The evidence to date from the level of engagement in the laboratory modernisation process by the relevant stakeholders would suggest that there is now a real opportunity to deliver on the commitment in the National Recovery Plan (2011-2014) to introduce major change in our publicly funded medical laboratory services, writes Pat O’Dowd, HSE Assistant National Director – Contracts, Commercial and Support Services Directorate.
Laboratory medicine services are a key enabler of high quality patient care. They must at all times conform to internationally recognised standards and ensure the quality, responsiveness and accuracy of their contribution to patient care in the context of an increasingly dynamic and constantly changing health care environment.
The future system of service delivery for laboratory medicine services must complement the process of clinical service reorganisation that the HSE is currently implementing. International best practice would suggest that the future configuration of laboratory medicine services will consist of the following complementary components:
- A hot laboratory stream which will deal with laboratory medicine service requirements in acute settings. (secondary and tertiary levels).
- A cold laboratory stream which will manage large volumes of routine tests, most of which will originate from primary and community settings.
- Point of care testing in which certain tests will be carried out at the point of service or by the patient themselves as part of Self Care Programmes.
Laboratory services are currently provided across 43 sites. Laboratory services currently cost the HSE approximately €370 million a year. Approximately 76 million tests are carried out annually, of which approx 40 per cent originate from general practice.
Recent developments in laboratory medicine services
The National Recovery Plan 2011-2014 includes a commitment to introduce major change in laboratory medicine services and associated work practices.The Public Service Agreement (2010-2014) acknowledges the advanced level of engagement of the relevant stakeholders ‘to deliver major change to the medical laboratory services and associated work practices’.
As part of a joint initiative between the HSE, the RCSI and the Faculty of Pathology, Dr. Gerard Boran, Consultant Chemical Pathologist, AMNCH, has been appointed as National Programme Director of Pathology Services. Dr. Boran will provide clinical leadership to the laboratory modernisation process.
The recent introduction of an extended working day and revised on-call arrangements in our laboratory services are seen as the initial steps in the laboratory modernisation process.
Service delivery options appraisal
The HSE, with the support of DKM Economic Consultants and the National Development Finance Agency, completed a detailed cost/benefit analysis in order to determine the optimal service delivery model for laboratory medicine services. The analysis included the evaluation of differing options for financing the various cold laboratory service delivery models including direct public provision, direct private provision and various public/private partnership models. A pre-competitive dialogue process was carried out with a number of interested private providers as well as with a number of publicly operated/funded laboratories.
Laboratory services currently cost the HSE approximately €370 million a year. Approximately 76 million tests are carried out annually, of which approx 40 per cent originate from general practice
The key conclusion reached in both the cost/benefit analysis and the pre-competitive dialogue processes was that the greater the level of consolidation of routine blood science activity, the greater the potential for value for money gains.
The difference between in-house and outsourcing options in financial terms was found to be marginal and when other non-financial considerations were taken in to account the balance of advantage was considered to have moved in the direction of an in-house service delivery option.
An intensive consultation process has been concluded under the Public Service Agreement (2010-2014) resulting in agreement on an in-house service delivery option.
Stakeholders have agreed to co-operate with the introduction of the associated savings, changes in work practices, increase in productivity, skill mix changes, reduced staffing levels and proposed governance arrangements.
Proposed governance arrangements
Under the proposed in-house service delivery option, each publicly funded laboratory will be aligned to a “Hub and Spoke” regional network configuration. In the proposed service configuration “Hub” labs would handle all of the high volume blood science workload originating from primary care as well as the urgent work generated by the acute hospital site with which it is co-located. The “Satellite” labs therefore will handle smaller test volumes than heretofore, essentially meeting the needs of their associated acute facility.
In most regions it is expected that there will be one designated “Hub” lab. This expectation is based on the fact that all of the analysis carried out to-date would clearly indicate a positive correlation between the level of consolidation of the high volume workload and the resulting economies of scale. In exceptional situations a business case for more than one “Hub” lab may be arguable due to, inter alia, particular geographical and logistical considerations. The attainability and sustainability of defined efficiency and service quality parameters will be key considerations in the evaluation of any proposed service configuration. Regions may also identify other added value changes in clinical and service delivery configurations across the non-blood science disciplines which they may wish to progress in parallel with this process.
Each of the regional networks will come under the central direction of a National Pathology Services Network. The National Pathology Services Network will determine the clinical and service delivery standards to be adhered to by each of the regional networks, the distribution and use of financial and human resources, the range and quantum of activity to be carried out and the strategic long-term direction of laboratory medicine services.
Current stage in the process
As part of a due diligence exercise, a series of regional briefing sessions have been held with HSE/publicly funded laboratories. Each of the four regions has been requested to make a detailed written submission in accordance with defined service quality and efficiency parameters. The deadline for receipt of the submissions is mid September, 2011. A key focus of the process for evaluating submissions received will be an assessment of the willingness and capacity of the publicly funded laboratories to provide a reconfigured, dedicated “cold” lab stream(s) within the efficiency/cost/quality parameters which might accrue through alternative approaches including outsourcing options.
The HSE will reserve its prerogative to pursue alternative service delivery options in circumstances where the efficiency/cost /quality parameters are not (or are deemed not capable of) being achieved across both “hot” and “cold” service streams in all or some of the “Hub and Spoke” regional networks.
The evidence to date from the level of engagement in the Laboratory Modernisation process by the relevant stakeholders would suggest that there is now a real opportunity to deliver on the commitment in the National Recovery Plan (2011-2014) to introduce major change in our publicly funded medical laboratory services.