MEMORANDUM
FROM TEST.ME
I would be grateful if the following information
could be considered for the evidence session for your Meeting
Wednesday 25 November:
I read with interest your recent quote that
the above programme has been "inefficient and wasted public
funds" and that "This is a classic example of what can
go wrong when a national programme is rolled out unthinkingly
in a locally-managed NHS."
I agree, particularly for "remote testing"
as outlined below in chronological order:
BACKGROUND
Nearly two years ago our company (Preventx)
presented to DoH/HPA/NCSP our vision for a national website, whereby
15-25 year olds could access a postal test. Importantly,
the delivery of the test would also be provided at national level.
In our presentation, we explained that:
The target age group routinely order goods and
services online, and that their preferred method to access a chlamydia
test was via an online service (effectiveness and efficiency).
There were numerous economies of scale in offering
a postal doing this (including marketing and operational economies
and efficiencies).
We presented that in excess of 180,000 tests
per annum would be completed, and that this would make a meaningful
contribution to the overall numbers. (We now believe these
projections were too prudent and that in excess of 350,000 tests
per annum could be completed).
However, we were informed that DoH policy did
not allow the national delivery as we described, and that we should
instead approach all 152 Primary Care Trusts. We tried to
argue that other services (eg bowel cancer screening were national),
and that there was already appalling wastage. (Basically, for
all of the reasons now identified by the NAO report). We suggested
that the DoH Policy should be changed, to no avail. This was June
2008.
In November 2008 we launched our website,
www.freetest.me. Freetest.me is promoted nationally, with 15-24 year
olds looking for a chlamydia test offered the "best"
option. Our service was modified to allow participating PCTs to
include their local "brand". If, for example you enter
the demonstration age "911", and any valid post-code,
then you will see Cornwall PCT branding on the website and this
local "branding" has then also been replicated on the
specimen collection form sent to patients.
As above, there are numerous economies of scale:
Marketing example: if you google the search term
"chlamydia test", freetest.me will appear first in google
for natural (unpaid search)—incidentally, above the NCSP
website. It should be apparent that a single PCT will not be able
to achieve first position in google. There are numerous other
examples of marketing economies of scale.
Operational example: our company has invested
more in IT and Business Operational Processes than a single PCT
could sensibly economically afford in developing operational processes.
As a trivial example, negative patients are automatically electronically
notified in the way the patient has chosen to receive their results:
in contrast, a significant number of PCTs are manually texting
"negatives" with their results.
We now have very clear proof that our service
works, in terms of economy, effectiveness and efficiency. Our
service is world class, with every aspect of the process well
thought-out and executed. Our company supplies all aspects of
the service: marketing; kit design, assembly and supply; patients
results handling and data collection and reporting, with the lab
test supplied by the leading laboratory test company in this field.
I've attached a copy of our service information to provide some
indication into the quality and professionalism of our offer.
In comparison, we have yet to see a single PCT offer which even
matches a single aspect of our service—at best their offer
is average.
VALUE FOR
MONEY: PRICING
Our average price is £21.40 per completed
test. This varies very marginally from PCT to PCT, but is pretty
tightly defined as ranging from £19.80 to £21.75.
These costs are inclusive of all wastage (eg marketing, and unreturned
kits). This is significantly less than the £56 average
reported by the NAO.
Note: we fully accept that our quoted price
of £21.40 is not a complete apples: apples comparison
with the £56. Our price does not include the cost of treatment
and partner notification: we have asked the NAO for the cost of
"treatment" and "partner notification" so
that we may add these costs back to our service, but unfortunately,
we have not been provided with this figures. On the other hand,
there is clearly a very wide range of prices £33 to
£256, and it is unclear to me what is—and what is not—included
in these figures, and how these costs have been treated.
VALUE FOR
MONEY-EFFICIENCY
AND EFFECTIVENESS
We are currently processing over 200,000 test
requests per annum, and we have yet to start marketing our service—we
are waiting until we have a "critical mass" of PCTs
to justify an economic return. However, more than 80,000 tests
have been lost from PCTs which have not joined our service. As
above, these lost tests would be at a price which is basically
less than half of the average currently paid by PCTs. The NAO
report that, if the average cost were reduced to be £33 in
the next year, then this would save £40 million per
annum. Per today, we already have a service which delivers an
increased number of tests and at significantly less than £33.
COMMUNICATION
We now have 30/152 PCTs who have joined
our full service. Frankly, we fail to understand why all PCTs
have not joined. At present, they are losing tests, which could
be fulfilled at a price less than they are currently paying. Unfortunately,
we have also been unable to readily communicate our message to
PCTs. The DoH/HPA/NCSP are, for perhaps understandable reasons,
unable to endorse our service—but, again this obviously
leads to a fragmented service. Generally, there appears to be
a lack of joined up thinking between DoH/HPA/NCSP/PCTs.
NAO RECOMMENDATIONS:
A CONUNDRUM FOR
REMOTE TESTING:
b-i) NAO recommended that "The HPA to…perform
a cost-effectiveness ..of remote testing…through websites";
and b-iv) and b -vi) "The Department (of Health) should also
undertake reviews of online screening, data gathering and testing-kit
procurement, with a view to putting national or regional arrangements
in place".
We welcome and agree all these recommendations.
However, there then appears to be a conundrum
between the respective organisations:
DOH:
In our most recent correspondence with the DoH,
we were again advised that:
"The issue remains the same, that local
health economies are responsible for how they deliver services,
since budgets were devolved to local control towards the end of
the 1990s. This was a major shift in NHS policy and so there is
no longer central control of how aspects of ongoing service such
as this should be delivered, as this would impact local spending".
NAO:
The NAO recommend (b-iv)…"The Department
should also undertake reviews of online screening, data-gathering
and testing kit procurement, with a view to putting national or
regional arrangements in place".
PUBLIC ACCOUNTS
COMMITTEE:
I also note that "The Committee does not
consider the formulation or merits of policy (which fall within
the scope of departmental select committees); rather it focuses
on value-for-money criteria which are based on economy, effectiveness
and efficiency".
CONCLUSION
Hence, for what the NAO refer to as "Remote
Testing" at least, there appears to be to be a conundrum:
DoH Policy does not allow "National delivery"; and yet
this is precisely where value-for-money based on the NAO Report
and also on PAC criteria lives.
So, which of the above organisations has the
overall authority for decision making?
NATIONAL AUDIT
OFFICE: REPORT
FEEDBACK
We are sympathetic to the challenge faced by
the NAO, in that the information they were seeking was probably
not readily accessible. Nevertheless, we felt some aspects could
have been addressed: briefly, these are:
— More rigorous cost analysis, in particular
a check list of what is—and what is not—included in
the costs.
— How costs have been treated, eg depreciated
over time?
— Analysis of cost by "location".
The HPA report is very qualitative, but seems to imply that the
primary source of "location" ie outreach is the most
time consuming (and expensive);
— Analysis by process stage: for example,
the cost of "patient treatment".
NAO: CASE STUDY
We spent two to three hours meeting with the
NAO, following which we were advised that the NAO was considering
making a "case study" of our service (presumably, for
the right reasons!). In the event, we were informed that the report
length had to be reduced, so there was no mention of our service.
We are disappointed to note that there is no mention of our contribution.
We initially presumed this was for the usual fear of "endorsement",
but then noted that Roche and Pharmacy are included in the methodology.
PREVENTX/FREETEST.ME
CONCLUSIONS AND
RECOMMENDATIONS
We understand the initial logic of treating
chlamydia as a "special case" and stripping out of GUM
Clinics etc. It is the execution which has been poorly thought
through.
We strongly recommend that although a national
postal service should be considered, care of patients should still
be delivered at local level, either by the current NCSP offices
or via the GUM service within a patient's PCT. The dispatch of
postal tests however, and potentially laboratory services should
be delivered nationally.
Assuming patient care is available in some form
via services in the local PCT, we would recommend one of the following
national kit service options:
(1) Kits are requested from a national website
and are posted directly to the patient. Kits are returned to the
nationally commissioned laboratory. Negative results are handled
automatically, positive results are passed to the patient's local
PCT's designated care point (eg in the current NCSP system, the
screening office). Patient care is then handled locally.
(2) As above, kits are requested from a national
website, however each kits return postal address is printed "live"
and depends on the patients PCT. The kit is sent to the patient,
and when returned is addressed to the PCTs locally commissioned
laboratory. The results would automatically feed into local patient
management systems as they do at present, and patient care is
then handled as it is currently. This would require existing Chlamydia
screening tenders for laboratory services to be in pace (as they
are under the NCSP at present).
Both of the above would require a national website
and brand to be developed (or use an existing commercial brand,
such as freetest.me) and the development of nationalised test
kits and request forms etc. As with the freetest.me service, the
forms in the kits are simplified and pre-printed as the patients
details are collected online.
Preventx Limited is the only organisation worldwide
currently in a perfect position and with experience to deliver
either of the above services.
To be able to tender for a national remote testing
service, DoH Policy will need to be modified. However, prior to
going to tender it is recommended that DoH should run a "beauty
parade" so that they may be properly briefed on what specification
to go to tender for. I'm afraid that, we feel that the DoH is
still not grasping what's really needed, so there's a risk an
inferior service may be commissioned. An irony here is that, although
our company is unique in offering a national delivery service,
we have probably upset so many people along the way trying to
tell them how this should be done that, if common sense does prevail
we may be unsuccessful!
In addition, "treatment" could also
be offered online: there is already a mechanism in place through
a patient group directive (PGD).
In addition, other STI tests could also be tested
online using the same sample (for example, to test seven STI's).
The above offers a "patient centric"
solution: offering a service in the way young people prefer.
20 November 2009
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