Barts Health NHS Trust is very large – one of the largest in the UK, with over 16,000 staff across five hospitals. The pathology department has grown as the hospitals have merged, and the cellular pathology department is now a single entity serving a population of approximately 2 million patients across East London. It owes its size to multiple mergers of several smaller departments over a period of more than 15 years.

The scope of the merger

The easiest merger was when the two cellular pathologists from St Andrews Hospital in Bow put their microscopes in the car and moved up the road to Whitechapel. It was many years ago, and St Andrews has now closed, but this was a team of two good professionals and a small number of great scientists. They knew they were working in isolation, and they actively wanted to join colleagues at the Royal London Hospital (RLH). It was made easier because they maintained good relationships with their clinical colleagues, already knew their pathology colleagues at RLH from having a few sessions there, and, perhaps, because they didn’t tell too many people what was happening. This was an era where business cases and public consultation were uncommon at department level.

Subsequently, a far more extensive merger occurred, partly reflecting amalgamation of the Trusts themselves. This was the large-scale unification of several departments from both St Bartholomew’s Hospital and RLH. It was made more attractive, and much easier, by the construction of a new building, which was helped by a multimillion pound investment from the Barts Charity as an enabling work for the impending PFI hospital. A brand new, purpose-built, five-storey premises dedicated to pathology and pharmacy helped considerably to join 14 disparate departments together. Building a new molecular pathology suite and a flow cytometry facility also helped overcome some of the concerns around centralisation. Indeed, attracting people into the best pathology premises in the UK started to seem easier than asking them to relocate to a space within warrens of small labs in Victorian buildings or in an ugly 1960s block with narrow corridors and asbestos tile ceilings. Therefore, we were fortunate that the context of our major merger was one of a wholescale improvement in our facilities. Some mergers lack that advantage.

Staff considerations

The stage during which the geographical location of the building was debated was interesting, and rehearsed many of the discussions about laboratory and pathologist disposition that we still consider. The balance of clinical input into multidisciplinary team meetings (MDTMs), transfusion laboratory provision, transport time for urgent specimens and cover for frozen sections were discussed enthusiastically. At the time, the two major acute sites were RLH and St Bartholomew’s hospital (SBH). Hot lab areas would be needed on both sites, but the enormous new A&E and hospital development at Whitechapel, and the availability of land, made Whitechapel the logical location. Mergers can make some staff very unhappy at the prospect of a move. “I would rather die than go to the Royal London” was one particular view, coming from a colleague who retired early rather than make the transition. Perhaps this reflected the location of SBH, which is in a lovely setting in the City of London, compared to RLH, which is in one of the poorest areas of the UK. Upmarket cafes and restaurants had to be sacrificed for fried chicken shops and low-cost curry houses. But the relocation was to an area of significant clinical need.

The emotional and sentimental connections with a workplace and the fear of change, at least for some staff, should not be underestimated. So much time is spent at work that we do need to make it, as far as possible, a pleasant experience. Colleagues are a major part of this experience, and potential dilution of strong working relationships by expansion of a department can be problematic. The emotional transition from one place of work to another is complicated by a range of other factors. Physical factors such as travelling time can be important. Had the decision been made to base our new department at SBH rather than RLH, it would have reduced many colleagues’ journeys to work. As it was, it added 20 minutes’ travelling time and a change of train to the journey of a colleague from SBH who, needless to say, was not impressed.

Allocating the new space

The provision of office space is often a difficult area across all disciplines, but especially in cellular pathology which requires a single occupancy quiet space (or dual occupancy if reporting with trainees) in which to concentrate on work. In cellular pathology during the RLH new-build process the consultants formed a task force to try to make office allocation as fair as possible. During yet another merger, this time of the Whipps Cross hospital cellular pathology team (which included six consultants) with that at the expanded RLH, the office allocation was again done as fairly as possible. Although seniority inevitable plays a role if there are no other distinguishing features between members of staff, the selflessness and adaptability of many colleagues was commendable.  A recent much-needed increase in consultant staffing, expanding the consultant base to cope with rising demand, has finally proved more difficult than previously because further office space is now limited, as are Trust finances to adapt existing spaces. Lack of such space can be demoralising and create tensions, and every effort should be made to prioritise this issue because the ultimate outcome of short term cost savings can be long term losses in terms of recruitment and morale.

Maintaining clinical links

The loss of proximity and personal interaction with colleagues on one or more sites can often be seen as a key risk factor when looking at mergers, and does have a potential detrimental effect. In practice, most of us will call colleagues with key results, and multidisciplinary meetings will continue. However, when not face-to face, the latter require top-class videolink facilities, and the provision and maintenance of these vital facilities are not always a priority for cash-strapped Trusts or for overworked IT staff. Many large departments already have networks of referral, or have specialists or expertise, that serve departments and patients well beyond their own hospital, often involving communication with clinical teams or other pathologists that they may never meet personally. Also, work is often absorbed from units or whole hospitals that do not have the relevant pathology support. For example, our cellular pathology service deals with all work from the Homerton Hospital, which is not part of our Trust. Our renal pathology team covers our own hospital, but also Basildon, Southend, Brighton and the Royal Free Hospitals. Phone calls and joint meetings can help maintain good working relationships, and the multidisciplinary team environment, even by videoconference, helps with interactions.

The practicalities: IT and specimen transport

The work involved in the preparation for such moves cannot be underestimated. Helpful preparations before we moved into the new building ranged from data and information sharing to visits between groups and secondments. It was useful to share workload data from existing departments, and this helped us to understand that everyone from all sites was working hard. Very hard! Also, trying to make as many process changes as possible prior to the physical move was a policy that was based on good evidence and one which worked well in practice. For example, immunoassay platforms and many common operating procedures were changed prior to the major move. Having lots of run-up time with ‘dump the junk’ skips and good routes for disposal of documents, old equipment and reagents was important. Having the medical physics team on hand to investigate and advise on potential radioactivity issues was also helpful. Clearance processes and certification (and sealing) of cleared areas was essential for handover. This all minimised potential confusion at the time of physical relocation. Similarly, managing expectations, with regular staff briefings and the acknowledgement that not everything was going to run smoothly, but that everyone would do their best to deal with problems as soon as possible, was useful.

Other practicalities included double running of platforms in blood sciences and other departments where new equipment was being commissioned in the new building, for validation of all platforms, testing of IT links, retesting of IT links and fall over protocols. The latter can always come in handy, not least when the pharmacy fork lift operator drove through the IT cable hub in the basement corridor. A single point of weakness had been identified and then reinforced, literally.

One process that might have worked more smoothly, and which caused some issues, was ensuring that the numerous routes of specimen transport were all reliably redirected to the new location. Transport and portering are key parts of the end-to-end processes for pathology, and are often not under the direct control of the pathology service. Making sure that every porter and every collection point team knew of the changes might have saved considerable time in specimen chasing. Maintaining a degree of healthy caution and testing end-to-end specimen-to-result pathways is also important during times of change. There is much value in reviewing single adverse incidents carefully to ensure that they are not herald events of a wider problem. If one primary care microbiology report has missed off a text comment that is present on the LIMS system, then there is a high probability that it is a system problem rather than a single rogue event.

Having a go-to set of individuals who could help get things sorted was a real success. Commercial organisations spend large amounts on project management and on change agents and planning. Generally the health services have very meagre resources for such mergers, and at departmental level tend to, and often need to, rely on existing staff with technical expertise who know the departments and who are able (and willing) to deal with practical problems as they arise. Giving some degree of dedicated time to such individuals is key.

Conclusions

The impact on pathology is often underestimated in the massive changes to process, technology and location that are made by all disciplines regularly. Examples of such change include: the introduction of new LIMS systems and paperless working; electronic transmission of results; integration with primary care systems; the wholescale change of cytology methodology with retraining of the entire workforce; migration to molecular testing in infection; creation of blood sciences facilities; adoption of mass spectroscopy; point-of-care and one-stop testing; extensive implementation of multidisciplinary team meetings; adoption of molecular pathology; and integrated reporting in cancer testing. These were large-scale changes in working practices whose implementation should be celebrated as evidence of the ability of pathology staff to support a real and continuing dedication to improvement and advancement, and of the great skills that exist in change management in our profession. Mergers like the ones that we have experienced are disruptive at the time, but they are one part of the continuing reorganisation that is an inevitable feature of pathology services and of the wider health service in a modern, highly developed healthcare system. Mergers can allow pathologists to specialise, to become more focused, opt for more flexible working, or develop academic or management roles that might not otherwise have been possible. There is also a resilience, both in workforce and in equipment, in larger departments or networks, that comes with having more of both, but do keep an eye on workload, since having staff who can cope with extra work in a crisis can turn into a sustained pressure that cannot be maintained. Ultimately, small can be beautiful, but there is strength in numbers, and this gradually becomes apparent once the dust has settled after a merger.

Professor Jo Martin
Professor of Pathology
Queen Mary University of London
Director of Academic Health Sciences
Barts Health NHS Trust
President-elect
Royal College of Pathologists

Professor Roger Feakins
Consultant Histopathologist
Barts Health NHS Trust