Pathology Modernisation: The Pathology Modernisation: The Carter Report and implicationsCarter Report and implications

Brian I. DuerdenBrian I. DuerdenInspector of Microbiology and Infection Inspector of Microbiology and Infection

Control,Control,Department of HealthDepartment of Health

The opportunityThe opportunity

The past : 1970 – 2000The past : 1970 – 2000– ““Infection is conquered”Infection is conquered”– A nuisance – impedes the modern medical success A nuisance – impedes the modern medical success

storystory– Microbiology/IC sort it out!Microbiology/IC sort it out!

Now – infection matters againNow – infection matters again– MRSA/MRSA/C. difficileC. difficile/HCAI/HCAI– Pandemic/avian flu; TB; BBV/STIPandemic/avian flu; TB; BBV/STI

The future: an The future: an Infection Service Infection Service for the 21for the 21stst centurycentury

Pathology ModernisationPathology Modernisation

1999 Modernisation of Pathology Services: 1999 Modernisation of Pathology Services: Modernisation Funding Modernisation Funding – HSC 1999/170; £10mHSC 1999/170; £10m

June 2002 Pathology: the essential service June 2002 Pathology: the essential service (Draft guidance for consultation)(Draft guidance for consultation)February 2004 Modernising Pathology Services February 2004 Modernising Pathology Services – £9.1m revenue, £54m capital£9.1m revenue, £54m capital

September 2005 Modernising Pathology: September 2005 Modernising Pathology: building a service responsive to patientsbuilding a service responsive to patients– Carter ReviewCarter Review

IoM Report July 2006IoM Report July 2006

August 2005 – May 2006August 2005 – May 2006– 20 meetings with SHA leads for Pathology 20 meetings with SHA leads for Pathology

ModernisationModernisation– Jointly with HPA Regional MicrobiologistJointly with HPA Regional Microbiologist

Report on DH IoM web pageReport on DH IoM web page

Network developmentNetwork development

Managed network operational 1Managed network operational 1Managed network planned Managed network planned – 1 well advanced; 3 proposed1 well advanced; 3 proposed

Formal network collaboration 6Formal network collaboration 6– Not single management/budgetNot single management/budget

Planned formal networkPlanned formal network– board in place 2; planning only 3 (1 SHA)board in place 2; planning only 3 (1 SHA)

Professional network 8Professional network 8Review of Pathology Services 5Review of Pathology Services 5No plans 6No plans 6

Modernisation fundsModernisation funds

IT investment 5IT investment 5

Service redesign 4Service redesign 4

Equipment 7Equipment 7

Not allocated 16Not allocated 16

Network IT programmes 7Network IT programmes 7– In full or partIn full or part

Network activitiesNetwork activities

Transport – recognised but not actionedTransport – recognised but not actionedTB servicesTB services– Fully coordinated 2Fully coordinated 2– Under review 10Under review 10– Individual responsibility 6Individual responsibility 6

ChlamydiaChlamydia– Fully coordinated 4Fully coordinated 4– Part coordination 1; funding problem 2Part coordination 1; funding problem 2– Under review 2Under review 2

Molecular diagnostics 1Molecular diagnostics 1

Problems Problems

StaffingStaffing– Medical; biomedical and clinical scientistsMedical; biomedical and clinical scientists

On call servicesOn call servicesDistant site workingDistant site workingFunding – lack of!Funding – lack of!– Both existing services and network Both existing services and network

developmentdevelopment

Commitment Commitment Foundation TrustsFoundation Trusts

Carter report – August 2006Carter report – August 2006

Commissioned end-to-end core clinical serviceCommissioned end-to-end core clinical service– Stand alone serviceStand alone service

National specification/planNational specification/plan

Contestability/competitiveness/pluralityContestability/competitiveness/plurality

Economies of scale/rationalisationEconomies of scale/rationalisation– 10% gain10% gain

Define what we provide for patient care and Define what we provide for patient care and health protectionhealth protection

Key driversKey drivers

Close to patientsClose to patientsStreamlined around user requirementsStreamlined around user requirementsCompetitiveness, plurality of provisionCompetitiveness, plurality of provisionCommissioner-ledCommissioner-ledClinical leadership, business infrastructureClinical leadership, business infrastructureProductivityProductivityInformation requirementInformation requirementCore clinical serviceCore clinical service

Barriers to changeBarriers to change

IT end-to-end connectivityIT end-to-end connectivitySample collection fragmented serviceSample collection fragmented serviceLack of commissioner understandingLack of commissioner understandingLogistic/transport supportLogistic/transport supportVariability of test repertoireVariability of test repertoireInconsistency of configurationInconsistency of configurationComplex workforce/skill mixComplex workforce/skill mixLack of investmentLack of investmentSeparate point of care testingSeparate point of care testing

Priorities for changePriorities for change

National specification/planNational specification/plan

Creation of stand-alone providersCreation of stand-alone providers

IT connectivity (including health protection)IT connectivity (including health protection)

National reimbursement/tariffNational reimbursement/tariff

Large-scale workforce change – multi-Large-scale workforce change – multi-disciplinary workingdisciplinary working

Strong clinical leadership and Strong clinical leadership and management skillsmanagement skills

Carter recommendationsCarter recommendations

““Reform of supply of Pathology must precede Reform of supply of Pathology must precede commissioner-led provision”commissioner-led provision”Managed pathology networksManaged pathology networks– Free standing organisationsFree standing organisations– Economies of scaleEconomies of scale

NHS Trusts to have SLA for PathologyNHS Trusts to have SLA for PathologyCommissioners draw up specificationCommissioners draw up specificationDH commissioning specificationDH commissioning specification– Tariff, new technology, workforce reformTariff, new technology, workforce reform– Standardisation, independent accreditationStandardisation, independent accreditation

Carter Pilots – 12 sites; £1mCarter Pilots – 12 sites; £1m

ObjectivesObjectivesNew commissioning modelNew commissioning modelNew organisational modelNew organisational modelIncreased quality and responsiveness to Increased quality and responsiveness to patientspatientsReduce NHS costsReduce NHS costs

1 per SHA (+2) Oxford in SE SHA1 per SHA (+2) Oxford in SE SHA

Progress November 2006Progress November 2006

Pilots Project Board establishedPilots Project Board establishedRecognised need for inclusion ofRecognised need for inclusion of– Infection ControlInfection Control– Public health/Health Protection functionsPublic health/Health Protection functions– DataData– PH/HP investigation; CCDC supportPH/HP investigation; CCDC support– Specimens/cultures for typing etcSpecimens/cultures for typing etc

Will have a national stakeholder groupWill have a national stakeholder group– Inspector of Microbiology memberInspector of Microbiology member

Actions for MicrobiologyActions for Microbiology

IoM to provide national input based onIoM to provide national input based on– ‘‘HP functions of NHS Labs’HP functions of NHS Labs’– HCAI programmeHCAI programme

Regional Microbiologist (HPA) to liaise Regional Microbiologist (HPA) to liaise with Pilot Siteswith Pilot Sites– Project leadersProject leaders– Microbiology laboratoriesMicrobiology laboratories

Microbiologists in Pilot sitesMicrobiologists in Pilot sites– Ensure local inputEnsure local input

Blue Skies Agenda

Vision and GoalVision and Goal

*An integrated and cohesive, quality *An integrated and cohesive, quality assured infection service for the assured infection service for the clinical care of infected patients, clinical care of infected patients,

infection control and health infection control and health protection.protection.

*Investigation, diagnosis, treatment, *Investigation, diagnosis, treatment, control and prevention of infectioncontrol and prevention of infection

Workforce – trained professionalsWorkforce – trained professionals

Medical – range of competencies; trainingMedical – range of competencies; training– Laboratory, clinical advice/care/infectious disease, Laboratory, clinical advice/care/infectious disease,

infection control, health protectioninfection control, health protection

Biomedical/clinical scientistsBiomedical/clinical scientistsNurses/nurse consultantsNurses/nurse consultantsPharmacists Pharmacists IT specialistsIT specialists

multi-professional teamsmulti-professional teamsIn laboratories, clinical settings, hospital and In laboratories, clinical settings, hospital and community/primary care, health protection units community/primary care, health protection units (and even management and government) (and even management and government)

Laboratory servicesLaboratory services

ClinicalClinical– diagnosis, treatment, infection controldiagnosis, treatment, infection control

Health protectionHealth protection– surveillance reporting, outbreak investigation, samples for surveillance reporting, outbreak investigation, samples for

reference testingreference testing

Near patient testingNear patient testingCommunication and ITCommunication and ITStandards and SOPsStandards and SOPsSafety and biosecuritySafety and biosecurityAccreditationAccreditation

Compliance: HCC annual healthcheckCompliance: HCC annual healthcheck Code of Practice (HCAI)Code of Practice (HCAI)