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CHEMICAL-PATHOLOGY SERVICES
946
Making Efficiency in
ingham, laboratory size varies less than hospital size. Of laboratories, about 120 perform less than 50 000 tests per year and 83 laboratories perform more than 200 000 tests per year (fig. 2). As expected, it seems that 403
Do
the National Health Service
CHEMICAL-PATHOLOGY SERVICES THE demands on a chemical-pathology service can be defined in different ways. There is the need of individual patients in their own geographical environment. There are the needs of groups of patients categorised in terms of the hospitals where they are investigated and treated, as well as in terms of the diseases they suffer. Then there are the needs as seen by the physician or surgeon in charge of the patient. The total amount of work generated will depend on the case-mix of the population treated, the requirements of the cliniciaps, and the laboratory resources available. The relevance of the information provided by the laboratory to the clinical problems will depend on intelligent interaction between the clinical and the laboratory staff. For my argument here, I shall hopefully assume that such interaction is always at its closest and best. Despite much rationalisation in recent years, England, Wales, and Scotland still have 600 hospitals with acute beds whose size is less than 100 beds and 800 with less than 200 beds. Most of these are very small, but many are between 50 and 100 beds. In the 50-100 group, a number are specialist hospitals for paediatrics, obstetrics, or orthopaedics. Small hospitals are mainly in rural districts and provide small towns with a local clinical service. If these hospitals are to be used to the best advantage, they must have a reasonable chemical-pathology service. At the other extreme there are 121 acute hospitals greater than 500 beds. In between are 250 hospitals with 200-500 beds (fig. 1). The resources deployed to provide a laboratory service are: the space which houses the laboratory; the skilled staff (technical, graduate scientific, and medical); and the specialised apparatus. To judge by the returns of the National Quality Control Scheme for chemical pathology organised by Prof. T. P. Whitehead in Birm-
Fig. 2-Distribution of laboratories by workload. there is a fairly close match between the number of larger laboratories and the larger hospitals. What is less clear is whether the provision of chemical-pathology services to smaller hospitals is equally satisfactory. For years many of us have assumed that the answer is to centralise services in larger and larger laboratories. The case has been made}, -1 for the large multispecialist chemical-pathology laboratory and the general department in smaller hospitals.}. There is certainly a need for both, and also for the super-specialist laboratory which supplies very special skills to the supraregional assay service. To some extent attitudes to the service provided in small hospitals reflect the indecision in the N.H.S. about the function of the smaller hospital. With the recent emphasis on the community hospital, the well-defined local need for a small hospital has been recognised. It is therefore timely to review ideas for the organisation of laboratory services for the small hospital and to question the conclusions of the past. *
the response to
Beds Fig 1-Distribution of hospitals (mostly England, Wales, and Scotland.
acute
beds) by size in
an
*
*
increase in workload has tradi-
tionally been a demand for an increase in staffand for more capital for high-output automated machinery. These demands have often been met in the long tem by reducing the number of peripheral laboratories with very small workloads and centralising their activities. No doubt, in the past, the small laboratory may have had greater difficulty in offering a comprehensive chemical-pathology service, in maintaining good standards of quality control, and in providing specialist interpretation of the data; but need this necessarily be so? By and large, unless one is paying for some special feature, the output of an automated analytical machine is directly proportional to its cost, so it is possible to match a particular workload to capital expenditure (fig. 3). ’). Furthermore, with some of the newest analysers the approach to smaller workloads can be very flexible. The
947
distance? How prepared are chemical pathologists to undertake supervision and give clinical advice to colleagues over long distances? Should there be responsibility payments to chief technicians or senior biochemists for taking technical charge of small departments? Can we get our labour relations right? These are the many questions which have to be answered once the possibility of a decentralised service is a
acknowledged. *
Fig. 3-Relation of capital
cost to
output of analytical appar-
atus.
very large, more powerful machines are economical only with very large workloads and pay their way only if there is a significant saving in staff. Bringing in specimens from numerous modest-sized hospitals does not necessarily lead to economies if transport costs are high. The poor discrimination of the large multi-channel analysers has been justified by the low cost per test, but of the 10-15 tests on each sample perhaps only 1-4 are relevant to the patient’s condition. If the clinician is prepared to be more selective in his demands (which implies good training and a logical approach to the requisition of tests) smaller analytical units can be brought nearer to the patient and turnround time reduced. Of necessity, a nucleus of technical staff exists in modest-sized hospitals to provide emergency services, such as estimations of urea, electrolytes, glucose, and blood gases, and they could well operate modern small-volume analysers to provide a traditional service in an efficient and costeffective way. there remain the problems of supervision and interpretation of data. The general pathologist, although primarily a histopathologist, has traditionally supervised such laboratories; and some laboratories have been supervised at a distance by chemical pathologists or senior graduate biochemists. We probably have sufficient consultants and top-grade biochemists to man the larger laboratories in the large hospitals. It is extremely unlikely that manpower would ever be sufficient to permit similar manning of the smaller hospitals, even if some of them are labelled as district general hospitals. Where a number of hospitals are close together, centralisation is often the right solution. Can the stand-alone laboratory provide an improved local service with caretully selected equipment? Can skilled senior biochemists or chief technicians lead such laboratories? Many probably do so without adequate recognition. Should they be accountable for their work to senior chemical-pathology staff in neighbouring large hospitals without detracting from the contribution that the general pathologist can make? Can quality-control systems be made to work at
*
*
How do other countries provide a chemical-pathology service? In a fee-for-service environment such as exists in West Germany and the United States, two extremes seem to have been established outside the large clinical centres. There is, on the one hand, a service very close to the patient, often in the G.P.’s office, and, on the other, the transport of specimens to distant commercial laboratories by post, for reasons of cost or reliability. An interesting variation of this arrangement is found in Ontario in Canada. Small and large hospitals provide a service close to the patient, but there is also situated in Toronto the "in-common laboratory", which was founded by some of the larger Toronto hospitals to provide a service for tests which they did not wish to do on an individual laboratory basis. In addition to these local arrangements, the in-common laboratory has extended its service to many small laboratories in Ontario (some of them several hundred miles away), achieving a rapid turnround time through the bank courier system for bringing the specimens in at night. After analysis the following morning, the results are returned by Telex. Part of this service resembles the supraregional assay service, which, despite its faults, has been a success in the United Kingdom. How worth while is it to bring some chemical-pathology tests close to the patient? Some of the apparatus designed primarily for use in the field in developing countries may prove suitable for small local clinical units in Britain, provided there are the right people to operate it. This operation could, in country districts, save the transport of either patients or samples to larger centres. This type of activity in countries which run private laboratories has led to legislative intervention in quality control, which many would wish to avoid here. It could nevertheless be of substantial service to patients. *
*
*
In many ways the difficulties which afflict the N.H.S. arise from rigidity in handling problems. It is difficult to get the right staff in the right place with the right resources. Maybe we can learn from the free-market situation how to deploy what we have efficiently (and with humanity) without falling into the trap of "overkill". The right equipment is available and there is much good-will among the staff. Given the right attitudes, the N.H.S. could provide a superior service at less cost. Northwick Park Hospital, Harrow, Middlesex HA1 3UJ
M. G. RINSLER REFERENCES
1. Hospital and Health Services Year Book. London. 1976. 2. Carter, P. M., Davison, A. J., Wicking, H. I., Zilva, J. F. Lancet, 1555. 3. Mitchell, F. L., Rinsler, M. G. ibid. 1975, i, 165.
1974, ii,
Making Efficiency in
ingham, laboratory size varies less than hospital size. Of laboratories, about 120 perform less than 50 000 tests per year and 83 laboratories perform more than 200 000 tests per year (fig. 2). As expected, it seems that 403
Do
the National Health Service
CHEMICAL-PATHOLOGY SERVICES THE demands on a chemical-pathology service can be defined in different ways. There is the need of individual patients in their own geographical environment. There are the needs of groups of patients categorised in terms of the hospitals where they are investigated and treated, as well as in terms of the diseases they suffer. Then there are the needs as seen by the physician or surgeon in charge of the patient. The total amount of work generated will depend on the case-mix of the population treated, the requirements of the cliniciaps, and the laboratory resources available. The relevance of the information provided by the laboratory to the clinical problems will depend on intelligent interaction between the clinical and the laboratory staff. For my argument here, I shall hopefully assume that such interaction is always at its closest and best. Despite much rationalisation in recent years, England, Wales, and Scotland still have 600 hospitals with acute beds whose size is less than 100 beds and 800 with less than 200 beds. Most of these are very small, but many are between 50 and 100 beds. In the 50-100 group, a number are specialist hospitals for paediatrics, obstetrics, or orthopaedics. Small hospitals are mainly in rural districts and provide small towns with a local clinical service. If these hospitals are to be used to the best advantage, they must have a reasonable chemical-pathology service. At the other extreme there are 121 acute hospitals greater than 500 beds. In between are 250 hospitals with 200-500 beds (fig. 1). The resources deployed to provide a laboratory service are: the space which houses the laboratory; the skilled staff (technical, graduate scientific, and medical); and the specialised apparatus. To judge by the returns of the National Quality Control Scheme for chemical pathology organised by Prof. T. P. Whitehead in Birm-
Fig. 2-Distribution of laboratories by workload. there is a fairly close match between the number of larger laboratories and the larger hospitals. What is less clear is whether the provision of chemical-pathology services to smaller hospitals is equally satisfactory. For years many of us have assumed that the answer is to centralise services in larger and larger laboratories. The case has been made}, -1 for the large multispecialist chemical-pathology laboratory and the general department in smaller hospitals.}. There is certainly a need for both, and also for the super-specialist laboratory which supplies very special skills to the supraregional assay service. To some extent attitudes to the service provided in small hospitals reflect the indecision in the N.H.S. about the function of the smaller hospital. With the recent emphasis on the community hospital, the well-defined local need for a small hospital has been recognised. It is therefore timely to review ideas for the organisation of laboratory services for the small hospital and to question the conclusions of the past. *
the response to
Beds Fig 1-Distribution of hospitals (mostly England, Wales, and Scotland.
acute
beds) by size in
an
*
*
increase in workload has tradi-
tionally been a demand for an increase in staffand for more capital for high-output automated machinery. These demands have often been met in the long tem by reducing the number of peripheral laboratories with very small workloads and centralising their activities. No doubt, in the past, the small laboratory may have had greater difficulty in offering a comprehensive chemical-pathology service, in maintaining good standards of quality control, and in providing specialist interpretation of the data; but need this necessarily be so? By and large, unless one is paying for some special feature, the output of an automated analytical machine is directly proportional to its cost, so it is possible to match a particular workload to capital expenditure (fig. 3). ’). Furthermore, with some of the newest analysers the approach to smaller workloads can be very flexible. The
947
distance? How prepared are chemical pathologists to undertake supervision and give clinical advice to colleagues over long distances? Should there be responsibility payments to chief technicians or senior biochemists for taking technical charge of small departments? Can we get our labour relations right? These are the many questions which have to be answered once the possibility of a decentralised service is a
acknowledged. *
Fig. 3-Relation of capital
cost to
output of analytical appar-
atus.
very large, more powerful machines are economical only with very large workloads and pay their way only if there is a significant saving in staff. Bringing in specimens from numerous modest-sized hospitals does not necessarily lead to economies if transport costs are high. The poor discrimination of the large multi-channel analysers has been justified by the low cost per test, but of the 10-15 tests on each sample perhaps only 1-4 are relevant to the patient’s condition. If the clinician is prepared to be more selective in his demands (which implies good training and a logical approach to the requisition of tests) smaller analytical units can be brought nearer to the patient and turnround time reduced. Of necessity, a nucleus of technical staff exists in modest-sized hospitals to provide emergency services, such as estimations of urea, electrolytes, glucose, and blood gases, and they could well operate modern small-volume analysers to provide a traditional service in an efficient and costeffective way. there remain the problems of supervision and interpretation of data. The general pathologist, although primarily a histopathologist, has traditionally supervised such laboratories; and some laboratories have been supervised at a distance by chemical pathologists or senior graduate biochemists. We probably have sufficient consultants and top-grade biochemists to man the larger laboratories in the large hospitals. It is extremely unlikely that manpower would ever be sufficient to permit similar manning of the smaller hospitals, even if some of them are labelled as district general hospitals. Where a number of hospitals are close together, centralisation is often the right solution. Can the stand-alone laboratory provide an improved local service with caretully selected equipment? Can skilled senior biochemists or chief technicians lead such laboratories? Many probably do so without adequate recognition. Should they be accountable for their work to senior chemical-pathology staff in neighbouring large hospitals without detracting from the contribution that the general pathologist can make? Can quality-control systems be made to work at
*
*
How do other countries provide a chemical-pathology service? In a fee-for-service environment such as exists in West Germany and the United States, two extremes seem to have been established outside the large clinical centres. There is, on the one hand, a service very close to the patient, often in the G.P.’s office, and, on the other, the transport of specimens to distant commercial laboratories by post, for reasons of cost or reliability. An interesting variation of this arrangement is found in Ontario in Canada. Small and large hospitals provide a service close to the patient, but there is also situated in Toronto the "in-common laboratory", which was founded by some of the larger Toronto hospitals to provide a service for tests which they did not wish to do on an individual laboratory basis. In addition to these local arrangements, the in-common laboratory has extended its service to many small laboratories in Ontario (some of them several hundred miles away), achieving a rapid turnround time through the bank courier system for bringing the specimens in at night. After analysis the following morning, the results are returned by Telex. Part of this service resembles the supraregional assay service, which, despite its faults, has been a success in the United Kingdom. How worth while is it to bring some chemical-pathology tests close to the patient? Some of the apparatus designed primarily for use in the field in developing countries may prove suitable for small local clinical units in Britain, provided there are the right people to operate it. This operation could, in country districts, save the transport of either patients or samples to larger centres. This type of activity in countries which run private laboratories has led to legislative intervention in quality control, which many would wish to avoid here. It could nevertheless be of substantial service to patients. *
*
*
In many ways the difficulties which afflict the N.H.S. arise from rigidity in handling problems. It is difficult to get the right staff in the right place with the right resources. Maybe we can learn from the free-market situation how to deploy what we have efficiently (and with humanity) without falling into the trap of "overkill". The right equipment is available and there is much good-will among the staff. Given the right attitudes, the N.H.S. could provide a superior service at less cost. Northwick Park Hospital, Harrow, Middlesex HA1 3UJ
M. G. RINSLER REFERENCES
1. Hospital and Health Services Year Book. London. 1976. 2. Carter, P. M., Davison, A. J., Wicking, H. I., Zilva, J. F. Lancet, 1555. 3. Mitchell, F. L., Rinsler, M. G. ibid. 1975, i, 165.
1974, ii,