pathology consolidation in england · 2019-09-20 · pathology pathology consolidation •...
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NHS England and NHS Improvement
Pathology Consolidation in England 29th August 2019
1. The drivers
History of consolidation in the NHS
Results : The Carter review
• Report saw £5bn of value opportunity 2020-21, if unwarranted variation removed.
• New Operational Productivity Directorate in NHSI to deliver report’s recommendations09.16)
The opportunity
Pathology Under the Microscope
Variation In Use Of MLA And BMS Staff In Acute Teaching Trusts
Average Non-Pay Cost Per Blood Sciences Test For Large And Medium Acute Trusts
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Improving the quality and value of NHS pathology services
Pathology Consolidation
NHS Improvement is working with trusts
to move towards 29 pathology networks
across England • Pathology is essential in over 70% of patient
pathways.
• High quality services, delivering timely results for
patients, will also support national priorities in genomics,
cancer care and integrated healthcare
• Currently there is national excess capacity in
equipment, yet we are seeing local workforce
shortages
• Variation of non-pay costs in routine testing from 2p to
£1.26 per test
• Networking at scale allows for better value, better
utilisation of capital equipment, faster turn around times
where required and more opportunities for the
workforce to undertake extended roles.
• NHS Improvement is engaging with the sector, with
strong support for the hub and spoke model
Workforce of 27
thousand
Processing 1.1 billion
tests per year
£2.2 billion
delivery cost
122 Pathology
providers
£2.2 billion
delivery cost
2. The aim
Financial
Operational
Clinical
• Allows for ESL to focus on what is clinically urgent and provide shorter TAT
• Allows for greater collaboration between pathologists, resulting in better quality
diagnoses
• Increases the standardisation of service across the UK
• The economies of scale benefits can lead to faster turn around time of routine
work and can enable the latest technology to be purchased
• Economies of scale benefits allow for better utilisation of expensive capital
equipment
• Less duplication of functions across the network such as HR, finance, logistics,
marketing etc
• Increased volume allows for greater negotiating power to drive down costs of
equipment, IT, reagents and consumables
• Improves service resilience through backup sites and increased workforce
• Networking across wider geographies provides a solution to localised recruitment
challenges
• Economies of scale allows for centralisation of low volume, high expertise testing
• Allows for standardisation of IT systems, logistics and result delivery
Benefits of consolidation
Modelling
Patient Flows
Population Size
STP Boundaries
Existing Partnerships
Analysis of 15/16 data
29 Networks
£200 million opportunity
Hub Shortlist
Network & methodology
Pathology
Pathology Consolidation
• Clinically lead service. Every result
issued has been monitored, reviewed or
commented upon by a medical clinician or
state registered (via HCPC) Biomedical or
Clinical Scientist.
• Integrated access to sub-specialty
expertise available for community,
primary, secondary and tertiary at a single
touch point. Scientists all have a sub-
speciality training, and have an active role
in many specialist MDT meetings.
• Accreditation and quality assurance
integral to service delivery. Pathology in
the UK has lead the way in clinical
accreditation for more than 20 years. UK
system is the basis of the current
international accreditation standard.
• Keen technology adopters. Moving
academic and novel technologies into
routine, safe, clinical practice.
Covers all healthcare across prevention, screening, monitoring and diagnosis from before conception
until post mortem. All with appropriate clinical and scientific support for local clinical teams.
3. Engagement and support
Communication & engagement
National engagement with key
stakeholders through National Pathology
Optimisation Delivery Group [NPODG]:
• Royal College of Pathologists
• Institute of Biomedical Science
• NHS England
• Regulatory bodies such as UKAS
• British in Vitro Diagnostics
Association
• Equipment suppliers
• Private sector operators
• Health Education England
• Workforce Representation Bodies
• Competition and markets authority
• NHS Digital / NHSx
• STPs
NPODG
Regulators
- UKAS
- CMA
- BIVDA
Clinical community
- RCPATH
- IBMS
Providers
- Trusts
- Private sector
providers
Suppliers
- Equipment
- Private sector
operators
Commissioners
- NHSE
- CCGs
Workforce
- Unions such as UNITE
- Health Education England
• Described and enabling 29 Pathology networks
• Publication of clinical and operational advice in the form of toolkits
• Development of specialist testing networks
• Facilitating network workshops involving clinical and operational teams
• Development and launch of the National Pathology Quality Assurance Dashboard:
• Identifying national funding and innovations:
Outputs
Pathology Consolidation
Data insights – Total costs
Barrier to consolidation Toolkit
Business case is too cumbersome and Carter compliance needs defining.
• Strategic Outline Case Template • Full Business Case Template
What services can be safely consolidated and how should a spoke service run?
• Essential Services Laboratory Template
How is risk shared? How are saving dispersed? Who is responsible for capital investment? How should a network be created and who is responsible for the operation?
• Commercial Structure Options • Operational Governance Guide • Clinical Governance Guide • Due diligence guide
IT will need large investment and is a significant barrier.
• IT Procurement Guide
How do I outsource my pathology and ensure I am getting the best deal?
• Pathology Outsourcing Guide
How do I structure the project of consolidating pathology services and what steps are involved?
• Network consolidation Framework Project Plan
What are the legal decisions that need to be made?
• Legal Watchpoints Framework
Pathology Toolkit Offering
Consolidation process toolkit support
https://improvement.nhs.uk/resources/pathology-networks-toolkit/
Consolidation lessons learnt
Lessons learnt from tPP
Commercial model guidelines
Extract from guideline document ‘Consolidated pathology network – Commercial structure and operational guide’ available on the
NHSI Improvement Hub at https://improvement.nhs.uk/resources/pathology-networks-toolkit/
Essential Services Laboratory
Principles
The ESL
The provision of laboratory services for the acute setting is vital to ensure safe patient care. We have developed a tool kit that describes the minimum service that should be available. ESL that vary from this toolkit should be justified using clinical evidence, or robust data to demonstrate efficient use of resources.
What does good look like
Clinical Governance • Clear leadership • Clear escalation points for local
issues
LIMS • Integration and full interoperability
Logistics • Harmonised with Hub • Timely
Quality • Provided by Hub • ISO 15189 • MHRA
Training • Supported by the Hub, delivered across the network
• Full rotation of staff
Business continuity • Clear robust, tested plans. • POC and emergency
procedures.
Implementation • Step change implementation, involving quality assessments and review
• Only the services needed to provide acute pathology provision should be commission in an ESL. All other work should be performed in the hub laboratory.
• Meet all regulatory and accreditation standards (MRHA, UKAS, HSE).
• Have a clear clinical and operational governance link to the Hub.
• Have a clear management structure. • True interoperability with the Hub, with a single LIMS
or full IT integration, common platforms and procedures.
• Full 24/7 rota, multidisciplinary assistant grades, aspiration towards multidisciplinary Biomedical Scientists.
• Have clear training strategy that is harmonised with the Hub laboratory, provided by staff supernumerary to the ESL.
• Have agreed performance metrics, service specification. Variation only where it is warranted.
improvement.nhs.uk/resources/pathology-networks-toolkit/
• Review service contracts – Level of cover versus clinical requirement.
• Review provision of complex testing against savings of retiring equipment and out sourcing
• Consolidation of consumables provider, with Trust and across aspirant network
• Consolidate referral activity to a single diagnostic provider.
Grip & Control: Action now
Inventory management
Non-recurrent
actions
Cash management
Procurement
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Governance & Comms
Pay cost actions
Non-pay / all cost actions
Rapid actions
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2
3
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• Consolidate referral activity to a single diagnostic provider.
• Review service contracts – Level of cover versus clinical requirement.
• Review logistics - operational delivery and contracting arrangements.
• Business cases and Capex review. • Demand management of testing –
RCPath/IBMS/ACB guidance
• Reduce reliance on agency / locums; • Review Out of hours arrangements
where the are outside of AfC • Review sample delivery time to reduce
out of hour staffing requirements • Review Consultant Job plans • Increase staff availability – remote and
flexible working • Improve staff retention –Training &
Development • Ensure all R&D activities are funded and appropriately priced.
• Consolidate referral activity to a single diagnostic provider.
• Demand management of testing – RCPath guidance
• Adopt just in time stock management • Introduction of automated stock
management systems to meet accreditation requirements and reduce staff time.
• Remove ad-hoc deliveries via improved stock management.
• Ensure all R&D activities are funded and appropriately priced.
• Sale of old equipment • Asset review. Consolidation on
technology type across disciplines
• Governance and cash management – PO or approved testing request route only.
• Capital and assets opportunities;
• Clear delivery plan on and around consolidation
• Engage staff and key stakeholders. Particularly Clinical users.
• Clinical need rather than clinical want
Drivers to achieve maximum efficiency
Incomplete network formation will reduce efficiency in the following areas: • Full realisation of pay savings (Requirement to maintain IT, Quality and Management
teams) • Logistics / transport • Liberation of estate costs from consolidation • Full realisation of non-pay savings (equipment, service contracts, consumables, IT) • Longer lead time to network set-up cost return on investment.
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10
20
30
40
50
60
70
80
90
100
Year 1 Year 2 Year 3 Year 4 Year 5
% Savings Possible in Network formation
% realisation of savings % realisation of savings % realisation of savings
4. Monitoring and approval
What does good look like?
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• Networks must benefit the NHS and have a patient focus.
• Clinically and scientifically lead.
• Training and education must complement both delivery of healthcare and sustainability of the future workforce.
• Advanced roles should be part of the future operating model.
• Innovation and research should be recognised as part of the networks function.
• Active engagement with workforce
Model Hospital – Cost per test
Spring 2018: NHS Improvement pathology networks
State of the Nation
1. Key actions
2. Key NHSI network consolidation check points
General next steps for networks
Confirmation of agreement with the composition of the network
Reassurance that commitment to managed service contracts will be postponed pending
agreement from NHSI
Agreement of approach at Executive Level
Commitment from all to timetable for Board agreement on a partnership or outsourcing
model with the aim of rationalising / Consolidating services
Formation of a project team / commitment to resources
A strategic outline business case, approved by all Boards for outsourcing of pathology
across a network
A governance structure, timetable and deliverables for a Steering Group to oversee
A local engagement plan
Written confirmation to NHSI that trust boards have formally agreed on pathology approach
with aim of rationalising NHS pathology services
Provide a written update on progress made to establish where services will be delivered, the
anticipated savings and implementation timeline
5. The State of the nation
National Update
*Or equivalent
Level of Engagement and continuing risk (%)
Agreement on local partnership operating model (%)
Networking on track and on target for 20/21 (%)
97% 89% 76%
Region (no. of Networks)
SOC* OBC* FBC*
London (5) 3 1 1
Midlands and East (8) 4 2 2
North (8) 8 1 0
South (8) 6 3 2
National Programme Updates
Carter Efficiency fund. - SoS has approved the remaining £50m Carter Capital Efficiency fund for Digital Diagnostics adoption and scale up. - Working with Office of Life Sciences to develop a how best to utilise this fund, likely to involve working with the Centres of
Excellence and Innovate UK. - The key theme of this fund will be added value and increased adoption. - Split between Pathology and Imaging programmes
NHS Digital – Unified Test List - First 350 lines of code delivered - NHS D working with NHE/I, PHE, RCPath - Seeking prioritisation list for next cohort of tests - Formal launch in April 2019 with next publication of
SNOMED CT
Publications State of the Nation (2019)
- Provide a public update to progress to date.
Microbiology and Histopathology ESL - Provide guidance and watch points for these services
in spoke laboratories
PQAD - Quality assurance tool monitoring laboratory
performance set out by the Barnes’ (2012) review
Highlights: • Networked provider demonstrating a
20% reduction on Cost per Test. • Network purchasing saving £26m over
life of contract. • Provider removes consultant shortage
issue by joining network. • Digital Pathology and interoperable
solution committed to by entire network.
• Existing networks expanding, and renewing commitment over longer periods
• Commitment extended into the Long Term Plan and People Plan
Lessons learnt and on going risks
Lessons learnt – to go further faster
• Greater commitments around Unified test list
• Programme funding to support each network
• Set IT and Digital Standards 5 years ago
• Greater and earlier connections into linked and aligned programmes.
• 5 FTE for a national programme is light
• More data insights to support the sector
Risks – to prevent continued progress forward:
• National, sustained commitment is vital.
• Regional Priorities need to respond to the national strategy, and visa versa
• Being able to influence Capital Spend to reward good
proactive
• Being able to align diagnostics to 100% of healthcare not just disease priorities groups.
• Shift between regulatory driven change to governance of the networks
Single message for success, be clear on the aim, know your red lines, pragmatic of the delivered proposal and understand the impact.
Questions?
Pathology Consolidation