FULL LABORATORY to HOT LABORATORY Remodelling the biochemistry service at Macclesfield District General Hospital within a hub and spoke managed network -------------------------------------------------------------------------------------------- DR. DAVID OLEESKY Consultant Chemical Pathologist & Clinical Lead for Biochemistry Mid Cheshire Hospitals NHS Foundation Trust February 2012
THE DRIVERS FOR CHANGE Review of NHS Pathology Services in England by Lord Carter of Coles (Second Report, 2008): proposed large consolidated managed networks QIPP & 20% saving in pathology costs (DoH, 2010) Existing services not robust due to: - single-handed consultant cover - BMS staffing strains, especially out of hours - inefficient use of & back up for analytical equipment Change in commissioning arrangements for primary care direct access pathology testing Remodelling of other clinical services: local/national
CURRENT PATHOLOGY SERVICES Cheshire Pathology Services set up as managed network between Crewe & Macclesfield in 2007 in line with first Carter report (2006), but only limited rationalisation achieved; both sites still have full labs. Stafford/Stoke/Burton: separate laboratory services Price Waterhouse Cooper undertook review of pathology services in 2010-1 for this area (excluding Burton) with option appraisal & financial modelling Recommendation: Strategic alliance with service consolidation to create managed pathology network through a hub & spoke model with 1 lead Trust
RECOMMENDED SERVICE MODEL Central hub laboratory sited in new facilities at University Hospital of North Staffordshire, Stoke-on-Trent, due to open September 2012 Spoke laboratories at Stafford, Macclesfield, Crewe & Burton (east of map - joined later) for core biochemistry & haematology tests for A&E and inpatients Mid Cheshire Hospitals NHS Foundation Trust, Leighton, Crewe East Cheshire NHS Trust, Macclesfield University Hospital of North Staffordshire NHS Foundation Trust, Stoke Burton Hospitals NHS Foundation Trust Mid Staffordshire NHS Foundation Trust, Stafford Cannock Chase Hospital (Mid Staffordshire Trust)
BIOCHEMISTRY SERVICE CHANGES Blood Science working group co-ordinating reconfiguration of biochemistry services in conjunction with haematology/blood transfusion, immunology and serology/virology (I am a member of this group) Central automated laboratory at Stoke-on-Trent for all GP work and more specialised tests - opportunity to repatriate tests currently sent externally to other labs Essential service ( hot ) laboratories at other main sites to perform a limited range of core tests required for timely patient management, for A&E & inpatients, & also outpatients on samples collected at these sites
KEY STEPS IN RE-MODELLING Obtain baseline data: workload/staffing/equipment Define core tests to be done at spoke laboratories: those needed urgently &/or high volume for A&E & inpatients/outpatients (e.g. renal & liver function tests) Establish equipment requirements to do these tests; harmonisation with central laboratory desirable Determine workforce requirements for robust round the clock service at each spoke laboratory Consider other logistical needs: IT, transport, space (probably can reduce lab footprint, with cost savings) Set out timescale for changes, with key target dates
SPOKE LAB: BIOCHEMISTRY TESTS Serum/Plasma Alanine Transaminase (ALT) Albumin Alkaline Phosphatase Ammonia [if paediatric inpatients] Amylase Bilirubin (total and conjugated) Bicarbonate Calcium Chloride [site-dependent] C-Reactive Protein Creatine Kinase (CK) Creatinine Digoxin Ethanol/Alcohol [site-dependent] Gamma GT Gentamicin Glucose [fluoride oxalate plasma] Human Chorionic Gonadotrophin Lactate Dehydrogenase (LDH) Lithium Magnesium Paracetamol Phosphate Salicylate Theophylline Total Protein Troponin I or T (equipment-dependent) Urate Urea Vancomycin [site-dependent] Desirable as high volume tests: Haematinics: Ferritin, Folate, Vitamin B12 Lipids: Cholesterol (total/hdl), Triglycerides Thyroid Function (free T4 & TSH) Whole Blood [Lab &/or POCT analysers] Blood Gases, Carboxyhaemoglobin, Lactate CSF: Glucose, Total Protein Urine: Sodium, Potassium, Urea, Creatinine Serum & Urine: Osmolarity to be calculated
WORKFORCE ISSUES Staff at spoke labs ideally multi-disciplinary trained (i.e. able to work in both biochemistry & haematology) Equitable treatment equal opportunities for staff throughout network, wherever they are currently based Establishment of a unified team, so that don t end up with factions based on site of origin ( them & us ) TUPE (to lead Trust) & physical workplace re-location Natural wastage rather than redundancy is best way to reduce staff overall, i.e. not filling vacancies Risk of staff leaving prematurely before laboratories re-configured, for personal/logistical reasons, leading to pressure on remaining staff & service delivery
STAKEHOLDER ENGAGEMENT Staff - those involved in planning/implementation & other staff currently working in pathology Purchasers GP commissioners & acute trusts Service users clinicians & patients Liaison at overall strategic level & by working groups SUMMARY Complex project with many aspects major change to biochemistry service at Macclesfield, with fewer tests done on site - but only part of wider rationalisation of pathology services over most of Cheshire/Staffordshire to ensure that they are robust & financially sustainable