Consolidation Lessons Learned

South West London Pathology was established in 2014 to provide a single integrated pathology service for southwest London. Its founder trusts – St. George’s University Hospitals, Kingston Hospital, and Croydon Health Services – could see immediately that three separate pathology services were not sustainable or affordable in the long run. In response to Lord Carter’s report on pathology in 2008 (1), the National Health Service (NHS) in London had called for the creation of five pathology clusters in the capital – and South West London pushed ahead. Why? Because the chief executives at the time could see they were all facing the same issues: difficulties with recruitment, staffing, and training, and a decreasing cost base that made it difficult to invest in new equipment or technology.

The South West London Pathology business case was built around consolidation to make services more cost-effective and thus rationalize investment – so the process had to move quickly once the network was formed. The team needed to organize building work, standardize working processes, and install, test, and validate new equipment.

On day one, staff had their employment transferred to St. George’s as the host trust, but nothing else happened (which was very anticlimactic!). Over the next two years, though, cellular pathology relocated to one laboratory, microbiology consolidated from three sites into one, and a blood sciences hub laboratory was created at St. George’s, with spokes at Croydon and Kingston. A program of complete re-automation across all sites and all disciplines was completed and a single laboratory information system was rolled out (albeit a legacy product that would later need to be replaced).

The consolidation was completed by September 2016 – and it was a success. By the end of year three, the initial investment of £8.5 million had been repaid, and the network has delivered annualized benefits of just over £8 million ever since. There is also a robust commercial agreement in place between the partners that enables South West London Pathology to bid for and win new work. Since “go-live,” South West London Pathology has picked up contracts from the Royal National Orthopedic Hospital in Stanmore and the New Victoria Hospital in Kingston – so it’s clear that the network has saved money and is now competitive. Even so, we would never claim to be the perfect network; we made some key mistakes and learned some important lessons along the way.

At the start, we had three trusts that counted tests differently, called them different things, used different reference ranges, and had different platforms, preferences, and costs. I often say that pathology does the same thing differently on different sites – but we needed to create a culture in which we were all doing the same things in the same ways. Of course, everybody thought their approach was the best, so we had to win over hearts and minds. Over five years, we won some battles and lost others, but we all agreed on one thing: standardization is critical – and the sooner we get there, the better.

The next lesson we learned is that you must have a single laboratory information system. Your LIMS is your workflow; every member of staff interacts with the LIMS, so every process they perform and every change you want to make goes through the LIMS.

We pushed the legacy LIMS system that we had at St. George’s to our spokes. It was not an ideal solution because it was not designed for a network; we had to use integration engines to make it “talk” to the systems in use at the three trusts. And it no longer has the functionality we need now, which is why we are currently in the process of implementing a next-generation LIMS.

The system we chose is cloud-ready, so it is not as dependent on trust IT setups. It’s flexible and configurable, so we will be able to use it to further harmonize workflows and to support the network as it expands. We are supporting Epsom and St. Helier NHS Trust in rolling out the same build, so that the southwest London sector is served by a single LIMS and can work as a network across four acute trusts.

We have also learned that our staff are our biggest asset. The business plan called for a round of redundancies – something we would not do again because we lost a lot of expertise. We have also had some recruitment issues in blood services at our spoke sites (what we call “essential service laboratories”). We stripped them down too much, which has been a challenge because, if all high-end tests come to the hub, people don’t want to work at the spokes because of the reduced repertoire. We are now moving to develop a rotation for staff so that they can do core services at Kingston and Croydon and come into St. George’s to conduct specialist work. We have also realized that we took our eye off training in some areas, which we are addressing.

I think there are three reasons why South West London Pathology has progressed, when other networks have not. At the outset, there was corporate buy-in; we had determined, committed agreement from the chief executives and chief financial officers. There was also strong clinical leadership – and operational ownership (because operations did the implementation). I believe that networks are the way forward; they are a much better use of resources, a much better prospect for the service, and they have a good impact on patient pathways. But they won’t happen just because the Department of Health and Social Care or NHS England/Improvement say they should. You must have those three elements in place.

Networks go through phases of development. The first phase is transition, which can take two or three years. The second phase is stabilization – and we are reaching the end of that now. The third phase is delivery. Our investment in new LIMS technology will enable that – but it’s our investment in staff and training that will sustain it; after all, it’s our staff who deliver it.