A Review of Pathology Laboratories in Northern Ireland

Mr John Dowdall, Comptroller and Auditor General and Head of the Northern Ireland Audit Office, has today published a report on the provision of pathology laboratories in Northern Ireland. Pathology laboratories in Northern Ireland process over 6.3 million tests each year at 16 sites, at a cost of over £41 million. This service is provided by a workforce of around 870, the majority of whom are Medical Laboratory Scientific Officers (paragraph 5 of Summary).

The report draws attention to a number of concerns relating to:

• the strategic role of the Department of Health, Social Services and Public Safety (and the Department of Health and Social Services before it) in controlling and monitoring the number and distribution of laboratories, and the extent and rate of rationalisation;
• independent validations of the quality of the services provided by these laboratories; and
• the differences in staffing levels and costs between hospitals in Northern Ireland and those in England and Wales. Significant variations also occur in the prices charged for carrying out laboratory tests.

Main Findings

The Strategic Role of the Department (Part 1 of the Report)

In 1983, the Department adopted a policy that recommended concentrating laboratory services on 6 main sites. Except in special circumstances of need or location, resources were not to be used to establish new or to indefinitely perpetuate smaller laboratories. In 1992, the Department accepted that there were too many laboratories. With the introduction of the internal market in the health service, the Department considered that service development was a matter for local decision (paragraphs 1.7, 1.8, 1.15 and 1.19).

The Audit Office is surprised that there has been no clear Departmental policy on the provision of laboratory services since 1983. Although the Department endorsed the results of a 1995 strategic review in England, the Audit Office questions whether it has done enough to set out its own strategy and to ensure that all parties are clear as to their responsibilities (paragraphs 1.22 and 1.26).

Rationalisation of the Service (Part 2 of the Report)

In April 1999, 61 discrete laboratory services were provided from 16 sites compared to the same number from 18 sites in 1982. Developments have included the withdrawal of some services and the merging or relocation of others. New laboratories have been built (eg Coleraine) and facilities upgraded (eg the Royal Victoria and Tyrone County Hospitals). However, there has been no change in the overall number of discrete services provided (paragraphs 2.1 to 2.3).

Any rationalisation needs to ensure that the laboratory service structure is the optimum to provide a viable and high quality service responsive to its users' needs (paragraph 2.8). The Audit Office stresses the importance of appropriate liaison and consultation with strategic decision-makers, pathologists and local managers to ensure future developments (such as those which might arise from the recommendations of the Acute Hospitals Review Group) support facilities that are likely to give the most efficient health care to the population (paragraphs 2.15 and 2.16).

Quality of Service (Part 3 of the Report)

In 1992, the Department said that it no longer had a role in decisions about laboratory closures but was interested in standards which would be protected by an accreditation process, using a national voluntary scheme set up by the profession itself. Health Boards would expect providers to place contracts with accredited laboratories (paragraphs 3.1 and 3.2). In addition to this, all laboratories take part in national external quality assessment schemes that compare the quality of a laboratory's performance in its analytical work, with national performance (paragraph 3.7).63 per cent of laboratories had received full or partial accreditation and a further 7 per cent had applied (paragraph 3.5). The Audit Office fully accepts that laboratories can provide a high quality service without having been formally accredited. However it is concerned that 28 per cent of all laboratories (17 departments) had not applied for accreditation and one department had not been approved, due to poor accommodation and the level of staff. The Audit Office was surprised that some purchasers do not enquire into how quality is assessed within the service, while others stipulate in their contracts that laboratories have to be accredited (paragraphs 3.5 and 3.18).

The Audit Office recommends that the Department undertakes an early review into the extent and degree of external assessment of laboratories and the efficiency of the work that they perform (paragraph 3.19). There are problems associated with making compulsory, a system developed for a voluntary scheme. However, a timetable needs to be agreed with all parties and local action monitored to achieve the aim of all laboratories being accredited at an early date. Consideration should also be given to the introduction, as in England, of a mandatory requirement for the accreditation of cervical screening laboratories (paragraph 3.20).

Pathology Workforce (Part 4 of the Report)

In September 1999, 69 consultant pathologists were in post against a complement of 76. Taking into account the impact of new developments and possible rationalisation, the Department should assure itself that all action possible is being taken to fill vacant consultant posts, particularly in vital support areas (paragraphs 4.2 and 4.8).

With regard to the non-medical workforce, the Audit Office found little evidence that formal criteria had been used to determine staffing levels, with more reliance being placed on local decision rather than specific guidelines and the benchmarking of tests (paragraph 4.12). Staffing levels for laboratory technical staff are similar to those in England and Wales, although a greater proportion of staff in Great Britain is employed in the basic grades (paragraph 4.15). In Northern Ireland, a greater percentage of technical staff also receives additional remuneration for responsibilities or specialist skills that do not warrant a higher grade (paragraphs 4.18 and 4.20).

Health Service providers said that there is a variety of issues which impact on the grading of staff in Northern Ireland compared to Great Britain, but the Audit Office considers that there is a need for an objective reappraisal of how the technical staff grading and payment system has been applied (paragraph 4.20 and 4.22).

Costs (Part 5 of the Report)

Spending per head of population on laboratories, at 1997-98 levels, was estimated to be 28 per cent more in Northern Ireland than in England (paragraph 5.5). While acknowledging the Department's reservations on the comparisons, the Audit Office recommends that the Department satisfies itself as to the causes of variations in costs between hospitals and the significantly higher cost is the main Belfast hospitals. It should also seek reasons for the higher level of spending on laboratories in Northern Ireland and in view of the significantly different "cost per patient" figures in hospitals with similar laboratory expenditure, it should review the different methods of accounting to ensure that they are consistent (paragraph 5.8).

At present, most laboratory work is purchased under block contract, based on individually priced tests. Prices charged were compared with a group of English hospitals. Despite wide variances in the prices quoted, those of the English hospitals were generally lower (paragraphs 5.9 to 5.13).

However, the tests which were quoted in the report were for high volume tests in the main specialties. Different methods of pricing are used throughout Northern Ireland and there may be differences in the intensity and level of staff involvement in testing. These can result in significantly different prices for nominally similar tests (paragraphs 5.15 and 5.18). The Audit Office recommends that the Department encourage the development and adoption of common protocols in laboratory testing (paragraph 5.21). While recognising that comparisons within Northern Ireland have limitations, the Department should introduce performance measurements, which provide benchmarks across the range of specialties within the pathology services in Northern Ireland (paragraph 5.28).