Viewpoint: The future of pathology services and their provision

GPs in the UK are at a disadvantage compared with their counterparts in Europe when it comes to provision of pathology services, writes England's former national director for primary care Dr David Colin-Thome.

Dr David Colin-Thome: 'The role of private providers could be to offer collaboration with the NHS such as joint ventures.'
Dr David Colin-Thome: 'The role of private providers could be to offer collaboration with the NHS such as joint ventures.'

Up until now, GPs have had to accept what managerially led PCTs had negotiated. In Germany the role of choice of provider and tariff has meant the introduction of reduced price, and a more efficient service delivered at possibly half the cost if not lower than what we deliver in England.

For instance, Lord Carter’s report of 2006 proposed that, compared with other countries, England makes relatively little use of automated ‘front end’ technology (eg for sample tracking and reception) - widely used for instance by German providers.

There is the need to get away from the sterile argument of who is the better - private or public?  It is a particularly British obsession. Western European healthcare is also based on social value and yet believe in and deliver on a mixed economy of public and private providers.

GP views

So what do GPs want? I consulted some CCG leaders for their opinions.

Overarching ideas:

  • GPs and CCGs have to manage population health within a budget.  Pathology providers need to contribute to this
  • GPs want: lower cost; higher quality; value-added service; and, an easy life
  • There is a significant Pareto with 8-10 tests covering most of the volume although as ever some significant variations
  • Mixed views on current providers, but GPs not generally treated as customers

Financial savings/ transparency:

  • PCT block contracts are not transparent – GPs don't know what tests cost
  • A national tariff for GP pathology would be desirable/ essential for a choice of provider

Value-added services:

  • Phlebotomy and convenient blood collection points
  • Access to medical advice by 'phone or email (big variation in frequency used), particularly for less frequently used tests
  • Strong relationships between GPs and pathologists

Increasingly empowered patients:

  • Patients increasingly know/understand their (e.g. HbA1C, HDL, LDL) numbers.  Patients want access to their records, especially those with long-term conditions.
  • Labs should provide results to be accessible and easily interpreted by patients as well as GPs
  • Should support GPs to help patients understand tests results (e.g. website, leaflets?)

IT integration across the health economy:

  • Most GPs already ordering and receiving results electronically
  • Results should be available to GPs, across the health economy, and to patients as  well as integrate with other systems
  • Results/advice via a number of media (electronic patient record, web-portal, iPhone etc)
  • Tests ordered by GPs should not be repeated in hospital

Support clinical governance:

  • Provide value-added data, eg potential over/under testing by GP practice; population trends etc

Adopt new technology (provided evidence-based) which improves speed or quality of diagnosis and or convenience:

  • Most GPs have some point of care testing in the GP’s surgery but many would like more.  Eg troponin testing combined with ECG would reduce acute referrals
  • Appropriate genetic testing
  • Patient and GP convenience – eg for the future, mail blood spot on blotting paper

But there are perceived blocks and a commissioning opportunity to develop a higher-value service

Reaction of acute providers:

  • Will attempt to thwart private entry. Will claim loss of GP work will destabilise them
  • May attempt to re-test on basis of not trusting results
  • But CCGs will not generally be deterred from switching providers to get better quality/ lower cost

Private and public provision

In my experience and in undertaking reviews of care in the NHS, both private and public providers can be the providers of good and indeed poor care. Success depends on the quality of clinical and managerial leadership rather than the mode of ownership. And for other private industries whose products could endanger us we trust their integrity - cars, bridges, buildings and indeed such as operating theatre equipment and pharmaceuticals. Of course regulation is required but equally so for the public sector as for instance the number of recent hospital elderly care scandals.

There is now greater scope enhanced by clinical leadership of commissioning for involvement of pathology in the whole patient pathways (from the selection of the most appropriate test or investigation, to the interpretation and provision of clinical advice across the spectrum of clinical specialties). Pathology indeed needs to be managed in future as an end-to-end clinical service in its own right optimally as an independent cost centre or indeed business – both as a provider of high quality laboratory-based services and an integral part of the clinical aspects of the patient’s journey.

A key transformative opportunity for commissioners in responding to their key influencers - the patients, the public and their GPs. So if any change to provision is claimed to destabilise a hospital, it highlights poor hospital business and clinical management and leadership. Our very well-rewarded hospital leaders need to have the capability to respond to a changing environment. Other successful industries and healthcare providers in other countries do so as an integral part of their job.

The role of private providers could be to offer collaboration with the NHS such as joint ventures but where ‘knee jerk’ opposition occurs we need competition - how else do we get better value and deliver on the QIPP (quality, innovation, productivity and prevention) ‘Nicholson’ challenge?

  • Dr Colin-Thome was national director for primary care in England. He is now a GP advisor for pathology provider synlab.

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