas that this Committee has looked at to date. It is difficult to resist the conclusion that the snail's pace on improvement of the structure for the rationalisation of pathology services, the need for which was recognised in 1982, reflects a long-standing weakness in the Department's pursuit of value for money on behalf of the tax-payer. This needs to change dramatically and the Department needs to raise its game substantially if the public is to have confidence that the extra resources which they are being asked to provide are being effectively used. MAIN REPORT THE STRATEGIC ROLE EXERCISED BY THE DEPARTMENT AND THE PROGRESS WHICH HAS BEEN MADE IN SECURING DESIRABLE RATIONALISATION 8. The Department's policy on laboratory services was promulgated in 1983.
This policy accepted that laboratory services should be concentrated, as far
as possible, on six main sites (the Royal Victoria, Belfast City and Ulster
Hospitals in Belfast, and the Antrim, Craigavon and Altnagelvin Hospitals).
Resources were not to be used to establish new laboratories, or to indefinitely
perpetuate existing small laboratories which provided a full range of routine
services for a limited local demand, except in special circumstances. 9. In the early-1990s, reforms in the health service led to the establishment
of Health and Social Services Trusts to provide health and social care within
an internal market. In response to concerns within the pathology profession
as to the potential effects of this, the Department confirmed that the 1983
policy was still current. As very little action arising from the policy had
taken place, it was accepted, in 1992, that there were still too many laboratories. 10. The Committee noted that, although there have been some changes in the
distribution of laboratory services since 1983, there was no reduction in the
overall number of services from then until 1999. We asked the Accounting Officer
what action the Department had taken to implement its policy during that period
and what plans it had to reduce the number of laboratories. We were told that
the number of laboratories has reduced since 1999 as a result of the rationalisation
of some services within Belfast and elsewhere. 11. We also asked about the implications for the profile of laboratory services
arising out of the recommendations of the report on Acute Hospitals, published
in June 2001. The Accounting Officer advised us that responses to a subsequent
consultation exercise were being evaluated and the Minister intended to publish
proposals early in 2002. This would also take account of the results of the
Department's own review of pathology services. 12. In view of the considerable problems being faced by the health service with its current level of resources and its present configuration of structures and divided responsibilities, this Committee would urge the Department to set out its proposals for the future organisation of pathology services as soon as possible. Uncertainty brings with it a lowering of morale and the potential for inefficiency and waste. The Committee would also be interested to see the recommendations of the Department's own Review of the Pathology Service when it is completed. 13. The Accounting Officer told us that laboratories must be linked closely
to where acute services are located as they provide essential services to deal
with emergency and trauma cases, which need an immediate response. Laboratory
services must, therefore, be available on site. He accepted that there was a
little more leeway in testing samples that are not of a life-and-death nature
and those services can be provided more remotely. 14. We fully accept that it doesn't make sense to rationalise laboratories
until the acute service is rationalised. What is disappointing, however, is
that it is clear from the C&AG's report that the need for rationalisation
was accepted in 1983, yet no progress was made in reducing the overall number
of laboratory services until the late 1990s and only slow progress has been
made since then. This is inexcusable. It also seemed to us that, in an area
the size of Yorkshire, yet with a much smaller population, there is no argument
in favour of having 14 laboratory sites. 15. Although the Department has maintained that the siting of the main laboratory
specialties is determined by the needs of the hospital concerned, we noted that
the Lagan Valley and Downe Hospitals do not have on-site laboratory facilities,
sending their tests instead to Belfast laboratories. These hospitals have also
had use of on-line access facilities since the early 1980s. We therefore asked
the Accounting Officer what consideration had been given by the Department,
during its various reviews, to providing off-site services. 16. The Accounting Officer told us that, when the full range of acute hospital
services is established, this will allow the Department to concentrate the major
laboratory sites next to the major hospitals. They would then deal with the
linkages that must be made with the smaller hospitals. They were unable to make
decisions yet, as they were still in the midst of a political debate regarding
the siting of acute hospitals. 17. We are not satisfied that we have been given an adequate response to this matter by the Accounting Officer. We re-emphasise our recognition of the link between acute hospitals and laboratory service provision. However, if the Lagan Valley and Downe Hospitals have been able to manage effectively, over a lengthy period, without on-site laboratory facilities, it is essential that the Department give full consideration to the opportunities being provided through changing technology, and to incorporating off-site testing in the options reviewed. The Committee expects to be assured that, following the reorganisation of acute hospitals, all such options will be reviewed. 18. In its strategic proposals* issued in 1998, the Department
had announced its intention to resite radiotheraphy, chemotheraphy and the related
laboratory services, from Belvoir Park Hospital to the Belfast City Hospital.
In view of a delay in implementing these proposals, we asked the Accounting
Officer for his comments on the latest position. 19. He referred to the creation of the cancer centre at Belfast City Hospital,
supported by four cancer units through-out the Province. He told us that work
is well in hand with the unit at Craigavon now up and running. However, the
transfer of services to the Belfast City Hospital creates the need for a new
building and facilities for which a business plan, based on a cost of some £30
million, has been submitted by the Belfast City Hospital Trust. The Trust decided
that it wanted to develop the project further and a new plan estimates the cost
to be £56 million to £59 million. The Accounting Officer told us
that he wanted to ensure that the jump in expenditure was justified, but hoped
to be able to progress quickly to implementation stage. We note from an Assembly
answer* that Department of Finance and Personnel approval has
been given to the business case. 20. There has already been a considerable delay since the date that the proposals were made to move services from the Belvoir Park Hospital to the Belfast City Hospital and it is clear that the opening of the new facility is still some years off. We welcome the Department's determination to ensure that the Trust's proposals and costs are justified and it is important to take the views and advice of others before coming to a final decision. 21. Nevertheless, we are concerned at the lapsed time taken to implement these
proposals, which were generated to improve the arrangements for care and treatment
of patients. We view this delay as wholly unacceptable. Delay in implementation
will inevitably adversely affect overall patient care. We therefore urge the
Department to ensure that future delays are minimised, where possible, and that
this facility is given very high priority status when the Department reviews
the distribution of its resources. 23. We asked about the financial impact of the move to Craigavon. The Accounting
Officer asserted that the move was concerned with ensuring that the Department
was able to provide safe and effective services, rather than saving money. He
acknowledged that one of the major underlying factors in the need to rationalise
and reconfigure services is the desire that the Department has the benefits
of aggregating specialties in different places and bringing all the support
services in round them. The present temporary arrangements are more costly than
before and money has had to be put 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. He estimated the additional laboratory costs resulting from the
transfer, which have been funded by the Southern Board, to be an additional
one-off cost of £60,000 and on-going costs of some £6,000 per annum
for the transport of specimens. 24. We will be monitoring developments in the future organisation of services both at the Belfast City and Craigavon Area Hospitals. Although we welcome the movement, albeit slow, towards rationalising the service where improved efficiency is the intended outcome, we would like the Department's assurance that the care of patients still attending the Belvoir Park Hospital and those previously attending the South Tyrone Hospital is in no way compromised by the decisions to move. THE STEPS TAKEN BY THE DEPARTMENT TO ENSURE THAT THE SERVICES PROVIDED BY LABORATORIES ARE OF THE HIGHEST QUALITY 25. The Department's policy, over many years, has been that quality and safety
of care should have primacy over the geographical accessibility of services.
Commissioners of health care are expected to take this into account when entering
into contracts with those hospitals and other bodies that provide that care.
In relation to pathology laboratories, the Department told its Pathology Advisory
Committee, back in 1992, that standards in laboratories would be protected through
the accreditation process, which would provide a hall-mark of performance. 26. We were concerned to note, from the C&AG's Report, that in June 2000,
only 45 per cent of the pathology services throughout Northern Ireland had been
unconditionally accredited and 18 per cent had been conditionally accredited.
While some services were then in the accreditation process, we noted that one
service had been refused unconditional accreditation and 28 per cent of services
had not even applied for accreditation. 27. We questioned the Accounting Officer about this deficiency and why
Health Boards and general practitioners were still using laboratories which
are not accredited. We also asked him about the two methods of accreditation
used; the process run by the Clinical Pathology Accreditation (CPA) (UK) Ltd,
a nationally recognised company set up by the pathology profession itself, and
which has defined standards for the organisation and performance of laboratories
and monitors compliance with these standards; and the National External Quality
Assessment (EQA) Schemes, which provide a means of comparing the quality of
a laboratory's performance in the accuracy of its analytical work, with national
performance. The Accounting Officer referred to accreditation as a useful badge
that allows everyone to feel satisfied that a rigorous test has been passed. 28. We were told that the CPA scheme covered both service quality and the
wider issues of accommodation and staffing. There are difficulties with staffing
and accommodation that would create problems in using the CPA methodology at
present. However, the Department is delaying investing in accommodation,
pending decisions on rationalisation. The Accounting Officer indicated that
if CPA accreditation was refused, it would be counterproductive, in that laboratory
services could not be provided. He told us "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". 29. He accepted that CPA accreditation of the totality of the laboratories
and their provision has not been addressed, reliance being placed on the EQA
Scheme, through which all laboratory services were tested regularly. He advised
us that these tests are being passed and he was satisfied that general practitioners
and hospitals are getting the laboratory services that they need. He described
the standard of laboratory services in respect of their ability to analyse and
test samples as first class. However, he said that it was desirable that all
laboratories should be assessed under the CPA system. 30. We see from the C&AG's Report that the conclusions and recommendations
emanating from the 1995 NHS Strategic Review of Pathology Services in Great
Britain were endorsed by the Department in 1997, and that these included the
requirement for purchasers and providers of health services to incorporate accreditation
or a commitment to obtain accreditation as a condition of any pathology contract.
We also noted that the absence or non-involvement of consultants and the absence
of accreditation were key points raised by the review, in 1997, into the failures
of the Kent and Canterbury Hospitals Trust histopathology department. 31. The Department blames accommodation problems and a shortage of consultant
staff. While we recognise that the health service has undergone considerable
organisational change over the last ten years, we must point out that these
problems were highlighted as long ago as 1982. In referring to the CPA accreditation
system, the Accounting Officer talked of the best becoming the enemy of the
good and he placed reliance on the EQA scheme, where the quality of services
is checked frequently and has always met the scheme's standard. However, he
also told us that the wider accreditation, through the CPA Scheme, of the totality
of the laboratories and their provision had not been addressed. 32. We are not satisfied that sufficient emphasis has been placed by the Department on the need to ensure that services are fully accredited. Although the Accounting Officer was able to tell us that more laboratories had achieved complete or partial accreditation since the C&AG's report, he also admitted to us that the Altnagelvin Hospital's haematology service and the laboratories at the Mater Hospital had had their accreditation withdrawn because they did not have the requisite consultant cover. He told us that the same services would continue to be provided, which leads us to speculate on the Department's whole attitude. 33. We are unconvinced of the sufficiency of how this policy is being implemented,
particularly as the Accounting Officer accepted that everyone should strive
for accreditation. When pressed on this issue, he acknowledged that the service
was getting by, but it was not what he would like. He told us that while
they were not achieving the best possible service, they were still delivering
laboratory services to a high standard. In order to assure the public, he told
us that the laboratories were doing the job for which they were put in place. 34. In a response to written Assembly questions in May 2001 (AQW 2695/00
& 2714/00), the Minister of Health, Social Services and Public Safety commented
on an incident at the Royal Group of Hospitals Trust, where incorrect results
had been given to haemophiliac patients after they had been tested for Hepatitis
C. We sought the Accounting Officer's assurance that these problems were not
in any way linked to the fact that the haematology laboratories in question
had not been fully accredited and whether this was evidence of the need for
compulsory accreditation. We were pleased to be given an absolute assurance
that these errors were not linked to the accreditation problem at that hospital. 35. We referred back to the position at the Belvoir Park Hospital and asked
why no application had been made for the accreditation of Belvoir Park Hospital's
laboratories. We were concerned that the delay in transferring services from
that hospital to the Belfast City Hospital might have an impact on the quality
of the service being given at Belvoir. The Accounting Officer told us that staff
had been transferred to the Belfast City Hospital Trust and that all laboratories
are now part of the Belfast City Hospital's laboratory provision. While the
Belvoir Park site provided a high quality service, the equipment there was old.
The Department had hoped to furnish the new Belfast City Hospital site with
new equipment and let the old equipment come to the end of its useful life at
the Belvoir Park site but the delay in setting up the new centre at the Belfast
City Hospital has meant that new equipment will have to be installed at the
Belvoir Park site and then moved across. 36. It is of vital importance that any delay experienced in the transfer of services from Belvoir Park to Belfast City Hospitals does not lead to a reduction in the high quality of service provided at present. Although the laboratories at the Belfast City Hospital are fully accredited, we do not see how those at Belvoir can automatically be assumed to be incorporated within that assessment rating, merely because of an ownership transfer. We are aware of the problems of ageing equipment at Belvoir and we impress on the Department the importance of keeping standards of care for patients at the highest level during this interim period. We agree with the Department's decision to go ahead with the replacement of equipment and urge it to implement this as soon as possible. 37. Although not referred to in the report under review, we asked the Accounting
Officer about the retention of human organs inquiry, which was set up by the
Minister in 2001. The Accounting Officer told us that his Department did not
know that human organs were being kept for reasons that were outside the remit.
This only became apparent when the issue emerged in England and was then investigated
in Northern Ireland. 38. While we accept this response, it is our view that this issue is, nevertheless, disturbing. It underlines the extent to which the Department is remote from the actual practice for which it is supposed to be responsible in the health service. We don't think it unreasonable to expect the Department to be more conversant with these matters. 39. The Committee was told of the deficiency in the post-mortem consent
procedure and the actions taken by the Trusts to improve practices to ensure
that proper consent is given in future. When we asked the Accounting Officer
to assure us that proper consent procedures were in place in other aspects of
pathology, we were told that the Department had learnt from the process and
that the practice had changed substantially. The outcome of the current review
will allow the Department to make any further changes that are necessary. 40. We would urge the Department to complete its review regarding the retention of organs as soon as possible. We would also like the Department to recognise that it has a prime responsibility for safeguarding the interests of the public at large, and particularly the sick and their relatives. We would urge them to be more proactive on their behalf to ensure that such incidents are not repeated. THE ORGANISATION OF THE PATHOLOGY WORKFORCE, IN PARTICULAR THE LEVEL OF CONSULTANT COVER AND THE GRADING SYSTEM THAT EXISTS FOR OTHER STAFF 41. The Committee noted, from the C&AG's report, that a number of consultant
pathologist posts throughout Northern Ireland were vacant and the Accounting
Officer acknowledged that, of the 78 consultant posts in pathology, only 68
posts were currently filled. At the same time there are increasing demands
on the service as a result of a number of factors, including concerns about
quality in the cytology field, the development of the breast cancer screening
programme and the implementation of the policy to establish more cancer centres. 42. We had already been told that the accreditation of some laboratories
has been withheld, and of other laboratories withdrawn, as a result of a lack
of consultant cover. We are also aware that inadequate consultant cover was
determined to be a major contributory factor in the failure of the systems at
the Kent and Canterbury Hospitals Trust, which led to a large number of patients
being given incorrect results from cervical screening tests. We asked the Accounting
Officer whether the absence of consultant cover restricted the range of
conditions that some hospitals can treat. We were told that the networked approach
adopted by the Department, has allowed it to maintain services, with consultants
covering more than one site. 43. When we questioned the Accounting Officer about what the Department
was doing to remedy the situation and to train consultants to fill the vacancies,
we were told of its annual medical workforce plan, which aims to review the
number of posts currently in place against the number needed and the staff occupying
those posts, along with a profile of predicted retirement ages and other wastage
factors. We were also advised of a shortage of consultant pathologists throughout
the United Kingdom, particularly in special fields such as histopathology and
the Department is in contact with its English counterpart over increasing the
number of training places in pathology. Attracting people to pathology was claimed
to be an uphill struggle, as issues such as the organ retention problem tend
to put off young medical students, who view pathology as a less attractive option.
We were assured that the funding of these posts is not a problem. 44. We find it difficult to understand or accept the Accounting Officer's view that the service, at present, is comprehensive and adequate to meet people's needs. The Department has established that it needs a complement of 78 consultant pathologists to operate an efficient and effective service. Whilst the Committee appreciates that there is a very high standard of service being given by the staff who are in post, it is inconceivable that the service is able to operate to the required level of efficiency and effectiveness with understaffing approaching 13 per cent. An absence of permanent on-site consultant cover at major centres of acute hospital care, such as Altnagelvin Hospital, is unacceptable. 45. We recognise that there are difficulties in recruiting people to pathology, but we impress on the Department the need to explore every option to encourage suitable applicants to come forward. We consider it a great pity that the Department had not done more to bring this problem into the public arena. These posts fulfil a pivotal role in ensuring that a quality service is provided and this is essential to ensure that the public retains its confidence in the health services. 46. The Committee, while recognising the valuable work that is carried out by staff in the pathology service, did not specifically question the Accounting Officer about the numbers and grading of laboratory staff or about the award of discretionary pay. However, we are aware of the interest of Assembly members in these matters following a debate in November 2000. We have also noted what the C&AG had to say on the subject in his report. 47. We endorse the recommendation of the C&AG that there needs to be an
objective reappraisal of how the technical staff grading and payment system
is applied, to ensure that future placements and regrading are made on an equitable
basis across the service and that discretionary payments are only awarded for
the purposes for which they were intended. The Committee is totally behind the
principle that pay must be seen to be sufficient to attract appropriately qualified
staff and it should be applied equitably throughout the service, recognising
the value of experience and skills. THE STEPS BEING TAKEN BY THE DEPARTMENT TO ADDRESS THE VARIATIONS IN THE COSTS OF LABORATORY WORK AND THE PRICES OF SPECIFIC TESTS 48. The C&AG's Report showed that there were significant variations
in costs between hospitals in Northern Ireland and that the level of spending
on laboratories here is generally higher than in England and Wales. We drew
the Accounting Officer's attention to the recommendation in that report that
the Department should introduce performance measurements which provide benchmarks
across the range of pathology specialties. When we asked him for his views on
this and whether his Department had issued guidance on benchmarking, he accepted
the importance of benchmarking in securing value for money. He wished to be
sure that every laboratory benchmarked itself against others, both in Northern
Ireland and elsewhere, and he informed us of an initiative which calculates
comparative total costs or reference costs for each Trust in order to produce
an accurate cost-per-test. He acknowledged that, prior to the C&AG's report,
the Department had not been engaged in the necessary benchmarking but he accepted
that it was now committed to benchmarking. 49. We noted the Accounting Officer's acknowledgement that his Department was not engaged in benchmarking prior to the C&AG's Report. While this is surprising, given that the value of benchmarking had been recognised, we welcome the fact that the Accounting Officer is now committed to introducing suitable measurements. 50. The Committee is also encouraged by the statement from the Deputy Treasury
Officer of Accounts that the new guidance to be issued by the Department of
Finance and Personnel on service delivery agreements would emphasise the importance
of benchmarking as a performance measurement and monitoring tool. 51. The Committee asked the Accounting Officer about the comparative prices
charged for undertaking tests in different hospitals in Northern Ireland, and
between Northern Ireland and the sample of NHS hospitals listed in the C&AG's
Report. 80 per cent of the prices quoted were higher in Northern Ireland. 52. The Accounting Officer said that he was not surprised at the differences.
He suggested that prices here might be higher because laboratory services in
England were based around district general hospitals which were substantially
larger than most hospitals in Northern Ireland and were therefore able to benefit
from economies of scale. In comparing laboratories, he made the point that different
laboratories use different equipment with different reagents that have different
prices. Some laboratories are more manual, requiring more staff time. The Belfast
Link Laboratories (at the Royal Victoria and Belfast City Hospitals) provide
regional, in addition to common, services and this more complex work involved
leads to higher costs. 53. We expressed our astonishment at some of the wide price variations
shown. For example a pregnancy test costs £14.20 in the Altnagelvin Hospital,
yet only £2.05 in laboratories in the Southern Board area service. We
asked the Accounting Officer to explain this and to confirm whether doctors
in the Londonderry area were aware of the much cheaper prices to be obtained
elsewhere. He told us that this competitive environment had been created when
the Trusts and GP Fundholders had been established, supposedly to provide a
market place where general practitioners could shop around and find the cheapest
test. This actually created a problem, in that laboratories could not be certain
of the level of activity with which they had to deal. If they brought prices
down, they risked finding themselves in an uncompetitive position where they
were unable to recover costs. As a result, there has been a change to block
contracts. 54. It cannot be acceptable that, as an example, the price of a pregnancy test is £14.20 in one place in Northern Ireland and only £2.05 in another. Similarly, it cannot be a measure of consistency in costing that one Trust charges the same price for all tests within a specialism, yet other Trusts cost each test individually. Any attempt to measure cost effectiveness in these circumstances must be meaningless. 55. In view of these differences and inconsistencies, we asked the Accounting
Officer about the level of competition in this sector. He told us that it was
clear that competition was regarded as being unhelpful and was not seen as having
achieved its intended purpose. They were now moving away from the competitive
approach to one that is based on collaboration, with benchmarking as a test. 56. We welcome this move away from competition. There is another significant
point of accounting principle concerned with the recovery of costs at laboratories.
We welcome the fact that the Department has stipulated the importance of recovering
full costs in contracts and the need to ensure that there is no cross-subsidy
between contracts. 57. We asked the Accounting Officer to confirm that no laboratories had
been subsidised by others, in view of the wide range of costs per patient and
prices charged for tests. He referred to the annual costing guidance issued
to all Trusts, requiring Trusts 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. He told us that he has received an annual assurance from the
Chief Executive of every Trust to the effect that each Trust had complied with
this guidance. 58. While we noted the Accounting Officer's comments at the Hearing, we
received a further statement from him to the effect that Belfast Link Laboratories
were carrying out a pricing review of their laboratory prices. Although this
review would not lead to a reduction in the total laboratory costs for the HPSS,
it was accepted that it may lead to a redistribution of costs between the various
Trusts. This suggests to the Committee that cross-subsidisation between laboratories
has taken place and it is therefore important that the Department ensures that
an appropriate redistribution of costs takes place. 59. In view of the inconsistency in the way that some tests are carried
out, leading to a variation in the prices charged, there would seem to be a
good reason for introducing protocols for laboratory testing, aside from the
obvious clinical reasons for ensuring that standards are maintained. We asked
the Accounting Officer for further information on the use of protocols. 60. We were told that different laboratories have different protocols in
place, depending on the varying types of equipment, reagents and procedures
being used. Each laboratory test follows a clearly defined protocol (or standard
operating procedure). In Northern Ireland, common protocols currently exist
mainly for some regional specialties. There are also common protocols in cervical
screening, certain tests carried out within the haematology specialty and in
reporting on histopathology biopsy specimens. 61. In view of the different starting points in respect of the equipment
and reagents currently in place, we were told that it is a difficult exercise
to achieve and further steps needed to be taken to standardise equipment and
processes. However, the Accounting Officer told us that there was a clear acceptance
by professionals that the development of common protocols is important and he
expected their development to be taken forward fairly quickly. 62. We welcome the fact that work is progressing in the development of common protocols for carrying out tests. The Department must not place reliance solely on the participation of laboratories in accreditation schemes. While these might give assurance on the quality of testing, the Department must also take into account the efficiency of the process. To measure that efficiency, it is important to be comparing activity performed in the same way in all laboratories. 63. We therefore urge the Department to do all it can to promote the wide-spread use of common protocols throughout the pathology service, beginning with the adoption of those that are in place elsewhere. We also expect the Department to monitor progress in this area. 64. The Committee noted that, in 1998-99, laboratories processed over 6.3
million requests for tests to be carried out and we questioned the Accounting
Officer about the relative workloads of staff in similar laboratories who specialise
in the same areas. However, we were not given any comfort by the Department's
response. Although we were told of the recording of the number of requests,
it was made clear to us that these figures did not give a true picture of relative
workloads. It was known that the number of requests had increased, but when
we asked the Accounting Officer about the example of increased cholesterol testing,
we were told that the Department's specialist advisory committees had not informed
him that certain laboratories are suffering from an overload. 65. The Department needs to review how workload is measured, so that it can properly benchmark activity at different locations. This should be acceptable to all laboratories. We would expect the Department to be able to satisfy us that it has taken action to resolve this difficulty within a reasonable timescale. 66. Finally, we asked the Accounting Officer what his Department was doing
to collaborate with laboratories in the Republic of Ireland and whether, for
example, a doctor in Londonderry could send pregnancy tests to a laboratory
in Letterkenny which charged less. The Accounting Officer emphasised the clinician's
need for a speedy response. We were told that laboratories in the Western and
Southern Board areas had confirmed to him that they are not aware of general
practitioners accessing laboratory services on a cross-border basis. 67. However, some hospitals in the Republic of Ireland access Belfast Link
Laboratories for virology and specialised biochemistry testing (trace metals
and toxicology). The Belfast laboratories, in turn, use some laboratories in
Great Britain, but not in the Republic. s. See also PAC Report on Health and Personal Social Services - Executive Directors' and Senior Managers' Pay, Contracts and Termination Settlements, (5/00/r), 16 May 2001a. Review of Pathology Laboratories in Northern Ireland, NIAO, February 2001 [NIA 31/00]p. Putting it Right: The Case for Change in Northern Ireland's Hospital Service, DHSS, 1998A. QW 1244/01 |
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