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Cellular Pathology Review

November 2010

Bwrdd Iechyd Hywel Dda Health Board

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Contents Number Title Page

Executive Summary and Recommendations

3

1 Aim 4

2 Background/Current Situation 42.12.2

External reviewRisks in Current Service Delivery

45

2.3

2.42.5

Request to Transfer of Consultant Services from BGH to PPH ReviewConsultant Recruitment and Retention Increasing Clinical Demands on the Service

56

62.6 Laboratory Services/Mortuary Services 6

3 Methodology 7

3.1 Project Board 73.2 Process 8

4 Drivers for Change 8

55.15.25.3

Option AppraisalDetailed AppraisalDiscussions with ABM UHBHighest Scoring Options

10101011

66.16.2

Option ShortlistDiscounted OptionsPreferred Options

111112

77.17.2

FinanceCurrent BudgetOutline Costing for the 2 Preferred Options

1313

13

88.1

ConclusionIncremental Approach

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9 Recommendations 15Appendices1 Option Appraisal Scoring Schedule2 Staffing Costing Schedule


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Executive Summary and Recommendations

1 Aim The report reviews and makes recommendations to the Corporate Directors’ Group for the future provision of safe, sustainable and efficient Cellular Pathology Services within Hywel Dda Health Board.

2 Background/Current SituationA number of factors have influenced the necessity to review Cellular Pathology Services across Hywel Dda. The main risks within the current service provision include:

o Insufficient clinical staff to support the serviceo Over reliance on locum appointments and reliance on external agencieso Diagnostic errors in reporting with medico legal implicationso Inability to meet Cancer standards/MDTs

3 Option AppraisalA detailed option appraisal was undertaken and scored against weighted selection criteria. Preliminary discussions were undertaken with ABM UHB colleagues as to a regional approach. There were 2 preferred options namely:

o One centralised site for both consultants and laboratory services. The autopsy facility is contained within WWGH with 4 body stores

o One centralised site for consultants and two laboratory sites.

4 FinanceOutline costs for the 2 preferred options include:

o Centralisation of consultant accommodation at WWGH would entail circa £55k capital costs.

o Achieving some economies of scale in consultant posts should be possible, whilst at the same time agreeing to a future proofed model and establishment of consultants. This needs to be further tested during the implementation of Phase 1.

o Centralisation of laboratory workforce could achieve savings estimated at £64,000

o The capital cost of centralised laboratory accommodation cannot be calculated at this stage as currently there is no vacant appropriate facility on any of the hospital sites. Depending on the identified options there will be additional estates related costs, including depreciation.

o If laboratories are kept at two sites there would be no opportunity for workforce savings within the laboratory staff cohort.

5 Conclusion and RecommendationA staged approach will need to be implemented as follows:Phase 1 - In late November 2010, following refurbishment of the Branwen Suite at WWGH, consultants will be able to be centralised at WWGHPhase 2 - Will include the centralisation of laboratories and workforce. Options for suitable centralised accommodation will be further reviewed and costed by March 2011 and implemented by September 2011.

Conclusions have been made primarily to reduce risk, ensure safety and guarantee high quality Cellular Pathology (Histopathology, Cytopathology and Autopsy work) service provision.


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Cellular Pathology ReviewNovember 2010

1 AIM

The report describes and informs the Corporate Directors’ Group of the need for change, the review process, including option appraisal, and makes recommendations for the future provision of sustainable and efficient Cellular Pathology Services within Hywel Dda Health Board. The report was commissioned by Tony Chambers, Director of Planning, Performance and Delivery and Bernardine Rees, Executive Lead for Cancer Services.

The report builds upon the recommendations made within the following reports:Cellular Pathology Report approved by the Hywel Dda Trust Board – July 2009Royal College of Pathology Report regarding WWGH - 2009Future Delivery of Pathology Services in Wales - August 2008Review of Histopathology Services in Wales – currently out to consultation

2 BACKGROUND/CURRENT SITUATION

Over the last four years a number of factors have influenced the necessity to review Cellular Pathology Services across Hywel Dda NHS Trust and latterly the Health Board. They are detailed as follows:

2.1 EXTERNAL REVIEW

Following the 2009 Royal College of Pathologists review into errors of reporting at West Wales General Hospital of one particular Consultant, the key recommendation stated that the newly formed Hywel Dda NHS Trust should develop and implement plans for the re-organisation of Cellular Pathology services into fewer, larger departments; probably just one and that the present level of fragmentation should not be allowed to continue. It clearly stated that a consultant working alone was not supported by the Royal College of Pathologists as it leads to a poor quality service, diagnostic drift and isolationism.

These recommendations were in keeping with the second recommendation of the Welsh Assembly Government publication - The Future Delivery of Pathology


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Services in Wales which states services should be located to maximise critical mass provided this does not compromise local service delivery and Royal College of Pathologists guidelines.

2.2 RISKS IN CURRENT SERVICE DELIVERY

The main clinical risks are identified as follows:

o Insufficient clinical staff to support the serviceo Over reliance on locum appointments and reliance on external

agencieso Diagnostic errors in reporting with medico legal implicationso Inability to meet Cancer standards/MDTs

2.3 REQUEST TO TRANSFER CONSULTANT SERVICES FROM BONGLAIS GENERAL HOSPITALTO PRINCE PHILP HOSPITAL

In 2007, an initial approach was made, with the full support of the resident Consultant in Histopathology, Cytopathology and Autopsy work by the Chief Executive of Ceredigion NHS Trust requesting that Carmarthenshire NHS Trust accommodate the Cellular Pathology Service in preparation for local development on the Bronglais site. This was coupled with the need to future proof a service to which it was likely to be difficult to recruit a new Consultant in Histopathology, Cytopathology and Autopsy work. As a result, the new Front of House Scheme, Bronglais General Hospital (BGH) has no planned replacement facility to house the Cellular Pathology Laboratory Service and the existing facility will b removed as part of the enabling works.

Following Trust Board approval of Cellular Pathology Report (July 2009) the single-handed Consultant in Histopathology, Cytopathology and Autopsy work at BGH was transferred to Prince Philip Hospital (PPH). The benefits of this proposal lead to increased Consultant cover, reduction of the potential risk of single-handed working at BGH, increased ease of obtaining second opinion from colleagues, and increased opportunity to recruit and retain Consultants in Histopathology, Cytopathology and Autopsy work and qualified Biomedical Scientist staff to support the work of Bronglais General Hospital.

The processing of specimens for BGH was subsequently transferred to PPH. The transfer of specimens has been undertaken by a dedicated transport link and the Consultants in Histopathology, Cytopathology and Autopsy work are able to report utilising a robust IT infrastructure. Clinical links are maintained with BGH via video link and telephone and MDT meetings are supported via video conferencing.


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2.4 CONSULTANT RECRUITMENT AND RETENTION PROBLEMS

Despite the above reduction in Cellular Pathology consultant and laboratory bases within Hywel Dda, the Cellular Pathology service is currently in a crisis situation. There is currently an establishment of nine Consultants in Histopathology, Cytopathology and Autopsy work, however, despite numerous advertisements on the NHS jobs’ web-site and the British Medical Journal there have been no interested suitable candidates. There will shortly (after the 11th November 2010) be only 2.6 substantive Consultants in post and there is an over reliance on locum consultant appointments.

There are further interviews planned for December 2010 and there are a number of interested applicants, the majority of which have been trained overseas.

The inability to recruit is consistent with elsewhere in England and Wales but also reflects the unattractiveness of Hywel Dda posts within the current model of service. At present, there are three Cellular Pathology service bases for consultant staff and their teams at WWGH, PPH and Withybush General Hospital (WGH). Consultant accommodation is inadequate.

2.5 INCREASING CLINICAL DEMANDS ON THE SERVICE

There are increasing clinical demands on the cellular pathology service and include:

o Cancer Services’ targets and deadlines including the requirement for Consultant Histopathology, Cytopathology and Autopsy work to attend MDTs

o Screening Programme requirements including: Cervical and Colorectal screening

o Minimum data setso The need for double reportingo Changing demands of Clinical Services within the Health Board including

the repatriation of patients

2.6 LABORATORY SERVICES/MORTUARY SERVICES

The infrastructure of all the laboratories within Hywel Dda is in need of modernisation. This has an adverse influence on obtaining Clinical Pathology accreditation in all disciplines and the Future Delivery of Pathology Services in Wales Report proposes the Health Board considers the provision of Cellular Pathology Services onto one site.


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Mortuary facilities across the Health Board are variable, with a new build about to become operational at WWGH in January 2011. This new facility at WWGH will enable the accommodation of the autopsy work which is no longer able to be carried out on the BGH site.

3 METHODOLOGY

3.1 PROJECT BOARD

A Project Board was established in September 2010 to direct the detailed review of Cellular Pathology services and includes the following members:

Name DesignationDr John Murphy (Chair) Clinical Lead Cellular Pathology/

AMD PathologyMansell Bennett (Project Lead) General Manager Clinical Support

Services Andrea Stiens Pathology Services ManagerHelen ThomasDavid Addington-HallLia Dura

Lead Scientific Staff

Keith Jones Assistant Director of Finance (Modernisation)

Alison Bishop Human Resources LeadMarilyn Wilkinson Project Support Manager -

Planning

The key responsibilities of the Project Board members are outlined as follows:

• Instigate the collection of base line assessment information relating to the current service (financial, workforce, equipment, infrastructure, activity data, service needs of the organisation)

• Undertake an option appraisal process including risk assessment, benefits realisation and provide recommendations for future service provision

• Develop outcome targets which can be monitored and which will demonstrate the impact of the service redesign option implemented;

• Ensure that equality and diversity is taken into account throughout the process


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All members of the Project Board are aware that some of the issues discussed are likely to be sensitive and have been requested to demonstrate confidentiality and respect for colleagues, patients, carers and the public.

3.2 PROCESS

Following the recommendations of the Royal College review in Carmarthenshire and the Future Delivery of Pathology Services in Wales Report (2008), the opportunity for co-location of Consultants in Histopathology, Cytopathology and Autopsy work across the three counties has been further explored.

The Project Board has identified an extensive number of options as a start for the review process and has carried out the subsequent appraisal and scoring against agreed selection criteria.

Further work has included the outline costing of a small number of the highest scoring options. Indicative capital costs have been supplied by the Estates Department for centralised consultant accommodation at WWGH.

Recommendations have been made as to the most appropriate option to secure safe, sustainable and efficient Cellular Pathology service provision for the future.

4 DRIVERS FOR CHANGE

The reasons for the review and the drivers for change need to be further emphasised and include the following:

Ability to recruit and retain Consultants and provide a sustainable service including the issues below:

oInability to provide a safe quality serviceoNot able to facilitate sub-specialisationoInappropriate accommodationoUnable to cover leave (annual, study and sickness) oSkill-mix review and investigate other roles to support consultant

workloadoLong-term sustainability

Improvement of clinical governance, quality, safety and minimisation of clinical risk including the issues below:

o Reduce isolation, lone working and diagnostic drift and enable appropriate clinical mass

o Enable double reportingo Support to MDTso Reduction in caseload sent to external serviceo Reduction in turn around times


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o Reduction in legal claimso Support All Wales Bowel screening and Cervical screening programmeso Local control on qualityo Ability to standardise equipment, processes and procedures reducing

waste and variationo Reduction of breaches against Cancer targets

In line with national guidance including:o Royal College of Pathology Report o Future Delivery of Pathology Services in Wales

Impact on patients/public including:o Accessibility

To meet the needs of the health economy via Hywel Dda’s Five year Strategic Framework – ‘Right Care, Right Place, Right Time, Every Time…..’ which includes:

o Optimise the delivery of quality health care in the most appropriate setting

o Delivery of quality health services efficientlyo To make sure the right health care teams are available to give local

people the care that they needo To reduce harm and provide a better quality of serviceo Reduce waste and duplicationo Increase clinical team working, peer review and back up arrangement

Ability to meet CPA and HTA accreditation standards for laboratories which includes the following:

o Single quality management systemo Standardised processes and procedureso Appropriate workforce skill mixo Suitable accommodation and equipmento Continuous improvement process

Affordability including:o capital build costs or refurbishmento excess travel o equipmento transportation costs of specimenso costs of legal claimso CPA and HTA licensing costso Improved ability to meet financial targets

Workforce development and sustainability -impact on Consultant and technical staff including:

o Relocationo Training and developmento Support for regular clinical audit and review


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o Career structureo Working relationship between consultants and scientific staffo Recruitment and retention

Ability to Implement including;o Capacity to delivero Service accommodationo IT compatibility / connectivityo Transporto Availability of capital funding

The above drivers for change have been used as selection criteria and subsequently scored against the options for development.

5 OPTION APPRAISAL

5.1 DETAILED APPRAISAL

The Project Board initially identified ten options and detailed the respective advantages and disadvantages of each option (this report is available on request).

An extensive option appraisal was undertaken by the Project Board. Individual options were each allocated a consensus weighting. The options were scored against the selection criteria, detailed in section 4 above. (The Option Appraisal Scoring Schedule is attached as Appendix 1)

5.2 DISCUSSIONS WITH ABM UHB

As part of the option appraisal process, Project Board members (Cellular Pathology Lead, Project Lead, Pathology Manager and Project Support Manager) discussed the issues facing Cellular Pathology services with ABM UHB colleagues (Clinical Histopathology Lead and Pathology General Manager). ABM UHB colleagues confirmed they had currently a staffing establishment of 14 consultant histopathologists and they were in discussion with their Health Board for further consultants. They confirmed they had currently insufficient capacity to assist Hywel Dda because of their consultant numbers.

For the future, there was agreement of the potential need to work together in a networked approach. This would allow a critical mass of resources and allow consultants to specialise. There will be a willingness to discuss issues and needs in further detail, to enable both Health Boards to ensure future provision of a safe, sustainable and effective service.


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It was recognised there would be the requirement to establish a small working group to undertake a baseline assessment of activity and staffing resources. This may also give the impetus for other Pathology Services to work together on a regional basis.

5.3 HIGHEST SCORING OPTIONS

The highest scoring options are identified as follows:

Option Descriptor

Option 4a One centralised site for both consultants and laboratory services. The autopsy facility is contained within WWGH with 4 body stores

Option 4 One centralised site for both consultants and laboratory services leaving autopsy facilities on all sites.

Option 5 One centralised site for consultants and two laboratory sites

Option 7 South West Wales Regional Network approach – including Hywel Dda HB and ABM UHB

6 OPTION SHORTLIST

6.1 DISCOUNTED OPTIONS

The following two options have been discounted:

Option 7 –South West Wales Regional Network approach – including Hywel Dda HB and ABM UHB

This has been discounted as an immediate option due to the confirmation from ABM UHB colleagues that there is currently insufficient capacity to assist Hywel Dda. This option has not been costed at this time.


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Option 4 - One centralised site for both consultants and laboratory services, leaving autopsy facilities on all sites.

This option has also been discounted as the Project Board has considered that the option is not practical to implement due to the additional travel time required when consultants are needed to undertake autopsies on other sites. This option has not been costed at this time.

6.2 PREFERRED OPTIONS

The following two options have been identified as the preferred options:

Option 4a - One centralised site for both consultants and laboratory services. The autopsy facility to be contained within WWGH with 4 body stores

This option is the highest scoring and is the first choice option. It includes the centralisation for both consultants and laboratory services on one site.

WWGH has been identified as the centralised site for consultants due to the largest percentage of the work and the more complex cancer work being undertaken at WWGH and also as the new Mortuary facility is on this site.

The centralisation of laboratory services has been identified as ideally needing to be located within Carmarthenshire, due to the need to be in close proximity to the Consultants’ base. There is the requirement for Pathology Laboratory teams to work alongside clinical teams to maximise effectiveness.

This option creates a critical mass in test numbers enabling equipment to be fully utilised. Also the scientific staff workforce can be more efficiently developed with improvement in career progression.

Option 5 - One centralised site for consultants and two laboratory sites

This option again entails centralisation of consultants at WWGH for the reasons outlined above in option 4a. This option would require one consultant to travel daily to the WGH laboratory for Surgical Takes (cut-up) and for post mortems. Alternatively, cut-up could be transferred to the main site and sent back to WGH laboratory for processing.


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7 FINANCE

7.1 CURRENT BUDGET The current direct budget across the three counties stands at £2.748m which includes staffing and non-pay. This is shown in Appendix 2 together with the costs reflecting the two preferred options calculated on the basis of revised workforce models.

7.2 OUTLINE COSTING FOR THE 2 PREFERRED OPTIONS (4a and 5)

7.2.1 OPTION 4a - One centralised site for both consultants and laboratory services. The autopsy facility is contained within WWGH with 4 body stores

Centralisation of Consultants at WWGH

Consultant Workforce - Centralisation of the current establishment of 9 wte consultants does not realise savings against current budget, though benefits will accrue from avoiding expensive locum staff and the reduction in the cost of external agencies, depending on the ability to recruit to all posts.

Achieving some economies of scale in consultant posts could be possible, whilst at the same time agreeing to a future proofed model and establishment of Consultants. It is to be recognised that there are continuous increasing clinical demands on histopathologists, due to clinical expansion in a number of specialities and changes in clinical practise which have been largely unfunded to date. Examples include the Bowel Screening Programme and evening Endoscopy clinics at WGH.

Should centralisation of consultants release, for example 1 wte post, savings of £135,000 would be achievable. The potential for reduction will need to be tested fully at the next stage, in light of the emerging Royal College model, with the need for detailed activity analysis and consultant job planning.

Centralised Consultant Accommodation - An area has been identified at WWGH which would enable Consultants to work together. This would allow consultants in Histopathology, Cytopathology and Autopsy work at WGH and PPH to transfer to this site once the rooms have been refurbished, thus ensuring an improved working environment and a safer service. The capital costs of refurbishing this area circa £55,000, including equipment costs.

Centralisation of Laboratories including options at WWGH/PPH/WGH


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Laboratory Workforce (including Autopsy facilities)- Depending on the final staffing model agreed for a centralised laboratory and autopsy facility, savings achievable can be estimated as £64,000. There is the need for further discussion with HR regarding the staffing model, implications for staff and the projected timescales for savings to be achieved. Under this option it is assumed that Body storage facilities at the 3 remote sites are staffed by 2 wte band 3 at each location.

Non Pay - It is assumed that activity levels will not change materially as a result of this centralisation but benefits could accrue from standardisation of systems/processes. This will need to be tested fully at the next stage, but additional specimen transportation costs are assumed at £300 per week based on current costs, an additional £15,600 per annum.

Centralised Laboratory Accommodation - Capital Costs are not able to calculated at this stage. Currently there is no vacant appropriate accommodation for a centralised facility on any of the hospital sites and identification of space for this facility would be dependant on the clinical service model that will be agreed at part of the Five Year Strategy engagement process. It is not envisaged there would be the requirement for a new build, but, is likely to incur additional estates related costs including depreciation which will have to be scoped as part of a wider economic appraisal.

7.2.2 OPTION 5 - One centralised site for consultants and two laboratory sites

Savings on Consultant costs are the same as in Option 4a above.

If laboratories are kept at two sites there will be no opportunity for workforce savings within the laboratory staff cohort.

(Appendix 2 details the estimated costs of staffing skill mix (both Consultant and Scientific) within both options 4a and 5).

8 IN CONCLUSION

8.1 INCREMENTAL APPROACH

The Project Board proposes that a staged/incremental approach will need to be implemented as follows:

Phase 1 - This will include the effecting of Option 5 during late November 2010. Consultants will be centralised and transferred from WGH and PPH to WWGH.


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The refurbished Branwen Suite at WWGH will enable centralised accommodation for consultants.

Phase 2 - The second stage will include the full implementation of Option 4a. In addition to the centralisation of consultants, this stage will include the centralisation of laboratories and workforce. In parallel with the emerging Clinical Services Strategy, this solution will allow sufficient time for the laboratory accommodation facilities on WWGH, WGH and PPH sites to be further reviewed and detailed costings to be undertaken. It is anticipated this work will be undertaken by March 2011 with implementation of the laboratory centralisation by September 2011.

Conclusions have been made primarily to reduce risk, ensure safety and guarantee high quality Cellular Pathology service provision.

To inform future efficiencies, Cellular Pathology Services as a whole will need further consideration.

9 RECOMMENDATION

The Corporate Directors’ Group (CDG) is requested to agree the Cellular Pathology Services proposal for Phase 1 as outlined in Section 8 above, with immediate effect. It is the view of the Project Board that the incremental solution would deliver a more robust service with enhanced quality to the population of Hywel Dda Health Board and its surrounding border counties.

A full business case and economic appraisal of the preferred options for Phase 2 would then be undertaken subject to approval of this paper, and this can be commenced immediately.


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Hywel Dda Health Board

Histopathology Option Analysis

Options 4 &5 with Post Mortem Skill mix 3

With 9 Consultants

With 8 Consultants

With 9 Consultants

With 8 Consultants

Current£Annu

al Option 5 Option 5 Option 4a Option 4a

Summary

Sum of Budgeted WTE

Sum of Budget Cost

WTE £

WTE £

WTE £

WTE £

Consultant 9 1214122 134902 9 1214122 8 1079219 9 1214122 8 1079219Non-pay 0 312364.7 0 312365 0 312364.7 0 312364.7 0 312365

Transportation 0 0 - 0

- 0 15600.00 0 15600

Technical Band 2 3.62 62571.00 17285 3.6262571 3.6262571.00 0 - 0

-

Technical Band 3 4 75365.00 18841 4 75365 4 75365.00 6 113047.5 6 113048Technical Band 3 - Post Mortem 18841

- 6 113047.5 6 113048

Technical Band 4 4.54 106575 23475 4.54106575 4.54106575 4.8 112678.4 4.8 112678Technical Band 4 - Post Mortem 23475

-

- 4 93898.68 4 93898.7

Technical Band 5 6 174219 29037 6 174219 6 174219 0 - 0

-

Technical Band 5 - Post Mortem 29037

-

- 2 58073.00 2 58073

Technical Band 6 6.22 196050 31519 6.22196050 6.22196050 10 315192.9 10 315193Technical Band 7 10.19 383024 37588 10.2383024 10.2383024 6.5 244323.5 6.5 244323Technical Band 7 - Post Mortem 37588

-

- 1 37588.22 1 37588.2

Technical Band 8a 3 150992 50331 3 150992 3 150992 2 100661.3 2 100661Technical Band 8b 2 106220 53110 2 106220 2 106220 1 53110.00 1 53110

Admin Band 3 1 19354.00 19354 1 19354 1 19354.00 -

-

Admin Band 4 6 140286 23381 6 140286 6 140286 4 93524.00 4 93524Income 0 -193634 0 -193634 0 -193634 -193634 -193634Grand Total 55.57 2747509 55.62747509 54.62612606 56.32683598 55.32548695

Difference from Current cost

-

- 134902.4 63910.97 198813


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