Details have emerged on the HSE's plans to reorganise hospital laboratory services, which could result in significant job losses, writes Martin Wall
There are currently two investigations underway into high-profile errors made by hospitals in dealing with cancer tests sent to laboratories for analysis.
Irrespective of the outcome of these inquiries, the Health Service Executive (HSE) will use the two cases to press its case for fundamental reforms in the way laboratory medicine services are structured in the State.
A new report carried out by external consultants Teamwork for the HSE and accepted by the HSE board, has found that the overall quality of the analysis of tests by laboratories here is satisfactory and that there are numerous examples of good clinical and organisational practice.
However the report, which has been sent to the Department of Health for approval and remains unpublished, argues that the "whole system quality" of the current laboratory arrangements "is not good enough".
Under the existing system more than 40 hospital laboratories around the Republic deal with over 58 million tests a year ordered by hospital doctors for in-patients, out-patients and those in accident and emergency departments as well by GPs in the community.
The report says that these "hot" and "cold" tests from hospitals and GPs are processed together and delivered within a 9am to 5pm timeframe with limited work carried out outside this period and then at premium cost.
It expresses concern that there are no hospital laboratories where all the various disciplines are accredited. It describes the general condition of the laboratory estate around the country as "poor" and typically "out-moded" while it also argues that information systems in hospital laboratories are "generally old with poor functionality and limited connectivity". It says that the electronic reporting of results back to GPs, while increasing, is limited.
The report also highlights what it terms "inflexible organisational and working arrangements" within the current system.
It says that there are chronic problems in relation to the transportation of samples from GPs to laboratories.
"There is no standardised service, many collection timings do not meet the clinical needs and are too infrequent; specimens are often not fit for analysis by the time they arrive at the laboratory and there are health and safety and other regulatory implications," it states.
In its blueprint for the future the HSE has effectively proposed that the current system should be broken up. It argues that routine tests ordered by GPs - the so-called "cold" tests such as for blood science, cytology or microbiology - should be separated from those requested from within hospitals and carried out by new stand-alone, highly automated laboratories.
It proposes that there should be three new highly automated laboratories dealing with "cold tests", possibly provided by the private sector. It suggests that these should be based in Dublin, the south and the west and together would need to be able to deal with the 18.5 million tests currently referred by GPs each year and have to capacity to meet significant future expansion.
The report recommends that the services of the existing 40-plus hospital laboratories dealing with "hot" tests requested for hospital patients should in future be concentrated in a much smaller number of advanced new facilities. It proposes that new "hot" laboratories should be co-located at eight to 14 designated acute regional hospitals and that at that point local hospital laboratories should be withdrawn.
The HSE says that a centralised laboratory system would be more efficient, offer guaranteed "turnaround times" for tests ordered by hospital doctors and GPs and provide for new information technology, education and training and research structures as well as the development of new pathology clinical networks between hospitals.
The problem for the Government in considering such a move is that the HSE recommendations will be hugely controversial both from the perspective of local politics and industrial relations.
Department of Health officials have briefed ministers in recent weeks that most hospitals would be affected by the "widespread rationalistion of services" recommended in the confidential HSE report. They have also advised that the implementation of such proposals would have to take account of social partnership.
The centralisation of services and the establishment of centres of excellence and regional networks are not new concepts in the overall health service reform programme. Broadly similar proposals have already been set out for cancer and maternity services.
However, the laboratory report is the first reform document to openly raise the spectre of significant job losses and the privatisation of services currently carried out in public hospitals.
There are around 3,000 staff working in the public hospital laboratory system.
However, the report makes clear that there would be "a substantial reduction in the total number of the technical workforce needed in the future, as a result of the reduction in the number of laboratories and the gain in efficiencies and productivity".
It also says that there would be "substantive changes in laboratory practices with automated platforms requiring cross-discipline working and new patterns of work".
Any move towards wholesale job losses in a sector employing more than 3,000 people and the effective privatisation of the community laboratory work would cause major problems for the trade unions and have significant implications under the terms of the Towards 2016 partnership agreement.
The explicit acknowledgement in the report that the centralisation plan would generate "substantial savings" on the HSE's current €328 million annual bill for laboratory services would not go unnoticed by staff and unions.
The report says these savings could be made through "market pricing, automation, changes in workforce profiles and procurement".
More broadly, the comments and recommendations set out may once again raise the concerns of local communities at the long-term plans of the HSE for local hospitals. It openly states that "not all current hospitals will meet the future healthcare models for acute hospitals".
It says minor urgent care in A&E departments and routine planned care in out-patients is likely in future to be provided in local settings.
Local campaigners and politicians are likely to ask if, as the report states, that in the future there will be eight to 14 designated acute regional hospitals around the country, what are the plans for the two dozen or so other centres, particularly in relation to services such as A&E.
The controversial Hanly report with its recommendations for a slimmed-down network of acute services may have been killed off for political reasons, however, local groups will wonder whether the thrust of its findings live on in the various specialty reform plans of the HSE and whether the laboratory report provides a glimpse of its future thinking.