Efficiency ingrained

The idea of efficiency savings in pathology goes back well before the recent recession, reports Richard Mackillican

Everyone in the NHS is bracing themselves for cuts but some are more used to having to deliver more services for their funding than others.

“My professional background in pathology dates back to 1989 and since then there has been a steady increase in demand for pathology tests as measured by the number of samples we receive for analysis, whilst at the same time pathology departments have been told year on year to make cost improvements in their budgets,” says Dr Julian Barth, president of the Association for Clinical Biochemistry. “In a way there has been a process of tightening belts and improving efficiency which goes back decades.”

Given the importance of diagnostic services to the health service, why does Dr Barth think that pathology has been such as focus for efficiency savings?

“I think that this has happened because pathology has a relatively well ring fenced budget, whereas clinical services are far more diffuse in terms of where the costs are. Taking my personal medical work as a chemical pathologist as an example, the actual costs of my out-patient services involve medical secretaries, out-patient clerks and nurses, pharmacy, pathology tests and transportation of patients. All these costs all fit into separate silos of funding. This means that it is quite complex to make savings in one area without major ramifications on the linked services.”

“The problem for us in pathology is that we are a well defined unit, where we know the breakdown of our costs such as staffing, consumable and computing. This means that it has been relatively clear what pathology costs are and, moreover, whenever cost savings have been demanded, we have managed to deliver by increasing efficiency by automation the use of IT to both control operations and deliver reports. This is a process which has been going for a long time and so is nothing new.

“One of the aspects which worries me is that since we have already been squeezed over the years, most laboratories regard themselves as short staffed with insufficient resource for optimal training of their staff. I am concerned that further financial restraints will result in paring pathology down to a results service and there will be a loss of the clinical advisory services which help clinicians to choose the right tests and to interpret them correctly. This is becoming a more important part of our work as junior hospital medical staff work shifts and the laboratories provide continuity of oversight of patients in both primary and secondary care.

“Taking into account the current economic worries which the NHS is facing, coupled with past experience constant budgetary restraint, we anticipate that budgets are only going to get tighter.

“I think that it is going to be an interesting process, given the potential savings calculated by Lord Carter are well known and savings are expected be achieved by pathology services although given the magnitude of the current financial situation, the whole NHS will be expected to find similar savings. The potential for savings are supported by the external benchmarking reports which show a fair degree of variability between hospital laboratories.”

This benchmarking data comes from the University of Keele which runs a service in which around 60 laboratories take part. The benchmarking analysis includes the output per person in each laboratory.

“These studies have shown that there is considerable variability in areas such as work load and the complexity of that workload. This variability remains even after subdivision by the type of host institution. What we don’t know is whether the most expensive or least cost efficient laboratories are actually delivering the best quality services, because we are only looking at the operating costs of pathology services rather than the effect of those services on the whole patient pathway and the clinical outcomes.”

“I think that there is scope for pathology services to study each other so that we can learn and share best practice with each other. But, so far, this has not happened and I think that there needs to be much more incentive for people to go and learn from each other.

“The Department of Health’s QIPP programme has a philosophy of sharing information but we need to find the best way to encourage everyone to take this new non-competitive approach to change. In fact, Bruce Keogh, the NHS medical director, has approached all the professional societies, including the Association for Clinical Biochemistry, which he regards as untapped resources and has invited us to help take a lead in driving this improvement.

One of the issues which the Association of Clinical Biochemistry is particularly interested in is measuring the quality of services and ensuring that the current high clinical standards are upheld, despite funding issues.

“We are keen to maintain, if not enhance, the current level of quality of services but we are deeply concerned that service quality will suffer as a consequence of the tough economic period facing us, because the only driver will be financial. This is largely because pathology is measured by operational quality and there are to date no well accepted quality indicators in laboratory medicine.

“The Association for Clinical Biochemistry has established a list of quality indicators and has just surveyed its members to measure how well these indicators represent clinical practice by laboratories and, secondly, whether they represent appropriate indicators that can be used to measure improvement. These indicators are mostly related to assessing how well pathology services are focussed on helping to ensure that the right test is done on the right patient at the right time and interpreted correctly.”