I think Trevor has described the best approach possible. And of course 
there is a lot more detail in:

Author(s): TA Gray ;  RG Cooper ;  J Galloway ;  J Marples
Source: Annals of Clinical Biochemistry      Volume: 39 Number: 4Page: 
340  -- 344
DOI: 10.1258/000456302760042632
Publisher: Royal Society of Medicine Press
Abstract: Clinical budgeting is the process whereby clinical users are 
charged for the resources they use. A system for recharging users for 
the costs of tests was introduced at the Northern General Hospital, 
Sheffield, in 1995, and has been in operation since. The system has 
allowed pathology to maintain budgetary balance, has automatically 
compensated for workload increases, has allowed the introduction of new 
tests, and has encouraged clinical users to include pathology costs in 
their bids for funding for clinical developments. The system works 
according to rules agreed between pathology and its users at the 
outset, but once set up takes a minimal amount of work to operate and 
maintain.

... and the full text is on-line through the ACB site.

We moved to something similar in Oxford. But this would be a very 
difficult development for each laboratory to work through individually. 
Wouldn't it be better if it was a national initiative... I'd be 
prepared to call that modernisation! If we could move to that financial 
model that then we could respond in a co-ordinated way to innovation, 
NSFs....

Jonathan


On Wednesday, June 18, 2003, at 07:19  pm, Trevor Gray wrote:

> For my ha'penn'orth both Martin and Paul have a point.  We must keep up
> with the literature and when, as Paul points out, a test has earnt its
> evidence-based place in the repertoire, do what we can to introduce it.
>
>
> The problem, as Martin outlined, is that too many labs are constrained
> by lab. budgets imposed by management who regard them as cost centres
> not as part of the (in modern jargon) patient-process.  i.e. we are 
> seen
> as the problem not part of the solution, which in the case of BNP we
> genuinely are as we can help with a lot of the short-term problems in
> cardiac ultrasound waiting lists.  In the longer term, BNP will 
> probably
> be used to monitor treatment so the potential workload will steadily
> increase.
>
> Those of us that have convinced our management to include pathology
> costs in patient treatment costs (i.e. see us as part of patient
> treatment not a costly by-product) through mechanisms such as clinical
> budgeting or internal trading, only have to convince our clinicians 
> that
> it is worth the cost and they then are able to include it as part of 
> the
> patient care package.  In many cases, pathology costs, being relatively
> low compared with inpatient costs etc. disappear altogether (though not
> for BNP at current cost !).  In our case the clinicians are delighted 
> to
> fight our corner on our behalf, clinical budgeting will do the rest.
> (See our Annals paper on clinical budgeting last year).  We can then
> stop seeing new expensive tests as an intractable problem but more as a
> further opportunity for the laboratory to add value to their output (of
> largely irrelevant U&E!).
>
> The problem in our case is that internal trading will only cover the
> internal economy of the hospital and we have still to persuade our GPs
> to pay for their increasing pathology workload.  So we will have to
> restrict BNP to hospital consultants only - and when that happens I
> don't expect it to last a month without pressure from GPs on their
> managers to let them have it.  Actually we are introducing it as a
> carefully monitored research project, funded by soft money, but guess
> what will happen when clinicians hear it is available. The "research" 
> is
> intended to persuade the PCTs. If this sounds like politics, so be it,
> but it is more about managing in the current NHS environment.  There 
> are
> plenty of ways and means of putting pressure on.  NICE and clinical
> governance are another way in.
>
> So, if we are convinced that a test has a good evidence base, then the
> clinicians will almost certainly want it and will help you put pressure
> on managers to fund it.  This is essential - the funding mechanisms I
> mentioned above then remove some of the obstacles and make getting up
> and running easier.  As laboratory managers we need to influence the
> environment in which we operate locally (by making sure we are on good
> terms with both managers and clinicians) as well as making sure our
> science is good.
> Trevor
> --
> Trevor Gray
> Dept. of Clinical Chemistry,
> Northern General Hospital,
> Sheffield S5 7AU
>
> 0114 271 4309
>
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