Examination of Witnesses (Questions 580
- 599)
THURSDAY 22 NOVEMBER 2001
KAREN WARD,
PROFESSOR JOHN
LILLEYMAN, MR
ROGER SPILLER,
DR RAY
PRUDO-CHLEBOSZ
AND GAIL
WANNELL
580. Were the senior pathologists actually looking
to press ahead with this change or were they suspicious of it?
(Ms Wannell) It would be fair to say that there were
anxieties about the service and what it meant. The way forward
for us was to define a consultant-led service where a lot of the
qualitative aspects and management of the service on the qualitative
aspect were retained by the pathologists.
581. I am just getting at the politics behind
it. Were the senior pathologists arguing for this as a good idea
or were they suspicious as well?
(Ms Wannell) They were suspicious as well. It has
been quite a cultural shift but they are very much for it now.
582. Is there any financial advantage now in
getting use of labs they can use for other purposes?
(Ms Wannell) It would be fair to say that the consultants
are members of the trust, they have a consultant contract. It
is no different from any contract of our physicians or surgeons
and within that there is the aspect if any member of staff or
consultant is doing private work, they drop one financial session.
When we had the contract with SmithKline Beecham, our pathologists
dropped one financial session to enable them to do private work.
There has never been any compromise on NHS work. There has never
been a conflict between the private sector work they do, which
is in their own time, and the NHS time.
Andy Burnham
583. This issue of cost and quality goes to
the heart of the inquiry we are doing. It would be extremely helpful
if you could give the Committee more evidence about quality gains
and more analysis of this ten per cent saving and what you think
it would be costing the trust to provide the service in house
today, given that you may not have been able to maintain it and
the investment and capital may not have been keeping pace if you
had not gone down a private sector route. If you could give the
Committee any further evidence on those points, that would be
very useful. I understand that you are linking together with Ealing
to tender for the service next year. What has prevented a bigger
west London consortium coming together for that service? The NHS
plan talked about developing regional services for pathology.
How is that going to happen, if at the stage when you are tendering,
somebody comes in and asks why you do not all get together?
(Ms Wannell) We do have a west London pathology consortium.
Effectively what that consists of is three networks: two outer
London ones and one inner London network. One of the outer London
ones consists of Ealing and ourselves. As you saw from the submission,
we and Ealing are going through a re-tender process at the moment.
What it is fair to say is that at the moment it is appropriate
because of the way our contract is, we need to have a new contract
for pathology services. What we are doing within the contract
is not closing the door to extending the opportunity for more
cold work coming in. There is a realistic assumption because you
are going more towards a regional pathology service that the two
outer London networks will in the future come together as one
network. There will effectively be an inner London and an outer
London network linking to the increased size of population. Hopefully
what we shall see in time, and we are aiming to issue a contract
next year, is flexibility within that contract to accept more
work and hopefully in time with more volume enable us to bring
costs down.
584. A pathology service for the whole of London.
Is that what you are saying?
(Ms Wannell) We are starting first of all looking
at Ealing and West Middlesex, then potentially we are looking
at more outer London trusts joining that in time. We have to work
that one through.
585. I am trying to get at whether the Department
is pushing you to go even bigger. There seems to be a desire for
regional pathology services, yet trusts are forming their own
alliances on an ad hoc basis. Where is this going to meet
in the middle?
(Ms Wannell) On the modernisation aspect, where we
look to stop, the emphasis is more moving towards populations
between one to two million and the cost of hospital reorganisation
will focus around that to get the right level of economies of
scale and also to maintain a local service which people can relate
to.
Mr Burns
586. Could you tell us with regard to West Middlesex
and Ealing what the experience of your members working there has
been?
(Professor Lilleyman) Ms Wannell has just explained
that the consultants who are working for West Middlesex, to the
best of my knowledge and belief, are content with the arrangements
there. It is fair to say that they have not managed to convert
large numbers of their colleagues in the NHS to that way of thinking,
nor do I think they have tried very hard so I am fairly neutral
on that point. Without prejudice, one can say that they are content
with what is happening there.
(Mr Spiller) As far as our members are concerned,
I suppose everybody is a little conservative when it comes to
changing employer so there is a lot of opposition to private sector
involvement. As far as Quest are concerned, our members seem to
be reasonably happy with the way things are going there. They
were not happy to go in the first place, but having got there,
they are reasonably content. We are not quite as happy with the
arrangements at Quest as we are with Doctors' Laboratory where
our members seem to be rather more committed and to favour the
way in which they have been dealt with. The laboratory there is
still on site and it enables family-friendly policies to be operated,
whereas the idea of moving to an off-site and even relatively
distant laboratory makes it difficult for many of the staff. One
should bear in mind that as far as pathology staff are concerned,
two thirds are women and many of them are part time and have family
responsibilities. As a result of that one needs to bear in mind
the ability to move staff into centralised laboratories. That
is a problem whether we are talking public or private sector,
but the attitude sometimes in the private sector is less helpful.
On the same point, the NHS plan and agenda for change and making
the change, the document on health care scientists, really stresses
the integrated nature of the work which is now done in hospitals
and our worry is that where work is taken significantly distant
from the hospital, it removes the ability for inter-departmental
working of the kind that is being envisaged. At the same time
it potentially creates a barrier for staff so that if they do
move, it has to be between the private sector and the public sector
or back again and there is no fairly smooth path for their career
development. It makes life more difficult. It also puts in place
this barrier between clinical and scientific work, which we are
just in the process of breaking down. At the time we are trying
to break down barriers, other barriers are replacing them.
Siobhain McDonagh
587. I should like to ask Ms Ward and Dr Prudo
a question. Both of your companies have both private and NHS clients.
Is there any difference in pricing structure or turnaround time
for both these sets of clients? If so, why?
(Ms Ward) The service we provide to any of our clients
is based on their particular needs. If we are looking at the contract
we have with the NHS, then the clinical need is the single thing
which determines how quickly a test is performed. If you are looking
at the private sector, we contract with a number of different
organisations who have very different needs. It is a question
of making sure we can provide the service they are looking for.
The single most important thing in determining turnaround time
is the clinical need for that particular specimen.
588. Generally would you say that you were quicker
in the NHS or the private sector?
(Ms Ward) You cannot say one or the other. It is the
clinical need. In the contract we have with the West Middlesex
Hospital, there is an on-site laboratory which is focused very
much on the in-patient activity. It is able to work to the needs
of the hospital without having the demands of general practitioners
and other people who send in work. That work is directed to the
off-site laboratory which is geared to deal with their needs more
effectively. Certainly the on-site laboratory is there purely
and simply to cater for the needs of the clinicians and the patients
at the hospital. It has no distractions in terms of large volumes
of work arriving from GPs; it is purely there for the inpatients.
589. Would you say it is more expensive to the
NHS or the private sector for doing the same test?
(Ms Ward) It is very hard to generalise because we
do not have a price list as such. Any contract we have is developed
on the basis of what that particular client needs. The NHS, because
of the volume, is more favourably priced, but it is very difficult
to say on that basis, because we do not have a contract and say
they will get a ten per cent discount or a 20 per cent discount.
It is put together for that individual client.
(Dr Prudo-Chlebosz) Turnaround times are usually set
by the consultant, taking into account the clinical needs of the
institution. For example, in a DGH where there is an accident
and emergency department, clearly the turnaround times have to
reflect that. Turnaround times are a key attribute of the service
level agreements and it is something which is very much in the
hands of clinical consultants, pathologists who are in charge
of pathology departments. Perhaps there is more room for utilising
outside experts from other areas, because my experience has been
that pathologists in the private sector are usually more attentive
to matters like turnaround times than in the NHS. There is no
real reason for that. Perhaps it might be that private sector
laboratories are more flexible in their working practices and
allow for services which could not otherwise be provided. I am
surmising that. What I am saying is that there is opportunity
to have whatever turnaround time you like and with modern pathology
systems, where you have integrated IT, where you have new technology,
it is more expensive to discriminate between private pathology
and NHS pathology than to ensure that the configuration of the
department is such that all work is put through quickly. On pricing,
pathology sounds as though it is a simple exercise, but in fact
there is a large logistic element to it, to do with taking samples,
transporting samples, making them available in electronic format
and depending on the level of service, whether you want a courier
to pick up samples every hour, every day all clearly affects the
costs. It is difficult to make straight comparisons because some
of the pricing element is to do with patient convenience. If you
want a patient to have seven-day-a-week access to phlebotomy services
there is a cost for that. Intrinsically I do not see any differences
and certainly our company has no policy of charging one sector
more than another but adjusts it to the needs of the particular
institution.
590. Ms Wannell stated that there is a joint
interest between the trusts and the provider of pathology services
to limit tests. Can you explain how this was addressed in your
current contract and how it might be looked at in any future contracts?
How different was this from your practice prior to contracting
out?
(Ms Wannell) When we mentioned limiting tests we were
really talking about making sure that the service is provided
on clinical quality and that we are doing best practice on that
side. What we mean is that we want to make sure that a test is
not repeated unnecessarily or that junior doctors are actually
calling for tests which are not necessary. The idea is that we
are developing more of a protocol approach. Within the contract
we have started to work on that aspect of developing protocols
for certain tests. There is an aspect that it is quite time consuming
on all sides, Quest, the pathologists and the trust, but it is
a way forward to enhance the quality on that side. That is the
aspect on the limiting tests side.
591. Would the clinicians in your hospital agree
that there has been no interference as a result of the contracting-out
of pathology services with their ability to treat and order tests
on the basis of need?
(Ms Wannell) Absolutely. The whole aspect for us is
that the contract has been very much clinically led. The whole
focus on the division of tests between on site and off site has
very much been done with the pathologist and the clinicians involved.
Karen Ward mentioned earlier the tests which are done on site
for the inpatients. It is very much the urgent tests which are
done on site, so clinical quality and clinical need is not detrimental
and, working with the consultants, we have identified which tests
are not needed straightaway; it has very much been done on clinical
need.
Dr Naysmith: We should look at staff issues
a bit more closely. There is some unease at the management of
pathology being contracted out whilst the scientific, technical
and support staff remain as NHS employees. Do you have any views
on this? Is it something which can be managed or is it something
which is really very, very difficult to manage?
Chairman
592. Before you answer that, may I mention that
according to the papers this morning some agreement was reached
yesterday. It only mentioned Unison so I do not know whether your
organisation was involved in that and whether this is relevant
to answering that question.
(Mr Spiller) The Unison question relates to three
hospitals and the contracting out of the soft services. We are
not involved in that process anywhere. Up until recently it was
being argued that clinical services would not be involved in private
sector. That clearly is no longer the case because we are not
talking about clinical services and pathology involving the private
sector. The retention of employment model which has been developed
to cover these three pilot studies, which Unison signed up to
yesterday, is one in which we have been involved, but we feel
frankly that it is inappropriate as far as pathology is concerned
because it identifies a level of supervision which would be contracted
out, which would go to the private supplier, but the rest of the
staff would not. A pathology laboratory is not supervised in that
way. Almost everybody in a laboratory has some supervisory or
managerial responsibility and indeed a clinical responsibility
as well as you move through that structure. There is a continuum.
There is no natural breakpoint. The natural breakpoint to date
has been seen as the pathologist because everything has to go
through the pathologist. That will increasingly not be the case,
so there is no natural break point. Therefore any private sector
involvement in pathology is likely to create an artificial break
point and that concerns us greatly. It concerns the professional
development of the staff, not that the private sector will not
train or provide that, but that you are not in an environment
in which there is an obvious process to go through. You have to
change employer often in order to make changes. Within the NHS
that is not a problem. You are effectively with the same employer,
moving sites. Moving back and forth between the private and public
sector creates enormous problems.
Dr Naysmith
593. Can you give us some examples of the problems
it produces?
(Mr Spiller) Fortunately there has not been much opportunity
yet to find good or bad examples.
594. What sorts of things would you predict?
(Mr Spiller) Pensions, for example. Pensions are the
biggest single issue because of the different nature of pensions
in the public and private sector. That is an area where we find
there would be problems moving back and forth. There are nearly
always losses to the employee when you move pension schemes. No
two actuaries ever quite agree on what benefit you are bringing
with you. There is a difficulty there and we spent four years
developing agenda for change and a new salary structure and a
lot is based around that in terms of professional development
and recruitment and retention. Having gone through that route
where we believe we shall be able to recruit into medical science,
then we would be starting to break it up and reducing—not
removing but reducing—the career opportunities. We do see
difficulties there.
595. Perhaps I could ask Karen Ward what her
experience has been in Manchester with this kind of thing. Do
you have any observations on the difficulties, if any?
(Ms Ward) I presume you are referring to the various
reports which have appeared in the Health Service Journal.
596. Yes.
(Ms Ward) When we visited Manchester we were asked
by the four chief executives to make a presentation to the working
group, which we did. That was purely and simply a presentation
on what our approach was to developing partnerships. We had various
discussions with the laboratory staff, the consultants, trust
managers and certain union representatives. Whilst there was some
vigorous debate about it, I would not say that we encountered
out and out opposition, certainly from MSF. They were concerned
about how partnerships would be developed, because obviously the
unions, as is their role, are concerned about terms and conditions.
It is fair to say that when people look at our terms and conditions,
when people look at the culture in our organisation, I have not
met anyone who has been to our facility who has not come away
very, very impressed by the commitment of the staff, the general
atmosphere of the place and the ethos of the place.
597. How would the terms and conditions compare
between National Health Service conditions and what you were offering?
(Ms Ward) We tried very hard to keep the basic salary
very comparable with the NHS. The difference is probably in areas
such as training and development and opportunities for staff to
develop their particular skills. As far as we are concerned, staff
are a key resource. We cannot provide an excellent service unless
we have excellent staff. We are prepared to put a lot of time
and effort into developing excellent staff. Our voluntary turnover
rate is probably the lowest in our particular industry. We work
very hard because we have a very strong belief that we need to
have that kind of environment to encourage staff to join us and
to stay with us.
598. You prefer that to the retained contract
situation.
(Ms Ward) We do not have a preference one way or the
other. What is important is how the staff are managed and that
they are given those opportunities, they are given the right training
and development opportunities and that they feel part of a positive
organisation That is what is important to them.
599. Dr Prudo, do you have any views on this?
(Dr Prudo-Chlebosz) There is room for all kinds of
models. In the Ealing model the staff transferred to the Doctors'
Laboratory contracts under TUPE and then were given a choice whether
they stayed with their NHS contracts or came over to TDL contracts.
There are differences and will continue to be. Pensions is one
of them. What we do is provide a set of flexible benefits which
the NHS does not provide and we allowed the staff to choose which
contract they wanted to be employed under. It is interesting that
after a period of a few years, most staff voluntarily chose to
go to a TDL contract, even though the salaries are much the same.
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