After recent controversies, there is widespread agreement that the hospital laboratory system needs to change. David Labanyireports
With two investigations under way into cancer test errors, the hospital laboratory sector is feeling the bitten tongue of public criticism.
The investigations are taking place against a backdrop of regular leaks from an unpublished Health Service Executive (HSE) report on reform for the sector. It recommends deep job cuts and fewer labs.
While representatives of the 3,000 odd hospital laboratory workforce have responded coldly to the leaked plan, describing it as "unrealistic", there is an acceptance the service must change.
Tom Moloney, executive officer designate for the Academy of Medical Laboratory Science (AMLS), agrees change is required but says "there is a lot of disquiet about the findings".
"The profession would accept that the way services are delivered needs to be changed, but the simple idea that labs extend their working day, if done in isolation, simply won't have any impact. You have to look at the whole service."
Although he doesn't formally take up his new role until November, last week Moloney went to Birmingham to observe how Britain is handling similar reform.
"Lord Carter of Coles has led a national review of UK pathology services. They have taken a different approach, more in tune with partnership. Many of his proposals are being piloted before they are introduced nationally and he is talking to service providers and service users before making final recommendations."
The HSE report, carried out by external consultants Teamwork, did not seek submissions from bodies such as the AMLS and was based on laboratory visits and discussions with senior managers, he says.
"I don't know why they took this approach. I would have thought that before a radical change, the first thing you do is your market research. Perhaps they thought it would be quicker. However, because it hasn't been officially published yet, any time gain has been lost," he says.
While the report found the overall quality of test analysis carried out by more than 40 hospital labs in this State was good, it identified a lack of a standardised service, with many sample collections not meeting clinical need and some not fit for analysis once they arrive at the laboratory.
Although approved by the HSE's board in May, the report remains unpublished. This may be because of its recommendation of job cuts and increased private-sector involvement.
The report suggests reducing the number of laboratories which carry out urgent hospital tests from about 40 to no more than 14, based in large regional hospitals and setting up three large private sector labs to handle tests from GPs.
It says most samples are processed between 9am and 5pm and the working arrangements in most laboratories are "inflexible".
"If you withdraw labs from smaller hospitals, you need to have a plan about how you supply services to these regions. From what I understand of the report, how this will be dealt with was not spelt out."
With these reservations in mind, Moloney thinks it is "unlikely the recommendations in the report will be 100 per cent implemented. And if implemented in any form, reform will be over quite a period of time."
He offers an example of the often tortuous pace of health service reform with a snippet of history from the Meath hospital where he worked in the late 1960s. It amalgamated with the Adelaide and National Children's Hospital at Tallaght in 1999 but "the first talk of a merger was in 1885".
Moloney says the academy will be seeking a meeting with the Minister once the report is published and he plans to outline its concerns on the HSE's proposals for private sector involvement.
"If the private sector acts in a supportive role, there is no problem. But if it is going to take on a wider role, there are issues to be examined."
One of these is the cost of staff training. "This is an issue across the whole health service because by and large medical staff are trained by the public system and it is a cost that is not fully appreciated or quantified. This cost is substantial and must be built into efficiency estimates."
The other issue the academy wants to address is accreditation and regulation. "At the moment there is no overarching agency and you don't need a licence to set up a laboratory," Moloney says.
The Health Information and Quality Authority (HIQA) is investigating a laboratory at University College Hospital Galway where two separate errors resulted in a delayed diagnosis for a cancer patient.
However, the tests were taken from a cancer patient at Barringtons' Hospital in Limerick which is a private institution and is outside the HIQA's remit.
"I think we are going to have to look at accreditation becoming mandatory for all labs. We have spoken recently to HIQA about this and they are anticipating a move to accrediting all hospitals."
Moloney is less certain about the need for a national reporting system for laboratory errors - similar to those for blood transfusions and medicine dispensing - saying that with 58 million tests a year such a system would be "hugely bureaucratic".
"Test volumes are growing about 10 per cent a year as the population gets larger and older and there is more screening. What we need are systems, such as anonymous reporting of near misses to counter errors."
Cost is one of the main reasons the HSE is keen to reform the laboratory system. The bill for laboratory services is about €328 million annually and the Teamwork report suggests a more centralised service would generate substantial savings through "automation, changes in workforce profiles and procurement".
With the controversial Teamwork report to ensure his two-year post at the academy is eventful, the question arises why did he seek the role?
"I have just retired from the Mater and I am 45 years working. The question arises of how do you want to go into retirement? Do you want to stop dead? My new role is a logical next step."