Pathology Support for Services at FrenchayHospital

FrenchayHospital delivers world class services in a number of specialties and it is important that they receive the same high quality laboratory support. In the Blood Sciences there are high speed analysers to ensure that the needs of sick patients and the targets in A+E are met. Blood transfusion is available to meet the urgent needs of major accident victims arriving at Frenchay;

The challenges in Cellular Pathology are different. Instant diagnosis is required at one stop breast clinics and intra-operative frozen sections but paraffin processing for most diagnoses takes from 2—24 hours depending on the specimen and can therefore be done off site. It is important that instant diagnosis is robust and is therefore frequently delivered by two pathologists.

In delivering the service we face two problems

a)the imminent loss of two pathologists from FrenchayHospital leaving Dr Ibrahim as the sole pathologist at that site (from December 2010)

b)CPA standards require that the same service is delivered at all the laboratories in one Trust (compliance required by March 2011)

It has been very difficult to recruit locums or indeed permanent consultants to Cellular Pathology in Bristol. Currently there are three jobs advertised two jointly with UHB (in GI pathology) one solely for NBT (in breast pathology). These predate the two resignations; approval has been given to advertise for the two further posts. One locum is in place doing mainly GI work, a second is due to arrive mid November to assist with breast and skin pathology.

Currently all GI specimens collected at Frenchay are dissected and reported at Southmead. It had been planned to move the whole cellular pathology service from Frenchay to Southmead but this has been challenged, on quality grounds, principally around the need for double reporting. However a move of the breast service to Southmead to accommodate the transfer of UHB patients and the development of emergency facilities at Frenchay would address this problem but that is unlikely to happen before mid-2011.

The Bristol Histopathology Review, looking at the quality of Cellular Pathology in Bristol, is due to report in December. Simultaneously the Bristol Pathology Review has been looking at the most effective delivery of all pathology services across the City.

It is likely that we will reach a solution on all these issues by the end of 2011, unfortunately the imminent departure of two of the three consultants at Frenchay precipitates a problem in December 2010. We have to seek a solution that delivers a high quality and safe service to all patients at NBT whilst delivering the quality that our patients and out clinicians expect.

In looking for a solution to these problems the following points must be considered

1 we recognise the immense contribution of Nassif Ibrahim to the breast and plastic surgery service at NBT and recognise his concerns in maintaining the quality of the service

2we need to build a team in Cellular Pathology that uses the experience of the senior consultants and allows the development of new recruits. New consultants in Cellular Pathology have not usually had time to develop their specialist experience.

3 we need to avoid leaving pathologists in isolation and build a strong diagnostic team around integrating Southmead and Frenchay Cellular Pathology Laboratories

5we need to address the CPA failures as a result of different practices at Southmead and Frenchay

4 like medical records we need to have only one site for slide filing so slides are all kept in one place and are accessible for reporting or MDTs on either site

6 we need to demonstrate to the Bristol Pathology Review that high quality services can still be delivered when the pathologist is separated from the processing

Proposed Solution

1 Nassif Ibrahim will remain the full time pathologist at Frenchay supported by Nick Rooney Monday Tuesday am and Friday. Where Nick Rooney is not available Karin Denton will be able to cover Fridays at Frenchay. Nick Rooney will cut-up and report skin and GI pathology and assist Dr Ibrahim with frozen sections and other difficult cases. He will deliver his commitments in lymphoreticular disease at the Wednesday and Thursday MDTs by using the support of other specialists at Southmead and cross site working/teleconferencing and using the HILIS web-based reporting package. He will continue to deliver his commitment to the Monday Lymphoma MDT at Taunton by driving straight to Frenchay from Taunton arriving at approximately 11am. He will continue to provide his share of the renal on-call service for Southmead.

2The locum arriving in December will assist Nassif Ibrahim at Frenchay delivering and developing his breast pathology skills under the tutelage of Dr Ibrahim, Tuesday Wednesday and Thursday, the days of the one stop breast clinics and the breast surgery lists. The locum will work with the consultants at Southmead on Monday and Friday developing skills in skin pathology in particular with Jon Oxley and sarcoma reporting with Zsombor Melegh and Nahida Banu.

3The pathologists at Frenchay will cut-up and report cases at Frenchay to maximise their PAs and avoid time wasted by travelling across the city. Some uncut cases will be referred to Southmead for dissection, on Tuesday-Thursday this is likely to be mostly GI work, on Monday/Friday it will be some of the skin or breast work.

4Blocks will be processed and slides produced at Southmead and delivered to the consultant at whichever location they are working.

5BMS staff will be based at Frenchay to support the cut-up frozen sections and one stop clinics. Full support will be given to the Frenchay pathologists by staff based at Southmead to ensure that the service and job plans are equitable across sites. A robust system of pathologist specific slide transfer between laboratories will be added to the existing system of specimen transport.

6The service will be continuously reviewed and adjusted to help the delivery of the service. Once the Breast Service moves from Frenchay to Southmead the integration of the breast pathology consultants from UHB will have to be considered.

I believe this solution addresses all the quality issues raised so far whilst being deliverable during the time that the surgical specialties are still split across Southmead and FrenchayHospitals.

Nick Rooney

Head of Pathology

10-11-10