Agenda item

The Health Partnerships Overview and Scrutiny Committee were presented with an interim report on the incidents that had occurred with pathology results provided to GPs in Brent and Harrow.  Following completion of the investigation, members of the committee have since received a copy of the Root Cause Analysis Investigation report.  The report now being presented to the committee is an update on the actions being taken to address the issues identified and the recommendations in the Root Cause Analysis.

Jo Ohlson (Brent CCG Chief Operating Officer) introduced the final report in respect of the incidents and subsequent investigation for pathology services in Brent and Harrow.  Pauline Johnson (Interim Head of Quality and Safety, Brent CCG) then drew Members’ attention to the six actions listed in the resulting action plan as set out in the report.  Dr Patel, chair of the Root Cause Analysis (RCA), was also present to respond to members’ questions. 

Members then discussed the item and raised a number of issues.  One member commented that the incidents may not have happened had there been more staff with the necessary expertise and the number of consultants available was queried.  Further comments were sought in respect of the reference in the report to GPs not attending working group meetings and were steps being taken to ensure that they did.  It was acknowledged that there had clearly been communication issues, in particular a lack of cascading information down to staff at all levels, with CROs not sure who was responsible for ensuring this was happening and it was asked whether this had now been addressed.  An update on the communications strategy was also sought.  In relation to transportation of samples, it was enquired why it had not been specified in the service specification that samples be transported at room temperature, despite clinical opinion stating they should.  Information was sought with regard to future arrangements for risk assessments and would this include involvement from GPs.  The committee asked for an explanation of the process for when laboratories presently issued tests.  A member commented that  the incident and the RCA had flagged up issues that were also national ones and it was asked whether there had been a formal response to this.

A member acknowledged that one of the main reasons the pathology contract had undergone a procurement exercise was to test if the market could produce potential savings.  However, although this was necessary, there was no evidence to suggest that a proper risk assessment had been undertaken and it was asked what had been learnt from this.  It was enquired whether both the previous and current provider of pathology services was clinically accredited and what date had they been confirmed as being so.  It was commented that in the Francis report, it had been stated that consultants had been commissioned to advise hospitals as opposed to CCGs and it was asked how expert advice had been sought during the procurement.  Members asked what the total costs of the incident had been and what steps were being taken to address management and leadership issues in respect of the CCG and Central Middlesex Hospital. It was commented that the procurement of the pathology contract had been undertaken without the knowledge of GPs and she asked what steps were being taken to keep them informed. 

In reply to the issues raised, Pauline Johnson advised that although consultants were being used at around the time the incident happened, some of them had not been able to devote as much as time as had been hoped. In respect of GPs being absent from meetings, initially there had been two GP representatives, however they each had a heavy workload, so the membership allocation for GPs had been extended to increase the likelihood of GP presence at future meetings.  Pauline Johnson acknowledged that there had been clinical advice to ensure samples remained at room temperature during transportation and although this had not been specified in the contract, this area was to be re-visited.  She stated that a risk assessment would be undertaken in respect of any future procurement exercises.  Members heard that there was a communications strategy, however this was presently being reviewed, and GPs and TDL were being involved in this.  The review was due to finish at the end of July 2013 and a new communications strategy would follow.  Pauline Johnson informed the committee that when a laboratory wanted to issue tests, the Director of Compliance at TDL would report to herself and SROs.  If the tests were urgent, the results would be sent to the GP on the same day, whilst all others would be available within either 48 hours or five working days.  TDL were also formulating a response in respect of issues that had been identified nationally.  Pauline Johnson advised that both the previous and present pathology services provider was clinically accredited and it was noted that TDL had recently revised the accreditation process.  In terms of consultants providing advice, for hospitals this was in providing on-going support in respect of quality assurance. The CCG did not have automatic right of access to consultant advice, however they could still make such a request. 

Jo Ohlson added that TDL produced a regular newsletter and this was being monitored for the quality of the information it was providing.  She acknowledged that there had not been adequate consultation with GPs during the procurement and this had been identified and addressed by the RCA and action plan.  The committee heard that information on key changes and developments, such as procurement exercises, would go the lead doctor and practice manager at each practice and this issue would be looked at further.  Many lessons had been learnt as a result of the RCA and it was acknowledged that the pathology service had not been sufficiently clinically robust.  There had been a risk assessment in terms of the service, although a separate one had not been undertaken specifically in terms of the procurement, although there would be for future ones.  With regard to costs of the incident, these had not been quantified as such and would be difficult to do so.  The costs would be incurred by the GP practices in using resources to contact patients, whilst there were also delays in receiving test results.  However the RCA and action plan had been put together to ensure such an incident did not recur.

Dr Patel confirmed that there was now a minimum of five GP representatives for meetings with the CCG.  With regard to issues raised nationally as a result of the incident, he informed members that Ealing Hospital NHS Trust had advised its GPs about this.  Rob Larkman (NHS North West London) added that the way CCGs operated was fundamentally different to PCTs and that steps would be taken to ensure grassroots input from GPs.  A key priority was to develop leadership and managerial skills within the CCG, whilst the procurement of the pathology service aimed to ensure high quality services at better value for money.  Tina Benson (Director of Operations, North West London Hospitals Trust) informed the committee that TDL were responsible for the laboratory contracts and the CCG in managing the acute services contract.  Dr Sarah Basham (Brent GP) added that there had been a long history of disseminating information to GPs in Brent and she added that lead GPs, who were responsible for cascading information to other staff, had done this well in Brent.

The Chair felt that concerns for pathology services remained, with a  number of serious issues needing further consideration.  It was of the utmost importance that a safe and effective pathology services was provided and there was evidence to suggest that this was not completely the case.  The Chair requested that an update on this item be provided at the next meeting on 24 July 2013 to show evidence of progress and that the committee would also like to look at the CCG’s procurement processes in more detail.