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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 ------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. ACB Web Site http://www.acb.org.uk List Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List Instructions (How to leave etc.) http://www.jiscmail.ac.uk/