Redesign of Health and Social Services - Consultant Histopathologist and Pathology Manager - Transcript - 7 May 2014

Health, Social Security and Housing Scrutiny Panel

Consultant Histopathologist and Pathology Manager - Full Business Case

WEDNESDAY, 7th MAY 2014

Panel:

Deputy J.A. Hilton of St. Helier (Acting Chairman) Deputy J.G. Reed of St. Ouen

Senator S.C. Ferguson

Witnesses:

Consultant Histopathologist Pathology Manager

[14:04]

Deputy J.A. Hilton of St. Helier (Acting Chairman):

Good afternoon, and welcome to this Health, Social Security and Housing Scrutiny Panel. I am Deputy Jacqui Hilton, Acting Chair of the panel.

Deputy J.A. Hilton:

Thank you very much indeed. I would like to start by offering the apologies of our Chair, who is currently unwell, the Deputy of St. Peter . Thank you very much for coming this afternoon and making the time to speak with us. I would like to start by asking you, Dr. Southall, exactly what do you do and what does your title mean?

Consultant Histopathologist:

My training and my position in Jersey for the past 20 years has been a consultant in histopathology, and what that means is I perform diagnostic biopsy work, so surgical specimens that come to the laboratory, taken off by surgeons or general practitioners, are sent into the lab for histological microscopic diagnosis. So that is the bulk of the work that I deal with on a day-to-day basis. We also have an involvement particularly with the Deputy Viscount in doing post-mortem examinations, so when people die in the community or in the hospital, sometimes we need to discuss the case with the Deputy Viscount as to whether he or she is interested in whether the case needs to be referred to the Deputy Viscount, in which case a post-mortem is often carried out to find the cause of death. My other role, which I have been doing for the past 3 years, is as a clinical director for support services. Support services in this case means pathology. There are other clinical directors representing big departments within the hospital, medicine, surgery, radiology, so I form part of the group of clinical directors.

Deputy J.A. Hilton:

Okay. You sit on the clinical directors' board?

Consultant Histopathologist: Yes, that is right.

Deputy J.A. Hilton:

Okay, thank you. Mr. O'Keeffe, you are the Pathology Manager.

Pathology Manager: That is right.

Deputy J.A. Hilton:

Can you just briefly explain to us what that entails as well, please?

Pathology Manager:

Yes. There are 4 departments with pathology, there is histopathology, which is Peter's background; there is microbiology, the study of infection; haematology, the study of blood; and biochemistry, the study of chemicals in the blood. Each of those areas has a consultant, such as Peter, and then a laboratory of staff who support with diagnostic testing. My role is to manage those laboratories, so I am accountable for the budget, I am accountable for the staffing, I am accountable for the quality of the work that is being produced in those laboratories and responsible for their performance.

Senator S.C. Ferguson:

There were problems going on with the path lab, were there not, with regard to the weekend staffing? Have you sorted those out and how did you do it?

Pathology Manager:

We have not fully sorted them out, but we are well on the road to it. There was a negotiation between the management team and the staff, the permanent staff of the department, which resulted in there being no agreement by which those staff could or would work outside of their contracted working hours, which were Monday to Friday, 9.00 a.m. until 5.30 p.m., so as an interim measure the hospital has hired locum staff to cover those out of hours shifts. Clinically, that is a fairly acceptable way of doing things. It means the hospital continues to get its service, and in fact feedback from clinicians around the hospital is the service has improved since we have done that. However, it has not achieved the original objective of going into the negotiation, which was to save some money. So what we are doing is we are replacing those locum staff with contracted 2-year fixed-term contract staff, who are starting around about now, the first one started with us yesterday and the remaining 4 will come on board over the next 5 or 6 weeks. They will take over the running of this out of hours' service. The purpose of that is it delivers the original cost saving, it allows us to begin to delivery some efficiency savings. One of the issues with the old system, apart from the cost, is that biomedical scientists, those are the people who staff the laboratories in Jersey, have always been highly specialised - and scientists should specialise - but in the big scheme of things, Jersey General Hospital is a relatively small hospital and it is entirely possible for one person to manage of the out of hours workload. What we were doing is because everyone was so specialised, if you happened to, at 2.00 a.m. in the morning, need the 2 most basic tests on the repertoire, a full blood and some electrolytes, one of those is a haematology test and one is a biochemistry test, so you had to call in 2 scientists from home to do the 2 tests and that was a bit silly. So we have still got that system with our current locum staff and we want to move away from that to having a team of multi-disciplinary staff who can pretty much deal with the entire repertoire, regardless of which scientific discipline the test happens to traditionally sit in. That in itself is not an absolute long-term solution, it solves the problems for 2 years and allows us to deliver some efficiency savings and some modern ways of working. What we really need to do is get back to the negotiating table with our team of permanent staff and say: "What do we need to do to agree some sensible rates of pay and some sensible ways of delivering some additional training to get the existing permanent team working in a more modern, more multi-disciplinary way?"

Senator S.C. Ferguson:

There were some rather stupid comments, were there not, made about comparing the cost in Guernsey to the cost in Jersey, and it was comparing apples and oranges. Is the lab going to lose its accredited status?

Pathology Manager:

I would certainly hope not. We are due a surveillance visit from the accrediting body in June. I would hope to be able to demonstrate to the assessor that we have continued to operate at required quality levels.

Senator S.C. Ferguson:

Yes. Anyway, I am sorry, Deputy , carry on.

Deputy J.A. Hilton:

That is okay. Thank you very much indeed for that update. Turning to you, Dr. Southall, could you briefly outline to us your personal involvement in the future hospital programme?

Consultant Histopathologist:

As a clinical director, I have been privy to various meetings that have been held for the clinical directors through Bernard Place, the Clinical Director for the future hospital, together with Helen O'Shea and Julie Garbutt, so we have had close involvement. I think what we would like for the clinical directors is to have at least half a day for all the clinical directors, together with Helen O'Shea and Bernard and Julie, to talk about perhaps in more detail what the structure of the future hospital is going to be on the dual site.

Deputy J.A. Hilton:

You said you would like to be able to do that, but that has not happened?

Consultant Histopathologist:

No, I think it has been planned, but we have just been trying to find the right suitable day and I think Helen is working on that at the moment.

The Deputy of St. Ouen :

Can I ask, is it your belief that we are moving towards a dual site hospital ...

Consultant Histopathologist: Dual site, yes.

The Deputy of St. Ouen :

... rather than a single site hospital, as we have at the moment?

Consultant Histopathologist:

That is what I understand it to be, yes, at Overdale and where the General Hospital is at the present time, yes.

Senator S.C. Ferguson:

So we need 2 path labs then?

Consultant Histopathologist:

As it stands at the moment, with the architect's plan that we have seen, and that was drawn up at the end of the summer, the main pathology laboratory is going to be situated at Overdale with what is described as a hot laboratory on the main hospital site. Adrian can talk to this perhaps in more detail, but the hot laboratory will be a 24/7 laboratory, it will be med-staffed continuously throughout the whole week and to be able to provide essential emergency tests for patients within the hospital at all times. That would include blood transfusion and the blood sciences test that Adrian has alluded to, which is haematology and clinical chemistry and some microbiology tests as well.

Senator S.C. Ferguson:

Yes. Are you actually a pathology scientific officer?

Pathology Manager:

Yes, I am professionally qualified as a biomedical scientist. My history is in working in pathology laboratories and that is how I have ended up getting to the role of Pathology Manager.

The Deputy of St. Ouen :

Just going back a step, who was it that confirmed to you or the clinical directors that the dual site option, that was the final decision being made on it?

Consultant Histopathologist:

I think it is what is generally understood as to what the future hospital is. It is based on 2 sites and I think that is ...

The Deputy of St. Ouen :

Maybe I will rephrase the question. What do you base that comment on?

Consultant Histopathologist:

From the meetings that I have been to and from the information that has been given to me from ...

The Deputy of St. Ouen : From?

Consultant Histopathologist:

From Julie Garbutt, from Helen O'Shea, from Bernard Place.

Deputy J.A. Hilton:

How many meetings have you attended; do you know offhand? Have there been sort of half a dozen or ...

Consultant Histopathologist: Since ...

Deputy J.A. Hilton:

I think probably since about 2012, the year before the last, when the process started.

[14:15]

Consultant Histopathologist:

Probably since last autumn would be when I got to be more involved.

Deputy J.A. Hilton: Autumn 2013?

Consultant Histopathologist: Yes.

Deputy J.A. Hilton:

So at that point then the decision would have been made to follow the 2 site option anyway, I think.

Consultant Histopathologist: I think so, yes.

Deputy J.A. Hilton:

So that was probably prior to you attending these meetings with ...

Consultant Histopathologist: Yes, yes.

Deputy J.A. Hilton:

Thank you. Do you have any particular concerns regarding the proposals?

Consultant Histopathologist:

No. I have been here 20 years working in Jersey, and the idea of a new hospital with a lot more facilities and treatment facilities, benefits for patients is tremendously exciting. It is going to take a long time to fulfil that, but I fully support it. Probably the reason we are here is where pathology is going to be sited and we will talk about that, but perhaps our preferred option would be for pathology to be on one site, which if it is going to be on one site would have to be the site where the General Hospital is.

Deputy J.A. Hilton: The General Hospital?

Consultant Histopathologist:

At the moment, we have a main laboratory at Overdale and the emergency laboratory on the main ...

Deputy J.A. Hilton:

Why do you think the decision has been made to have the main laboratory at Overdale rather than at the General Hospital?

Consultant Histopathologist:

Possibly it may be one of logistics, because where we are situated in the hospital at the moment is fairly central and that is going to be one of the first areas to be demolished, yes.

Deputy J.A. Hilton: Yes, of course.

Consultant Histopathologist:

So once that has happened, we need somewhere to go to and it does seem easy to have a new ...

Deputy J.A. Hilton: To relocate you.

Consultant Histopathologist: To Overdale, which we would ...

Deputy J.A. Hilton:

That sounds to me quite unusual, to have the main path lab where Overdale is, which is basically all the outpatients and everyone else, but have a hot lab in the General. That seems to be the wrong way around to me. Is it?

Senator S.C. Ferguson:

I do not know. Have you analysed how your work sort of pans out, what percentage of your work comes in from G.P.s (general practitioners) and outpatients and how much comes from actual theatre?

Consultant Histopathologist: Yes.

Pathology Manager:

Approximately half of our work comes from the primary care community, from general practitioners, and approximately half comes from within the hospital, and of that, about half of it is outpatients and about half of it is inpatients, so if you separate off the outpatients from the inpatients, what you are left with is with the dual site model, approximately a quarter of the pathology work originating in the acute site, approximately a quarter of the work originating in the outpatient side and approximately half of the work continuing to originate within the primary care community. The issue is that the work that originates in the primary care community is not urgent, the work that originates within the outpatient areas is not urgent, but the work that originates within the inpatient areas is a combination of urgent work that needs doing as quickly as possible, so from A. and E. (Accident and Emergency) and critical care, and not urgent work, but still work which we want quite quickly. If you are an inpatient in the hospital having your daily bloods done, you would expect the results to be back within about 4 hours or something like that. That becomes logistically challenging if you have to do that through an off-site model.

The Deputy of St. Ouen :

You speak about the fact that the area that you are occupying is likely to be the first to be developed.

Consultant Histopathologist:

We are there until about 2018, I think.

The Deputy of St. Ouen :

How important is it to have up-to-date specialised facilities for you to conduct your work, or would it be possible to relocate the path lab within a general type of building as a short-term measure?

Pathology Manager:

It is more about what you put in the accommodation. As long as the accommodation is warm and watertight and the sorts of things that you would normally apply to whether a building is suitable for occupation or not, it is the equipment you put within it and the way you lay it out and the way you work within that that makes it modern versus not so modern.

The Deputy of St. Ouen :

Right. I am just thinking out loud, but it could be the case that obviously there would be a requirement for you to be temporarily relocated and then returned at the later date to the central building.

Consultant Histopathologist:

That is one possibility and we have had conversations with Helen O'Shea, because things are moving fairly fast now. Indeed, I think the final business case has to be in later this year.

Deputy J.A. Hilton:

The outline business case, I think in September.

Consultant Histopathologist: Oh right, is it September?

Deputy J.A. Hilton:

No, July. Well, it is some time in the next few months. It is the outline business case, yes.

Consultant Histopathologist:

What we would like to do, and I think we would have her support to do this, would be to have an external review of what pathology is now and what it is likely to be in the future and what facilities we need, what footprint we would ... because the buildings we have at the moment are very old, they have got a lot of walls everywhere and we would not build ...

Senator S.C. Ferguson:

I suppose, yes, but what about equipment? Does this mean you are going to have all new equipment in both sites or just one site?

Pathology Manager:

Shall I pick that up? Some of the equipment in pathology is already quite new, so we have not done too badly in the past in terms of equipment. You are not looking at a department that is in an appalling state, though some of the equipment is on its last legs and needs replacing. If we were looking at a single site model - and I mean a single site for pathology, not a single site for the whole hospital - then you would not replace the items of equipment like for like, but you would certainly replace the equipment with about the same amount of it. If you needed to equip 2 laboratories in order to service 2 sites, you end up needing more equipment and therefore have a bigger equipment bill. That is fundamentally how it would work out.

Consultant Histopathologist:

What we will have started doing and will continue to do, the words these days are Lean and working smarter, and we can do that in pathology. That is part of what Adrian's job is to do, is to look at our skill mix and what we do and what our equipment is.

Senator S.C. Ferguson:

Yes, but surely the point about Lean is to get together with your frontline staff and look at it, not just dictate from on high, with respect.

Consultant Histopathologist: No. It will be with ... there will be ...

Senator S.C. Ferguson:

No, but I have followed Lean somewhat, and as I understand it, it involves everybody, from yourself, the great and good, down to the frontline cleaners getting together and discussing how they do the job and ways of improving.

Consultant Histopathologist:

Yes, that is a major task that is going on in the hospital as a whole at the moment and we need to apply ... we want to get involvement for pathology as well, so we want to take that forward and to be a part of that. It is not just me or Adrian dictating that, it is for everybody to be involved in in the pathology ...

Yes, because I believe that when you get together like that, the great and good, as I say, with respect, find out all sorts of interesting things as to how the place is working.

The Deputy of St. Ouen :

Do the clinical directors, your fellow clinical directors, support a particular view on where the pathology lab should be located?

Consultant Histopathologist:

I have not canvassed them all, but speaking to one or 2 of them, they think the better idea would be for pathology to be as one unit on one site. That would be the General Hospital site.

The Deputy of St. Ouen :

Because, as I say, just to recap, dual site, equipment more expensive, staffing costs. Has an exercise been done to try and identify what the potential additional costs might be?

Pathology Manager:

No, it is too early to say at the moment, but I think there is a general expectation within pathology that there are things in terms of modernisation, in terms of Lean working which we could be doing and there is an expectation that as we deliver those things, we will be delivering cost savings and efficiency savings, so you would expect the sort of cost of providing a pathology service to be going down if you compare like with like. If we switch to a model where we have to run 2 pathology laboratories in 2 places with a bigger footprint, more equipment, which has a higher capital cost and higher running costs and more staff, then that is going to increase our costs and there will be some amount of horse-trading yet to be calculated between how the efficiency savings are saving money and how the dual site model is costing money and what is the trade-off between the 2. Now, at the moment we do not have any numbers to hang on that, but I would like it to be understood that we could potentially deliver efficiency savings in pathology; we will deliver efficiency savings in pathology, but they are likely to be masked by the additional running costs of switching to a dual site, not ...

Senator S.C. Ferguson:

But obviously the management would come back to you and say: "Well, only a quarter of your work is done in the hospital, done with the acute I.C.U. (Intensive Care Unit) and so on, but three- quarters of it is dealing with routine stuff and we will use that as a basis." How are you going to come back and argue that with them?

Pathology Manager:

What you end up doing is that the three-quarters you can deliver a reasonable amount of efficiency within. You can take it to a new site, you can do a new layout, you can ...

Senator S.C. Ferguson:

Yes. No, my question was if they come back to say to you: "Well, three-quarters of your work is not urgent, quarter of it could well be urgent, so that is why we would like the main lab up at Overdale and the hot lab ..."

Pathology Manager: Yes, right.

Senator S.C. Ferguson:

What arguments do you have back for them to say that you want it all in one spot?

Pathology Manager:

The key thing is that the three-quarters, the non-urgent work, can easily be transported around, so you could set up the Overdale site and the only interaction with pathology could be a plastic box that people put specimens in and someone comes and collects it every couple of hours and takes it down to the main laboratory. That will not affect the turnaround times for any of those patients in that setting at all. They are not going to need the results until the next time they come back for their outpatient's appointment in a week's time. If it takes us a week to produce the number, no one knows, no one cares, no one notices. Down at the acute site, people are coming in through A. and E. with acute issues that need resolving straight away and so we have to provide an immediate response. You cannot do that from another site, so you have to do that on the acute site, and then as soon as you have got your laboratory there on the acute site providing the A. and E. and the critical care service, you might as well also use it for the inpatient work which is originating on that site and requires a reasonably quick turnaround time.

Deputy J.A. Hilton:

So are you saying that you cannot provide that service, like the acute service, from the hot lab within ... because you mentioned about having a hot lab at the General Hospital.

Pathology Manager:

Right, so the General Hospital, the model is the General Hospital has a small laboratory, a hot laboratory, an acute laboratory and that is the laboratory from where we provide those services for emergency urgent cases. Seeing as the laboratory is there present on that site, it then makes sense to also use it for the hospital inpatient work.

Deputy J.A. Hilton:

So you are both of the opinion that there should be one path lab now and it should be located at the General Hospital?

Pathology Manager:

Yes, so you have got three-quarters of the work, but it does not matter whether you do it on site one or site 2, and quarter of the work that must be done on site one.

Deputy J.A. Hilton:

That is immediately as well?

Pathology Manager: Yes.

Consultant Histopathologist:

Yes, and Dr. Mattock and Dr. Muscat respectively are the consultants, and Dr. Goulding, my colleague in cellular pathology or histopathology, we are all of the same mind on that.

Deputy J.A. Hilton: Okay. You mentioned ...

Senator S.C. Ferguson:

Have you discussed this with the management at all?

Consultant Histopathologist: Yes. Everybody is listening to us ...

Senator S.C. Ferguson: They are taking no notice.

Consultant Histopathologist:

No, no, no. What is happening is that, as I understand it, we have the original plan and I understand it that no ... so that is the plan that is being worked to, but no final decisions have been made as yet, and in conversation with Bernard and with Helen, I am confident that they are listening, our views are being taken on board, they know our concerns about where pathology should be located and we are awaiting the ... as I mentioned, Helen, I think, will support an external review of pathology and where it might be located, how best to run it for the future.

Deputy J.A. Hilton:

Where are you with the external review? Has she just expressed a view that it should be carried out or is it in motion at the moment?

Consultant Histopathologist:

No, that is just a conversation. I think she and other people have been ... you are talking to them later this week.

Deputy J.A. Hilton: Tomorrow.

Consultant Histopathologist:

Yes, so you can speak to them about that.

[14:30]

So while at the moment the laboratory is split on 2 sites, that may not be the final decision, because other areas that are on the plan at the moment may shift around, so there may be other ways of dealing with this.

The Deputy of St. Ouen :

Can I ask, prior to the decision to move towards the dual site option, what involvement, if any, did you have in looking at the feasibility of a single site development?

Consultant Histopathologist:

I had no formal involvement in that. I was aware of what Andrew McLaughlin's ideas were previously as to how a new hospital could be ... or the current acute hospital where the General Hospital is now could be developed over a period of time by refurbishment, but that is not where we are now and so we have ...

The Deputy of St. Ouen :

Did the clinical directors ever meet with Atkins, the external consultants that were brought in to look at the feasibility and the development of the hospital?

Consultant Histopathologist:

Yes, I remember meeting with them as well, yes, and speaking with them.

The Deputy of St. Ouen :

During that meeting or meetings, did discussions ever revolve around the services that should be provided within a new hospital?

Consultant Histopathologist:

I cannot recall that. No, I do not remember being party to a discussion about that with them.

Deputy J.A. Hilton:

What difference do you believe that the changes will make to the role of the medical staff in the hospital and primary care and also particularly in relation to your work? We have just talked about the location of the staff. Have the staff expressed an opinion about the 2 site option to you?

Consultant Histopathologist: The staff in pathology?

Deputy J.A. Hilton: Yes.

Consultant Histopathologist:

Only mainly the consultant staff that I have spoken to, and certainly the staff in my department in cellular pathology feel that it should just be on one site.

Deputy J.A. Hilton:

Be in the one place, yes.

Pathology Manager:

I have spoken to a number of pathology staff about it from different disciplines and I think it is safe to say that 100 per cent of the opinion is that pathology should be located on one site and that site needs to be the same site as the acute hospital services, in particular, the blood transfusionists have got very strong views on it, that they struggle to see how a dual site model could work for blood transfusion. I have to say, I have got quite a ... I have got a much wider experience than that, and we could make blood transfusion work across a dual site model, but it would be easier to do it in one place.

Deputy J.A. Hilton:

Do you know of any other hospitals, acute hospitals, that have their main path lab located somewhere else?

Pathology Manager:

It is becoming more common in the U.K. (United Kingdom), so the trend at the moment in the U.K. is to merge pathology services together into single sites serving a number of hospitals in a geographic area. Obviously that is not going to work for Jersey, but it allows us to look at what could happen in those circumstances and what they generally end up with is to have this sort of small acute lab on the site where you need it and then a big sort of large lab off-site somewhere else, where the bulk of the non-urgent work goes to. The reason that they are doing that is because by doing that, their volumes are so large that they can deliver really quite considerable cost savings and efficiency savings. Our volumes are not that large. All we are doing is taking a relatively small number to start with and dividing it into one quarter and three-quarters, so we are not ending up with a laboratory that is doing more than any laboratory is doing to start with, but only ending up with 2 laboratories, both of which are doing less than the one laboratory was doing to start with. So we are introducing an inefficiency rather than introducing an efficiency.

Deputy J.A. Hilton:

Dr. Southall, have you been asked about your view on single bed units, because there is a drive to have mainly single-bedded rooms. Have you been asked your view on it? We are interested to know what your view is.

Consultant Histopathologist:

My view is from a pathology point of view, and particularly from the infection control aspect, it is a very good thing, because it allows effective barrier nursing and patients can be isolated in a comfortable environment and there is no knock-on effect of closing other beds in smaller-bedded units. I think there are advantages to it. I have heard other people say that there are disadvantages to it as well, but as a pathology-based consultant, I do not visit the wards particularly often, but ...

Deputy J.A. Hilton: Your personal view?

Consultant Histopathologist:

When I have been in hospital, it is nice to have a single bed and I would prefer to have it that way, yes.

The Deputy of St. Ouen :

So with regards to spread of infection and the like?

Consultant Histopathologist:

Yes. I think the spread of infection is certainly less in a single-bedded ward environment.

The Deputy of St. Ouen :

Would any advice come from the path lab, depending on the particular test you use, where you would personally advise individuals to be isolated from another?

Consultant Histopathologist:

That would be the responsibility of Dr. Muscat to advise fellow clinicians and nursing staff about ...

The Deputy of St. Ouen :

Does that advice come from the path lab?

Consultant Histopathologist:

From the infection control team, yes, which is headed up by Dr. Muscat, yes, so there is close involvement there. You asked about the effect on other medical staff?

Deputy J.A. Hilton:

Yes, whether other frontline staff have been included in any discussions around the single bed option. Are you aware of your staff? No.

Consultant Histopathologist:

I am not. You would probably need to ask ...

Pathology Manager:

I do not think the single bed issue is a big thing for pathology. I do have a personal opinion on it.

Deputy J.A. Hilton:

We are interested in your personal opinions.

Pathology Manager:

It is based on 2 things. First of all, most of my career I have spent working in independent hospitals where there are only single rooms and a lot of the patients that were in those hospitals were there because they could have a single room. It is far preferred by patients over having to have a sort of shared ward area. The other thing is that I have been a patient in a hospital in a 4- bedded bay. I was only in for one night and it was horrible and miserable and I would not wish it upon anybody. My opinion, based on personal experience, is give me a single room any day, thank you very much.

The Deputy of St. Ouen :

So with all the proposed changes around and the redesign of Health and Social Services, apart from sort of the location of the path lab, what are the other potential implications for yourself and your department?

Consultant Histopathologist:

On a day-to-day basis, consultation with other doctors in the hospital and individual patients, and what we have set up over the past few years are meetings called M.D.T. (Multi-Disciplinary Team) meetings, where on a weekly basis we ... for example, today I have had 3 M.D.T. meetings which involved the breast team, the urology team and the head and neck, E.N.T. (Ear, Nose and Throat), so that involves the consultants, the nursing staff, the radiologists. It is particularly mainly about patients who have cancer and it is what the diagnosis is, how the diagnosis is made, what further tests need to be carried out and what is the sort of consensus view of the team as to what treatment should be offered to a particular patient. So it is sort of individual patient discussion, but with colleagues in a room like this, where we have all the facilities to look at the radiology, the histopathology, the biopsies and diagnoses and to talk about those particular patients. So that is something that takes place hopefully in a designated room where we can just carry on to do that. While we could do that on 2 sites with very good I.T. (information technology) systems in place, there is nothing better than sitting in a room sometimes and looking at the body language of people and see what they are saying and making sure they have picked up on the important points.

Deputy J.A. Hilton:

So basically you are saying if oncology was at Overdale, that would make that a little bit more difficult?

Consultant Histopathologist:

No, I think the patients can still be treated. They would have a fantastic facility up there, perhaps, but it is bringing everybody together and where is that meeting going to be?

Deputy J.A. Hilton: Yes, that is right.

Consultant Histopathologist:

You have to rely on people to be there and to easily to get to the ...

The Deputy of St. Ouen :

So basically your role is prior to people receiving treatment, you identify the problem?

Yes, it is starting at the beginning, identifying what the problem is, making a diagnosis and taking it step by step as to ...

The Deputy of St. Ouen :

What about the development of services within the community? What thoughts do you have on potential impact on the services you provide as we move towards that model?

Pathology Manager:

I think as a pathology department, we need to be open to and willing to facilitate the movement of appropriate services into the community. To give you an idea of something that is not working at the moment, but could work better, and a community-based solution might well be a solution, at the moment if people are having Warfarin therapy, which is a tablet that you take to thin your blood, you have to have a test every so often to see whether the dose needs changing. At the moment, all of those patients come into the hospital to have their blood taken and then they go back home again. As a number of them are elderly, some of them are picked up on the hospital transport and brought into hospital to have their blood taken and then picked up on the hospital transport and taken back home again. That is a dreadfully inefficient way of providing that service because the test that we are doing on that specimen of blood is a really simple test that can be done on a simple little meter, but you cannot quite buy it from the chemist yet, but it is not far away. It is certainly worth doing a feasibility study to say: "Would it be more efficient to provide that service in a community setting rather than bring hundreds of people from all around the Island into the hospital just to have their blood taken and then to drive them all home again?"

Deputy J.A. Hilton:

Like a district nurse would be quite capable of carrying out that service, visiting people, especially the elderly, in their homes?

Pathology Manager:

Yes, or even a more junior member of staff than that, so for what we are paying for a driver to go and get someone up and bring them to hospital and then take them back again later, you could pay someone to visit the patient's house once, do the test while they are there and then move on to the next patient. Those are the sorts of things, but that needs to be done within the governance arrangements of pathology, so just because the test is no longer being done in the pathology laboratory, it still ought to be the responsibility of the pathology team to ensure that there is an appropriate training programme in place for the people who are doing those tests, that there is appropriate quality assurance of the instruments that are being used to do those tests, that we

know that they are working properly and giving the right results. Those are the sorts of things that we need to co-operate with and facilitate in order to help move appropriate services.

Consultant Histopathologist:

It is called point of care testing, so it is closer to the patient.

Deputy J.A. Hilton:

So what work is currently being done to make these things happen?

Pathology Manager:

So the particular example I have given, there is quite a lot going on, so as part of the hospital's Lean project, there is a lady called Sue Cox, who is a Lean practitioner, who is specifically tasked with looking at that particular thing and working out what would be the most efficient way of doing it. On the one hand, if you simply look at the tasks and the time taken and distances travelled, you can work out that it would be much more efficient to do things in one way, but you also have to take into account what would be the cost of providing these meters in the community and so on and so forth. So that is what she is working on at the moment, which we are supporting.

Deputy J.A. Hilton: Okay, thank you.

The Deputy of St. Ouen :

Sorry, I just want to get back to the decisions around a single site versus a dual site. Can you just confirm what consultation process, if any, took place prior to the preferred option of a dual site being explored?

Pathology Manager:

There is a fact that I have not shared, because it did not come up earlier, which is that I am quite new in my post and I have only been here in Jersey for 5 weeks.

Deputy J.A. Hilton:

I did think that at the start, and I thought: "Oh, I wonder how long this gentleman has been here?"

The Deputy of St. Ouen :

I will direct my question to Dr. Southall.

Pathology Manager:

Yes, so I cannot answer the question, and the reason I cannot answer the question is because I have not been here long enough to give an answer.

The Deputy of St. Ouen : Thank you. Dr. Southall.

Consultant Histopathologist:

Thank you. We had the consultation team with Atkins and they were doing the feasibility study looking at the various potential sites.

Deputy J.A. Hilton: The different sites, yes.

Consultant Histopathologist:

The different sites. I understand it was their decision. It was not ... we were not necessarily party to making that decision. I think it was decided that a dual site would be the preferred option.

[14:45]

The Deputy of St. Ouen :

Let me help you here. We have been told that once decisions around the dual site had been started to be considered, services were prioritised. Well, a prioritisation process was gone through. Were you party or have you been party to a prioritisation process when the decision was taken not to spend the £450 million but to spend £300 million on developing a hospital on 2 sites?

Consultant Histopathologist: I do not recall that, no.

The Deputy of St. Ouen :

No. That is a good answer, thank you.

Deputy J.A. Hilton:

Okay, just going back to the 2 site option again, do you think there is any risk to patient safety having the path labs on 2 different sites?

Consultant Histopathologist:

No, we can run it perfectly safely. I think there is no risk to patient safety. I think it is you have an opportunity to build a hospital on 2 sites for the future. We felt if it stays the same, we feel it will not be as it is at the moment on the main laboratory site at Overdale and the smaller laboratory at the main hospital.

Deputy J.A. Hilton:

It is the wrong way round, is it not?

Consultant Histopathologist:

Yes. Well, it should just be on one site and we think that should be on the acute site.

The Deputy of St. Ouen :

We do not necessarily experience severe weather conditions that often, but could there be any issues if you were operating the main laboratory from Overdale and for whatever reason samples from the hospital could not reach you?

Consultant Histopathologist:

The 2 sites are not very far apart and I would not ...

The Deputy of St. Ouen : One is up a hill.

Consultant Histopathologist: One is up a hill, yes.

Pathology Manager:

One of the advantages of having a dual site model with a laboratory on both sites is business continuity, so if there were, for example, a fire in one of the laboratories, you have always got the other one to fall back on. We do not have that facility at the moment, so it is not all bad, but on balance, it would still probably be better to have ...

The Deputy of St. Ouen :

Then offset against the cost of running 2 sites rather than singly could be significant, because there are presumably additional staff that you would require.

Pathology Manager:

Yes. The Deputy asked whether there was a clinical risk, but the short answer is no, there is not a clinical risk, but the long answer is the reason that there is not a clinical risk is that we identify what all the potential risks are and what are all the things that could go wrong working this way. We put things in place to make sure that those things cannot go wrong, but those things that we put in place cost money, so that means more equipment, it means more staff, it means higher running costs.

The Deputy of St. Ouen :

You mentioned about providing for a whole range of different services that are currently being provided. Have you been party - and whether it is the role of consultants, histopathologists or indeed a clinical director - with regard to what services should be provided on-Island and off- Island?

Consultant Histopathologist:

Yes. What we are trying to achieve is to bring services back to Jersey that currently will have been dealt with by patients treated off-Island at other centres. That is happening. With the arrival of the new breast surgeon and general surgeon, Matt Stephenson , a new gastrointestinal surgeon and a new urologist, that is having a tremendous impact on the work that I do, in particular with the surgical specimens that are coming through, so rather than patients being sent away to have their cancers treated and removed, the surgeons are doing it in the hospital now, so patients are not having to go to off to the mainland.

The Deputy of St. Ouen :

What is the main reason behind that, bringing more services back to the Island?

Consultant Histopathologist:

One, it is better for patients if they can be treated here. It is not necessarily a great experience to go off from home and not have your family here or your relatives here to support you while you are undergoing treatment. If they can be cared for in the hospital, as they have been doing, hopefully they will be able to go back home sooner and be discharged from the hospital, without having long transport inbetween. One is cost. The hospitals that we have to contract with do charge a lot of money for the services that they provide and it is bringing the control of those finances back to Jersey so that we can ...

The Deputy of St. Ouen :

So what impact will the increase in these additional services have on your department?

Consultant Histopathologist:

I am getting busier and we may need another histopathologist, but that is probably a small price to pay for making the diagnosis here and having the services brought back to Jersey.

The Deputy of St. Ouen :

But all of these factors have been taken into account prior to returning services to the Island, have they?

Consultant Histopathologist:

Everybody is aware of them, but it is only when you realise what the impact is on the ground, when it is put into practice. We know that patients who were previously going away to have their rectal cancers excised are now staying in Jersey and so those surgical specimens are coming to me and my colleague and we have to deal with them properly, according to stringent guidelines, and issue the report back to the surgeons so they can discuss it with the patient. So it is happening, in practice. Everything that we wanted to happen with the appointment of new consultants and the potential that they can give to Jersey with what they offer is really happening.

The Deputy of St. Ouen :

What effect will an ageing population have on the services that you currently provide?

Deputy J.A. Hilton: It is increasing.

Consultant Histopathologist:

It is increasing. Pathology is really at the heart of diagnosis of about 70 per cent to 80 per cent of patients in the Island in general practice and within the hospital, so the tests that are carried out, be they blood tests or cellular pathology, histopathology tests or microbiology tests, they all have potential impact on the patient's treatment, and once you have that diagnosis the patient hopefully will start on the right treatment.

The Deputy of St. Ouen :

Currently, have the discussions around the future provision for a pathology lab, have these issues been factored in or are they still to be determined?

Consultant Histopathologist:

I think they are still to be determined, would you agree, Adrian?

Pathology Manager:

Yes, I do not think we have got down to that layer of detail yet.

Consultant Histopathologist:

But with an external review, that is the kind of detail that we want to go down to, because it is for the future as well. What we are doing now is going to be quite significantly different, I would think, in 5 years' time.

The Deputy of St. Ouen :

But if that work is still to be done, obviously it is still impossible then to determine what the financial implications might be and the impact on obviously the taxpayer/patient.

Pathology Manager:

I think we can describe what the factors are that affect it, but I do not think we are in a position to hang some numbers on it. Earlier I talked about 2 key factors. One is there are efficiency savings to be found in pathology; one is that if we move to a dual site model, the costs will go up, and there will be a balance between those 2. A third and fourth factor, which we have just discussed, is increasing complexity from bringing more things back on to the Island, which pushes up the costs, and the ageing population that you referred to, which pushes up costs. There will be a balance to be found between all 4 of those factors, and where we are sitting today, I do not think we have got a forecast of where that balance lies.

The Deputy of St. Ouen :

When would you anticipate having that information?

Pathology Manager:

I do not think I can answer that, having done 5 weeks in post. I barely even know who is going to do it yet, never mind when they are going to do it.

The Deputy of St. Ouen :

Bearing in mind that presumably there are certain matters that need to be dealt with prior to agreeing sizes and shapes of hospital, when do you anticipate that work being completed? When would you expect the work to be completed, given your previous experience elsewhere?

Pathology Manager:

I would expect the work to be completed before we finalise a plan and start getting quotations and that sort of thing.

Deputy J.A. Hilton:

When you refer to "the work" you mean the review?

Consultant Histopathologist:

Yes. I think if we are successful in getting a review, then that would have to be done very quickly, during the summer, so that we have an answer by ...

The Deputy of St. Ouen :

The review would not necessarily deal with all the financial implications, would it?

Pathology Manager:

I would anticipate it being a part of the review, so one of the things that the review needs to consider is what is the likely workload going to be in the future that we need to be planning for. It is not going to pull figures out of thin air, but we could reasonably predict what the likely percentage increase in workload is going to be in the future and that sort of thing. That side of things is relatively straightforward.

The Deputy of St. Ouen :

If we are looking to create a sustainable funding mechanism for the hospital and social care in the community, would you expect that information to be created or developed first before agreeing the sustainable funding mechanism or after?

Pathology Manager:

There are 2 ways of doing things. You can either work out exactly what you think your activity is going to be, then you can work out all the finances, or you can set a budget and say: "That is the amount of finance there is" then you can work what money and you can deal with that budget. Which of those approaches you take is a political decision which I am not going to make a comment on.

The Deputy of St. Ouen :

Okay. In your experience to date elsewhere, what approach have you found the best?

Pathology Manager:

The approach that I have found normally is implemented in practice is a combination, so I have normally had somebody telling me that I may have X amount of money to operate a pathology service and I tell them that that is not enough because I am expecting the workflow to increase by so and so per cent and therefore I need this amount of money, and then there is some horse- trading is the way things have worked, in my experience. So there is a top-down approach and a bottom approach going on at the same time and a meeting in the middle.

The Deputy of St. Ouen :

How does that best serve the patients that you are seeking to support?

Pathology Manager:

If it ultimately delivers ... if I am a patient, I am also a taxpayer, so I have got a conflict of interest as a patient before I even start, because I want the very best healthcare service for me and my family, yet I do not want to pay any more taxes at the end of every month, so a balance has got to be found. I think as long as when we are making our decisions about where we are going to find that balance, we believe we have got the patient's best interests at heart, I believe we cannot offer any more than that.

The Deputy of St. Ouen :

I am pleased to hear this, but what role do you see the patient/taxpayer taking in those discussions? Are you suggesting: "We know best, therefore we will tell you what you can have" and that is the end of it, or would you expect some consultation to take place around some of the trade-offs, costs et cetera that certain options would work ...

Pathology Manager:

I think we are wandering out of my area of knowledge and my area of expertise. I think decisions about how we make those sorts of decisions are primarily political decisions and I am not a politician.

The Deputy of St. Ouen :

But you will be part of it, you have told us.

Pathology Manager:

I would expect to be sitting there saying: "These are the services that I want to provide because I believe that that is the best service that I can deliver to patients." That would be my role in it.

Deputy J.A. Hilton:

Just 2 quick questions from me before we wrap up. Have you seen increased waiting lists since the additional consultants have been taken on who are now carrying out these procedures that did not use to take place?

Consultant Histopathologist:

I am aware of all the waiting lists, because they are discussed at the clinical directors' meetings. I would just need to see the list again to ...

Deputy J.A. Hilton:

No, specifically in the path lab I was talking about.

Consultant Histopathologist: Oh, the path lab?

Deputy J.A. Hilton:

Yes, not the others. No, just the path lab.

Consultant Histopathologist: What do you mean by "waiting lists"?

Deputy J.A. Hilton:

I am just interested to know whether the time of turning around the tests has increased since all these additional services are being carried out.

Consultant Histopathologist: There is a potential for that.

Deputy J.A. Hilton:

That is what I am trying to ...

Consultant Histopathologist:

Yes, it is sort of peaks and troughs. The test where there is probably the most consultant direct input is in cellular pathology, where we have to look at the specimens and describe them, look at them under the micro and write the report.

[15:00]

With the complexity of those cases, there can be an increase in the time that it takes to turn around a case, but hopefully it is not detrimental to the patient.

Deputy J.A. Hilton:

Because I could not recall, I think you mentioned earlier that you were expecting to see an increase in the amount of work coming into the path lab. Did you say that there was consideration being given to taking on an additional histopathologist?

Consultant Histopathologist:

We have put in an application in the spring review for a third consultant histopathologist.

Deputy J.A. Hilton:

Oh right, okay. The other thing I just wanted to ask is what consultation has taken place with yourself and your colleagues with regard to delivering radiotherapy on the Island? Have you taken part in any discussions around that issue?

Consultant Histopathologist:

Yes, with Bernard here, and again with the clinical directors' meeting, the possibility of introducing radiotherapy on the Overdale site has been talked about, yes.

Senator S.C. Ferguson:

Oh, it is the Overdale site now?

Consultant Histopathologist:

Oh, I am sorry, I do not know. I thought it was the Overdale. It may be or it may not be.

Senator S.C. Ferguson: Sorry, it is just it keeps moving.

Consultant Histopathologist: In the hospital somewhere.

Senator S.C. Ferguson:

It is a moveable feast, I think, at the moment.

Pathology Manager:

I am aware that that conversation is going on, so it is not being had behind a closed door and it is being talked about.

The Deputy of St. Ouen :

What percentage of work is currently undertaken by the path lab in relation to private practices or private insurance, private patients?

Consultant Histopathologist: I do not know the exact figure.

The Deputy of St. Ouen : Roughly, roughly.

Consultant Histopathologist:

Roughly? It is between 10 per cent and 20 per cent, I would think, but that is ...

The Deputy of St. Ouen :

Are private patients treated any differently to those that are accessing the public service in the path lab?

Consultant Histopathologist:

Not that I am aware of. From my own personal ... the way that I deal with it, specimens are treated in exactly the same way, so they are dealt with as they come in.

Pathology Manager:

In the time that I have been here, I have not seen any evidence of specimens from private patients and specimens from public patients being treated any differently. I have not seen 2 workstreams going through the laboratory. That is not an absolute guarantee, but that is based on what I have seen so far.

The Deputy of St. Ouen :

The final question around that is given that we are going to have a new hospital, given that we could end up with bringing a number of services back to the Island, do you see private provision growing in the future or declining?

Consultant Histopathologist: I do not know.

Pathology Manager:

I have got some experience of this, so most of my background is in private hospitals in the U.K. At various times over the sort of 15 years or so that I have worked in that industry, I have seen the cost of private medical insurance go up and down and I have seen the public perception in the U.K. of the quality of National Health Service services go up and down. What I have noticed is that when there are lots of sort of health scandals in the newspapers and so on, more people tend to take the private option is one influencing factor. The other factor is the cost of private medical insurance. When it goes up, the number of people who can access it goes down and more people come through the N.H.S. (National Health Service) route.

The Deputy of St. Ouen :

So it is your belief that with the new hospital we are not likely to see a dramatic increase?

Pathology Manager:

It depends what is being said about the new hospital in the press, so if all the news in the Jersey Evening Post is about the fantastic new hospital and what an exciting facility it is, the number of private patients I expect will reduce, because everyone will want to go to the new exciting public hospital. If all of the news in the Jersey Evening Post is about what a disaster the new hospital is, then I expect that more people will choose to go private.

Deputy J.A. Hilton:

It is 3.05 p.m. so we will close the meeting. Thank you. Thank you very much indeed for coming.

[15:04]