NEW YORK (360Dx) – In a massive, countrywide restructuring of pathology services, National Health Service England is consolidating 122 pathology service providers into 29 networks in a move to standardize care, improve efficiency, and reduce cost.
The project, which involves transitioning disparate pathology groups across the public health system in England toward a hub-and-spoke delivery structure is designed to better manage pathology resources while reducing unnecessary cost.
"We may have as much as 50 percent spare capacity in our current operating model, and that capacity is needed in case of any failures," said David Wells, head of pathology consolidation at NHS Improvement, a regulator and improvement organization with NHS. "When we move to hub and spoke, we can free up that capacity and we can reutilize the funding for that, so I think savings come in many areas of the service."
Pathology consolidation has been discussed for years within the government and the public health system, according to Wells, but the impetus for the current project was a 2016 report by Lord Carter of Coles, a member of the House of Lords tasked by the Secretary of State of Health with exploring ways to find efficiencies within NHS.
The report found "unwanted variation" across the healthcare system, including a more than twofold variation in the cost of pathology services to local hospitals, known as trusts. As a result of the report, NHS Improvement was assigned to design and implement a more consolidated pathology services structure.
As a first step toward structuring a consolidation, NHS Improvement hired lab consulting company LTS Health, which began by gathering data from disparate labs across England.
"The first thing we realized was there was not a comprehensive database that gives a picture of pathology on any day," said Chris Fourie, CEO of LTS Health UK. "Despite it being the National Health Service, [pathology groups] operated very much in silos. They didn't share information, so we didn't know where the buckets of excellence were."
The data collection process, which took three to four months, gathered information across multiple data points including testing volume by lab department and sub-department, cost of overhead, cost of equipment, types of IT systems, and the length of time that IT systems had been in place, according to Wells and Fourie.
There was also significant data collection related to the workforce, which was a critical area to study, both because it represents a large portion of the cost of laboratory services, and because labs in England have staffing pressures due to shortages of available personnel, according to Fourie and Wells. Workforce data was collected on total lab staffing, staffing by qualification level, lab pay scales, management ratios, senior scientist ratios, work rates, overtime costs, and the cost of temporary workers to fill employment gaps. The data collection effort resulted in a database with hundreds of pathology data points.
"What we ended up with was the largest data collection in pathology ever undertaken in England," Wells said.
The pathology data was funneled into an NHS "model hospital" portal that also includes data points on other hospital departments. The portal enables hospitals to benchmark their institutions and specific departments against other hospitals throughout the health system, according to Wells.
The first data collection involved a massive effort on the part of the laboratories, and LTS tried to keep communication open to minimize pushback, said Laura Comilla, commercial director, Americas for LTS Health, during a presentation at the G2 Lab Institute conference in Washington, DC in October.
"We held workshops to make sure people understood what they are collecting. We also created a hotline for people to contact if they had questions on the data collection, or the consolidation, or any part of the tools that were being used," she said.
The data collections are now conducted quarterly, but initially it was an adjustment, she noted, and efforts were made to demonstrate the benefits of using the data, so that it would be perceived as a tool, rather than a burden.
"A letter outlined here are some of your key areas of opportunity to look at in your organization with either automation, with staffing. All of that was laid out in terms of how you go about change, and why you are seeing variances. That was a key to gaining credibility," she said.
The benchmarking tools were used by LTS Health and NHS Improvement to plot a course for change.
"We wanted to understand who was performing above average, whether we could get groups performing below average to perform at the average, and what the impact of that would be," Fourie said.
The benchmarking and analysis led LTS Health and NHS Improvement to create a new pathology framework for England with 29 pathology networks, each serving between three and eight hospital trusts. The pathology networks are each being created with the aforementioned hub-and-spoke model, with a central laboratory in each network supporting smaller satellite laboratories, according to Fourie. The goal was for each network to serve populations ranging in size from 1.5 million to 2.5 million.
"Because of this data, we could monitor with a high degree of accuracy the impact of transferring volumes from smaller centers to a single larger center and only retaining the essential services laboratories in the smaller centers," Fourie said.
Using a framework developed in connection with LTS Health, NHS Improvement assigned hospitals to 29 networks, based largely on existing patient pathways, according to Wells.
"In the event of a patient going to one hospital, if it didn't offer the required care, where would the patient go next? That's how we formed out networks on the whole," Wells said, adding that geography and population size were also considered.
Hospital trusts that felt they were misplaced were permitted to make the case for why they would be better placed in another network, and so far five hospitals have been allowed to switch from their original assigned network, according to Wells.
In terms of establishing the networks, NHS Improvement provided guidance but left it up to network members to decide which entity should serve as the hub and how the network should be structured.
"In some of our networks we have some well-established and pretty large, world-famous teaching hospitals, so we don't necessarily want to get into an argument about which one should have the right to be the hub," Wells said.
NHS Improvement views pathology networking as a hospital responsibility, not just a pathology department responsibility, and hospital chief executives have been tasked with ensuring that the hospital's pathology department is networked, according to Wells.
NHS Improvement holds a workshop with each network to communicate requirements and answer questions of network members, but the structure of the network is left up to network members. So far, most networks have formed joint ventures, with one hospital trust taking the lead in pathology services management on behalf of the others, but it is up to network members to determine how their networks will be structured.
"The joint venture is probably the sweet spot, and the most effective way of doing it, but there can be anything from alliance contracting agreements, which just means agreeing that every time you buy, you buy together, to outsourcing where your pathology services are run for you on your behalf," Wells said.
One of NHS Improvement's key efficiency expectations of the new structure is better utilization of laboratory personnel.
"The phrase that we use is we want people working to the top of their license, so where we have consulting-grade scientists, we want that they spend their time on consulting-grade scientist roles. Where we have medics, they should be spending their time on the roles they are qualified to do, not things that others should be doing," Wells said.
Wells expects the network structure will also enable labs to better fill workforce gaps from personnel within their networks and rely less on more costly staffing agencies or short-term recruitment.
The network arrangement is also expected to achieve savings by consolidating purchasing into larger bulk purchasing contracts and by reducing overhead costs through a centralized management structure.
Four hospital networks are already up and running, according to Wells, with two more scheduled to be operational by the end of the fiscal year in March of 2019. All networks are expected to operational by 2021, he said.
Hospitals that have already started to implement pathology networks have so far saved £33.6 million, with a further £30 million predicted for 2018-2019, according to data provided by an NHS Improvement spokesman. Overall, switching to a network structure is expected to save NHS England at least £200 million by 2020-2021.
Long term, hospitals will submit the pathology data that was collected for the Model Hospitals portal on a quarterly basis, and the data will enable NHS Improvement, and the labs themselves, to continually monitor performance. Wells expects the new hub-and-spoke structure will also help better standardize the quality of pathology care across the system, improving care.
"By consolidating, we are able to deliver 24/7 services far easier and far more resiliently, while better using the workforce," Wells said.