Final Pathology Report - NHS Wales Pathology Report.pdf · It is proposed to continue to have a...

13/04/2007 13:14:24 Authors Diagnostics Redesign Group Report

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Diagnostics Redesign Group

Pathology Group Report

Contents Page

Section

Description

Page Number

Executive Summary 2 1 Introduction 4 2 Terms of Reference 4 3 National Context 4 4 Service Strategy 6 5 Local Context 7 6 Existing Arrangements 7 7 Laboratory Information Management Systems 8 8 Activity 9 9 Links to other service redesign groups 10 10 Demand, activity and capacity 10 11 Impact of NICE guidelines 11 12 Accreditation 12 13 Service Solutions 12 14 Pathology Service Configuration 14 15 Transport 14 16 Repatriation of testing done outside the region 15 17 Next Steps 15 18 Workforce 15 19 Finance and Activity 19 20 Management Arrangements 21 21 References 22 22 Recommendations 23 23 Acronyms 24

Appendix 1 Supporting Structure 25 Appendix 2 Growth and Demand Management Model 26 Appendix 3 Option Appraisal 28 Appendix 4 Terms of Reference 39 Appendix 5 Membership of the group 40


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Executive Summary Pathology investigations are involved in 70% of all clinical diagnoses. In addition to their diagnostic role they are critical to the management of cancer, long term chronic diseases such as diabetes and heart disease, population screening for disease and have central role in the achievement of Welsh Assembly Government (WAG) targets. Many aspects of the service are available 24 hours a day, seven days a week. There are important connections with all aspects of the health service through from primary to secondary and tertiary care. The service is delivered in highly sophisticated laboratories through to directly to the patient by the use of point of care testing. Every result obtained has to be of the highest quality with laboratories participating in the Clinical Pathology Accreditation (UK) scheme and using both internal and external quality assessment schemes. Over 2 million test results per annum are reported from the main laboratories at Ysbyty Glan Clwyd, Ysbyty Gwynedd and Ysbyty Maelor with additional services provided at Llandudno General. Following the North Wales Secondary Review (2006) the Diagnostic Re-design Group were invited to consider how pathology services might be organised to meet future pressures on the service. Pathology is to a large extent dependent on the modes of delivery of other clinical services. As it is planned to have three Accident and Emergency departments in the three main hospitals then timely access to laboratory results (within 4 hours for a number of tests) has to be available. It is proposed to continue to have a major laboratory presence on each site. The group reviewed future demand for services based on the Carter Report, the RKW work in the South Wales laboratories and the recent experience of local laboratories. Estimated growth rates ranging from 1-2% p.a. in cytology to 10% p.a. in histopathology were tempered with a 25% efficiency factor drawn from the Carter Report. This produced an investment requirement of £1.67 million to 2014/15 rising to £3.48 million by 2019/20. It is anticipated that this investment can be funded from the savings produced by admissions avoided and reduced lengths of stay from the earlier and improved diagnostic services proposed. The redesign group concluded that the way laboratory services are currently delivered is not economically sustainable, particularly with the anticipated increase in demand. It proposes that the laboratory services move towards a Managed Network across North Wales. This will, because of economies of scale, enable future pressures to be managed in a more appropriate manner. Within the network, consideration will be given to repatriating many investigations which are sent out of the region to allow them to be done more cheaply and allow everyone’s patients equal access to laboratory investigations, whether through the laboratory or closer to their home through point of care testing. The provision of an expanded service in future will present challenges in workforce planning. The service currently employs slightly less than 400 people across North Wales. Meeting demand will require flexible use of the new career framework for the NHS, co-ordinated use of existing staff and recruitment of new staff across North Wales. A managed network will facilitate this. The linear expansion of the present staffing arrangement is not feasible or affordable.


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The improved provision of information across North Wales Trusts (and beyond) and between primary and secondary care will be necessary to underpin the network proposed. All laboratories are closely involved with the project to replace the existing Telepath computer system that will start delivering in April 2008 that will facilitate the above proposals. These proposals are in line with the All Wales Future Delivery of Pathology Services project.


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1 Introduction 1.1 The group builds upon the vision for services put forward in the consultation

document ‘Designed for North Wales’, and its supporting work including the benchmarking against UK best practice undertaken by Teamwork. It will develop a sufficiently detailed picture of services to inform the Regional Strategic Service Plan and the local health economy Strategic Outline Cases.

2 Terms of Reference

The group needs to look at services for diagnostics in the round, but it will focus particularly on:

1. To link closely with the work of the national and regional pathology networks. 2. The facilitation of long-term condition management in the community. 3. The facilitation of optimising the use of day surgery and minor outpatient procedures. 4. Minimising the number of visits to a hospital site for diagnostic tests. 5. Minimising the duplication in tests. 6. Exploiting the potential offered by IT developments 7. The group’s work needs to link to the Access 2009 work (but not to duplicate it). 8. The need to shorten patient pathways. 9. The exploration of models of diagnostic delivery e.g. out of hours, planned and unplanned work. 10. The development of point of care testing (POCT)

3 National Context 3.1 Designed for Life 3.1.1 Designed for Life identifies the need to provide appropriate evidence based, quality

assured clinical treatment and care. This will require the development of a more corporate approach in NHS Wales with organisations working together rather than separately. The strategy contains a number of design principles and key objectives influencing diagnostic services including:

• Access to appropriate services when they are required.

• Diagnostic investigations that contribute to the effective delivery of patient pathways.

• The use of technology and tele-health to reduce the need for hospital attendances.


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• Appropriate use of Point of Care Tests (POCT) to streamline service delivery. POCT are done remotely from the laboratory at the point where the patient is seen by the clinician.

• Comprehensive access to diagnostic test results that will contribute to effective demand management and appropriate use of services.

• Optimised services using the latest technology to provide effective test requesting, results reporting, images, and information to clinicians and specialists.

• The development of specialist units staffed by well trained professionals and supported by high quality diagnostics

3.1.2 Vision 2015 will be delivered through a series of strategic frameworks, each

covering three years. Redesigning Care 2005-08 places emphasis on service redesign and reconfiguration via clinical networks and performance management as key enablers for improving health and social care in Wales.

• To support service redesign and reconfiguration Designed for North Wales

identifies care provision within four levels: Level 1 Primary Care Networks Level 2 Local Services Level 3 Acute Services Level 4 Tertiary and highly specialist care

• At level 1 effective and rapid diagnosis will be available locally with high quality diagnostic facilities providing on-site support for treatment and diagnosis at level 2. Levels 3 and 4 will deal with complex cases that require a concentration of skills and equipment. Anticipated diagnostic service configurations are described in more detail below.

Pathology services Level 1 Services will be delivered through a

combination of sample delivery to a level 2/3 facility and Point of Care Testing supported by the pathology department

Level 2 Depending on the configuration of clinical services, laboratories will be focused on providing a rapid response service referring most routine work to the level 3 facility

Level 3 It is envisaged that pathology services will be concentrated on level 3 sites and will provide a


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combination of hot and cold testing with centralised specialist cold testing. Note: The location of specialist testing e.g. biochemistry will need to be agreed within the appropriate network, region/sub region

Level 4 As level 3 with additional tertiary referral/specialist testing centre

3.1.5 Strategic Framework 2, Delivering Higher Standards, focuses on the delivery of

higher standards of clinical service and quality, followed by Strategic Framework 3, Ensuring Full Engagement, which aims to deliver full engagement by 2015, characterised by improving standards of health, a responsive service providing high quality care and efficient and effective use of resources.

4. Service Strategy 4.1.1 The aim of the Diagnostic Services Programme is to implement the

recommendations made in the Strategy through the modernisation of Diagnostic Imaging and Pathology services. This requires new models of delivery that maximise the benefits of recent technological advances, to ensure that diagnostic services can support the overall modernisation programme.

4.1.2 The Programme is developing an integrated approach linking national, regional

and local levels to ensure that high quality services are provided consistently across Wales in the most cost effective and efficient manner. A planned programme of developments has commenced and is designed to support the delivery of Designed for Life.

• The key strategic principles are that:

• Clear organisational infrastructure arrangements should be developed to support the delivery of modern Diagnostic Services. Services must be planned to make optimum use of resources whilst ensuring equity and consistency across Wales.

• Demand must be managed effectively.

• All Diagnostic Services should participate in accreditation schemes.

• The workforce should be structured around the known and projected needs of Diagnostic Services.

• The workforce should be valued, supported and their skills used effectively.


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• The deployment of equipment and introduction of new technologies should be planned strategically ensuring an appropriate match of demand and capacity.

• An integrated information management and technology infrastructure is crucial to the delivery of modern Diagnostic Services.

• An effective integrated transport system will be necessary to support the delivery of future models for Diagnostic Services.

5 Local Context 5.1 The planning for the improvement of clinical services across North Wales is now its

second phase. The initial phase was the consultation document, Designed for North Wales. Following the adoption, with some modifications, of Designed for North Wales, five service redesign groups have been meeting to draw together a regional service plan by March 2007 to inform the local service plans within each health economy and the capital business plans which are being submitted to support these. The structures supporting this are attached as appendix 1.

5.2 The management implementation arrangements for post March 2007 are still under

consideration by the North Wales Health Planning Forum. However, local implementation teams within each health economy will need to further develop the regional service plans and capital plans.

6 Existing Arrangements 6.1 The term ‘pathology’ describes clinically led diagnostic, laboratory and post mortem

services, and public health services based in Trusts in Wales. This includes direct patient care, interpretation and clinical liaison.

6.2 The services cover a range of tests on blood and other human materials necessary

for diagnosis and monitoring of a wide range of clinical conditions so that appropriate treatment can be given, and the investigation of the reasons why people may have died and the care of their body if they do so in hospital.

6.3 The scope of the Pathology Project therefore includes the following pathology

disciplines provided by the NHS in North Wales: blood transfusion; clinical chemistry; cytology; genetics; haematology; histopathology; immunology; microbiology; and toxicology. In addition to providing pathology services to Trusts other users include Local Health Boards, Coroners, Cervical Screening Wales, Breast Test Wales, Blood Transfusion Services, services to Industry, drug testing and food and environmental work at Glan Clwyd and Bangor

6.4 Pathology services across North Wales are organised around 3 laboratories each

delivering a full range of services with some regional services.


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• Gynaecological Cytology Screening is done in Ysbyty Glan Clwyd, Ysbyty Maelor and at Llandudno General for North West Wales.

Cross Trust (Regional) services:

• Toxicology at Ysbyty Gwynedd • Stem cell harvesting at Ysbyty Gwynedd • Renal calculi studies at Ysbyty Maelor • Metal analysis at Ysbyty Glan Clwyd • Renal biopsies tumour markers

6.6 In addition NPHS microbiology services are provided at Ysbyty Gwynedd and

Ysbyty Glan Clwyd

• Pathology requests from general practice accounts for around 45%-50% of laboratory work. The demand for pathology services from primary care is currently growing at a faster rate than secondary care, as a consequence of national initiatives such as

• National Service Frameworks, • NICE guidelines • General Medical Services contract. • The emergence of GPs with a special interest. • The introduction of the Human Tissue Act

6.8 There is limited regional standardisation in terms of equipment and procurement

This leads to different levels of service delivery and potential sustainability risks. The facilities supporting services are also inadequate in some cases, with consequent, levels of variability in functionality and capacity. There is currently no single vision or clinical service model for pathology; however the modernisation project is developing proposals for the future delivery of pathology services not only in the Regions but also in the whole of Wales

7 Laboratory Information Management Systems: 7.1 There are currently 3 pathology IT systems in use across North Wales provided by

one supplier. These systems are localised, not integrated, and currently obsolete in terms of what the market can offer. They have been configured in different ways and do not operate to common definitions and coding. This introduces significant difficulties in collecting consistent data for strategic planning and benchmarking and discourages networking between existing Trusts.


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8 Activity 8.1 Due to the differences in the way laboratories have configured their processes and

tests, obtaining comparable and accurate data from each Trust is problematical. The most comprehensive data available has been obtained from the Acute Hospital Portfolio (AHP) using information collected in 2005. It is accepted that there are flaws in the AHP information and until systems and data definitions have been standardised comparisons between pathology laboratories will be a major problem.

• Activity in most areas of pathology has increased significantly over the last few

years and there are a number of reasons for this including:

• Impact of the GP Contract • National Service Frameworks • NICE Guidelines • General increase in screening initiatives • Antibiotic resistance – NPHS/ Microbiology • Specialist services e.g. Immunology, genetics • Creeping developments e.g. thiopurine methyltransferase, troponins • Increased referrals as a consequence of reporting e.g. GFR • Bowel Screening

• There is no evidence to suggest that pathology activity will decrease over the next

few years and it is anticipated that further increases will occur due to initiatives such as the ‘2009 access project‘ designed to reduce waiting times. Examples of other factors that will increase demand are:

• Introduction new tests e.g. BNP • Point of Care Testing (POCT) • Introduction of molecular techniques for diagnosis and treatment

monitoring • Molecular testing for cytology

8.4 At the same time pathology services are under pressures that will work to reduce

activity. There are financial pressures associated with Trust SCEP programmes and pressure to reduce the number of test being undertaken as it is estimated that 25% tests may be unnecessary. (Carter Report)

• The following table show the current level of activity in pathology across N Wales.

NWW C&D NEWT North Wales

Haematology 255,256 251,778 276,370 783,404Biochemistry 292,520 348,904 249,682 891,106Microbiology 131,717 149,000 132,578 413,295Histopathology 21,232 11,526 11,414 44,172Cytology 21,172 2,210 15,462 38,844Total 721,897 763,418 685,506 2,170,821


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Source: AHP data 2005 (The above data does not compare like with like it will be replaced with comparable trust data) 9 Links to Other Service Redesign Groups

• Designed for North Wales will result in a large number of service redesign developments some of which will have an impact on pathology services. In particular the development of a cancer network and the associated targets will have an impact on histopathology test turnaround. In addition the emphasis on community based care models for patients with long term conditions is likely to increase demand from this sector. The effects of these developments on pathology services need to be quantified

Recommendation A formal review of the impact on pathology of service changes arising out of the redesign initiative should be undertaken with particular emphasis on Accident and Emergency, chronic conditions and the cancer network 10 Demand, Activity and Capacity (Carter Report) 10.1 The Carter report showed that pathology accounted for 4% of the NHS spend.

There has been an increase in demand of over 10% across pathology disciplines during the past 3 years (ranging from 18% in biochemistry to -2% in cytology).

10.2 In the case of N Wales figures for C&D show a consistent increase in demand over

9 years of 11% for chemical pathology and 5% for haematology (requests). In the case of NEWT annual increases recorded (sets) over 5 years are biochemistry 12.8%, haematology 5.5%, microbiology, 0.6% and blood transfusion 4%

10.3 Demand growth is not expected to slacken for reasons discussed elsewhere in this

report. There is however a need to manage this demand particularly where it is believed that many test are unnecessary. The Carter report estimated that unnecessary reporting to be in the order of 25%

• A modelling exercise was undertaken to determine the effects of these issues

across North Wales. A sample of pathology services from 6 Trusts across Wales shows the range of activity increases between October 2005 and October 2006:

Clinical

Chemistry Haematology Microbiology Histology Cytology

Range of increase (% of requests)

6 – 11 4 – 8 4 – 10 4 – 16 1 – 2

Source Diagnostic SOP 12/06 10.5 The above figures were used to predict demand over the period to 2019/20. These

raw demand growth figures were then modified by the assumed impact of demand management. The results are shown in the table below. Additional detail can be found in appendix B.


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2006/07Demand Mangement Reduction NWW C&D NEW North Wales

Haematology .0-25% 270,571 266,885 292,952 830,408Biochemistry .0-25% 317,384 378,561 270,905 966,850Microbiology .0-25% 140,937 159,430 141,858 442,226Histopathology .0-25% 23,355 12,679 12,555 48,589Cytology .0-25% 21,490 2,243 15,694 39,427


Haematology .0-25% 277,843 274,057 300,825 852,725Biochemistry .0-25% 333,601 397,903 284,747 1,016,250Microbiology .0-25% 150,803 170,590 147,045 468,438Histopathology .0-25% 24,888 13,511 13,379 51,778Cytology .0-25% 21,130 2,206 15,432 38,767






Haematology .0-25% 432,832 426,934 468,635 1,328,401Biochemistry .0-25% 687,437 819,943 586,766 2,094,146Microbiology .0-25% 254,728 288,151 256,393 799,271Histopathology .0-25% 58,272 31,634 31,326 125,807Cytology .0-25% 19,559 2,042 14,284 35,885

NoteDemand management is assumed to be 0% 2006/07 through to 25% in 2014/15 and to remain at this rate to the end of the projection (25% estimate is derived from Carter Report)

Pathology Demand Projection 2006/7 - 2019/20Growth rates allowing for demand management

11 Impact of NICE guidelines

• NICE guidelines are of two types. Technology appraisal that need to be picked up and followed and clinical guidelines where the implications of new care pathways recommended by NICE need to be picked up and evaluated by the relevant departments.


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Recommendation The pathology network has a system in place of horizon scanning NICE guidance as it appears and evaluating the impact on the department. 12 Accreditation

Fundamental to improving patient care through modernised pathology services is the need to deliver a consistent quality service across Wales. There is a need to ensure that all laboratories meet accreditation requirements and other standards that define the provision of consistent, high quality services. The Diagnostic Service Programme is currently developing a national framework document that will identify standards and best practice for laboratory services in Wales.

DEPARTMENT NWW C&D NEWT CLINICAL CHEMISTRY Accredited Conditional Registered* Including: IMMUNOLOGY TOXICOLOGY

HAEMATOLOGY Conditional Conditional Registered* Including: BLOOD BANK INFERTILITY PHLEBOTOMY HISTOLOGY Registered* Conditional Registered* Including: CYTOLOGY

N.P.H.S. (MICROBIOLOGY) Accredited Conditional

Registered (not NPHS)*

STEM CELL N/A N/A

* registered and awaiting inspection 13 Service Solutions 13.1 The expansion of diagnostics in primary care is the vital for the management of

demand in secondary care. The service solutions to bring this about need to redesign the care pathway on a disease or condition specific basis. There are tools emerging to do this such as the Map of Medicine. Any variation from the agreed pathways would require consultant authorisation.

13.2 Electronic referrals will allow a screening to take place via on-screen pathways that

will improve efficiency


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14 Pathology service configuration Option appraisal

• An option appraisal was carried out to determine the most appropriate arrangements for pathology services in North Wales. The criteria and the weights used in the exercise were derived from the approach used in the RKW exercise in south Wales. However the options were generated by the pathology redesign group .The options evaluated were;

Option 1) Reflect the current arrangements and can be viewed as a federation but attempting to meet targets. Option 2) A centralised main laboratory with satellite laboratories providing services to Accident and Emergency departments. Option 3) A managed network across North Wales Option 4) A wider network e.g. as in histopathology and could embrace an all- Wales network.

• The scores from the option appraisal clearly showed a preference for option 3, a managed network. The results are as follows more detail can be found at appendix C

Option 1

As we are but meeting all targets from current arrangements + internal service re-design

Option 2 One main laboratory and 2/3 satellites with POCT being undertaken in A&E and primary care

Option 3 Managed network across trusts with

equal distribution of work BUT with each

trust taking on specialised services as with toxicology at

Ysbyty Gwynedd

Option 4 Networking alternatives e.g. All Wales histopathology linked to regional network\

weighted scores Total for cold work

2008 1915 2695 2365

Total for hot work

2052 1943 2661 2341

Total score 4059 3858 5356 4706Un-weighted scores

Total for cold work

218 208 291 256

Total for hot work

230 209 288 254

Total score 448 417 579 510

14.3 Option 3 was the preferred option both on a weighted and un-weighted basis.


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• It was confirmed that option 3 is a managed network. It was also acknowledged that a managed network can take many forms from a loose association as at present, through increasingly formalised but organisationally distinct “federated” models, through to a single organisation managing a unified budget and workforce. Details about how the network will be managed will need to be resolved as part the next phase of the project – including a detailed financial appraisal. It was agreed that a significant amount of work would be required to develop such a network with a timescale of potentially 2 to 3 years Furthermore, given the need to tailor the network to the situation in N Wales, the process would by its nature be evolutionary with a number of major issues lying on the critical path such as

• Development of an integrated IT system • Development of a transport system • Establishment of a work force plan • Need to define a management structure and associated operational

and quality control processes

• At a more fundamental level there are a number of challenges that need to be met:

• The planned network will have to be cost effective. • The vision of the network will have to be acceptable to Chief Executives. • There will have to be agreement on allocation of budgets • Agreements over how future developments will be funded and located

14.6 Full details of the option appraisal can be found at appendix C

• Benefits of a managed Network

• Provides a critical mass of skills and resources, • The development of specialisations would enable the repatriation of specialist work currently being done outside the region. This may result in significant savings. • National guidance is pointing to regional networks • Would enable existing issues to be resolved e.g. immunology • Recruitment and retention may be improved by the establishment of a network through which individual interests and specialisation could be pursued. Manpower problems may be easier to solve with a larger, regional workforce. • The network would provide additional resilience. • Will enable further reconfiguration to be achieved in a managed way.

15 Transport

• The managed network will depend on an effective and efficient transport system. The existing arrangements for transport are provided by a mix of non-patient ambulance vehicles, internal hospital transport, dedicated pathology transport and


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private taxis. The system is fragmented due to the need to provide a service to other departments. As a consequence:

• There is limited time for sample taking in some GPS surgeries • Delays in reporting due to late arrival of samples • Degradation of samples in transit • Unbalanced workload in laboratories due to the arrival of many specimens in the mid afternoon • A review of transport is underway which will help describe and cost a future transport system.

16 Repatriation of testing done outside the region 16.1 One of the benefits that is to be obtained as a consequence of the establishment of

a managed network will be a critical mass of expertise and specialisation that will enable the network to undertake tests that are currently done outside of the region. This will make significant savings, increase the local level of expertise and decrease turn-around times for results.

• In the case of the North West Wales NHS Trust the cost of tests done outside the

trust is in the range of £180k to £140 therefore it is likely that across the 3 trusts the annual cost is in the order of £500K

Recommendation There should be an additional exercise to identify the number and cost of tests performed outside of N Wales. 17 Next steps A financial appraisal will be required to compare the costs of the 4 options. Including

the costs of a transport system to support the network and the impact of the repatriation of test currently undertaken outside of N Wales The outcome of the exercise would be shared with pathology staff across the region.

Recommendation A financial option appraisal be undertaken to evaluate the 4 options to take into account transport, repatriation of test done outside the region and the new management arrangements required to support the network. 18 Workforce

• Details of the pathology workforce are shown in the table below. Source: Life and Services Summary – Wales


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Clinical

Scientist Advanced

Practitioner MLSO/Biomedical

Manager Consultants (Grade A and B)Biomedical

scientist Scientist

LIFE SCIENCES SUMMARY - NORTH WALES - ALL DEPARTMENTS Number Wte Number Wte Number Wte Number Wte Number Wte North West Wales 1 1.0 9 6.0 2 1.6 62 59.4North East Wales 1 1.0 11 7.0 7 5.6 1 0.6 52 49.6Conwy & Denbigh 4 2.5 11 9.4 2 2.0 1 0.7 57 52.3

Total 6 4.5 31 22.4 11 9.2 2 1.3 171 161.3

MTO / MLA/ATO Student/Trainee Technician Cyto-screener assistant

Total numbers of staff

LIFE SCIENCES SUMMARY - NORTH WALES - ALL DEPARTMENTS Number Wte Number Wte Number Wte Number Wte Number Wte North West Wales 6 5.6 3 2.3 42 32.8 3 3.0 128 111.7North East Wales 15 12.9 1 1.0 34 23.7 8 6.9 130 108.3Conwy & Denbigh 3 2.4 1 1.0 50 38.2 2 2.0 131 110.5 0 0.0

Total 24 20.9 5 4.3 126 94.7 13 11.9 389 330.5

• There are a large number of factors which impact on the pathology workforce some of which are common to the NHS workforce some are unique to the scientific disciplines that make up pathology.

Common Factors • Ageing workforce • Extension of the working day in response to various initiatives (outside of

pathology) • The counterbalancing factor to extended working due to the provisions of the

European Working Time Directive, (EWTD) • Changing patterns of working time • Emphasis on work life /balance


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Specific issues • Staff shortages in specific areas e.g. histopathologists • Growth of the female workforce, particularly in the biomedical scientific group • Need to retain a career profile that recruits and retains pathology staff needs

particular attention • Dealing with issues arising from the bimodal age profile within pathology

• In response to a growing demand for some clarity around role redesign and the

wide range of workforce modernisation projects that have been ongoing, a Career Framework for the NHS has been published. The aim of the framework is to provide a guide for the NHS and partner organisations on the implementation of a flexible career and the skills escalator concept which will enable an individual with transferable, competency-based skills to progress in a direction that will meet service and individual needs. The Career Framework has nine levels (see Fig 1) and in many but not all cases there will be a 1:1 mapping between the level in the Career Framework and the equivalent pay band in Agenda for Change. There is not an automatic read-across, however, as ultimately the outcome of job evaluations will determine remuneration. The Career Framework levels are largely based on levels of responsibility.


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NHS Career framework


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19 Financial case

This section has not yet been signed off by the finance and activity group. As such, the figures remain provisional and may be subject to change. It is included in order to give an indication as to the financial and activity implications of the group’s work.

19.1 Table A below sets out the total activity (requests) delivered across North Wales by

surgical services during 2005/06. In the absence of more up to date and reliable data the futures are based on the AHP 2005 submission up rated to 12 months from the original 6 month, April to September 2005, submission.

Table A

NWW C&D NEWT North WalesHaematology 255,256 251,778 276,370 783,404Biochemistry 292,520 348,904 249,682 891,106Microbiology 131,717 149,000 132,578 413,295Histopathology 21,232 11,526 11,414 44,172Cytology 21,172 2,210 15,462 38,844Total 721,897 763,418 685,506 2,170,821 19.2 This activity utilised the following resources amounting to £million as detailed in

table B. Table B Expenditure 05-06 North West

Wales £m

Conwy and Denbighshire

£m

North East Wales

£m

Total

£mPay 2.625 4,199 4.072 10,986Non pay 1.448 964 2.829 5,241Total 4.073 5,163 6.901 16,137 19.3 Demography Whilst the population of North Wales in total will stay relatively stable over the next twenty years, there will be considerable increase in the number of people over the age of 65. Since older people are the heaviest user of health services this will bring it with increased demand on services. The change in demographic profile is shown in the graph below.


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Estimated and Forecast Population for North Wales

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

2006 2009 2014 2020 2025

Years

Popu

latio

n Fi

gure 0-15

16-64

65-84

85+

This will bring with it the following increase in demand for services. 19.4 Value for Money There is however a need to mange this demand, particular where it is believed that many tests are unnecessary. The Carter Report estimated that unnecessary reporting is in the order of 25% and this has been factored in to deflate the activity growth projections. 19.5 Investment required As set out in section 10 above the demand for pathology services is expected to continue to rise on year on year at a level greater than that driven purely by the demographic factors set out in 19.3 above. This reflects the increasing importance of early diagnosis in preventing and managing illness and should be paid for by reducing hospitalisation and outpatient visits. Taking into account the factors outlined in sections 19.3 to 19.5 above pathology activity is expected to grow as follows:


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Table C Financial year

Haematology requests

Biochemistry requests

Microbiology requests

Histopathology requests

Cytopathology requests

2006-7 830,408 966,850 442,226 48,589 39,4272007-8 852,725 1,016,250 473,181 51,778 40,0182009-10 896,308 1,119,171 541,745 58,609 41,2282014-15 992,658 1,392,702 759,826 78,116 44,4142019-20 1,328,408 2,094,146 1,065,695 125,807 47,846 This will require the following additional investment. In order to estimate the financial impact of the forecast increase in demand 50% of the adjusted English tariff for 2005-06 has been used. Table D Annual Increment Cost Increase

Haematology Biochemistry Microbiology Histopathology Cytopathology Total

£m £m £m £m £m £m

2007-8 0.07 0.05 0.12 0.04 0.00 0.282009-10 0.13 0.10 0.27 0.08 0.01 0.592014-15 0.29 0.27 0.87 0.21 0.02 1.672019-20 1.01 0.70 1.22 0.52 0.02 3.48

Financial Year

19.6 Conclusion There is a net requirement for investment estimated at £1.67 million to 2014/15 and £3.48 million to 2019/20 to underpin the new more community based models of care. This report highlights the financial and activity elements most directly related to the changes in pathology practice described in this report. However, to get a full picture of the financial implications reference needs to be made to the report of the finance and activity group. 20 Management arrangements

• A key theme running through the discussions of many of the service redesign groups is the need for pan-North Wales planning and co-ordinated action to ensure that the right mix of skills is available across the region. This will minimise referrals to specialist services out of area and continue to support three emergency access portals. Whilst there is currently a Regional Pathology Network it is recommended that a formal management network is established in North Wales to underpin the services for the next twenty years. This will extend to identifying a separate budget and a management unit for pathology. The network would then be responsible for delivering a defined level of services across North Wales.


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Recommendation That the North Wales Health Planning Forum commissions a piece of work to examine and recommend a course of action on creating a managed network for pathology services across North Wales.


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21 References Right Test, Right Time, Right Place – Framework for Primary Care Access to Imaging – The Royal College of Radiologists and The Royal College of General Practitioners 2006 Cheshire and Merseyside Strategic Health Authority Diagnostic Strategy Diagnostic Services – Strategic Outline Programme October 2006 Carter Report – Royal College of Pathologist – September 2006


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22 Recommendations Ref

Item

Action

Timescale

9 Links to other redesign groups

A formal review of the impact on pathology of service changes arising out of the redesign initiative should be undertaken with particular emphasis on Accident and Emergency, chronic conditions and the cancer network.

Trusts Autumn 2007

11 Impact of NICE guidelines

The pathology network has a system in place of horizon scanning NICE guidance as it appears and evaluating the impact on the department.

Regional Pathology Network

Ongoing

16 Repatriation of testing done outside the region

There should be an additional exercise to identify the number and cost of tests performed outside of North Wales.

Regional Pathology Network

Autumn 2007

17 Next steps A financial option appraisal be undertaken to evaluate the 4 options to take into account transport, repatriation of test done outside of the region and the new management arrangements required to support the network.

Trust Finance Directors

Autumn 2007

20 Management Arrangements

That the North Wales Health Planning Forum commissions a piece of work to examine and recommend a course of action on creating a managed network for pathology services across North Wales.

NWHPF April 2007


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23 Acronyms

Acronyms

Meaning

AHP Acute Hospital Portfolio EWTD European Working Time Directive NICE National Institute of Clinical Effectiveness NPHS National Public Health Service POCT Point Of Care Testing SCEP Service Change and Efficiency Plan WTE Whole Time Equivalents


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Appendix 1

NNoorrtthh WWaalleess SSeerrvviiccee DDeevveellooppmmeenntt AAnndd IImmpplleemmeennttaattiioonn SSttrruuccttuurree

North Wales Health Planning Forum (Chief Executives Forum)

Service Transformation Co-ordination Team

Service Redesign Regional Plan Design Brief Local Implementation Teams Groups and SOP Business Case Preparation & Delivery (SOCs, major Business cases) Long Term

Medical Conditions (includes acute and unscheduled care)

Surgery (includes

elective and emergency care)

Diagnostics

Children & Families

LHB Primary Care, Commissioning and Estates Strategies

⇒⇒

Boards – Trusts: North East Wales, Conwy and Denbighshire, North West Wales

LHBs: Wrexham, Flintshire, Conwy, Denbighshire, Anglesey, Gwynedd

Mental Health National Initiative

East West Centre Llandudno Hospital

Project Support Team Regional HR Group Regional Finance Group


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Appendix 2

2006/07 Growth RatesEstimated Growth Rate NWW C&D NEW North Wales

Haematology .4-8% 6% pa 270,571 266,885 292,952 830,408Biochemistry .6-11% 8.5% pa 317,384 378,561 270,905 966,850Microbiology .4-10% 7% pa 140,937 159,430 141,858 442,226Histopathology .4-16% 10% pa 23,355 12,679 12,555 48,589Cytology .1-2% 1.5% pa 21,490 2,243 15,694 39,427


Haematology .4-8% 6% pa 286,806 282,898 310,529 880,233Biochemistry .6-11% 8.5% pa 344,362 410,739 293,932 1,049,032Microbiology .4-10% 7% pa 150,803 170,590 151,789 473,181Histopathology .4-16% 10% pa 25,691 13,946 13,811 53,448Cytology .1-2% 1.5% pa 21,812 2,277 15,929 40,018


Haematology .4-8% 6% pa 322,255 317,864 348,911 989,030Biochemistry .6-11% 8.5% pa 405,391 483,532 346,024 1,234,947Microbiology .4-10% 7% pa 172,654 195,309 173,783 541,745Histopathology .4-16% 10% pa 31,086 16,875 16,711 64,672Cytology .1-2% 1.5% pa 22,471 2,346 16,411 41,228


Haematology .4-8% 6% pa 431,250 425,374 466,921 1,323,545Biochemistry .6-11% 8.5% pa 609,569 727,066 520,301 1,856,936Microbiology .4-10% 7% pa 242,156 273,930 243,739 759,826Histopathology .4-16% 10% pa 50,064 27,178 26,914 104,155Cytology .1-2% 1.5% pa 24,208 2,527 17,679 44,414


Haematology .4-8% 6% pa 577,109 569,246 624,846 1,771,201Biochemistry .6-11% 8.5% pa 916,583 1,093,257 782,354 2,792,195Microbiology .4-10% 7% pa 339,637 384,202 341,857 1,065,695Histopathology .4-16% 10% pa 77,697 42,178 41,768 167,743Cytology .1-2% 1.5% pa 26,079 2,722 19,045 47,846

Note

1 Activity figures taken from All Wales SOP2 Growth rates derived from All Wales SOP. Also Carter Report estimates growth at 10% average across disciplines and the Select Committee on health estimates 8% growth

Pathology Demand Projection 2006/7 - 2019/20Raw Growth Rates


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2006/07Dem and M angem ent Reduction NW W C&D NEW North W ales

Haem atology .0-25% 270,571 266,885 292,952 830,408Biochem istry .0-25% 317,384 378,561 270,905 966,850M icrobiology .0-25% 140,937 159,430 141,858 442,226Histopathology .0-25% 23,355 12,679 12,555 48,589Cytology .0-25% 21,490 2,243 15,694 39,427


Haem atology .0-25% 277,843 274,057 300,825 852,725Biochem istry .0-25% 333,601 397,903 284,747 1,016,250M icrobiology .0-25% 150,803 170,590 147,045 468,438Histopathology .0-25% 24,888 13,511 13,379 51,778Cytology .0-25% 21,130 2,206 15,432 38,767






Haem atology .0-25% 432,832 426,934 468,635 1,328,401Biochem istry .0-25% 687,437 819,943 586,766 2,094,146M icrobiology .0-25% 254,728 288,151 256,393 799,271Histopathology .0-25% 58,272 31,634 31,326 125,807Cytology .0-25% 19,559 2,042 14,284 35,885

Note

(25% estim ate is derived from Carter Report)

Dem and m anagem ent is assum ed to be 0% 2006/07 through to 25% in 2014/15 and to rem ain at th is rate to the end of the projection

Pathology Dem and Projection 2006/7 - 2019/20Grow th rates a llow ing for dem and m anagem ent


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Appendix 3 Option appraisal Pathology service configuration Option appraisal An option appraisal was carried out to determine the most appropriate arrangements for pathology services in N Wales. The criteria and the weights used in the exercise were derived from the approach used in the RKW exercise in South Wales. However the options were derived from the work of the pathology redesign group .The options evaluated were: Option 1) reflect the current arrangements and can be viewed as a federation Option 2) Is a centralised main laboratory Option 3) Is a managed network across North Wales Option 4) Describes a wider network e.g. histopathology and could embrace an all-Wales network. The scores from the option appraisal clearly showed a preference for option 3 a managed network. The results are as follows


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Option 1

As we are but meeting all targets from current arrangements + internal service re-design

Option 2 One main laboratory and 2/3 satellites with POCT being undertaken in A&E and primary care

Option 3 Managed network across trusts with

equal distribution of work BUT with each

trust taking on specialised services as with toxicology at

Ysbyty Gwynedd

Option 4 Networking alternatives e.g. All Wales histopathology linked to regional network\

weighted scores Total for cold work

2008 1915 2695 2365

Total for hot work

2052 1943 2661 2341

Total score 4059 3858 5356 4706Un-weighted scores

Total for cold work

218 208 291 256

Total for hot work

230 209 288 254

Total score 448 417 579 510


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The results of each option are show in the following pages

Option 1 Professional Group

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COLD WORK Weight 1 2 3 4 5 6 7 Access 7.6 4 3 5 3 3 2 5 25 2-5 Integration 7.6 5 2 3 1 2 2 2 17 1-5 Demand management 3.8 2 3 3 1 2 2 2 15 1-3 Education & research & audit 7.6 3 3 3 1 3 2 3 18 1-3 Resilience 7.6 3 2 3 1 3 3 2 17 1-3 Scientific critical mass 5.3 2 2 3 1 3 3 2 16 1-3 Sustainability 15.2 2 3 3 1 4 3 2 18 1-4 Support for local and regional clinical/public health strategies 15.2 3 3 5 2 3 3 3 22 2-5 Clinical governance and quality assurance 15.2 3 3 4 2 3 3 3 21 2-4 Work force (including morale recruitment and retention 11.4 3 3 5 1 3 4 3 22 1-5 Ease of implementation and risk impact of revenue & funding gap 3.8 5 4 4 4 3 2 5 27 2-5

Total for cold work 35 31 4118

32

29

32

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HOT WORK Access 7.6 4 4 5 3 4 5 5 30 3-5 Integration 7.6 5 2 3 1 2 3 3 19 1-5 Demand management 3.8 2 3 3 2 3 3 3 19 2-3 Education & research & audit 7.6 3 3 4 1 3 2 3 19 1-4 Resilience 7.6 3 2 3 2 4 2 2 18 2-4 Scientific critical mass 5.3 2 2 3 1 3 2 2 15 1-3 Sustainability 15.2 2 2 3 1 3 2 2 15 1-3 Support for local and regional clinical/public health strategies 15.2 3 3 5 2 2 3 3 21 2-5 Clinical governance and quality assurance 15.2 3 3 4 2 4 3 3 22 2-4 Work force (including morale recruitment and retention 11.4 3 3 5 1 3 4 3 22 1-5

Ease of implementation and risk impact of revenue and funding gap 3.8 5 4 5 4 3 4 5 30 3-5

Total for hot work 35 31 43 20

34

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Total score 70 62 8438

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Option 2 Professional group

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COLD WORK Weight 1 2 3 4 5 6 7

Access 7.6 4.5 2 4 2 1 2 3 18.51-4.5

Integration 7.6 3 2 3 3 1 4 4 20 1-4 Demand management 3.8 2 3 4 2 1 4 4 20 1-4 Education & research & audit 7.6 2 3 3 2 3 2 4 19 2-4 Resilience 7.6 2 3 3 2 2 2 5 19 2-5 Scientific critical mass 5.3 3 2 2 2 3 4 4 20 2-4 Sustainability 15.2 2 3 3 3 2 2 4 19 2-4 Support for local and regional clinical/public health strategies 15.2 3 3 3 4 2 3 4 22 2-4 Clinical governance and quality assurance 15.2 2 3 3 4 1 2 4 19 1-4 Work force (including morale recruitment and retention 11.4 2 3 4 1 3 1 2 16 1-4 Ease of implementation and risk impact of revenue & funding gap 3.8 2 3 2 1 2 4 1 15 1-4 Total for cold work Total 27.5 30 34 26 21 30 39 207.5


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HOT WORK Access 7.6 4 3 5 3 1 2 3 21 1-5 Integration 7.6 3 2 2 3 1 3 5 19 1-5 Demand management 3.8 2 3 1 3 2 3 4 18 1-4 Education & research & audit 7.6 2 3 1 2 3 2 4 17 1-4 Resilience 7.6 4 3 3 3 1 3 5 22 1-5 Scientific critical mass 5.3 3 2 1 2 4 4 5 21 1-5 Sustainability 15.2 2 2 3 2 2 4 4 19 2-4 Support for local and regional clinical/public health strategies 15.2 3 3 4 4 2 3 4 23 2-4 Clinical governance and quality assurance 15.2 2 3 1 4 2 3 4 19 1-4 Work force (including morale recruitment and retention 11.4 2 3 3 1 3 2 2 16 1-3 Ease of implementation and risk impact of revenue and funding gap 3.8 2 3 4 1 1 2 1 14 1-4 Total for hot work 29 30 28 28 22 31 41 209 Total score 56.5 60 62 54 43 61 80 416.5


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Option 3 Professional Group

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COLD WORK Weight 1 2 3 4 5 6 7 Access 7.6 4.5 3 4 4 3 5 5 28.5 3-5 Integration 7.6 5 3 5 4 5 4 4 30 4-5 Demand management 3.8 2 4 4 3 2 4 4 23 2-4 Education & research & audit 7.6 3 3 5 3 4 4 4 26 3-5 Resilience 7.6 3 4 4 3 4 5 4 27 3-5 Scientific critical mass 5.3 3 3 4 3 4 5 4 26 3-5 Sustainability 15.2 3 4 4 4 3 4 5 27 3-5 Support for local and regional clinical/public health strategies 15.2 3 4 4 4 4 5 5 29 3-5 Clinical governance and quality assurance 15.2 3 4 5 4 3 4 4 27 3-5 Work force (including morale recruitment and retention 11.4 3 4 3 4 1 4 5 24 1-5 Ease of implementation and risk impact of revenue & funding gap 3.8 4 3 4 3 1 4 4 23 1-4 Total for cold work 36.5 39 46 39 34 48 48 291


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HOT WORK Access 7.6 3 4 4 3 3 4 5 26 3-5 Integration 7.6 5 3 5 4 4 4 4 29 3-5 Demand management 3.8 2 4 5 4 2 4 4 25 2-4 Education & research & audit 7.6 3 4 5 3 2 4 4 25 2-4 Resilience 7.6 3 3 5 4 3 5 4 27 3-5 Scientific critical mass 5.3 3 4 5 3 3 4 4 26 3-5 Sustainability 15.2 3 3 4 4 2 4 5 25 2-5 Support for local and regional clinical/public health strategies 15.2 3 4 4 4 3 4 5 27 3-5 Clinical governance and quality assurance 15.2 3 4 5 4 3 5 5 29 3-5 Work force (including morale recruitment and retention 11.4 3 4 4 4 2 4 5 26 2-5 Ease of implementation and risk impact of revenue and funding gap 3.8 4 3 3 3 2 4 4 23 2-4 Total for hot work 35 40 49 40 29 46 49 288 Total score 71.5 79 95 79 63 94 97 579


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Option 4 Professional Group D

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COLD WORK Weight 1 2 3 4 5 6 7 Access 7.6 3 4 3 4 3 3 2 22 2-4 Integration 7.6 2 4 3 4 3 2 4 22 2-4 Demand management 3.8 2 4 5 4 1 5 3 24 1-5 Education & research & audit 7.6 3 4 4 4 2 4 4 25 2-4 Resilience 7.6 3 4 4 4 3 4 4 26 3-4 Scientific critical mass 5.3 2 3 4 4 2 4 5 24 2-5 Sustainability 15.2 2 4 4 4 3 3 4 24 2-4 Support for local and regional clinical/public health strategies 15.2 3 4 3 5 2 4 3 24 2-5 Clinical governance and quality assurance 15.2 3 4 4 5 2 4 4 26 2-5 Work force (including morale recruitment and retention 11.4 3 4 3 4 2 3 1 20 1-4 Ease of implementation and risk impact of revenue & funding gap 3.8 2 2 5 2 1 4 3 19 1-5 Total for cold work 28 41 42 44 24 40 37 256


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HOT WORK Access 7.6 3 4 4 2 3 3 2 21 2-4 Integration 7.6 2 4 3 4 3 3 4 23 2-4 Demand management 3.8 3 4 3 4 1 3 3 21 1-4 Education & research & audit 7.6 3 4 4 4 3 5 4 27 3-5 Resilience 7.6 3 4 4 5 4 3 4 27 3-5 Scientific critical mass 5.3 3 4 4 3 4 5 5 28 3-5 Sustainability 15.2 2 4 4 4 2 3 4 23 2-4 Support for local and regional clinical/public health strategies 15.2 3 4 4 5 1 2 3 22 1-5 Clinical governance and quality assurance 15.2 3 4 4 5 2 4 4 26 2-5 Work force (including morale recruitment and retention 11.4 3 4 3 4 2 3 1 20 1-4 Ease of implementation and risk impact of revenue and funding gap 3.8 3 2 3 2 1 2 3 16 1-3 Total for hot work 31 42 40 42 26 36 37 254 Total score 59 83 82 86 50 76 74 510


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In attendance at the option appraisal

Name Title David Gozzard

Medical Director / Consultant Haematologist

Keith Griffiths

Consultant Clinical Biochemist

Martin Giles

Consultant Chemical Pathologist

Robin Wiggs

Directorate General Manager

Clive Williams

Consultant Chemical Pathologist

Nick Looker

Consultant Microbiologist

Andrew Butters

Project Director

Adrian Thomas

Directorate General manager

David Nuttall

Biomedical Scientist 4 /Advanced Practitioner – Histopathology

Mark Lord

Consultant Histopathologist


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Appendix 4

SERVICE RE-DESIGN GROUPS

DIAGNOSTICS Introduction The group will build upon the vision for services put forward in the consultation document ‘Designed for North Wales’, its supporting work including the benchmarking against UK best practice undertaken by Teamwork. It will develop a sufficiently detailed picture of services to inform the Regional Strategic Outline Plan and the local health economy Strategic Outline Cases. The work of the group will inform the regional chronic disease management plan to be submitted as part of the delivery programme for Designed for Life. Terms Of Reference The group needs to look at services for diagnostics in the round but it will focus particularly on

1. To link closely with the work of the national and regional radiology networks. 2. The facilitation of long-term condition management in the community. 3. The facilitation of optimising the use of day surgery and minor outpatient

procedures. 4. Minimising the number of visits to a hospital site for diagnostic tests. 5. Minimising the duplication in tests/screening. 6. Exploiting the potential offered by IT developments 7. The groups work needs to link to the Access 2009 work (but not to duplicate it). 8. The need to shorten patient pathways. 9. The exploration of models of diagnostic delivery e.g. out of hours, planned and

unplanned work. Timescale The group needs to produce work to inform

1 The Strategic Outline Plan – final report by the 31st October 2006. 2 Three health economies Strategic Outline Cases estimated date for completion

the 31st March 2007. 3 The regional Chronic Disease Management Plan due for completion by the 31st

March 2007. Meetings The first meeting will take place on the 11th September at 5 pm in the Boardroom, Glan Clwyd.


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Appendix 5

DIAGNOSTICS SERVICE REDESIGN GROUP Name

Title

Organisation

Dr David Gozzard - Chair Medical Director Conwy and Denbighshire Andrew Butters Project Director Geoff Lang Chief Executive Wrexham LHB Mr Adrian Thomas Directorate

Manager Conwy and Denbighshire NHS Trust

Ms Tina Bailey Directorate Manager

North West Wales NHS Trust

Dr N Looker NPHS Glanville Owen CHC

representative

Mrs P Nash CHC representative

David Owen CHC representative

Pathology Keith Griffiths – Sub Group Chair

Consultant Pathologist

North West Wales NHS Trust

Dr Martin Giles Consultant Conwy and Denbighshire NHS Trust

Dr Clive Williams Consultant North East Wales NHS Trust Ms Pearl Huey Biomedical

Scientist North West Wales NHS Trust

Mr Ian Walker Biomedical Scientist

Conwy and Denbighshire NHS Trust

Mr Chris Wright Biomedical Scientist

North East Wales NHS Trust

Dr David Watson Clinical Director North East Wales NHS Trust Colin Heath North West Wales NHS Trust David Nuttall Conwy and Denbighshire NHS

Trust

Final Pathology Report - NHS Wales Pathology Report.pdf · It is proposed to continue to have a...

Documents

Transcript of Final Pathology Report - NHS Wales Pathology Report.pdf · It is proposed to continue to have a...