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

5

6

7

8

Governance & Comms

Pay cost actions

Non-pay / all cost actions

Rapid actions

1

2

3

4

• 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.

0

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