Walk into most acute trusts in England and the pathology lab still looks much as it did in 2008, when Lord Carter of Coles first told the health service that fragmented, hospital-bound testing services were quietly bleeding money it could not spare. Separate blood sciences departments, separate procurement contracts, separate rotas of biomedical scientists covering the same handful of tests a few miles apart. The recommendation then was straightforward: consolidate these services into regional networks, pool purchasing power, centralise the routine work and free up specialist capacity for the complex diagnostics that actually need a hospital site. Seventeen years, two further reviews and one abolished oversight body later, roughly a third of the networks NHS Improvement mapped out in 2017 are still operating largely as independent trust-level services. The savings promised for 2020/21 were never fully banked, and the opportunity cost has compounded every year since.

This matters more now than it did a decade ago, because Lord Carter is back. The Institute of Biomedical Science commissioned him last autumn to conduct a fresh UK-wide review of pathology, due to report early this year, and its very existence is an admission that the earlier programme did not finish the job. Pathology is not a peripheral service line. Somewhere between seventy and eighty per cent of clinical decisions in the NHS rest on a laboratory result, and the total pathology budget across England runs past two billion pounds a year. When a system that large fails to realise even the two hundred million pounds in annual savings NHS Improvement identified as achievable, the shortfall does not disappear. It shows up elsewhere, in locum cover for chronically understaffed labs, in duplicated capital spending on equipment that a shared hub could have run more efficiently, and in the slower turnaround times that ripple forward into every diagnostic pathway built on top of them.

The reasons the reforms stalled are not mysterious, and they are largely structural rather than technical. Consolidation asks a trust to surrender direct control of a clinical service to a neighbouring organisation, often one it has spent years competing with for elective volume and workforce. It requires upfront capital at a moment when capital budgets are tightly rationed and, under current guidance, subject to Treasury sign-off above certain thresholds. It demands IT interoperability between systems that were never designed to talk to each other, and it depends on clinical buy-in from pathologists who have watched previous reorganisations arrive with promises and leave with redundancies. None of this is a reason to abandon the model. It is a reasonably complete explanation for why voluntary, incentive-light consolidation has moved at the pace it has.

The current NHS context makes the cost of further delay harder to justify. Community Diagnostic Centres depend on pathology capacity that can flex across a wider geography than a single trust. Digital pathology, which the sector has been promised for years, only pays for itself at scale, and scale is precisely what a network of unconsolidated single-site labs cannot offer. Meanwhile trusts are already being asked to close a multi-billion pound deficit largely through headcount reduction, which makes the case for genuine efficiency gains, rather than blunt staffing cuts, considerably more urgent than it was when the 2017 targets were set.

What the Carter review chooses to recommend this time will matter less than what DHSC and NHS England are willing to enforce. Previous rounds treated consolidation as guidance for trusts to adopt at their own pace, and a third of them simply did not. If ministers want the diagnostic ambitions in the current reform agenda to be more than a restated wish list, pathology cannot remain the exception that every workforce and productivity plan quietly assumes has already been sorted. It has not. The labs are still where they were, and so, broadly, is the money.