Report on Pathology Laboratories in Northern Ireland

Report on Pathology Laboratories in Northern Ireland
SESSION 2001/2002 SIXTH REPORT
Ordered by the Public Accounts Committee to be printed 20th February 2002

Report: 06/01/R (Public Accounts Committee)

PUBLIC ACCOUNTS COMMITTEE
TOGETHER WITH THE PROCEEDINGS OF THE COMMITTEE RELATING
TO THE REPORT AND THE MINUTES OF EVIDENCE

Table of Contents

SIXTH REPORT
THE PUBLIC ACCOUNTS COMMITTEE HAS AGREED
TO THE FOLLOWING REPORT:

PATHOLOGY LABORATORIES IN NORTHERN IRELAND

INTRODUCTION

1. The Public Accounts Committee met on 29 November 2001 to consider the Comptroller and Auditor General's Report on his "Review of Pathology Laboratories in Northern Ireland" (NIA 31/00, Session 2000-01). Our witnesses were:
n Mr Clive Gowdy, Accounting Officer, Department of Health, Social Services and Public Safety (DHSSPS)

• Mr Brian Grzymek, Director of Secondary Care, DHSSPS
• Dr Glenda Mock, Senior Medical Officer, DHSSPS
• Mr John Dowdall, Comptroller and Auditor General (C&AG)
• Mr Brian Delaney, Deputy Treasury Officer of Accounts, Department of Finance and Personnel (DFP)

2. The Committee also took Written Evidence from Mr Gowdy (Appendix 1).

3. The Department of Health, Social Services and Public Safety is responsible for providing or ensuring the provision of health and social care for the population of Northern Ireland. It is therefore responsible for ensuring that pathology laboratory services, which play an essential part in such provision, are organised and managed in such a way that they are able to provide that support, efficiently, effectively and making the best use of resources.

4. Expenditure on laboratories is approximately £54 million annually. The service is provided by a workforce of around 870 people who process some 6½ million tests each year.

5. In taking evidence, the Committee focused on four main issues:

• the strategic role exercised by the Department and the progress which has been made in securing desirable rationalisation;
• the steps taken by the Department to ensure that the services provided by laboratories are of the highest quality;
• the organisation of the pathology workforce, in particular the level of consultant cover and the grading system that exists for other staff; and
• the steps being taken by the Department to address the variations in the costs of laboratory work and the prices of specific tests.

OUR PRINCIPAL CONCLUSIONS AND RECOMMENDATIONS ARE AS FOLLOWS:

6.1 In view of the considerable problems being faced by the health service, this Committee would urge the Depart-ment to set out its proposals for the future organisation of pathology services as soon as possible. Uncertainty brings with it a lowering of morale and the potential for inefficiency and waste. The Committee would also be interested to see the recommendations of the Department's own Review of the Pathology Service when it is completed.
Main Report paragraph 12.

6.2 We fully accept that it doesn't make sense to rationalise laboratories until the acute service is rationalised. What is disappointing, however, is that it is clear from the C&AG's report that the need for rationalisation was accepted in 1983, yet no progress was made in reducing the overall number of laboratory services until the late 1990s and only slow progress has been made since then. This is inexcusable. It also seemed to us that, in an area the size of Yorkshire, yet with a much smaller population, there is no argument in favour of having 14 laboratory sites.
Main Report paragraph 14.

6.3 We are not satisfied that we have been given an adequate response to our questions about the sending of tests by the Lagan Valley and Downe Hospitals to Belfast laboratories and the use of on-line access facilities. If the Lagan Valley and Downe Hospitals have been able to manage effectively, over a lengthy period, without on-site laboratory facilities, it is essential that the Department give full consideration to incorporating off-site testing in the options reviewed. The Committee expects to be assured that, following the reorganisation of acute hospitals, all such options will be reviewed.
Main Report paragraph 17.

6.4 There has already been a considerable delay since the date that the proposals were made to move services from the Belvoir Park Hospital to the Belfast City Hospital and it is clear that the opening of the new facility is still some years off.
Main Report paragraph 20.

6.5 We are concerned at the lapsed time taken to implement these proposals, which were generated to improve the arrangements for care and treatment of patients. We view this delay as wholly unacceptable. Delay in implementation will inevitably adversely affect overall patient care. We therefore urge the Department to ensure that future delays are minimised.
Main Report paragraph 21.

6.6 We will be monitoring developments in the future organisation of services both at the Belfast City and Craigavon Area Hospitals. Although we welcome the movement, albeit slow, towards rationalising the service where improved efficiency is the intended outcome, we would like the Department's assurance that the care of patients still attending the Belvoir Park Hospital and those previously attending the South Tyrone Hospital is in no way compromised by the decisions to move.
Main Report paragraph 24.

6.7 The Department's policy, over many years, has been that quality and safety of care should have primacy over the geographical accessibility of services. We were concerned to note, from the C&AG's Report, that in June 2000, only 45 per cent of the pathology services throughout Northern Ireland had been unconditionally accredited and 18 per cent had been conditionally accredited.
Main Report paragraphs 25 and 26.

6.8 We see from the C&AG's Report that the conclusions and recommendations emanating from the 1995 NHS Strategic Review of Pathology Services in Great Britain were endorsed by the Department in 1997 and that these included the requirement for purchasers and providers of health services to incorporate accreditation or a commitment to obtain accreditation as a condition of any pathology contract. We also noted that the absence or non-involvement of consultants and the absence of accreditation were key points raised by the review, in 1997, into the failures of the Kent and Canterbury Hospitals Trust histopathology department.
Main Report paragraph 30.

6.9 The Department blames accommodation problems and a shortage of consultant staff. While we recognise that the health service has undergone considerable organisational change over the last ten years, we must point out that these problems were highlighted as long ago as 1982. In referring to the Clinical Pathology Accreditation (CPA) system, the Accounting Officer talked of the best becoming the enemy of the good and he placed reliance on the External Quality Assessment (EQA) scheme, where the quality of services is checked frequently and has always met the scheme's standard. However, he also told us that the wider accreditation, through the CPA Scheme, of the totality of the laboratories and their provision had not been addressed.
Main Report paragraph 31.

6.10 We are not satisfied that sufficient emphasis has been placed by the Department on the need to ensure that services are fully accredited. Although the Accounting Officer was able to tell us that more laboratories had achieved complete or partial accreditation since the C&AG's report, he also admitted to us that the Altnagelvin Hospital's haematology service and the laboratories at the Mater Hospital had had their accreditation withdrawn because they did not have the requisite consultant cover. He told us that the same services would continue to be provided, which leads us to speculate on the Department's whole attitude.
Main Report paragraph 32.

6.11 We are unconvinced of the sufficiency of how this policy is being implemented, particularly as the Accounting Officer accepted that everyone should strive for accreditation. When pressed on this issue, he acknowledged that the service was getting by, but it was not what he would like it to be.
Main Report paragraph 33.

6.12 It is of vital importance that any delay experienced in the transfer of services from Belvoir Park to Belfast City Hospitals does not lead to a reduction in the high quality of service provided at present. Although the laboratories at the Belfast City Hospital are fully accredited, we do not see how those at Belvoir can automatically be assumed to be incorporated within that assessment rating, merely because of an ownership transfer. We are aware of the problems of ageing equipment at Belvoir and we impress on the Department the importance of keeping standards of care for patients at the highest level during this interim period. We agree with the Department's decision to go ahead with the replacement of equipment and urge it to implement this as soon as possible.
Main Report see paragraph 36.

6.13 We asked the Accounting Officer about the retention of human organs inquiry, which was set up by the Minister in 2001. While we accept the response that the issue only became apparent when it emerged in England and was then investigated in Northern Ireland, it is our view that this issue is, nevertheless, disturbing. It underlines the extent to which the Department is remote from the actual practice for which it is supposed to be responsible in the health service. We don't think it unreasonable to expect the Department to be more conversant with these matters.
Main Report paragraphs 37 and 38.

6.14 We would urge the Department to complete its review regarding the retention of organs as soon as possible. We would also like the Department to recognise that it has a prime responsibility for safeguarding the interests of the public at large, and particularly the sick and their relatives.
Main Report paragraph 40.

6.15 The Committee noted, from the C&AG's report, that a number of consultant pathologist posts throughout Northern Ireland were vacant and the Accounting Officer acknowledged that, of the 78 consultant posts in pathology, only 68 posts were currently filled.
Main Report paragraph 41.

6.16 We find it difficult to understand or accept the Accounting Officer's view that the service, at present, is comprehensive and adequate to meet people's needs. The Department has established that it needs a complement of 78 consultant pathologists to operate an efficient and effective service. Whilst the Committee appreciates that there is a very high standard of service being given by the staff who are in post, it is inconceivable that the service is able to operate to the required level of efficiency and effectiveness with understaffing approaching 13 per cent. An absence of permanent on-site consultant cover at major centres of acute hospital care, such as Altnagelvin Hospital, is unacceptable.
Main Report paragraph 44.

6.17 We recognise that there are difficulties in recruiting people to pathology, but we impress on the Department the need to explore every option to encourage suitable applicants to come forward. We consider it a great pity that the Department had not done more to bring this problem into the public arena.
Main Report paragraph 45.

6.18 We endorse the recommendation of the C&AG that there needs to be an objective reappraisal of how the technical staff grading and payment system is applied, to ensure that future placements and regrading are made on an equitable basis across the service and that discretionary payments are only awarded for the purposes for which they were intended. The Committee is totally behind the principle that pay must be seen to be sufficient to attract appropriately qualified staff and it should be applied equitably throughout the service, recognising the value of experience and skills.
Main Report paragraph 47.

6.19 We noted the Accounting Officer's acknowledgement that his Department was not engaged in benchmarking prior to the C&AG's Report. While this is surprising, given that the value of benchmarking had been recognised, we welcome the fact that the Accounting Officer is now committed to introducing suitable measurements.
Main Report see paragraph 49.

6.20 The Committee is also encouraged by the statement from the Treasury Officer of Accounts that the new guidance to be issued by the Department of Finance and Personnel on service delivery agreements would emphasise the importance of benchmarking as a performance measurement and monitoring tool.
Main Report paragraph 50.

6.21 The Committee asked the Accounting Officer about the comparative prices charged for undertaking tests in different hospitals in Northern Ireland and between Northern Ireland and in the sample of NHS hospitals listed in the C&AG's Report. 80 per cent of the prices quoted were higher in Northern Ireland. We expressed our astonishment at some of the wide price variations shown.
Main Report paragraphs 51 and 53.

6.22 It cannot be acceptable that, as an example, the price of a pregnancy test is £14.20 in one place in Northern Ireland and only £2.05 in another. Similarly, it cannot be a measure of consistency in costing that one Trust charges the same price for all tests within a specialism, yet other Trusts cost each test individually. Any attempt to measure cost effectiveness in these circumstances must be meaningless. Moreover, there is a significant point of accounting principle concerned with the recovery of costs at laboratories. We welcome the fact that the Department has stipulated the importance of recovering full costs in contracts and the need to ensure that there is no cross-subsidy between contracts.
Main Report paragraphs 54 and 56.

6.23 We also welcome the fact that work is progressing in the development of common protocols for carrying out tests. The Department must not place reliance solely on the participation of laboratories in accreditation schemes. While these might give assurance on the quality of testing, the Department must also take into account the efficiency of the process. To measure that efficiency, it is important to be comparing activity performed in the same way in all laboratories.
Main Report paragraph 62.

6.24 We therefore urge the Department to do all it can to promote the wide-spread use of common protocols throughout the pathology service, beginning with the adoption of those that are in place elsewhere. We also expect the Department to monitor progress in this area
Main Report paragraph 63.

6.25 The Department needs to review how workload is measured, so that it can properly benchmark activity at different locations. This should be acceptable to all laboratories. We would expect the Department to be able to satisfy us that it has taken action to resolve this difficulty within a reasonable timescale.
Main Report paragraph 65.

GENERAL FINDINGS

7. To us as public representatives, the health service presents a particularly worrying problem because it combines both an urgent need for additional funding, with disturbing evidence of poor value for money in many areas* but particularly in the two areas that this Committee has looked at to date. It is difficult to resist the conclusion that the snail's pace on improvement of the structure for the rationalisation of pathology services, the need for which was recognised in 1982, reflects a long-standing weakness in the Department's pursuit of value for money on behalf of the tax-payer. This needs to change dramatically and the Department needs to raise its game substantially if the public is to have confidence that the extra resources which they are being asked to provide are being effectively used.

MAIN REPORT

THE STRATEGIC ROLE EXERCISED BY THE DEPARTMENT AND THE PROGRESS WHICH HAS BEEN MADE IN SECURING DESIRABLE RATIONALISATION

8. The Department's policy on laboratory services was promulgated in 1983. This policy accepted that laboratory services should be concentrated, as far as possible, on six main sites (the Royal Victoria, Belfast City and Ulster Hospitals in Belfast, and the Antrim, Craigavon and Altnagelvin Hospitals). Resources were not to be used to establish new laboratories, or to indefinitely perpetuate existing small laboratories which provided a full range of routine services for a limited local demand, except in special circumstances.
C&AG's report* paragraphs 1.6 - 1.8

9. In the early-1990s, reforms in the health service led to the establishment of Health and Social Services Trusts to provide health and social care within an internal market. In response to concerns within the pathology profession as to the potential effects of this, the Department confirmed that the 1983 policy was still current. As very little action arising from the policy had taken place, it was accepted, in 1992, that there were still too many laboratories.
C&AG's report paragraphs 1.12 - 1.15

10. The Committee noted that, although there have been some changes in the distribution of laboratory services since 1983, there was no reduction in the overall number of services from then until 1999. We asked the Accounting Officer what action the Department had taken to implement its policy during that period and what plans it had to reduce the number of laboratories. We were told that the number of laboratories has reduced since 1999 as a result of the rationalisation of some services within Belfast and elsewhere.
C&AG's report paragraphs 2.1 and 2.3 and Minutes of Evidence, paragraphs 4 - 6.

11. We also asked about the implications for the profile of laboratory services arising out of the recommendations of the report on Acute Hospitals, published in June 2001. The Accounting Officer advised us that responses to a subsequent consultation exercise were being evaluated and the Minister intended to publish proposals early in 2002. This would also take account of the results of the Department's own review of pathology services.
Minutes of Evidence, paragraphs 7, 8, 11 and 12.

12. In view of the considerable problems being faced by the health service with its current level of resources and its present configuration of structures and divided responsibilities, this Committee would urge the Department to set out its proposals for the future organisation of pathology services as soon as possible. Uncertainty brings with it a lowering of morale and the potential for inefficiency and waste. The Committee would also be interested to see the recommendations of the Department's own Review of the Pathology Service when it is completed.

13. The Accounting Officer told us that laboratories must be linked closely to where acute services are located as they provide essential services to deal with emergency and trauma cases, which need an immediate response. Laboratory services must, therefore, be available on site. He accepted that there was a little more leeway in testing samples that are not of a life-and-death nature and those services can be provided more remotely.
Minutes of Evidence, paragraphs 48 and 49.

14. We fully accept that it doesn't make sense to rationalise laboratories until the acute service is rationalised. What is disappointing, however, is that it is clear from the C&AG's report that the need for rationalisation was accepted in 1983, yet no progress was made in reducing the overall number of laboratory services until the late 1990s and only slow progress has been made since then. This is inexcusable. It also seemed to us that, in an area the size of Yorkshire, yet with a much smaller population, there is no argument in favour of having 14 laboratory sites.
Minutes of Evidence, paragraph 44.

15. Although the Department has maintained that the siting of the main laboratory specialties is determined by the needs of the hospital concerned, we noted that the Lagan Valley and Downe Hospitals do not have on-site laboratory facilities, sending their tests instead to Belfast laboratories. These hospitals have also had use of on-line access facilities since the early 1980s. We therefore asked the Accounting Officer what consideration had been given by the Department, during its various reviews, to providing off-site services.
C&AG's Report paragraphs 2.5 - 2.10 and Minutes of Evidence, paragraph 36.

16. The Accounting Officer told us that, when the full range of acute hospital services is established, this will allow the Department to concentrate the major laboratory sites next to the major hospitals. They would then deal with the linkages that must be made with the smaller hospitals. They were unable to make decisions yet, as they were still in the midst of a political debate regarding the siting of acute hospitals.
Minutes of Evidence, paragraphs 37 - 39 and 48 - 49.

17. We are not satisfied that we have been given an adequate response to this matter by the Accounting Officer. We re-emphasise our recognition of the link between acute hospitals and laboratory service provision. However, if the Lagan Valley and Downe Hospitals have been able to manage effectively, over a lengthy period, without on-site laboratory facilities, it is essential that the Department give full consideration to the opportunities being provided through changing technology, and to incorporating off-site testing in the options reviewed. The Committee expects to be assured that, following the reorganisation of acute hospitals, all such options will be reviewed.

18. In its strategic proposals* issued in 1998, the Department had announced its intention to resite radiotheraphy, chemotheraphy and the related laboratory services, from Belvoir Park Hospital to the Belfast City Hospital. In view of a delay in implementing these proposals, we asked the Accounting Officer for his comments on the latest position. 
C&AG's Report, paragraph 1.25 and Minutes of Evidence, paragraph 13.

19. He referred to the creation of the cancer centre at Belfast City Hospital, supported by four cancer units through-out the Province. He told us that work is well in hand with the unit at Craigavon now up and running. However, the transfer of services to the Belfast City Hospital creates the need for a new building and facilities for which a business plan, based on a cost of some £30 million, has been submitted by the Belfast City Hospital Trust. The Trust decided that it wanted to develop the project further and a new plan estimates the cost to be £56 million to £59 million. The Accounting Officer told us that he wanted to ensure that the jump in expenditure was justified, but hoped to be able to progress quickly to implementation stage. We note from an Assembly answer* that Department of Finance and Personnel approval has been given to the business case.
Minutes of Evidence, paragraphs 14- 16 and 20.

20. There has already been a considerable delay since the date that the proposals were made to move services from the Belvoir Park Hospital to the Belfast City Hospital and it is clear that the opening of the new facility is still some years off. We welcome the Department's determination to ensure that the Trust's proposals and costs are justified and it is important to take the views and advice of others before coming to a final decision.

21. Nevertheless, we are concerned at the lapsed time taken to implement these proposals, which were generated to improve the arrangements for care and treatment of patients. We view this delay as wholly unacceptable. Delay in implementation will inevitably adversely affect overall patient care. We therefore urge the Department to ensure that future delays are minimised, where possible, and that this facility is given very high priority status when the Department reviews the distribution of its resources.
22. Acute services have been transferred from the South Tyrone Hospital to Craigavon Area Hospital and, as a consequence, the laboratories at South Tyrone have closed and testing has also transferred, a move which the Accounting Officer advised us was a temporary one, pending decisions on acute services across the Province. We asked about the impact on turnaround times for test results and whether the move had had an adverse effect on the timing and quality of results. We were told that the move has imposed some additional pressure on the Craigavon laboratory, but the impact on service delivery has not led to any significant increase in turnaround times.
Minutes of Evidence, paragraphs 93 - 100 and Appendix 1.

23. We asked about the financial impact of the move to Craigavon. The Accounting Officer asserted that the move was concerned with ensuring that the Department was able to provide safe and effective services, rather than saving money. He acknowledged that one of the major underlying factors in the need to rationalise and reconfigure services is the desire that the Department has the benefits of aggregating specialties in different places and bringing all the support services in round them. The present temporary arrangements are more costly than before and money has had to be put in to support the services. There will also be costs involved in the building that will eventually be needed to fulfil requirements in some areas. He estimated the additional laboratory costs resulting from the transfer, which have been funded by the Southern Board, to be an additional one-off cost of £60,000 and on-going costs of some £6,000 per annum for the transport of specimens.
Minutes of Evidence, paragraphs 102 - 110 and Appendix 1.

24. We will be monitoring developments in the future organisation of services both at the Belfast City and Craigavon Area Hospitals. Although we welcome the movement, albeit slow, towards rationalising the service where improved efficiency is the intended outcome, we would like the Department's assurance that the care of patients still attending the Belvoir Park Hospital and those previously attending the South Tyrone Hospital is in no way compromised by the decisions to move.

THE STEPS TAKEN BY THE DEPARTMENT TO ENSURE THAT THE SERVICES PROVIDED BY LABORATORIES ARE OF THE HIGHEST QUALITY

25. The Department's policy, over many years, has been that quality and safety of care should have primacy over the geographical accessibility of services. Commissioners of health care are expected to take this into account when entering into contracts with those hospitals and other bodies that provide that care. In relation to pathology laboratories, the Department told its Pathology Advisory Committee, back in 1992, that standards in laboratories would be protected through the accreditation process, which would provide a hall-mark of performance.
C&AG's Report, paragraphs 3.1 - 3.3

26. We were concerned to note, from the C&AG's Report, that in June 2000, only 45 per cent of the pathology services throughout Northern Ireland had been unconditionally accredited and 18 per cent had been conditionally accredited. While some services were then in the accreditation process, we noted that one service had been refused unconditional accreditation and 28 per cent of services had not even applied for accreditation.
C&AG's Report, paragraphs 3.5 and 3.6

27. We questioned the Accounting Officer about this deficiency and why Health Boards and general practitioners were still using laboratories which are not accredited. We also asked him about the two methods of accreditation used; the process run by the Clinical Pathology Accreditation (CPA) (UK) Ltd, a nationally recognised company set up by the pathology profession itself, and which has defined standards for the organisation and performance of laboratories and monitors compliance with these standards; and the National External Quality Assessment (EQA) Schemes, which provide a means of comparing the quality of a laboratory's performance in the accuracy of its analytical work, with national performance. The Accounting Officer referred to accreditation as a useful badge that allows everyone to feel satisfied that a rigorous test has been passed.
C&AG's Report, paragraphs 3.4, 3.7 and 3.8 and Minutes of Evidence, paragraphs 21 and 25.

28. We were told that the CPA scheme covered both service quality and the wider issues of accommodation and staffing. There are difficulties with staffing and accommodation that would create problems in using the CPA methodology at present. However, the Department is delaying investing in accommodation, pending decisions on rationalisation. The Accounting Officer indicated that if CPA accreditation was refused, it would be counterproductive, in that laboratory services could not be provided. He told us "we do not want to shoot ourselves in the foot by applying a standard that does not deal with laboratory provision in terms of service to hospitals".
Minutes of Evidence, paragraphs 22, 25 and 27.

29. He accepted that CPA accreditation of the totality of the laboratories and their provision has not been addressed, reliance being placed on the EQA Scheme, through which all laboratory services were tested regularly. He advised us that these tests are being passed and he was satisfied that general practitioners and hospitals are getting the laboratory services that they need. He described the standard of laboratory services in respect of their ability to analyse and test samples as first class. However, he said that it was desirable that all laboratories should be assessed under the CPA system.
Minutes of Evidence, paragraphs 23, 25 and 45.

30. We see from the C&AG's Report that the conclusions and recommendations emanating from the 1995 NHS Strategic Review of Pathology Services in Great Britain were endorsed by the Department in 1997, and that these included the requirement for purchasers and providers of health services to incorporate accreditation or a commitment to obtain accreditation as a condition of any pathology contract. We also noted that the absence or non-involvement of consultants and the absence of accreditation were key points raised by the review, in 1997, into the failures of the Kent and Canterbury Hospitals Trust histopathology department.
C&AG's Report, paragraphs 1.18 - 1.20, 3.9 - 3.15 and Appendix 3 of C&AG's Report.

31. The Department blames accommodation problems and a shortage of consultant staff. While we recognise that the health service has undergone considerable organisational change over the last ten years, we must point out that these problems were highlighted as long ago as 1982. In referring to the CPA accreditation system, the Accounting Officer talked of the best becoming the enemy of the good and he placed reliance on the EQA scheme, where the quality of services is checked frequently and has always met the scheme's standard. However, he also told us that the wider accreditation, through the CPA Scheme, of the totality of the laboratories and their provision had not been addressed.
Minutes of Evidence, paragraphs 23, 126 and 127.

32. We are not satisfied that sufficient emphasis has been placed by the Department on the need to ensure that services are fully accredited. Although the Accounting Officer was able to tell us that more laboratories had achieved complete or partial accreditation since the C&AG's report, he also admitted to us that the Altnagelvin Hospital's haematology service and the laboratories at the Mater Hospital had had their accreditation withdrawn because they did not have the requisite consultant cover. He told us that the same services would continue to be provided, which leads us to speculate on the Department's whole attitude.

33. We are unconvinced of the sufficiency of how this policy is being implemented, particularly as the Accounting Officer accepted that everyone should strive for accreditation. When pressed on this issue, he acknowledged that the service was getting by, but it was not what he would like. He told us that while they were not achieving the best possible service, they were still delivering laboratory services to a high standard. In order to assure the public, he told us that the laboratories were doing the job for which they were put in place.
Minutes of Written Evidence, paragraphs 131 - 134.

34. In a response to written Assembly questions in May 2001 (AQW 2695/00 & 2714/00), the Minister of Health, Social Services and Public Safety commented on an incident at the Royal Group of Hospitals Trust, where incorrect results had been given to haemophiliac patients after they had been tested for Hepatitis C. We sought the Accounting Officer's assurance that these problems were not in any way linked to the fact that the haematology laboratories in question had not been fully accredited and whether this was evidence of the need for compulsory accreditation. We were pleased to be given an absolute assurance that these errors were not linked to the accreditation problem at that hospital.
Minutes of Evidence, paragraphs 135 - 138.

35. We referred back to the position at the Belvoir Park Hospital and asked why no application had been made for the accreditation of Belvoir Park Hospital's laboratories. We were concerned that the delay in transferring services from that hospital to the Belfast City Hospital might have an impact on the quality of the service being given at Belvoir. The Accounting Officer told us that staff had been transferred to the Belfast City Hospital Trust and that all laboratories are now part of the Belfast City Hospital's laboratory provision. While the Belvoir Park site provided a high quality service, the equipment there was old. The Department had hoped to furnish the new Belfast City Hospital site with new equipment and let the old equipment come to the end of its useful life at the Belvoir Park site but the delay in setting up the new centre at the Belfast City Hospital has meant that new equipment will have to be installed at the Belvoir Park site and then moved across.
C&AG's Report, paragraph 1.25 and Minutes of Evidence, paragraphs 17 - 20.

36. It is of vital importance that any delay experienced in the transfer of services from Belvoir Park to Belfast City Hospitals does not lead to a reduction in the high quality of service provided at present. Although the laboratories at the Belfast City Hospital are fully accredited, we do not see how those at Belvoir can automatically be assumed to be incorporated within that assessment rating, merely because of an ownership transfer. We are aware of the problems of ageing equipment at Belvoir and we impress on the Department the importance of keeping standards of care for patients at the highest level during this interim period. We agree with the Department's decision to go ahead with the replacement of equipment and urge it to implement this as soon as possible.

37. Although not referred to in the report under review, we asked the Accounting Officer about the retention of human organs inquiry, which was set up by the Minister in 2001. The Accounting Officer told us that his Department did not know that human organs were being kept for reasons that were outside the remit. This only became apparent when the issue emerged in England and was then investigated in Northern Ireland.
Minutes of Written Evidence, paragraphs 30 and 31.

38. While we accept this response, it is our view that this issue is, nevertheless, disturbing. It underlines the extent to which the Department is remote from the actual practice for which it is supposed to be responsible in the health service. We don't think it unreasonable to expect the Department to be more conversant with these matters.

39. The Committee was told of the deficiency in the post-mortem consent procedure and the actions taken by the Trusts to improve practices to ensure that proper consent is given in future. When we asked the Accounting Officer to assure us that proper consent procedures were in place in other aspects of pathology, we were told that the Department had learnt from the process and that the practice had changed substantially. The outcome of the current review will allow the Department to make any further changes that are necessary.
Minutes of Evidence, paragraphs 32 - 35.

40. We would urge the Department to complete its review regarding the retention of organs as soon as possible. We would also like the Department to recognise that it has a prime responsibility for safeguarding the interests of the public at large, and particularly the sick and their relatives. We would urge them to be more proactive on their behalf to ensure that such incidents are not repeated.

THE ORGANISATION OF THE PATHOLOGY WORKFORCE, IN PARTICULAR THE LEVEL OF CONSULTANT COVER AND THE GRADING SYSTEM THAT EXISTS FOR OTHER STAFF

41. The Committee noted, from the C&AG's report, that a number of consultant pathologist posts throughout Northern Ireland were vacant and the Accounting Officer acknowledged that, of the 78 consultant posts in pathology, only 68 posts were currently filled. At the same time there are increasing demands on the service as a result of a number of factors, including concerns about quality in the cytology field, the development of the breast cancer screening programme and the implementation of the policy to establish more cancer centres.
C&AG's Report, paragraphs 4.2 - 4.7 and Minutes of Evidence, paragraphs 139 and 140.

42. We had already been told that the accreditation of some laboratories has been withheld, and of other laboratories withdrawn, as a result of a lack of consultant cover. We are also aware that inadequate consultant cover was determined to be a major contributory factor in the failure of the systems at the Kent and Canterbury Hospitals Trust, which led to a large number of patients being given incorrect results from cervical screening tests. We asked the Accounting Officer whether the absence of consultant cover restricted the range of conditions that some hospitals can treat. We were told that the networked approach adopted by the Department, has allowed it to maintain services, with consultants covering more than one site.
C&AG's Report, paragraphs 3.6, 3.9 - 3.11 and Minutes of Evidence, paragraphs 60 - 65.

43. When we questioned the Accounting Officer about what the Department was doing to remedy the situation and to train consultants to fill the vacancies, we were told of its annual medical workforce plan, which aims to review the number of posts currently in place against the number needed and the staff occupying those posts, along with a profile of predicted retirement ages and other wastage factors. We were also advised of a shortage of consultant pathologists throughout the United Kingdom, particularly in special fields such as histopathology and the Department is in contact with its English counterpart over increasing the number of training places in pathology. Attracting people to pathology was claimed to be an uphill struggle, as issues such as the organ retention problem tend to put off young medical students, who view pathology as a less attractive option. We were assured that the funding of these posts is not a problem.
Minutes of Evidence, paragraphs 67 and 141 - 149.

44. We find it difficult to understand or accept the Accounting Officer's view that the service, at present, is comprehensive and adequate to meet people's needs. The Department has established that it needs a complement of 78 consultant pathologists to operate an efficient and effective service. Whilst the Committee appreciates that there is a very high standard of service being given by the staff who are in post, it is inconceivable that the service is able to operate to the required level of efficiency and effectiveness with understaffing approaching 13 per cent. An absence of permanent on-site consultant cover at major centres of acute hospital care, such as Altnagelvin Hospital, is unacceptable.

45. We recognise that there are difficulties in recruiting people to pathology, but we impress on the Department the need to explore every option to encourage suitable applicants to come forward. We consider it a great pity that the Department had not done more to bring this problem into the public arena. These posts fulfil a pivotal role in ensuring that a quality service is provided and this is essential to ensure that the public retains its confidence in the health services.

46. The Committee, while recognising the valuable work that is carried out by staff in the pathology service, did not specifically question the Accounting Officer about the numbers and grading of laboratory staff or about the award of discretionary pay. However, we are aware of the interest of Assembly members in these matters following a debate in November 2000. We have also noted what the C&AG had to say on the subject in his report.

47. We endorse the recommendation of the C&AG that there needs to be an objective reappraisal of how the technical staff grading and payment system is applied, to ensure that future placements and regrading are made on an equitable basis across the service and that discretionary payments are only awarded for the purposes for which they were intended. The Committee is totally behind the principle that pay must be seen to be sufficient to attract appropriately qualified staff and it should be applied equitably throughout the service, recognising the value of experience and skills.
C&AG's Report, paragraph 4.22 and Minutes of Evidence, paragraph 2.

THE STEPS BEING TAKEN BY THE DEPARTMENT TO ADDRESS THE VARIATIONS IN THE COSTS OF LABORATORY WORK AND THE PRICES OF SPECIFIC TESTS

48. The C&AG's Report showed that there were significant variations in costs between hospitals in Northern Ireland and that the level of spending on laboratories here is generally higher than in England and Wales. We drew the Accounting Officer's attention to the recommendation in that report that the Department should introduce performance measurements which provide benchmarks across the range of pathology specialties. When we asked him for his views on this and whether his Department had issued guidance on benchmarking, he accepted the importance of benchmarking in securing value for money. He wished to be sure that every laboratory benchmarked itself against others, both in Northern Ireland and elsewhere, and he informed us of an initiative which calculates comparative total costs or reference costs for each Trust in order to produce an accurate cost-per-test. He acknowledged that, prior to the C&AG's report, the Department had not been engaged in the necessary benchmarking but he accepted that it was now committed to benchmarking.
Minutes of Evidence, paragraphs 51 - 53, 72 - 75 and 91.

49. We noted the Accounting Officer's acknowledgement that his Department was not engaged in benchmarking prior to the C&AG's Report. While this is surprising, given that the value of benchmarking had been recognised, we welcome the fact that the Accounting Officer is now committed to introducing suitable measurements.

50. The Committee is also encouraged by the statement from the Deputy Treasury Officer of Accounts that the new guidance to be issued by the Department of Finance and Personnel on service delivery agreements would emphasise the importance of benchmarking as a performance measurement and monitoring tool.
Minutes of Evidence, paragraphs 54 and 55.

51. The Committee asked the Accounting Officer about the comparative prices charged for undertaking tests in different hospitals in Northern Ireland, and between Northern Ireland and the sample of NHS hospitals listed in the C&AG's Report. 80 per cent of the prices quoted were higher in Northern Ireland.
C&AG's Report, paragraphs 5.10 - 5.16 and Minutes of Evidence, paragraph 69.

52. The Accounting Officer said that he was not surprised at the differences. He suggested that prices here might be higher because laboratory services in England were based around district general hospitals which were substantially larger than most hospitals in Northern Ireland and were therefore able to benefit from economies of scale. In comparing laboratories, he made the point that different laboratories use different equipment with different reagents that have different prices. Some laboratories are more manual, requiring more staff time. The Belfast Link Laboratories (at the Royal Victoria and Belfast City Hospitals) provide regional, in addition to common, services and this more complex work involved leads to higher costs. 
Minutes of Evidence, paragraphs 70, 71 and 90.

53. We expressed our astonishment at some of the wide price variations shown. For example a pregnancy test costs £14.20 in the Altnagelvin Hospital, yet only £2.05 in laboratories in the Southern Board area service. We asked the Accounting Officer to explain this and to confirm whether doctors in the Londonderry area were aware of the much cheaper prices to be obtained elsewhere. He told us that this competitive environment had been created when the Trusts and GP Fundholders had been established, supposedly to provide a market place where general practitioners could shop around and find the cheapest test. This actually created a problem, in that laboratories could not be certain of the level of activity with which they had to deal. If they brought prices down, they risked finding themselves in an uncompetitive position where they were unable to recover costs. As a result, there has been a change to block contracts. 
C&AG's Report, paragraphs 5.12 and Appendix 5, and Minutes of Evidence, paragraphs 160 - 167.

54. It cannot be acceptable that, as an example, the price of a pregnancy test is £14.20 in one place in Northern Ireland and only £2.05 in another. Similarly, it cannot be a measure of consistency in costing that one Trust charges the same price for all tests within a specialism, yet other Trusts cost each test individually. Any attempt to measure cost effectiveness in these circumstances must be meaningless.

55. In view of these differences and inconsistencies, we asked the Accounting Officer about the level of competition in this sector. He told us that it was clear that competition was regarded as being unhelpful and was not seen as having achieved its intended purpose. They were now moving away from the competitive approach to one that is based on collaboration, with benchmarking as a test.
Minutes of Evidence, paragraphs 56 - 58 and 80.

56. We welcome this move away from competition. There is another significant point of accounting principle concerned with the recovery of costs at laboratories. We welcome the fact that the Department has stipulated the importance of recovering full costs in contracts and the need to ensure that there is no cross-subsidy between contracts.
C&AG's Report, paragraphs 5.18 and 5.19.

57. We asked the Accounting Officer to confirm that no laboratories had been subsidised by others, in view of the wide range of costs per patient and prices charged for tests. He referred to the annual costing guidance issued to all Trusts, requiring Trusts to ensure that service costs are matched by expenditure and that they are not cross-subsidising or using one service's resources to fund another. He told us that he has received an annual assurance from the Chief Executive of every Trust to the effect that each Trust had complied with this guidance.
Minutes of Evidence, paragraphs 111 - 116 and Appendix 1.

58. While we noted the Accounting Officer's comments at the Hearing, we received a further statement from him to the effect that Belfast Link Laboratories were carrying out a pricing review of their laboratory prices. Although this review would not lead to a reduction in the total laboratory costs for the HPSS, it was accepted that it may lead to a redistribution of costs between the various Trusts. This suggests to the Committee that cross-subsidisation between laboratories has taken place and it is therefore important that the Department ensures that an appropriate redistribution of costs takes place.
Appendix 1.

59. In view of the inconsistency in the way that some tests are carried out, leading to a variation in the prices charged, there would seem to be a good reason for introducing protocols for laboratory testing, aside from the obvious clinical reasons for ensuring that standards are maintained. We asked the Accounting Officer for further information on the use of protocols.
C&AG's Report, paragraphs 5.20 and 5.21 and Minutes of Evidence, paragraph 76.

60. We were told that different laboratories have different protocols in place, depending on the varying types of equipment, reagents and procedures being used. Each laboratory test follows a clearly defined protocol (or standard operating procedure). In Northern Ireland, common protocols currently exist mainly for some regional specialties. There are also common protocols in cervical screening, certain tests carried out within the haematology specialty and in reporting on histopathology biopsy specimens.
Appendix 1.

61. In view of the different starting points in respect of the equipment and reagents currently in place, we were told that it is a difficult exercise to achieve and further steps needed to be taken to standardise equipment and processes. However, the Accounting Officer told us that there was a clear acceptance by professionals that the development of common protocols is important and he expected their development to be taken forward fairly quickly.
Minutes of Evidence, paragraphs 77 - 80 and 88.

62. We welcome the fact that work is progressing in the development of common protocols for carrying out tests. The Department must not place reliance solely on the participation of laboratories in accreditation schemes. While these might give assurance on the quality of testing, the Department must also take into account the efficiency of the process. To measure that efficiency, it is important to be comparing activity performed in the same way in all laboratories.

63. We therefore urge the Department to do all it can to promote the wide-spread use of common protocols throughout the pathology service, beginning with the adoption of those that are in place elsewhere. We also expect the Department to monitor progress in this area.

64. The Committee noted that, in 1998-99, laboratories processed over 6.3 million requests for tests to be carried out and we questioned the Accounting Officer about the relative workloads of staff in similar laboratories who specialise in the same areas. However, we were not given any comfort by the Department's response. Although we were told of the recording of the number of requests, it was made clear to us that these figures did not give a true picture of relative workloads. It was known that the number of requests had increased, but when we asked the Accounting Officer about the example of increased cholesterol testing, we were told that the Department's specialist advisory committees had not informed him that certain laboratories are suffering from an overload.
C&AG's Report, Executive Summary, paragraph 5 and Minutes of Evidence, paragraphs 151 - 158.

65. The Department needs to review how workload is measured, so that it can properly benchmark activity at different locations. This should be acceptable to all laboratories. We would expect the Department to be able to satisfy us that it has taken action to resolve this difficulty within a reasonable timescale.

66. Finally, we asked the Accounting Officer what his Department was doing to collaborate with laboratories in the Republic of Ireland and whether, for example, a doctor in Londonderry could send pregnancy tests to a laboratory in Letterkenny which charged less. The Accounting Officer emphasised the clinician's need for a speedy response. We were told that laboratories in the Western and Southern Board areas had confirmed to him that they are not aware of general practitioners accessing laboratory services on a cross-border basis.
Minutes of Evidence, paragraphs 168 - 178 and Appendix 1.

67. However, some hospitals in the Republic of Ireland access Belfast Link Laboratories for virology and specialised biochemistry testing (trace metals and toxicology). The Belfast laboratories, in turn, use some laboratories in Great Britain, but not in the Republic.
Appendix 1.

s. See also PAC Report on Health and Personal Social Services - Executive Directors' and Senior Managers' Pay, Contracts and Termination Settlements, (5/00/r), 16 May 2001

a. Review of Pathology Laboratories in Northern Ireland, NIAO, February 2001 [NIA 31/00]

p. Putting it Right: The Case for Change in Northern Ireland's Hospital Service, DHSS, 1998

A. QW 1244/01

PROCEEDINGS OF THE COMMITTEE
RELATING TO THE REPORT
SESSION 2001-2002
WEDNESDAY 29 NOVEMBER 2001

Members Present:

Mr B Bell (Chairperson)
Ms Ramsey (Deputy Chairperson)
Mr Carrick
Mr Dallat
Ms Morrice
Mr John Dowdall, Comptroller and Auditor General (C&AG) was examined
Mr Brian Delaney, Deputy Treasury Officer of Accounts was examined.
The Comptroller and Auditor General's report on A Review of Pathology Laboratories in Northern Ireland (NIA 36/00) was considered.
Mr C Gowdy, Permanent Secretary, Department of Health, Social Services and Public Safety, Mr B Grzymek, Director of Secondary Care and Dr G Mock, Senior Medical Officer were examined.

[Adjourned until Thursday 13 December 2001 at 10:30am]

* * * *

PROCEEDINGS OF THE COMMITTEE
RELATING TO THE REPORT
SESSION 2001-2002
WEDNESDAY 20 FEBRUARY 2002

Members Present:

Mr B Bell (Chairperson)
Ms Ramsey (Deputy Chairperson)
Mr Beggs
Mr Carrick
Mr Close
Mr Dallat
Mr Hilditch
Mr McClelland
Mr John Dowdall, Comptroller and Auditor General (C&AG) was further examined
Draft Report (Pathology Laboratories in Northern Ireland) proposed by the Chairman, brought up and read.
Ordered, That the draft Report be read a second time, paragraph by paragraph.
Paras 1 to 5 read and agreed to
Paras 6.1 to 7 postponed
Paras 7 to 67 read and agreed to
Paras 6.1 to 7 read and agreed to

* * * *

[Meeting adjourned until Thursday 28th February 2002 at 10:30am]

MINUTES OF EVIDENCE
Thursday 29 November 2001

Members present:

Mr W Bell (Chairperson)
Ms Ramsey: (Deputy Chairperson)
Mr Carrick
Mr Dallat
Ms Morrice
Witnesses:
Mr C Gowdy ) Permanent Secretary, Department
of Health, Social Services and
Public Safety
Mr B Grzymek ) Director of Secondary Care
Dr G Mock ) Senior Medical Officer
Mr B Delaney ) Deputy Treasury Officer
of Accounts
Mr J Dowdall ) Comptroller and Auditor General

1.The Chairperson: You are all very welcome to the Committee.

2.The Committee had difficulties with the Depart-ment's response to our report on senior executives' pay in health trusts. The Committee discussed that report - 'Report on Health and Personal Social Services: Executive Directors' and Senior Managers' Pay, Contracts and Termination.' - with Dr Andrew McCormick, the Treasury Officer of Accounts, and we considered your subsequent helpful letter. The Committee will produce a short report on the matter, and it is to be hoped that that will enable us to put it behind us. The Committee will continue to develop its professional relationship with the Department of Health, Social Services and Public Safety.

3.The Committee will explore what the Department has done to ensure that the Health Service receives the best possible support with the organisation, quality and cost of its laboratory services. The Committee recognises the essential nature of front-line health services and the support that those receive, as well as the valuable work of those in the pathology service. At an Assembly debate - possibly last November - MLAs showed broad support for the work of pathology staff. Laboratory work is complex and might be difficult for the public to understand, but the laboratories provide a range of services that are dispersed throughout the Province. Those services involve a substantial amount of public money, and the Committee's interest lies there. This discussion is taking place at a time when there is much debate on the state of the Health Service and concern about the delivery of services.

4.Paragraph 1.15 of the report, 'A Review of Pathology Laboratories in Northern Ireland', states that the Department told one of its advisory committees in 1992 that "very little action had resulted" since it announced its policy on laboratories in 1983, and that "consequently" there were then too many laboratories." Paragraphs 2.1 and 2.3 of the report show that there was no overall reduction in the number of laboratory services between 1982 and 1999. What action did the Department take to ensure that its policy was implemented during that period? How many laboratories are there at present? What plans do you have to reduce further the number?

5.Mr Gowdy: There has been a reduction in the overall number since the report was published. We now have 56 services that operate from 14 sites, by comparison with the 61 that operated from 19 sites in April 1999 when the report was published. Several changes have been happening. Belfast City Hospital and the Royal Group of Hospitals have been rationalising services between their sites. There is now a clear distinction in the overall remit of the Belfast Link Laboratories as to where those services are sited.

6.Work such as clinical haematology is now centred on the Belfast City Hospital site. Haematology services have been transferred from Ards Hospital. As a consequence of what has been happening at the South Tyrone Hospital, all the laboratory services have been withdrawn from it and, for the large part, are now based at Craigavon Area Hospital. Rationalisation is ongoing.

7.The Chairperson: Attention is drawn in paragraph 1.25 to the acute hospitals review group, whose work has implications for the future profile of laboratory services. That group's report is complete. What were its findings in regard to the profile of laboratory services?

8.Mr Gowdy: The acute hospitals review group report is designed to advise the Minister. She established the group to provide her with an independent review of how hospital services are organised. That group completed its report in the summer. The Minister then felt that it was important to get a reaction from people in Northern Ireland to the recommendations of the report. A pre- consultation period finished at the end of October. We got a massive number of responses - well over 100,000. Those responses are currently being evaluated. The Minister is keen that she should discuss with all her colleagues in the Executive how people feel about the recommendations of the report and how we might go forward. She intends to produce proposals, to be published early in 2002.

9.The Chairperson: Would they, for instance, alter the Department's thinking on policy?

10.Mr Gowdy: It would certainly have a substantial impact on the profile of laboratory services. The linkage between laboratory services and acute hospital services is necessarily close. Laboratories provide essential services to deal with emergency and trauma cases, which need an immediate response. Laboratory provision must, therefore, be linked closely to where acute services are provided. Plans for acute hospitals are a major determinant of laboratory services provision.

11.The Chairperson: How would they impact on your Department's current review of pathology services?

12.Mr Gowdy: We are keen to ensure that we take two things in tandem: how laboratory services need to match the needs of acute hospitals, and the professional issues, including staffing, where the services are best brought together, and the development of new technology, computer applications, et cetera. We are trying to examine the matter as a whole, and to bring together those two aspects early in 2002.

13.The Chairperson: Paragraph 1.25 reminds us of the Department's proposals in 1998 to resite radiotherapy, chemotherapy and related laboratory services, from Belvoir Park Hospital to Belfast City Hospital. The implementation of those proposals was delayed, but what is the latest position? I have an interest to declare, because a family member of mine avails of those services.

14.Mr Gowdy: The intention is to create a cancer centre at Belfast City Hospital, which is to be supported by four cancer units throughout the Province. Work is well in hand to establish those units, and, in the last few days the unit at Craigavon got up and running. We are seeing things develop.

15.The transferral of services from Belvoir Park to the Belfast City Hospital creates the need for a new building and facilities. It will be a state-of-the-art cancer centre, which will improve the quality of service to cancer sufferers in the Province. We needed a business plan, and received an initial one from the trust at a cost of just under £30 million. They decided that they wanted to develop the project further. The cost has now almost doubled; it has increased substantially to some £56 million to £59 million.

16.As the Public Accounts Committee, you will readily understand my role as the accounting officer in ensuring that this jump in expenditure can be justified. We must look carefully at what this means and what it is all about. That creates the delay factor that you referred to, and we are trying to minimise that delay. We are examining the new business plan that we received recently from the Belfast City Hospital Trust, and are consulting on it with colleagues in the Department of Finance and Personnel. We hope to be able to progress quickly to the implementation stage.

17.The Chairperson: Why has there been no application for the accreditation of Belvoir Park Hospital's laboratories?

18.Mr Gowdy: After the decision was taken to move the cancer services from Belvoir Park Hospital to the Belfast City Hospital, staff at Belvoir Park were transferred to the Belfast City Hospital Trust. Arrangements were made to take over the assets of Belvoir Park Hospital by the Belfast City Hospital, and that applies also to the laboratories. Laboratory services at Belvoir Park Hospital are now part of the Belfast City Hospital's laboratory provision under Belfast Link Laboratories, which was established a few years ago.

19.The Chairperson: How does the delay in transferring laboratory services to the Belfast City Hospital impact on the quality of services at the accredited Belvoir Park Hospital laboratories?

20.Mr Gowdy: The new cancer centre will be a state-of-the-art, leading-edge development. The Belvoir Park site provides a high quality service; they do a tremendous job, but with ageing equipment. We hoped to plan the move so that as we built the new cancer centre at the Belfast City Hospital we would be able to furnish it with new equipment, and let the old equipment come to the end of its useful life at the Belvoir Park site. This slight delay in the timescale has meant that we will have to install new equipment at the Belvoir Park site and then transfer it to the Belfast City Hospital site when the new centre is completed.

21.Ms Ramsey:: The Chairperson mentioned briefly accreditation. Why are boards and GPs still using laboratories that are not accredited?

22.Mr Gowdy: The clinical pathology accreditation (CPA) is all-embracing, and covers both service quality and the wider issues of accommodation and staffing. With the uncertainties over the long-term future of acute hospitals, we are concerned that we have been unable to make the necessary rationalisation of the laboratory services. We have been holding off on investment in accommodation, but underfunding has also contributed to that difficulty. Several laboratories have less than perfect accommodation, and they would not meet the CPA standard. That would be counterproductive, because laboratory services could not then be provided, and we would lose the ability to respond to the needs of the hospitals.

23.The current arrangements protect everyone to a satisfactory level through the national external quality assessment (NEQA) scheme, and all our laboratory services are tested at one- to six-month intervals. We know that they are passing those tests, so our services are being accredited. However, the wider accreditation, through the CPA system, of the totality of the laboratories and their provision has not been addressed. We are satisfied that the GPs and hospitals are getting the laboratory services that they need, but we would be unable to meet the overall accreditation standards of the CPA.

24.Ms Ramsey:: You mentioned the quality of services. Why bother with accreditation at all? The lack of accreditation has a knock-on effect on public confidence.

25.Mr Gowdy: That is the important point. Accreditation provides a useful badge that allows everyone to feel satisfied that a rigorous test has been passed, or that services have been maintained at a satisfactory level. We want all our hospitals to apply themselves to those tests. NEQA is one important test for us. But it is also desirable that all the laboratories should be assessed under the CPA system. Only six laboratory services out of 56 have yet to apply for accreditation. That is due to accommodation issues and the fact that some laboratories do not have the number of staff needed to secure that accreditation. Accreditation is a useful guide and reassurance that standards are being maintained, but we have a technical difficulty with using the CPA method-ology at present.

26.Ms Ramsey:: Paragraph 1.6 refers to the review that was carried out in 1982, which you mentioned earlier. I have discovered that the service was affected by deficiencies in accommodation and medical manpower. Paragraph 3.6 states that some laboratories do not even have full- or part-time accreditation because of current accommodation inadequacies. You also mentioned staffing. Does the fact that those problems have persisted since 1982 not highlight the failure of the Department's policies to address the necessary issues over a long period?

27.Mr Gowdy: As we said earlier, one of our major problems is that the future of acute hospital provision has not yet been settled, therefore the laboratory services cannot be settled yet. That means that it would be a waste of resources to invest in accommodation if we thought that a short time later we would be moving them elsewhere. The standards of accommodation in some laboratories do not meet the required standards therefore they would not receive accreditation. Our key aim is to ensure that the provision of laboratory services continues, because access to those services is necessary for the effective operation of a hospital service. We do not want to shoot ourselves in the foot by applying a standard that does not deal with laboratory provision in terms of service to hospitals.

28.Ms Ramsey:: With respect, the problem dates back as far as 1982. I understand your point about the review of acute services, however that has only happened in recent years. The shortage of staff and the problem with accommodation were highlighted in 1982 and they still exist.

29.Mr Gowdy: There has been an ongoing problem. The policy that was set out in 1982 sought to reorganise the laboratory services onto six main sites. Work started and some progress has been made, but that has taken some time. For example, Belfast Link Laboratories, which encompasses the City Hospital and the Royal Group of Hospitals illustrates effectively how such rationalisation can take effect. Our problem was that, as we entered the early 1990s, the acute hospital issue began to arise. It has been an ongoing problem for 10 years.

30.Ms Ramsey:: The human organs inquiry, which was set up by the Minister earlier this year, is not part of the report, but it is relevant. We are aware that there have been problems with it. I know that the Department has given interviews and made statements on the issue, but why was it unaware of the practices that were adopted in the laboratories at that time?

31.Mr Gowdy: Post-mortem examinations have always resulted in the retention of some organs, and that was done for good reasons. The Department was unaware that some organs were being kept for reasons that were outside the remit. That only became apparent when the issue emerged in England and was investigated here. The Department had seen no need to investigate what was happening in pathology in respect of organ retention.

32.Dr Mock: To complete the post-mortem examination properly, some organs had to be preserved before they could be examined. Although the post-mortem consent form covered that, it was not explicit enough for people to understand the full meaning. We understand that deficiency, and it has been addressed. In certain situations, before examining the brain, for example, the organ has to be preserved for several weeks so that it can be carefully sliced and examined. We understand that the public did not appreciate how a post-mortem examination is performed and the practices that are necessary to make a complete examination.

33.Ms Ramsey:: You both mentioned consent, and that is the key. This practice took place often without the consent of the families. Can you assure the Committee that that is not happening in other aspects of pathology?

34.Mr Grzymek: On the issue of consent, the families signed consent forms in line with practice throughout the British Isles. However, the Alder Hay Hospital situation highlighted the rigour with which consent forms must be completed, and the fact that those who filled in the forms did not have an acceptable level of understanding. Once that became apparent, new consent forms were issued. All the trusts in Northern Ireland have reviewed their consent forms, and they have issued leaflets and guides to assist the families who must sign them. The forms have become more detailed, so that when small specimens, such as slides, are to be held, it is brought to people's attention. In cases where specimens that are necessary for the completion of a post-mortem examination must be retained, the families are advised of that, and they are asked whether they wish the organ to be disposed of or returned. We have learnt from the process; the practice has changed substantially here, and that has been reflected in other areas.

35.Mr Gowdy: The outcome of the current review will help us to understand what happened and what happens at present. It will allow us to make any changes that are necessary.

36.Ms Ramsey:: It seems that most hospitals would opt to have their facilities on site, if they were given the choice. However, paragraph 2.6 points out that Lagan Valley Hospital and Downe Hospital have had on-line access to the laboratory services of the larger Belfast City Hospital since the early 1980s. When reviewing policies in 1983 and 1997, and more recently, as recommended by the Auditor General in paragraph 2.10, what consideration did the Department give to the provision of off-site services such as exist at the Lagan Valley and Downe Hospitals?

37.Mr Gowdy: The key issue has always been the number of acute hospitals that we are going to have. An acute hospital that provides the full range of emergency service needs to have on-site laboratories and the full range of equipment so that it can respond quickly.

38.Hospitals that provide less immediate treatment have always been able to access laboratory services with a greater time delay. We have always wanted to ensure that that time delay is minimised. Lagan Valley Hospital is close to Belfast, and computer links will help to speed up the process, however the tissue or sample must still be taken from the patient to the laboratory. One development is that the response can be quickly telephoned or relayed via a computer link. In the future we may be able to put the sample into an on-site machine and deal with it through the computer link.

39.We are always conscious that technology is taking us forward. We hope that when we establish the full range of acute hospital services, according to the profile which the Minister will determine, that will allow us to concentrate the major laboratory sites next to the major hospitals. We can then deal with the linkages that must be made with the smaller hospitals. Our key point is what that future hospital profile will look like.

40.The Chairperson: Accommodation and staffing aside, are NEQA standards in respect of quality of service as rigorous as those applied by the CPA?

41.Mr Gowdy: Dr Mock knows the detail of those systems.

42.Dr Mock: The 25 NEQA schemes cover the range of laboratory testing. The laboratory sends samples away and makes sure that its own results are as they should be, according to another laboratory. All our laboratories take part in those schemes.

43.The CPA scheme operates at a higher level, therefore to apply for accreditation under that scheme all the standards of the NEQA schemes must be satisfied. We are certain that all our laboratories are meeting the requirements of the NEQA schemes. However, not all of them have achieved the CPA accreditation, which takes account of other factors such as accommodation, and whether a consultant pathologist is on-site at the time, which could be difficult for us.

44.Mr Dallat: This is a £41 million industry. There has been little progress in achieving accreditation, no performance benchmarking, and no competition, and precious little was said this morning that would instil in the public a great deal of confidence. Perhaps we should put aside money issues. I am sure that the availability of pathology services is often a matter of life and death: a diagnosis can often mean that a person will live. Surely, in an area the size of Yorkshire, there is no argument in favour of having 16 sites?

45.Mr Gowdy: I assure the Committee that the standard of laboratory services in respect of their ability to analyse and test samples is first class. They provide a very fast, responsive service and they do it at a top level. We know that that is the case because the service's quality is tested regularly under the NEQA scheme - either monthly or every four to five months. I would not want the Committee to feel that our service operates below the necessary standard, for that is not the case.

46.Mr Dallat: I am not suggesting that. However, I am aware of the well-publicised cases in the Kent and Canterbury Hospitals National Health Service Trust where things did go wrong. It is therefore proper that the Public Accounts Committee should express its concerns about what might happen in the future. I was certainly not implying that it was currently the case.

47.Perhaps I might return to the issue of value for money. If any other Government Department were to award a contract without the basic guidance principles being in place, there would be uproar. Yet we spent £41 million on a service which, by your own admission, does not comply with the guidance that you brought in nine years ago. We have already discussed the matter at some length, but it is important. Now you have said that you await a review. You also said that everything depended on acute hospitals, although there are sound arguments that the services are not necessarily linked to the hospitals, as Sue Ramsey pointed out.

48.Mr Gowdy: I should re-emphasise the point that I made earlier. The necessary on-site laboratory services are those which provide for acute hospitals' emergency treatment. When a hospital deals with someone admitted with a life-and-death situation, they must test for several things very quickly. Those services must be available on site, so the relationship between laboratory services and acute treatment is extremely powerful. The location of acute hospitals is therefore a very major factor in deciding where laboratory services should be sited. The relationship is absolutely critical.

49.We have a little more leeway in testing samples that are not of a life-and-death nature, in which case we can wait a little longer for them. Those laboratory services can be provided more remotely. The key issue is where the acute needs will be and where we must base the major laboratory services to provide an emergency response. We cannot make that decision yet, for we are still in the midst of a political debate regarding the siting of acute hospitals. It is not an easy issue, as I am sure everyone appreciates.

50.Mr Dallat: Perhaps I might move on to the issue of performance. The Northern Ireland Audit Office recommended in paragraphs 5.28 to 5.30 that Departments introduce performance measures providing benchmarks for a range of specialities. What is your view on the absence of that information for support services such as laboratories? Have you issued any guidance to or exerted any pressure on funding Departments to ensure that bodies for which they are responsible undertake benchmarking as recommend by the Northern Ireland Audit Office?

51.Mr Gowdy: Benchmarking is an important factor in ensuring that we secure value for money. Our spending on laboratory services is currently £54 million, so I can update the figure contained in the report. Of that sum, £36·5 million in spent on services to hospitals. The other element of expenditure is for GPs and work in the community, which has been a growing area. GPs ask for more tests nowadays, and that also has to be factored into the thinking.

52.At all times we wish to be sure that every laboratory benchmarks itself against others, both in Northern Ireland and elsewhere. During our work with trusts to develop service delivery plans providing for an annual plan of provision we said that benchmarking information should be included. We currently have an initiative to calculate comparative total costs or reference costs for each trust, ultimately covering all acute specialities. That will give us the information we need to benchmark within Northern Ireland and with Britain.

53.We are trying to get much more information out of them on the cost-per-test issue. We have moved away from the old cost-per-patient indicator, which was not giving us sufficiently accurate information on the volume of testing activity. We are now focusing on the cost-per-test, or the number of requests made for a test, which will provide more benchmarking information.

54.The Chairperson: Mr Delaney, do you want to comment on benchmarking in your Department?

55.Mr Delaney: Yes, the Minister announced in the Budget statement that the service delivery agreements would be produced early in 2002. As part of our new guidance on service delivery agreements, we have emphasised the importance of benchmarking as a performance measurement and monitoring tool that the Departments should consider, and they will take that on board.

56.Mr Dallat: Mr Gowdy, you will be aware that laboratory personnel expressed some concern about competition in the sector. Was the Department aware of that concern? If so, did your staff try to redress it? If not, why was the Department not informed of the concern?

57.Mr Gowdy: We were aware of the concern. We always operate within the context of the political philosophies that the Government of the day wants to put in place. When the Conservative Government were in power, they created the trusts and a competitive environment, because they believed that that was the way to drive down costs. That is why competition came into the health sector.

58.It is clear from the representations by staff, particularly in the laboratories but not exclusively, that competition was regarded as being unhelpful. It was not seen as having achieved its intended purpose. As we have moved from a Conservative Administration to a Labour one, and then into a devolved Government, it has become clear that we are moving firmly away from the competitive approach to one that is based on collaboration and, I hope, benchmarking as a test.

59.Mr Dallat: We can blame on the Conservatives for a good deal, but they did disappear quite a while ago.

60.Paragraph 3·6 of the report tells us that some laboratories do not have full accreditation due to their lack of consultant cover. I note in paragraphs 3·10 and 3·11 that the inadequacy of consultant cover was the main reason for failure in the Kent and Canterbury cases that I referred to earlier. Does an absence of consultant cover restrict the range of conditions that some hospitals can treat? I will listen carefully to your answer, because so far your argument for retaining the 14 sites has been based on the assertion that they must be attached to, or close to, hospitals.

61.Mr Gowdy: Are you referring to consultants operating in the laboratories or consultant-led services in the hospitals?

62.Mr Dallat: I refer to consultant cover. In the report, we discovered that some laboratories could not operate because no consultant was attached to the hospital to carry out the work.

63.Mr Gowdy: Dr Mock will discuss the professional issues.

64.We have been aware that consultant pathologists are something of a rare breed. We currently have 68 consultant pathologists, and there are 10 vacancies, some of which are at specific laboratory sites, and this has had an impact on those services. Our networked approach, which Dr Mock can explain, has allowed us to maintain those services, with consultants covering more than one site.

65.Dr Mock: We currently have several vacancies for consultant pathologists, because people get other jobs and move on. However, some laboratories outside Belfast are run on a board basis - in the Northern Board, the Western Board and the Southern Board the services are networked. For example, the consultant pathologist in Altnagelvin Hospital provides cover to the Sperrin Lakeland laboratories. The same applies to Daisy Hill Hospital and Craigavon Hospital.

66.The Kent and Canterbury Hospital case was specific to cervical screening. We do not have those problems in our cervical screening services in Northern Ireland because we have consultant pathologists with a special interest. Our system has developed over the years to become heavily quality assured. We have a regional committee that scrutinises the work continuously, and we are happy that our cover at that level is assured.

67.Mr Dallat: Would you describe the service at the moment as being comprehensive and adequate to meet people's needs?

68.Dr Mock: Yes. There is a shortage of consultant pathologists throughout the UK, especially in special fields such as histopathology, which involves less clinical contact, making it a less attractive option in recent years. Our service is running well, it is quality-assured, and we are proud of it.

69.Mr Carrick: Mr Gowdy, you commented on benchmarking and comparative figures. I wish to draw your attention to the comparative prices of tests in appendix 5, 6, and 7, pages 77 to 81. It is an interesting revelation that 80% of the prices quoted in appendix 7 are higher in Northern Ireland than in the NHS hospitals. I realise that that was based on a sample, but I understand that the Northern Ireland Audit Office selected an area in England that has many similarities to Northern Ireland. How do you account for the evidence that the price of carrying out what is presumably the same type of test in Northern Ireland is on average higher than in England? What are you doing about that?

70.Mr Gowdy: The figures must be examined, and I will return to that point. The prima facie view is that we must ensure that we are comparing like with like - that is a very important requirement and we are not sure that that is being met. Even if we were comparing like with like, there is a substantial difference between England and here. Many laboratory services in England are based around district general hospitals, which are major beasts, and are substantially greater than most of the hospitals here. They are able to get economies of scale in their laboratory services because they operate on that larger scale. That difference is therefore likely to have an impact on cost, and we are not necessarily surprised that it exists.

71.To be able to justify any difference, we need to examine whether the costs are of a justifiable magnitude. We are going to review the average cost per request in each laboratory to give us the necessary information. Our current initiative is aimed at providing detailed costs for all groups of hospital procedures, and that will include laboratory services. This specific review to compare the average cost per request will give us the hard information that we need in order to identify the relevant the factors. Other points might apply, for example, different laboratories use different equipment with different reagents that have different prices. Some laboratories are more manual, and therefore require more staff time than they do pieces of equipment. Therefore, much depends on what the different laboratories are using as the basis for making their test. Different factors can underlie the differences, but a review needs to be carried out.

72.Mr Carrick: I accept that you are anxious to compare like with like, and that is important. However, before the Audit Office produced its report comparing Northern Ireland with north-east England, you had no other samples to which you could have referred. Do you accept that before the publication of that report you were not engaged in the necessary benchmarking?

73.Mr Gowdy: No benchmarking exercise was carried out before that point.

74.Mr Carrick: On reflection, do you feel that there should have been such an exercise?

75.Mr Gowdy: Yes, we accept that a benchmarking exercise needs to be in place.

76.Mr Carrick: I welcome the statement in paragraph 5.20 of the report that the Belfast City Laboratory has started to develop common protocols for laboratory testing. How many protocols are in place? How many different tests do they cover?

77.Mr Gowdy: Different laboratories have different protocols in place. If varying types of equipment, reagents and procedures are being used, there will be different protocols.

78.Dr Mock: In the Eastern Health and Social Services Board the laboratories are working together to develop common protocols. However, because of the different starting points of the laboratories in respect of their equipment and reagents, it is a difficult exercise to achieve. Common protocols would exist in cervical screening, for example, because slides are examined in exactly the same way in every laboratory across the United Kingdom.

79.The chemical tests require the laboratories to proactively develop together their method of performing the detail of the tests and the reagents to use, and to apply a common protocol. You can be assured that, because of the laboratories' participation in the NEQA schemes, the quality of test results can be stood over. Work towards creating common protocols is ongoing, and that work was discussed at a recent meeting of the Laboratory Services Advisory Committee (LABSAC).

80.The clinical directors of the laboratories are moving out of the competitive mould towards having co-operation and discussions on that issue. It makes sense to establish commonality throughout the service. Because laboratories have developed differently, and support different hospitals, they have developed differing techniques. We can nevertheless be assured that the results will be the same.

81.Mr Carrick: I appreciate your general response to specific questions, but for the record I ask how many protocols are currently in place and how many tests do they cover at the moment? You might intend to introduce further protocols and more tests, but it would be useful for the Committee to have the current figures.

82.Mr Gowdy: We do not have that information to hand, but we can provide the figures to the Committee later.

83.Mr Carrick: What is the annual value of the tests?

84.Mr Gowdy: We have 5·9 million requests for tests every year, and that figure has been going up. The increase over the previous year was 2·6%. Over the last four to five years the figure has grown by 22%; demand for tests is rising dramatically.

85.Mr Carrick: What percentage of those tests are covered by the common protocols?

86.Dr Mock: The clinical biochemical tests, which are automated, are most susceptible to common protocols, since they depend on the same reagents. Those tests form a large part of the work and have increased by over 60% in the past five years. That is because diseases are now looked after in the community, and there has been a huge rise in testing on behalf of general practitioners.

87.Mr Carrick: Perhaps that sort of information could be factored into your response to the Committee. Has the Department taken any action to ensure that those protocols are subsequently used in other laboratories?

88.Mr Gowdy: We have taken the issue of building common protocols with professionals very seriously. As the report acknowledged, there are two specialist committees with professionals as members, and the issues have been taken up in those different forums. There is a clear acceptance by professionals that the development of common protocols is important, and we expect that to be taken forward fairly quickly.

89.Mr Carrick: Perhaps that might also be reflected in your response to the Committee. Paragraph 2.5 of the report tells us that Lagan Valley Hospital and Downe Hospital refer all their laboratory work to the Belfast Link Laboratories, to which you referred in an earlier submission. Figure 10 shows that the cost of that work is relatively low, even disregarding the six largest acute trusts. If Down Lisburn Trust is satisfied with the work it has received since the early 1980s, is that good evidence that other trusts might benefit from referring more of their work to outside laboratories?

90.Mr Gowdy: The Belfast Link Laboratories provide regional as well as common services. The nature of the work at the two hospitals concerned is more complex and involves the more difficult cases. The cost of providing services is therefore inevitably higher than elsewhere. That complexity explains the higher costs at both Belfast City Hospital and the Royal Victoria Hospital.

91.We wish to ensure the proper service at the right cost by undertaking a benchmarking exercise. That is the real test, and it would enable us to make the necessary like-for-like comparisons which the global figures do not allow. It is necessary to look beneath them, and we are committed to doing so.

92.We must also be careful that the speed of response is factored in. There is no point in having a cheap test if it takes a long time.

93.Mr Carrick: I come to a matter of interest to residents of my constituency, Upper Bann. As a result of the transfer of acute services, the South Tyrone Hospital laboratories have been closed, and most testing has been transferred to Craigavon Hospital. Have you yet determined whether this move is temporary or permanent?

94.Mr Gowdy: It is a temporary move. All the changes at South Tyrone Hospital were in response to an immediate and urgent need to ascertain the safety and clinical provenance of the services. All the decisions were taken temporarily, depending on the eventual profile of acute services across the Province. No final decisions have been taken on South Tyrone provision.

95.Mr Carrick: What impact has that move had on turnaround times for laboratory test results?

96.Mr Gowdy: I am not in a position to answer that. Perhaps my colleagues can do so.

97.Mr Carrick: If you do not have the information to hand, perhaps you might supply it later.

98.Dr Mock: Do you mean in respect of patients going to South Tyrone Hospital or the speed of the response?

99.Mr Carrick: Has there been an adverse effect on the timing and quality of the laboratory test results?

100.Mr Grzymek: There should not have been an adverse effect, since urgent response times most often relate to those admitted for in-patient care. Those patients will have been transferred to a hospital such as Craigavon following the changes in South Tyrone. Ultimately the laboratory services will have moved with the patient, and the timing should have been kept short. It may have an effect on out-patient or other diagnostics in the hospital, and that is an area on which we must concentrate. However, emergency testing relates primarily to emergency admissions. The patients would have gone to Craigavon Hospital, and the services would have followed them.

101.Mr Gowdy: I am happy to make enquiries and pass on the response to the Committee.

102.Mr Carrick: I should appreciate that. I am sure that you are aware of the degree of public interest engendered by this issue. What financial savings does the Department expect to achieve by the move?

103.Mr Gowdy: It is not about saving money; it is about ensuring that the Department is able to provide safe and effective services. We are determined that people in Northern Ireland should have the highest possible quality of services. One of the major underlying factors in the need to rationalise and reconfigure acute hospital services is the desire that the Department have the benefits of aggregating specialities in different places and bringing all the support services in round them.

104.Ultimately the key factor is to ensure that whatever is put in place provides high-quality, safe, accessible services. There are a few difficult issues arising from the Hayes review that must be resolved. The public has made many comments on its recommendations.

105.Mr Carrick: Considering the rationale and motivation for the move, I am sure that there was a financial consequence. Were savings or increased costs incurred?

106.Mr Gowdy: The present temporary arrangement is more costly than the previous. The Department has had to put money in to support the services. There will also be costs involved in the building that will eventually be needed to fulfil requirements in some areas. In future there may be some asset sales on the other side of the balance sheet. However, the temporary arrangements at South Tyrone and Craigavon have been more costly.

107.Mr Carrick: Have those costs been quantified?

108.Mr Gowdy: I shall send you details of how much additional funding the Department has provided over the past 12 to 18 months.

109.Mr Carrick: I should like to know the additional costs involved, for funding may have fallen short of expenditure, something which may in turn cause financial burdens elsewhere in the Health Service.

110.Mr Gowdy: That is true. The issue concerns not only the Southern Board area. Other boards are also accessing the service there, and the Department has made some provision for them too. I shall send you details of the total cost.

111.Mr Carrick: Paragraphs 5.18 and 5.19 of the report state that you issued guidance on the importance of recovering full costs in contracts and the need to ensure there is no cross-subsidy between contracts stretching as far back as 1991. Have you checked whether trusts have complied with that when establishing prices charged for laboratory tests? In the light of the wide range of costs per patient shown in figure 10 and the prices charged in appendix 5, are you happy that there has been no subsidy of certain laboratories by others?

112.Mr Gowdy: The Department has seen no evidence to suggest there has been any cross-subsidy between laboratories. However, there may have been cross- subsidy in laboratories where consultants provided an outreach service to others. That would need to be investigated if you wished details. However, we issue annual costing guidance to all trusts, and the chief executive of each trust must give me a statement each year saying that they have adhered to it. That costing guidance requires them to ensure that service costs are matched by expenditure and that they are not cross- subsidising or using one service's resources to fund another.

113.Mr Carrick: Have you checked that trusts have complied both in establishing prices for laboratory tests and with the guidance?

114.Mr Gowdy: Yes, in that I have issued annual costing guidelines to them and asked the chief executive each year to assure me that his trust has complied with them.

115.Mr Carrick: Have you always received that assurance from every trust?

116.Mr Gowdy: Yes.

117.Ms Ramsey:: More than once discussion has touched on the issue of laboratory accreditation. I should be interested to know if any laboratories have lost it.

118.Mr Gowdy: Yes. Some of them have lost accreditation.

119.Dr Mock: Recently Altnagelvin Hospital's haematology service lost its accreditation owing to the difficulties caused by two consultant haematologists leaving. The Mater Hospital had full accreditation, but that has now been withdrawn, mainly because of accommodation but also because of consultant cover. However, that illustrates how the accreditation process established in 1992 has itself become more rigorous. Accreditation has raised standards, which is why it has never been made a mandatory obligation, for we have no control over a consultant deciding to move to another job. That can mean the withdrawal of accreditation from that service.

120.Ms Ramsey:: Will they continue to provide the same services as previously?

121.Dr Mock: Yes. Haematologists in Belfast and across the whole clinical network support services provided to patients at Altnagelvin Hospital.

122.Ms Ramsey:: I understand what you are saying, but does that not bring us back to my first point? What is the point of having accreditation? Is it not a failure to the public if laboratories are not accredited?

123.Mr Gowdy: No. That is the point we discussed earlier. The NEQA scheme tests all services, including those at the Mater and Altnagelvin, very regularly - monthly or quarterly - to ensure that services are at the level required. None of our laboratories has had that accreditation removed. The accreditation in this case is the wider one provided by the clinical pathology accreditation scheme, which embraces consultant cover and accommodation as well as service quality.

124.Ms Ramsey:: Is it not then a waste of time? What is the point of having accreditation?

125.Dr Mock: I understand what you are saying. We should be aiming for clinical pathology accreditation, for it is the best standard available across the United Kingdom. You are saying that we could have opted out of the whole system.

126.Mr Gowdy: It is where the best becomes the enemy of the good. The key issue for us is to ensure that hospitals enjoy quality services from their laboratories. The further issue regarding accreditation as you describe it is whether we have accommodation which fully meets modern standards. We cannot say that, for we have not been funded enough to do anything about that accommodation.

127.We have also experienced the problem that staff find pathology a less attractive option, meaning we have difficulty recruiting. If we did not have the staff numbers the CPA scheme believed necessary, we should lose accreditation. If that were mandatory, we should lose the capacity to provide laboratory services. The key assurance to the public is that the quality of services provided by our laboratory staff is checked very frequently and has always met the required standard.

128.Ms Ramsey:: I take on board what you are saying, but I remain unconvinced. From your words I take there to be no need for accreditation. If a test is carried out regularly, meaning accreditation is unnecessary, why have it?

129.Mr Gowdy: It is important that everyone strive for accreditation. If we did not have some sort of standard, you could never be sure of getting a quality service. The key for us - the basic absolute - has to be whether services are being provided to the right quality standards. We are getting that assurance. The accreditation beyond that is striving to put the best in place. We should all like to have the best here, but we cannot afford it; that is the key difficulty for us. We are also having difficulty recruiting. We should like, in an ideal world, to meet those standards, but failing to meet them is not necessarily going to destroy public confidence, for we can say that we shall not provide any services that do not meet those basic professional standards.

130.The Chairperson: That supplementary question has been answered, and I do not wish to get bogged down in it.

131.Ms Morrice: I shall go over a few of the areas that we have touched on. I wish to talk about accreditation, the shortfall in consultants, the problem of data and testing and also costing. I also wish to tease out the issue of accreditation because public confidence is such a huge issue. It is amazing to hear you say that we want the best but cannot afford it. In other words, we have not got the best. That is an important statement. Does it instil confidence in the public?

132.Mr Gowdy: Perhaps I might clarify the issue. It is a matter of having the best modern facilities and modern buildings staffed to the ideal level. We are getting by on -

133.Ms Morrice: Is that good enough?

134.Mr Gowdy: It is not what I should like. I certainly want us to achieve the best, but we see our laboratories deliver services at the appropriate high-quality level. To assure the public, the laboratories are doing the job for which they have been put in place.

135.Ms Morrice: You are talking about delivering the service. There has been mention of cervical screening cases at the Kent and Canterbury Hospitals National Health Service Trust. We are also aware of more recent problems with the Royal Group of Hospitals Trust from the Minister's response to a written Assembly question in May 2001. Incorrect results were given to haemaphiliac patients when testing for hepatitis C. Are such examples not clear evidence of the need for compulsory accreditation? Sue Ramsey has been asking why it is needed, but at the other end of the scale, if you had compulsory accreditation and we had to adhere to that, no mistakes could be made.

136.Dr Mock: Our level of accreditation in Northern Ireland is exactly parallel to the level in England. Not every laboratory is able to achieve accreditation, but all of them are working towards it. It was never designed to be a compulsory system in the United Kingdom; it is not the only one, and there are also difficulties. If your accommodation is not deemed appropriate, you could lose accredition. If the scheme were mandatory, that laboratory would have to have to stop providing a service. We are all anxious for that not to happen. Even in the best system there can unfortunately still be errors.

137.Ms Morrice: What assurance can you give that the problems at the Royal Victoria Hospital were not in any way linked to the fact that haematology laboratories have not received full accreditation, according to figure 5 in the book?

138.Mr Gowdy: We can give an absolute assurance that it is not because of this accreditation problem. The national external quality assessment scheme operates on the basis that it sends samples to all the laboratories providing all the different services, asking them to test them and return their results. It then assesses the quality of the service. No laboratory has failed to meet those standards. That is the assurance that we can give you. That test happens frequently - in some cases it is monthly, in others every three or four months. There is constant checking that our standards are sufficient. CPA accreditation, however, deals with the wider issues to do with getting quality infrastructure in place, something which we do not have.

139.Ms Morrice: Part of the failure of that accreditation procedure relates to the 10% shortfall in the number of consultants.

140.Mr Gowdy: We have 10 vacancies - we should have 78 consultants, but we have only 68.

141.Ms Morrice: One reason you cannot get accreditation is that you do not have consultants in post. What are you doing to remedy the situation and train consultants?

142.Mr Gowdy: A substantial effort is being made to improve the number of medical students who specialise in pathology.

143.Ms Morrice: Are those numbers increasing, and is there encouragement for young student doctors to specialise in that area of interest?

144.Dr Mock: It is not confined to us. We have particular problems in Northern Ireland because of our geographic isolation, so in most specialities we are trying to train our own consultants. Histopathology, which is a branch of pathology dealing with tissues, biopsy specimens and performing post mortems, currently has four vacancies in Northern Ireland. A few years ago we had eight training posts in that speciality in Northern Ireland, but only two people came forward for training.

145.Ms Morrice: That is fascinating; the machinery to provide skills to match industry and needs is failing badly, and surely it is obvious what is needed. If there are eight training places available, what is being done to attract young students?

146.Mr Gowdy: An annual medical workforce plan is in place. It aims to review the number of posts we have and need and how many people are in them, along with a profile of predicted retirement ages and other wastage factors. That workforce review is conducted annually, and projections are made of the numbers of staff needed.

147.Ms Morrice: What will the cost of recruiting extra staff be, and is the Department prepared to pay?

148.Mr Gowdy: If we could get the extra 10 consultants, there would be no problem, for we have financial provision for 78. We have talked to the Department of Health in England, which is concerned with the output of medical schools throughout the UK. It is trying to increase the number of training places in pathology. In our most recent discussions with the Department of Health, it stated it was increasing the number of UK training places by 40, and we hope to benefit from that. Unfortunately, issues such as organ retention tend to put off young medical students, who view pathology as a less attractive option. Attracting people to the speciality is an uphill struggle for us.

149.Dr Mock: That issue was discussed at a meeting earlier this week. The Royal College of Pathologists recognises that there is a problem attracting trainees. We have 180 medical students, and there are 40 different medical specialities they can enter when they qualify. Histopathology is just one of those, and that must be taken in consideration. In the mid 1990s there were a great many people training in histopathology in Northern Ireland, so it was perceived that opportunities might not be available upon completion of training. In fact demand for histopathologists has outstripped supply because of factors such as the cancer plan, the ongoing cancer initiatives, and the increased number of specimens from each patient which must be examined by the consultant pathologist. Demand has increased, and we currently have vacant funded posts around the Province without any applicants.

150.Ms Morrice: It is a great pity that you are not shouting louder about it, for I am sure that there are people who would be interested.

151.I shall move on because of time constraints. I wish to talk about the testing and the data. Paragraph 5 on page 7 of the report's executive summary states that laboratories processed over 6·3 million requests for tests in 1998-99. Mr Gowdy, you stated that the figure was 5·9 million but I shall not question that. Please give more detail on any data the Department collects on the different laboratories' workloads. Do the data enable the Department to draw any conclusions about the relative workloads of staff in similar laboratories who specialise in the same areas?

152.Dr Mock: The Department keeps a record of the number of requests for work to be done in the various speciality areas. However, that does not accurately reflect consultants' workload. It is difficult to calculate workloads. For example, a request to one branch for the result of a biopsy specimen may simply require a consultant to examine something. A request for a certain biochemistry test, however, might require several other tests to be carried out.

153.All our laboratories have agreed to record the number of requests. It would be difficult to collect the information by recording numbers, since the number of tests carried out on just one sample can vary so much. Such bald figures do not accurately reflect the situation. The laboratory staff are being put under increasing pressure. The Belfast Link Laboratories have examined the number of requests and tests carried out per medical laboratory scientific officer. We know that the number is increasing rapidly every year because of the increasing number of patients in the system.

154.Ms Morrice: Let us talk about examples we can understand. There has been an increase in the interest in cholesterol levels and heart disease. Has that interest resulted in an increase in requests for cholesterol testing, and have you tried to accommodate that and ease the workload by sending all cholesterol tests to one laboratory, for example? Can it be done, and are you working towards it?

155.Dr Mock: There has been a rapid increase in interest in that area. General practice requests for cholesterol testing have increased. However, I am not sure how the laboratories have accommodated it.

156.Ms Morrice: If the testing were rationalised in such a way, would it improve the situation?

157.Mr Gowdy: The speciality advisory committees have not told us that certain laboratories are suffering from an overload that would require the kind of rationalisation or transfer of tests you suggest.

158.Dr Mock: No, they have not. The volume of tests increases at different rates in the different specialities. For example, it has increased by 60% over the past five years in biochemistry. That figure tends to be closer to 4% in the other specialities. Cholesterol testing, an area you suggest has seen a huge increase, would fall into one of those smaller categories.

159.Ms Morrice: We should think of that as example only because it is an issue of which we have been made aware. I am conscious of the time, so I shall move on.

160.I was astounded that a pregnancy test cost £14.20 in one hospital - I believe it was Altnagelvin Hospital - and £2.05 in another. That is an incredible difference in price for a pregnancy test. Do doctors realise that they can shop around? Do doctors in the Derry area realise that, if they sent tests to Bangor Hospital or the Ulster Hospital, for example, it would be cheaper? They might have to pay only a quarter of the price.

161.Mr Gowdy: This situation arose because of the competitive environment created when the trusts and GP fundholders were established. They were supposed to provide a marketplace where GPs could shop around and find the cheapest test.

162.Ms Morrice: What happened?

163.Mr Gowdy: The problem developed for the very reason that GP fundholders were able to shop around. Laboratories could not be certain of the level of activity with which they would be required to deal. To bring prices down, they risked finding themselves in a position where they were unable to cover their costs. Different laboratories tended to specialise or carry out a higher volume of particular types of test, and they were able to charge a lower price because the volume of requests was high.

164.Ms Morrice: The number of requests for pregnancy tests in the Derry area is quite high.

165.Mr Gowdy: If everybody drove their costs down in that way, there would be a danger that the total costs would not be covered in each laboratory. It was becoming a problem, and that is why we changed to block contracts. Movement from place to place meant that some laboratories were in danger of going out of business. To put it in the private sector -

166.Ms Morrice: However, you slap £14.20 on every test - not only pregnancy tests - whereas other prices range from £2 or £3 to £8.

167.Mr Gowdy: That was done because the laboratories were working on the basis that GPs wished to have a common tariff of charges for every type of test. There was a great deal of concern that competition would drive people from one place to another and back again as they swapped their costs. That is not the way to run a care service. The other issue was that, because the Department was telling them that they had to meet their costs, the laboratories were getting concerned that the competitive approach meant that their volume of activity was less predictable. That meant that they were unable to cover their full costs.

168.Ms Morrice: I have one final question regarding cross-border co-operation, which is important. What is the Department doing to try to collaborate with the same sort of laboratories in the South? For example, is it possible for a doctor in Derry to send pregnancy tests to a laboratory in Letterkenny and have them done cheaper?

169.Mr Gowdy: Most clinicians want a speedy response. The further they have to send the test, the slower the results will be, for the sample must be taken somewhere. If the sample has to travel a longer distance, it will take longer. There is cross-border co-operation, but I am not sure if it has reached the point where testing can be done.

170.Ms Morrice: A new health body has been set up; is that not cross-border?

171.Mr Gowdy: I could quote numerous examples of practical co-operation. It tends to occur in the delivery of services, where patients can get treatment, for example, in liver transplant and heart surgery. I am not sure if laboratory work lends itself to such co-operation.

172.Dr Mock: I have not heard of co-operation in laboratory services specifically. However, I should be surprised if it did not happen, especially given Derry's location.

173.Ms Morrice: Perhaps you could find out if it is cheaper?

174.Mr Gowdy: We can check if there is cross-border laboratory activity, and we shall let the Committee know. As you can see, we are unaware of it happening at present.

175.The Chairperson: Would it make any difference to the price charged?

176.Mr Gowdy: It could make a difference.

177.The Chairperson: We might get a great deal of business from them in euros.

178.Mr Grzymek: I agree that there may be tests which are not particularly urgent. However, it is necessary to carry out many of the tests in the hospital for ease of access and transfer. Those would not be suitable for movement across the border. Some rare or specialised tests may be sent outside Northern Ireland, either East or South, depending on where they can be done. That happens only for rare conditions. In a population of 1·7 million, there are certain conditions of which we might see only one or two cases at a time. We should go to the best possible place for testing.

179.The Chairperson: That concludes the questions. We aimed to finish the meeting at 12.00, and we have just made it. My thanks go to the Members for being concise and to Mr Gowdy and his team for answering in such an efficient way that there was no need to drag the meeting out.

180.I shall sum up. Pathology laboratories are an important part of the Health Service, and doctors' ability to treat patients depends on their work. The Committee does not wish the trusts to make economies that put patients at risk or create additional costs for the rest of the Health Service. However, it is important to know whether locally based laboratory services function as efficiently as possible. That is what the meeting is about. It is particularly important because of the great financial pressure the Health Service is under. To use your expression, we do not want the best to be the enemy of the good.

181.Thank you for coming. I shall not see you before the festive season, so I wish you a happy Christmas

APPENDIX 1

Correspondence of 17 January 2002 from Mr Clive Gowdy, Accounting Officer of the Department of Health, Social Services and Public Safety

PUBLIC ACCOUNTS COMMITTEE EVIDENCE SESSION - 29 NOVEMBER 2001

During the above evidence session, I undertook to provide further information on a number of issues raised by the Committee. I am now writing to provide this information.

Common Protocols

We discussed with the Committee the issue of common protocols for laboratory tests. I agreed to provide further information on the extent of common protocols that are currently in place and the range of tests that they cover. The Committee also requested information on the progress being made with professionals in the implementation of common protocols.

A common protocol may be said to be in place when there is one common approach to conducting a test which is applied consistently when undertaking that test anywhere in Northern Ireland.Within each laboratory, each laboratory test carried out follows a clearly defined protocol (also called a standard operating procedure) and, for example, there will be numerous protocols covering clinical biochemistry, haematology and microbiology.

In Northern Ireland common protocols currently only exist for some regional specialties. Examples include:

Cervical screening - all cervical screening slides are examined in the same way by the cytology screeners across Northern Ireland. The number of slides processed are now over 100,000 per year.

Phenylketonuria - all babies in Northern Ireland have a heel prick blood sample taken during the first few days of life and this is tested for the disease phenylketonuria in the Link Labs laboratory. There will be 24,000 samples each year.

Cryptosporidium - in microbiology the Public Health Laboratory Service in Link Labs adheres to a common protocol which exists right across the UK, to comply with statutory requirements for cryptosporidium testing.

Xanthochromia - clinical biochemistry has agreed on a protocol for testing for xanthochromia right across the Province.

Haematology - in haematology the Regional Audit Group has developed common protocols for the diagnosis, investigation and treatment of certain diseases such as chronic lymphatic leukaemia, polycythaemia, thrombocytopaenia, anticoagulant management and the use of blood products.

Histopathology - in this speciality the Royal College of Pathologists has drawn up skeleton report proforma in the different specialty areas. These are used by histopathologists in reporting on biopsy specimens.

Before a wider range of common protocols can be put in place, further steps need to be taken to standardise equipment and processes across Northern Ireland. In each of our laboratories the standard operating procedure for carrying out a certain test may differ from that of another laboratory. This reflects the fact that laboratories may be using different types of analysers and different reagents to perform the same type of examination. Common protocols could be developed progressively, as opportunities come up for replacing major items of equipment and thus standardising the approach.

Impact of the Transfer of Laboratory Services from South Tyrone
The Committee was concerned about the impact on the timings of responses caused by the temporary move of laboratory services from South Tyrone to Craigavon Area Hospital. I promised to make enquiries and pass on the response to the Committee.

The Committee also requested information on the additional costs which have been incurred due to the temporary transfer of services from South Tyrone to Craigavon Area Hospital and information on whether these costs have been funded.

The temporary move of laboratory services from South Tyrone Hospital to Craigavon has imposed some additional pressure on the Craigavon laboratory, but the impact on service delivery has not been particularly significant.

General practitioners in Dungannon were able to access a very rapid turnaround of specimens in Dungannon laboratory, because of their proximity to it. Currently, if a specimen needs to be reported on urgently, it will be collected from South Tyrone Hospital reception and taken to Craigavon Area Hospital laboratory by taxi. Routine specimens are now collected by Craigavon laboratory from general practitioners, taken to the laboratory in the early afternoon and the results are available that evening.

Outpatient services for medical, surgical and haematology patients are carried out on the South Tyrone Hospital site. When results need to be available at the clinic on the day of the appointment, for example, in haematology clinics, the patients attend the hospital a few days earlier so that the result is back from Craigavon Area Hospital and available. For the anticoagulation clinic, a biomedical scientist from Craigavon Area Hospital attends South Tyrone Hospital and runs the tests while the clinic is taking place.

The South Tyrone Hospital wards have online access to the Craigavon laboratory and results are therefore available quickly to the clinicians at South Tyrone. Day procedures are carried out at South Tyrone Hospital. If a patient is unable to go home in the late afternoon he or she would be transferred to Craigavon Area Hospital for an overnight stay, and any laboratory tests required would be carried out there.

In summary, there has not been a significant increase in turnaround times of laboratory specimens with the move of work from South Tyrone Hospital to Craigavon Area Hospital. The large workload from general practice now arrives in the early afternoon and the laboratory has accommodated the extra demand in workload without a corresponding increase in time in reporting back the results.
The transfer of laboratory services from South Tyrone to Craigavon Area Hospital incurred additional one off costs of some £60,000 and ongoing additional costs of some £6,000 per annum for the transport of specimens. These excess costs have been funded by the Southern Health and Social Services Board.

Cross-subsidisation of Laboratory Services

The Committee explored the issue of cross subsidisation of laboratory services and sought assurances that Trusts have complied with the guidance when establishing the prices charged for laboratory tests.

All Trusts are required to set their prices as accurately as possible and Trust Chief Executives have confirmed that they are complying with the costing guidance. Nonetheless, it is also standard practice that laboratory prices are reviewed on a periodic basis. For example, Belfast Link Labs are currently undertaking a pricing review of their laboratory prices. Whilst the outcome of this review may lead to a change in the Belfast Link Labs' block contracts, it will not reduce the total laboratory costs for the HPSS, but may lead to a redistribution of costs between the various Trusts. This does not indicate cross subsidisation of laboratory services with other services and is simply a routine process to ensure that laboratory costs are fairly distributed between Trusts.

Cross Border Co-operation

We discussed with the Committee the potential for cross border co-operation in relation to laboratory services. Whilst there is a wide range of practical co-operation in relation to the delivery of patient services, I under-took to confirm whether any such cross border activity takes place in relation to the provision of laboratory services.

There is a small cross border element in the provision of laboratory services. Some hospitals in the Republic of Ireland access Belfast Link Labs for virology and specialised biochemistry testing (trace metals and toxicology). The Belfast Link Labs do not send specimens to Dublin but use some laboratories in Great Britain for specialised services.
The Western Area and Southern Area laboratories have confirmed that they are not aware of general practitioners accessing laboratory services on a cross border basis.