Excellent care with compassion

Pathology in the UK,

a road less travelledDr Martin MyersDirector of Pathology ServicesLancashire Teaching HospitalsPreston

• Diagnostic Hub at Royal Preston Hospital

• Rapid response lab at Chorley

– Clinical Biochemistry (5,200,000 tests p.a.)

– Haematology (1,100,000 tests p.a.)

– Cellular Pathology and Neuropathology (31,000 specimens p.a.)

– Microbiology and Virology (508,000 tests p.a.)

– Immunology (196,000 test p.a.)

• Staff

– 26 consultants

– 6 Clinical Scientists

– 125 Biomedical Scientists

– 130 support staff

Lancashire Teaching Hospitals

Pathology

Pathology service: Public Sector

Primary care

Secondary care

Tertiary care

Immunology

Histopathology

MicrobiologyHaematology

BiochemistryClinical Biochemistry

“local” service to 400,000 Specialist service to 1.6M

I shall be telling this with a sighSomewhere ages and ages hence:Two roads diverged in a wood, and I —I took the one less traveled by,And that has made all the difference.

The Road Not Takenby Robert Frost

Review of NHS Pathology December 2008

The 20 recommendations were welcomed by many in the Pathology community

• “The main objective must be improved quality and patient safety, delivered through service consolidation.”

• “Significant savings could be achieved through the reconfiguration and consolidation of pathology services, based on certain assumptions.”

• “We estimate that potential savings between 10 and 20% could be achieved.”

• “Consolidation provides the means of improving service quality, responsiveness and cost-effectiveness by enabling resources to be reinvested in pathology services.”

• “Reinvestment of savings is essential to deliver and assure service quality, and to support the rapid adoption of innovative new technology and new approaches to the delivery of pathology services.”

Review of NHS Pathology December 2008

But “Events, dear boy, events”

Coalition Government

•Decreased NHS spending

•NHS reform

Decreased NHS spending

% G

DP

% of GDP spent on health by UK

% G

DP

% of GDP spent on health by OECD Countries

http://www.kingsfund.org.uk/projects/nhs-65/alternative-guide-new-nhs-england

NHS Reform

• Decreased NHS spending and NHS reform translated the Carter plan for Pathology to a cost-orientated reform with centralisation to reduce the unit cost and produce savings of 20% (p.s. no re-investment)

• But there were voices that suggested that Pathology expenditure/productivity and quality was actually not bad!

Decreased NHS spending and NHS reform: Implication for Pathology

Spend per capita on in-vitro diagnostics

Pathology productivity and cost: Clinical Biochemistry

0

50,000

100,000

150,000

200,000

250,000

200

12

002

200

32

004

200

52

006

200

72

008

200

92

010

Year

Te

sts

pe

r B

MS

76% increase in productivity in 9 years

•20% decrease in cost per test over 9 years

Tests per BMS Cost per Test

Cost per test compared with size of Lab: Is bigger better?

£0.00

£0.50

£1.00

£1.50

£2.00

£2.50

£3.00

£3.50

£4.00

£4.50

0

2,000,00

0

4,000,00

0

6,000,00

0

8,000,00

0

10,000,0

00

12,000,0

00

14,000,0

00

Total tests per annum

cost

pe

r te

st

• Does increasing the workload offer financial advantage?

£0.00

£2.00

£4.00

£6.00

£8.00

£10.00

£12.00

0

500,000

1,000,0

00

1,500,0

00

2,000,0

00

2,500,0

00

Total tests per annum

Cost

per

tes

t (e

xclu

ding

blo

od p

rodu

cts)

Quality: Is Quality poor?

“The UK performed significantly better than the USA and Canada with lower laboratory error rates, shorter delays in reporting results and fewer repeat tests” Lord Carter

“….adults in the U.S. were more likely than their counterparts in the other countries to have been given incorrect results or experienced delays in notification about abnormal results, with rates double those reported in Germany or the U.K. Rates of lab errors were also relatively high in Canada.”

• The post Carter drive was for more centralisation to reduce unit cost.

• Costs have been reduced by

– Internal cost reduction

– Cost reduction through collaboration and networks• Sustainability issues for small laboratories

– No single model

– Composite of a variety of models evolving in time and space

• The success of the cost-orientated strategy through consolidation has been mixed with some large potential networks not getting to completion phase.

Pathology post Carter

Financial:

• Trusts did not like the idea of a perceived loss of a jewel in the crown

• When the potential cost savings of the new network configurations were investigated in detail:

– cost reduction projections were not deliverable

– and required large investment costs

– many Hospitals preferred internal DIY cost reduction

Pathology Consolidation: A hard road (1)

Competition Law

• Monitor (the sector regulator for health services in England), coming from a perspective of competition on cost, insisted that any potential networks be scrutinised to ensure that the cost element does not fall foul of competition laws.

Office of Fair Trading and Competition

Pathology Consolidation: A hard road (2)

NHS Reform

• At the time of Carter - PCTs (Primary Care Trusts) became very cost-orientated, preferring the competitive approach, and pushed pathology reform through

– Tendering out of pathology

– Threatening to tender out pathology unless consolidation occurred

• Post Carter - CCGs (Clinical Commissioning Groups) are more value-orientated

– preferred collaborative approach

– withdrew support from the tendering of pathology services

Pathology Consolidation: A hard road (3)

“Difficulties”• In many parts

of England

• Pathlinks: Lincolnshire

• Transforming Pathology Services (TPP): Cambridge

University hospitals NHS Foundation Trust, Colchester Hospital University NHS Foundation Trust, East and North Hertfordshire NHS Trust, Hinchingbrooke Health Care NHS Trust, the Ipswich Hospital NHS Trust and West Suffolk NHS Foundation Trust: OFT green light

• North London: University College London Hospitals NHS FT, Royal Free London NHS FT and The Doctors Laboratory Ltd: OFT green light

• Empath: Nottingham and Leicestershire

• GSTS/Viapath: Guys, ST Thomas’, Kings and Serco

Pathology Mergers: Successes

HSJ May 2014

• “Outsourcing giant Serco is embroiled in a fresh misuse of public funds scandal after a company it set up overcharged NHS hospitals millions of pounds”

• Internal documents leaked to Corporate Watch indicate Britain’s biggest pathology services provider, which was established by Serco in partnership with Guy’s and St Thomas’ hospitals, overcharged the NHS for diagnostic tests.

• The venture - first called GSTS and now trading under the name Viapath -

has also been dogged by allegations of cost-cutting and clinical failings.

The Independent August 2014

Pathology Post Carter

Mixed picture

– Some Pathology Networks formed

– Many tried and couldn’t

– Many initiated their own internal cost savings

– Many just kept their head down

– Some are having trouble with sustainability in the times of austerity

– Some are having trouble maintaining quality in times of austerity

The balance between cost and quality

CostQuality

Conflicting requirements of improved quality at a reduced cost is providing new challenges for delivering pathology in England

Quality Framework in 2014

RCPath KPIs

Performance KPIs

Trained

Registration

Competencies

CPD

HR KPIs

CQCUKAS

EQAIQCMHRA

SHOT

HSEEnvironmental Agency

Financial KPIs DATIX

Commissioner KPIs

Directorate Governance

Trust Governance Harmonisation

Traceability

CE Marking

Uncertainty

NICE

NPSA

Qualifications

KIMMS

Training

Personal EQAAudit

Report into the failings of Mid-Staffordshire Hospital

• “This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care.”

The Francis report

• The Francis Report fired a warning shot over the NHS about the balance between cost-orientatedstrategies and value-orientatedstrategies

• Following an incident at Sherwood Forest Hospitals NHS Foundation Trust

• Problems with quality assurance and an inadequate governance process in Pathology was reported to have negatively impacted upon the care of a number of women…

Pathology Quality Assurance Review: The Barnes Review

• Quality and value for money are both critical in Pathology

• Although the initial focus of the Carter Review was on internal efficiencies within the test production process (cost-orientated), the Pathology Modernisation Programme is now developing a value-orientated strategy

Cost-orientated and value-orientated Pathology

CostQuality

Value-Orientated Pathology

Pathology and Health Economics

• Ian Jacob, Health Economist University of Manchester

• Price of a test does not equal Value of a test

– Accountants speak of Price

– Economist speak of Value

• The value of a test is the commodity not the price

• Measuring cost is easy, measuring value is a little more difficult

• How can we show that we deliver a value-orientated Pathology service?

Value-Orientated Pathology

1. Pathology Pathway redesign

2. Reduction in variation

3. Digital Pathology

4. Personalised Medicine

5. Laboratory Anywhere

Value-orientated Pathology: 1. Patient pathway redesign

Consultation ResultsDiagnosticsPhlebotomy Diagnosis

Consultation Phlebotomy Diagnostics Results Diagnosis

Integrated pathway

Silo pathway

• In England less than 1% of commissioner cost is on direct access pathology

• Reducing pathology spent by 20% makes little difference

• If more is spent on pathway focussed pathology then could we save 20% of the pathway?

Value-orientated Pathology: 1. Patient pathway redesign

OPAT Service:

• Intravenous antibiotics are given when the condition cannot be treated with oral antibiotics.

• In the past, patients requiring i.v. had to stay in hospital to receive this treatment for days and sometimes weeks.

• On a daily basis the Microbiologists visit the wards with a list of patients who are on intravenous antibiotics. Where appropriate, patients are either switched to oral antibiotics and discharged or switched to the Outpatient Parenteral Antimicrobial Therapy (OPAT) service and discharged.

• In the last 6 months 1,377 bed-days were saved

Value-orientated Pathology: 1. Patient pathway redesign

Heart Failure:

Using NT pro BNP in a patient pathway resulted in over 50% reduction in ECHOs and faster patient pathway

Value-orientated Pathology: 1. Patient pathway redesign

IBD and IBS:

Using faecal calprotectin in a patient pathway resulted in reduction in endoscopy and faster patient pathway

Value-orientated Pathology: 1. Patient pathway redesign

Value-orientated Pathology: 2. Reduction in variation

• “Clinical variation is the enemy of Healthcare”

– Chris Brookes, Medical Director, Manchester Integrated Care Board

• Atlas and variation: Sir Muir Gray

Estimated annual rate of use for thyroid stimulating hormone (TSH) tests

ordered by GPs per 1,000 practice population, by PCT, 2012 (237.1/1000)

http://www.rightcare.nhs.uk/index.php/atlas/diagnostics-the-nhs-atlas-of-variation-in-diagnostics-services/

Value-orientated Pathology: 3.

http://www.england.nhs.uk/2014/02/14/npp-digital-first/

Value-orientated pathology: 3.

• Transformative infrastructure– The National Pathology Exchange

(NPEx)

– Virtual pathology

• Supporting patient self-management

– Renal Patient View project

– Automatic referral based on result

• Sharing information to improve patient care

• Business intelligence in pathology

– Using information to improve services and outcomes

• Safer sample management

http://www.england.nhs.uk/2014/

02/14/npp-digital-first/

Value-orientated pathology: 4. Personalised Medicine

Pathology services (including genetic tests) impact at all stages of care pathways

• Decision Diagnostics

• Companion Diagnostics

• Support Diagnostics

Value-orientated pathology: 4. Personalised Medicine

Adverse Drug Reactions

• Azothioprine can cause severe side effects in patients with thiopurine methyl transferase deficiency:– All patients have TPMT measure pre-azothioprine

• But what about the others?: Pharmocogenomics– “Several pharmacogenetic biomarkers are already utilized in clinical

practice and have been shown to improve clinical outcomes. However, a large number of other biomarkers have never made it beyond the discovery stage. Concerted effort is needed to improve the translation of pharmacogenetic biomarkers into clinical practice.” Munir Pirmohamed

Personalized Pharmacogenomics: Predicting Efficacy and Adverse Drug Reactions. Annual Review of Genomics and Human Genetics 2014 in print

Value-orientated pathology: 4. Personalised Medicine

Drug efficacy:

• Infliximab induces and maintains remission in Crohn’s Disease patients with moderate-severe disease, refractory to immunosuppressive agents

• One third of patients who respond initially relapse despite maintenance therapy

• International guidelines recommend intensification of treatment but measurement of anti TNF a and TNF reduces inappropriate expenditure

The way the NHS wants to deliver healthcare is changing

• Specialist Regional Hospitals

• Local Hospitals

• Community

• High street Home

Value-orientated pathology: 5. Laboratory Anywhere

? Local Diagnostic Services?

? Local Imaging Services?

? Local Genomics Services?

HealthcareHome - High Street – Community - Local - Specialist

High Street

Social Care Services

Hospice and Hospital

at Home Services

Community Pharmacy

and Medicines Services

GP Surgeries and

Out of Hours Services

Community Nursing and

Midwifery and Therapy

Services

? Regional Diagnostic Services?

? Regional Imaging Services?

? Regional Genomics Centres and Predictive Analytics Services?

? The Home Tests?

? The Gym Tests?

? Point of Testing

Services?

Maternity &

Neonatology

Care Services

(including children’s

trauma service)

(includes current A&E “minors” service)

Regional

Trauma

Services

Urgent

Care

Services

Cancer, Cardiac,

Stroke

Care Services

Mental Health

Care Services

(inpatients)

• Convalescent, Observation

and Place of Safety Beds and

Services.

• Minor Injuries and “Off-legs”

Front Door Services.

• Planned Care and

Rehabilitation Services.

• Outpatients and Long Term

Care Support Programmes

including Self-Care Workshops

and Self-Help Networks

Support Programmes.

• End of Life Services.

Local Care Services(including mental health and

planned care services)

Genetics

Services

Social &

Probation

and Police

Services

(including children’s

urgent care service)

Paramedic/Blue

Light Service

Services

Dr Patricia Oakley, Director, Practices made Perfect Ltd.Teaching and Research Fellow. Public Policy and Management King’s College, London

• Integrated patient pathway across all healthcare providers

Patient Pathway

HealthcareHome - High Street – Community - Local - Specialist

PathologyHome - High Street – Community - Local - Specialist

• Integrated pathology delivery across all healthcare providers

• During the Review, patient representatives explained that they assumed that the results of tests they received would be consistent, irrespective of the laboratory that had undertaken them.

• This assumption extends to all pathology carried out anywhere

• Quality, and quality standards must be equitable wherever it is delivered

Pathology Quality Assurance Review

• Pathology needs to be delivered :

– central (consolidated) automated and specialist laboratories

– rapid response labs in hospitals

– “lab in a box” in the community

– POCT for community and the home

• Delivered anywhere under

• Integrated healthcare

• Integrated informatics

• Integrated diagnostics

• Integrated Quality Management System

Value-orientated pathology: 5. Laboratory Anywhere

POCT

Home

Satellite Lab

High Street

POCT

Lab in a Box

Satellite Lab

Lab in a Box

Inte

grat

ed

IT Inte

grated

G

ove

rnan

ceLa

bo

rato

ry A

nyw

he

re

• The Carter Review was initially translated as being one of cost reduction

• Austerity is still with us but Pathology is changing from a cost-orientated silo to a value-orientated service embedded in the patient pathway

• Embedded pathology can improve patient pathway and reduce total pathway costs

• Pathology needs to respond to delivering Pathology anywhere, whilst maintaining quality

• Diagnostic Hubs will appear to ensure value for money, maintain and develop Specialist Pathology and support Laboratory Anywhere

Where is Pathology heading?

I shall be telling this with a sighSomewhere ages and ages hence:Two roads diverged in a wood, and I —I took the one less traveled by,And that has made all the difference.

The Road Not Takenby Robert Frost

• Pathology in the UK is taking the value-orientated path

• ….whilst still keeping any eye on the cost!