Evidence submitted by the Royal College
of Pathologists (WP 78)
1. INTRODUCTION
The Royal College of Pathologists (RCPath) welcomes
the request of the new Inquiry, made on 27 January 2006, to present
evidence on the current status of the Pathology Workforce in the
United Kingdom and the projected requirements of that specialty
within the terms of the Inquiry. The College thanks the Health
Committee for accepting this written submission.
The RCPath works closely and regularly with
the NHS Workforce Review Team and with members of the Department
of Health to share data and to formulate policy with respect to
Workforce planning. The complexity and extent of "Pathology"
in the United Kingdom precludes a detailed appraisal of the various
different specialties contained within the subject. Therefore,
this memorandum comprises a generic assessment of the common factors
principally constraining planning and development of the pathology
Workforce in the National Health Service. For reference purposes,
the Appendices contain greater detail with respect to each of
the individual specialties within the totality of "Pathology".
2. BACKGROUND
"Pathology" represents a combination
of clinical and laboratory-based (scientific) disciplines [Appendix
I] and activities that underpin a large amount of patient investigation
and management within the Health Service of the United Kingdom
and is required for up to 70% of diagnosis. The Workforce is extensive
and varied in its composition, including medically-trained pathologists
(3,468 of which 323 posts are vacant), clinical scientists (3,983)
and biomedical scientists (21,256) together with a wide range
of ancillary but essential support from a range of laboratory
assistants, phlebotomists, anatomical technicians, clerical, secretarial/administrative
and other personnel1. These latter figures are in general agreement
with the 28,242 non-medical scientists identified in the 2004
survey [Appendix II] of non-medical personnel within the NHS2.
These figures underestimate the total Workforce
necessary to deliver the Pathology service required by the UK
NHS. However, existing systems of data collection preclude a more
accurate assessment of the size, composition and complexity of
the Workforce currently delivering the Pathology service. Although
many activities are based in laboratories, Pathology is a "clinical
service that supports other clinical disciplines", and not
merely a "support service" and in many areas is also
responsible for providing the clinical service. Pathology is an
integral part of the multi-disciplinary team and discussions between
a Consultant Surgeon and a Consultant Pathologist are of a similar
status and nature to those between a surgeon and physician when
discussing how best to advise a patient and what treatment options
should be considered.
Pathology, defined by the Government as the
"Essential Service"3, comprises the four major specialties
of Histopathology (including Cytopathology), Haematology (including
Blood Transfusion), Clinical Chemistry (including Metabolic Medicine)
and Medical Microbiology (including Virology and Parasitology)
together with a number of smaller of specialties including Immunology,
Embryology and Medical Genetics. The group of laboratory-based
specialties termed "Pathology" analyses the entire spectrum
of bodily materials including fluids (blood, urine, cerebrospinal
fluid, ascites etc) and secretions (respiratory, cervical etc)
as well as intact tissues and their derivatives (proteins, lipids,
carbohydrates, hormones, minerals, nucleic acids etc) using a
variety of specific laboratory techniques.
The materials studied originate from individual
patients and the data generated through laboratory analyses are
assessed objectively against a spectrum of values or appearances
judged to represent "normality" within the caveats of
age, gender, disease, medication and other factors. Following
interpretation, decisions based upon the pathological data directly
affect the clinical management of individual patients. The role
of pathology is to identify, develop and provide the scientific
infrastructure that enables accurate diagnoses to be made and,
thereafter, to monitor patients and assess disease progression,
including response to therapy. Thus, pathologists (ie all those
involved in the practice of pathology) are patients' advocates
with respect to their clinical management. Following initial diagnosis,
interpretation of pathological processes potentially influence
disease progression and hence determine the outcome of each individual
patient.
Within the UK NHS, pathology currently provides
a highly efficient and effective service, despite the constraints
it has continued to endure over a number of years. While there
is no doubt that some improvements in structuring and delivery
of the pathology service could be made, these changes should be
considered only on the basis of informed understanding of present
structures and functions. There are few clinical situations in
which provision of pathological information is not acquired early
and used as an integral part of the clinical diagnostic-management
pathway. Increasing sophistication of the technologies and methodologies
routinely employed by pathologists is providing the constantly-evolving
scientific basis by which ostensibly identical diseases are being
sub-divided into biologically distinct entities (eg malignancies,
cardio-respiratory disease, hypertension, metabolic bone diseases,
autoimmune inflammatory disease etc etc), often requiring significantly
different therapeutic approaches.
Thus, the practice of Pathology (and hence the
role of Pathologists) is core to the clinical diagnosis and monitoring
of patients. In the very near future, Pathologists will also determine
the biologically appropriate therapeutic regimens employed to
manage individual patients and to change treatments as the diseases
affecting those individual patients become modified.
3. PATHOLOGY
WORKFORCE OVERVIEW
The NHS Pathology service in each of the subject
specialties previously identified (see Section 2) is provided
by an integrated workforce that can be considered in four broad
groups of: (1) Medically trained doctors; (2) Clinical Scientists;
(3) Biomedical Scientists and (4) Clerical/Secretarial/Administrative.
Smaller groups may be considered within these broad categories,
according to skills, training, competencies and responsibilities
(eg Anatomic Pathology Technicians may be included within the
group of Biomedical Scientists). Recruitment, development and
retention of an appropriately skilled Workforce "fit for
purpose" is crucial to an effective and reliable Pathology
service that is the cornerstone of modern healthcare delivery.
Within all pathology specialties, there is overlap
with respect to roles, technical competencies and responsibilities
between the principle groups [Appendix III]. Pathology Modernisation4,
5 as a concept initially set-out to explore the similarities and
differences between the activities of these groups and to make
recommendations with the objective of improving performance in
Pathology by adoption of new strategies and working practices.
Simultaneously, additional approaches embodied within the Knowledge
and Skills Framework6 and Agenda for Change7 prompted
and strengthened the drive towards rationalising practices within
pathology laboratories. Thus, diverse efforts are being made from
different agencies to remodel the structure and delivery of pathology.
Often, these pressures are uncoordinated, poorly-informed and
frequently conflicting in their purposes.
Within the "Pathology Workforce" the
concept of strict demarcation between individual specialties is
becoming outmoded with respect to innovations that include robotic
handling of specimens, modern molecular biological technology
and automated image analysis (from DNA arrays to histopathological
specimens). However, before the objective of a fully integrated
"cross-specialty approach to Diagnostic Pathology can be
attained, the fundamental and common factors of recruitment, retention
and competencies require to be addressed and current deficiencies
resolved.
4. EFFECTIVENESS
OF WORKFORCE
PLANNING
4A. Effects of Policy Announcements and Changes
(i) Workforce Planning in the Pathology
Specialties is unique within the National Health Service since
it involves a large number and diverse range of highly trained
personnel, both Medical and Scientific. Provision of appropriate
skills to a level of competence within the workforce involves
a delay of at least five years for those medically-trained to
reach MRCPath and at least four years for Clinical Scientists
to reach PhD.
(ii) There is increasing reliance on non-medically
trained personnel to take responsibility for ordering pathology
tests, often using protocols drawn up by pathologists (Demand
management) or for pathological investigations performed by a
variety of "One-Stop" agencies or "Walk-In"
centres to be repeated. There is also a significant trend for
personnel not trained or experienced in a broad understanding
of medicine to rely upon laboratory investigations for diagnostic
and monitoring purposes.
(iii) Emphasis on a "patient-led"
NHS and employment of Medical Care Practitioners8 without a broad
medical background is likely to increase demand on all sectors
of the Pathology service.
4B. Technological Change
(i) Technological change is occurring in
three major sectors of pathology activity:
(a) Near Patient, or Point of Care testing
is increasingly being deployed to allow regular monitoring without
the expense or inconvenience of transporting those patients to
a laboratory to perform tests. Increasingly, these modern instruments
convey data by telecommunication links9 to a central laboratory,
to clinicians and to the patients' electronic records. Such investigations
may be performed by the patients following training (eg blood
glucose measurements), by Medical Care Practitioners or by nurses,
thus obviating the need for doctors or laboratory personnel to
administer each test.
(b) Truly novel technologies allow acquisition
of patient-specific pathology data not hitherto available. These
modern technologies are often robotic and automated up to the
point of delivering the validated data. Obvious examples include
all molecular genotyping and phenotyping of human cancers. For
example, sentinel node assessment of a primary cancer not only
permits detection of otherwise occult micrometastases but simultaneously
provides unique information on tumour differentiation and biological
competence with respect to drug sensitivities, and hence therapeutic
options. Similar principles may be applied to haematological malignancies
as well as to the microbiological investigation of tissue infections
and infestations.
(c) Digitisation of a disparate array of
image-based information together with web-based telecommunications
provides ready access to mathematical analyses (application of
algorithms) and the integration of remote data to provide levels
of novel information not previously attainable.
(ii) Utilisation of these new technologies
is often hampered by shortages of personnel (workforce), expertise,
time and funding.
(iii) The lack of numbers of laboratory
personnel, particularly those with appropriate expertise, often
means that those available are fully committed to the traditional
delivery of service and have no flexibility or opportunity to
learn new skills. Time spent developing new methods of working,
including acquisition of new skills, is considered as detrimental
to efficiency, of delivering a service and attaining targets,
and hence is not encouraged or funded within the existing system.
(iv) To acquire and develop the new technologies
to a level of common usage within the NHS service requires increased
flexibility within the workforce.
(v) Introduction of automated instrumentation
will change the profile of the workforce. Fewer middle-grade scientists
will be required in preference to more technicians to supervise
the instruments together with more medically-trained pathologists
or clinical scientists to interpret the data, to advise clinicians
and to take-on increasing Clinical roles.
(vi) Technological change has been assumed
(erroneously by many) to be the panacea for correcting any perceived
inefficiencies within the existing pathology service. "Technological
change" can potentially achieve an increase in the availability
of pathological investigations through point-of-care testing using
a range of novel instruments outside main laboratories. This is
not necessarily cheaper or workforce saving but has a place and
a value in a number of clinical situations, particularly allowing
patients remote from hospitals to be closely monitored with the
tests being administered by non-medical and non-scientific staff.
(vii) Many such instruments are now readily
available, especially within the community. Effective deployment
of this technology requires the training of a support workforce
knowledgeable in technical aspects of administering the tests
but without responsibility for their interpretation.
(viii) The other major technological advance
involves the introduction of new technologies where there is no
previous expertise within laboratory medicine. Such new technologies
include the full range of evolving molecular biological methods
with which to detect and classify an expanding range of human
diseases (benign as well as malignant).
(ix) There are a number of newer innovative
technologies now seeking application in Pathology. These include
exhaled breath analysis to detect and monitor a range of non-respiratory
systemic illnesses including hepatic dysfunction and degenerative
CNS disease. These will ultimately provide rapid-access and non-invasive
technology with which to identify and manage patients with those
conditions.
4C. Influence of an Ageing Population
(i) With respect to workforce, the term
"Ageing Population" might be applied equally to laboratory
personnel as to the patients served by the pathology service.
(ii) The major specialties within pathology
contain a medical and a scientific component in which a high proportion
of each membership is within 10 years of retirement [Appendix
IV] and of which a significant proportion is within five years
of retirement.
(iii) This group of personnel within pathology
contains significant knowledge and expertise to ensure continuity
of training but is undergoing attrition before that knowledge
can be passed to the trainees entering the various professions
[Appendix V]. Loss of training capacity, probably affecting the
scientists more than the medically-qualified pathology workforce,
is resulting in numbers of laboratories no longer accepting trainees
in favour of maintaining target-oriented services in a manner
analogous to that already described for technological change (see
Section 4B(iv)). Without centrally-directed support, the Pathology
Workforce will continue to contract relative to workload and demand
because the capacity to train new recruits will continue to diminish.
(iv) Within the community, ageing populations
generally require more pathological investigations than younger
populations and are more likely to have chronic disease that needs
long term monitoring. However, many of the types of investigation
required are predictable and hence programmed monitoring of ageing
populations could be planned so that appropriate resources are
available. For example, occult thyroid dysfunction (both hyper-
and hypo-thyroidism) is more common with advancing age but can
be readily detected by appropriate laboratory investigations.
It is economically justifiable, through planned surveillance of
ageing populations, to prevent many diseases while they are yet
minimal from becoming clinically overt and requiring additional
NHS resources.
(v) Other diseases that benefit from early
pathology laboratory detection include diabetes, metabolic bone
disease, cardiac failure, hypertension, colorectal (and other)
neoplasia, renal failure and many more. However, while such programmes
are economically justifiable and hence desirable, the current
pathology Workforce is too small relative to the present or predicted
workload to implement such surveillance.
4D. Increasing use of Private Providers
(i) There is a general misconception that,
within the United Kingdom, a large private pathology sector is
available with capacity ready to accommodate excess work from
the public sector. While it may be true that highly selected parts
of the country's pathology workload could be performed within
private laboratories, this is demonstrably untrue for the totality
of pathological investigations.
(ii) The majority of work that would be
suitable for transfer falls into the low technology automated
category (typically routine biochemical and haematological). These
require little staff input.
(iii) These "high-volume, low-cost"
tests underpin much of the expense of more complex investigations
("low-volume, high-cost") that make NHS pathology laboratories
viable. Diversion of these automated and remunerative tests ("cherry-picking")
would seriously undermine current efficiency of NHS pathology
laboratories as well as fragmenting provision of an integrated
assessment of individual patients' pathological data.
(iv) A consequence of unrestrained use of
private suppliers would be a less efficient and less cost-effective
NHS pathology service in which unit workforce costs for specialist
complex investigations would be driven-up.
5. PREDICTING
FUTURE DEMAND
5A. Financial Constraints
(i) Pathology has often been viewed by Hospitals,
Trusts and Health Authorities as an expensive service removed
from the actual provision of healthcare. This view was reinforced
during the period of competitive tendering between laboratories
in which pathology budgets were reduced and services curtailed.
This led to significant inter-laboratory rivalry that has persisted
and remains a significant obstacle to development of "pathology
networks" in which cooperation rather then competition has
been the primary objective.
(ii) Current financial constraints originating
in this earlier era continue to inhibit development of pathology
services in two principal respects:
(a) A lack of financial flexibility to invest
in additional workforce, in developing new technology or in reconfiguring
services in favour of maintaining current working practices to
achieve targets (see Section 4B. vi). Such a rigid approach ensures
maintenance of the status quo by the majority of laboratories
within the NHS while ensuring lack of essential support for the
overall pathology service to evolve.
(b) The majority of laboratory budgets are
insufficient to continue supporting the final (fourth) year of
clinical scientist training. Provision of funding for this pre-registration
year has always been ad hoc in many laboratories. However,
different Pathology specialties are affected differently. For
example, Haematology and Immunology have been successful in developing
Grade A clinical scientist training schemes, although a number
of these trainees have left the specialties following completion
of training through lack of funding to support career progression.
Histopathology currently trains and employs few clinical scientists,
but is likely to require more as the nature of the tests performed
within those laboratories change. Conversely, Clinical Chemistry
is highly dependent on its scientist workforce but the combined
impact of factors including continued decline in funding relative
to demand, a large pre-retirement workforce and diversion of funding
to achieve service targets have reduced the capacity to maintain
this science-based workforce.
(iii) Responsibility for funding Pathology
within the NHS is about to be transferred to StHAs and to PCTs—two
layers of administration likely to be disbanded in the near future.
Unfortunately, the majority of persons working within these administrative
bodies are physically and experientially remote from investigative
aspects of patient care such that their appreciation of the value
of Pathology is frequently inadequate. History has repeatedly
shown Pathology to be a prime target whenever economies are to
be made and budgets cut.
5B. European Working Time Directive
(i) Throughout the Pathology Workforce,
but affecting medically-trained pathologists more than the scientist
workforce, it is common practice for individual personnel to work
more than 40 hours per week in order to complete outstanding work.
(ii) However, many Trusts consider it unnecessary
for pathologists to work more than 40 hours per week with the
consequence that only 10 PAs are offered to pathology consultants
under the terms of the new contract. Pathology trainees in many
laboratories do not receive banded payments for additional work.
If Consultants accept this reduction we may soon see a significant
reduction in the hours they work.
(iii) Current attitudes engendered in Trainees
to work only within fixed time schedules, and not to work outside
those planned times for which they are remunerated, will increase
the necessity for a larger Pathology Workforce, if workload demands
are to be successfully addressed.
(iv) The Working Time Directive (WTD) is
beginning to have an impact on pathology. Compliance with the
WTD without detriment to clinical services through lack of pathology
services will not be possible without consultant expansion to
enable reductions in working hours.
(v) There is some possibility for cross-cover
by developing links between neighbouring hospitals, which will
occur in parallel with changes in the acute services strategy.
However, the impact is likely to be slight in view of the need
to have local advice on site in all acute hospitals. Histopathology,
in particular, is a "hands-on" specialty at Consultant
level in most DGHs with little or no dedicated junior doctor cover,
thus precluding effective operational availability on more than
one site simultaneously. Many of the other specialties provide
a clinically based service and important pan-hospital services,
such as infection control and blood transfusion services.
5C. Feminisation and Part-Time Working of
Pathology Workforce
(i) An increasing proportion of medical
students are female. A similar trend is developing in the Pathology
Workforce whereby more medically trained pathologists are female
[Appendix VI].
(ii) Currently, women seek more time away
from work than men in order to look after children and young families,
thus increasing the total required headcount to match the full
time equivalents (FTEs) of the Workforce necessary to meet pathology
workload demands.
(iii) Increasing part-time working (whether
by women with family commitments or by men seeking less time at
work for whatever reasons) imposes an uncertainty on workforce
planning that cannot be fully compensated. In the workforce planning
algorithm used by the NHS Workforce Review Team and the RCPath
to estimate the numbers of medically-trained pathologists required
in future years, the factor used to relate "headcount"
to FTEs has fallen from 0.8 in previous years to 0.75 in this
current year—indicating a necessary increase in the numbers
to maintain the same effective Workforce.
(iv) To compensate for a declining Medical
Pathology Workforce through additional recruitment and training
requires approximately eight years to generate independent, competent
and effective Pathologists following their initial Medical training
(see Section 4A(i)).
5D. International Competition for Pathology
Laboratory Staff
(i) The UK Pathology Workforce (Medical
and Scientific) is currently trained to a very high international
standard. Organisation of an integrated Health Service (including
Pathology) is more extensive in the UK than anywhere else in the
world. These two factors provide a unique opportunity for UK pathology
to become a net exporter of Pathology services and hence to attract
revenue into the country.
(ii) The converse of this projected scenario
is that, without appropriate reorganisation, the UK NHS could
purchase some of its pathology services from other countries.
(iii) The UK could benefit (financially
and structurally) from reconfiguring its pathology services and
thus fully realize this currently undervalued resource.
(iv) There are significant potential opportunities
in working with UK-based manufacturers of pathology equipment
and instrumentation to develop "integrated packages"
that might be supplied as functional units to pathology laboratories
in less sophisticated countries. Development of equipment that
complies with common internationally-standard operating systems
would allow the direct interfacing of different pieces of equipment
from different suppliers ("plug-and-play") without supporting
monopolies. Manufacturers of such equipment would find ready markets
in Eastern Europe, the Middle East, the Indian subcontinent and
other parts of the world before those countries developed their
own systems.
(v) Development of large automated laboratories
that are environmentally competitive would make financial sense
for non-urgent pathology tests (eg clinical trials) or specialist
tests that would be expensive to establish on a small scale elsewhere
(including a wide range of Histopathology together with all of
the other Pathology sub-specialties). Installation of routine
digital image scanning together with web-conferencing have already
demonstrated this option to be viable.
(vi) The UK pathology workforce is highly
competent but requires additional funding to expand and to develop
further. This expertise is in international demand and should
be nurtured, developed and protected. Rather than allowing this
national resource to migrate from the UK, reconfiguration of pathology
services in which the trained expertise is fully exploited would
provide a strong business-case to purchasers of this expertise
from other countries.
(vii) The UK has always had a tradition
of attracting both trainees and pathologists from other countries.
This has not only supplemented workforce deficiencies but has
provided important international links and has helped enhance
the standard of medical practice world-wide. An increasing number
of doctors are now being seen from Eastern Europe. While the RCPath
does not support or condone recruitment of pathologists from "Third
World" countries or from any places where such expertise
is in short supply or its removal would be detrimental to its
location of origin, personnel trained in laboratory Medicine may
benefit from short periods of additional training in the UK, but
with the proviso that they return, with their added expertise,
to their country of origin following training.
(vii) Trained pathologists, trainee pathologists
and medical scientists may be recruited from countries within
the EEA, USA, Canada, Australasia and other countries where pathology
is already practiced at a high standard and where there is a surfeit
of this expertise. Such recruitment may prove beneficial to UK
pathology, to those persons choosing to work within the UK and/or
to international cooperation and understanding between foreign
nationals.
5E. Early Retirements, Resignations and Other
Losses
(i) The RCPath is unique within the NHS
in commissioning a bespoke Electronic Workforce Database (EWD)
able to encompass numbers and membership of all groups working
within pathology in the delivery of healthcare. Funding for this
database has been suspended, temporarily. However, both the DoH
and NHS Workforce realize that, without the proposed electronic
database, there will be incomplete understanding of current Workforce—in
terms of both numbers and competencies.
(ii) Until the EWD is established, the RCPath
will continue to maintain a database, updated annually, of all
Consultant pathologists currently in post as well as a listing
of those posts that, for any reason, have recently become vacant.
(iii) While the RCPath data are as accurate
as possible, several factors mitigate against this information
being a true representation of all posts available at any time
[Appendix VII].
(iv) Trusts and PCTs do not protect the
funding of Consultant Pathologist posts but rather consider vacancies
in Pathology posts to be opportunities to direct funding towards
so-called "front-line" posts directly identified with
patient-related activities.
(v) In recent years, Universities and other
academic institutions have transferred many pathology staff from
their academic (particularly HEFCE-funded) employment to the NHS
in order to be more competitive in previous and current RAE exercises.
(vi) Some senior academic Pathologists,
at the proposal of transfer to the NHS, have taken early retirement,
particularly when Trusts have refused to fund those individuals.
(vii) Inter-personal stresses caused by
increasing loss of Consultant Pathologist Workforce has directly
contributed to resignations and early retirements, particularly
in Histopathology10.
(viii) Loss of academic Pathologists from
medical schools has compounded the already diminished profile
of Pathology disciplines as an integral part of the new medical
curriculum and as viable career options, thus worsening problems
of recruiting `home-trained' medical staff into Pathology-related
professions11, 12.
6. CONSTRAINTS
ON ABILITY
TO MEET
PROJECTED DEMANDS
6A. Changing the Roles and Improving the
Skills of Existing Staff
(i) Pathology services are heterogeneous
with respect to the composition of the workforce within the different
pathology disciplines. However, all comprise various mixtures
of medically-trained staff (Consultants and Trainees) together
with clinical scientists, biomedical scientists and clerical/administrative
personnel. Some of the disciplines contain specialist staff such
as Anatomical Technicians (Histopathology) and Phlebotomists (Haematology
and Clinical Chemistry).
(ii) The career pathways for the individual
types of staff are becoming aligned through processes such as
the Agenda for Change and the Knowledge and Skills Framework.
Rationalisation of clinical scientist careers is currently being
undertaken. The long-term objective is to identify the roles of
all personnel to fulfil the activities identified within the Pathology
services and to align staff with appropriate skills and expertise
to those roles.
(iii) Lack of flexibility within the Pathology
Workforce caused by insufficient funding to generate an adequately
large human resource, poor retention of scientific staff following
initial training (see Section 5A(ii)) and concentration of available
resources on achieving short-term targets rather than investing
in reconfiguration to develop imaginative and modern methods of
integrated working are contributing to the retention of a rigid
and stylised approach to Pathology within the NHS.
(iv) Recruitment is a matter of profile13—whether
medical, scientific, technical or clerical. Individuals will not
be recruited into any profession that has no profile or appears
to have no relevance. Once recruited, individuals will not be
retained without personal job-satisfaction, prospects of career
progression and levels of remuneration that are competitive with
external options.
(v) The concept of "competency"
is defined as the product of skills (including knowledge) already
acquired (through school, university and/or medical school) together
with aptitude and ambition to progress to professional training
in the discipline.
(vi) Currently, there is a strong subjective
sense that, on entry, the skills and experience offered by science-trained
graduates is currently higher than at any time previously with
the consequence that there is a valuable opportunity for pathology
in the UK to recruit talented and well-trained young scientists
capable of developing the profession.
7. STRATEGIES
FOR MEETING
PROJECTED DEMANDS
7A. Nature of the Projected Demands
(i) There are two components to this question:
First, the size and nature of the projected demands and, second,
the size and competencies of the workforce to match the demands.
(ii) As UK healthcare becomes more proactive
with minimal diseases (new and residual) being detected earlier,
so the number and complexity of tests required will continue to
increase at a rate of approximately 13% per annum for the
foreseeable future, if the trends over the past decade continue
unabated.
(iii) Pathologists are also being asked
to provide many new types of information with respect to disease
phenotype, prognosis and likely response to therapeutic manipulations.
(iv) The fact that increasing amounts and
complexity of tests will be requested does not per se predicate
increasing numbers of pathology staff. As many new tests become
automated, and laboratories function as a 24/7 routine, the workforce
is likely to become redistributed from predominantly those with
"hands-on" expertise at the laboratory bench to a lesser
number with skills to supervise and maintain instruments together
with a larger number competent to interpret the data to be transferred
to clinicians and to be stored in patients' records. These evolving
profiles will be specialty-dependent according to the individual
levels of laboratory automation achieved.
(v) The numbers and profiles of clinically-trained
pathologists are likely to rise significantly as demand increases
to interpret more sophisticated tests related to individual patients.
Already, this change is most significant in Haematology and Clinical
Chemistry where pathologists are skilled in performing laboratory
investigations as well as clinically to manage patients. Similar
trends are already occurring in Medical Microbiology, Allergy
and Immunology and in Genetics and are about to occur in Histopathology.
(vi) Histopathologists now perform complex
investigations to determine the phenotype, prognosis and likely
response to treatment of a variety of diseases, not just cancer.
The potential clinical significance of these data frequently cannot
be encompassed in simple reports but require detailed interpretation
and simultaneous communication to clinicians and to patients in
order that appropriate management strategies might be formulated
and agreed and reviewed as response to treatment becomes apparent.
Therefore, it is most appropriate that Histopathologists adopt
a role more central to the clinical management of patients than
occurs at the present time.
(vii) The consequence of a more central
clinical role will be to support the profile and apparent relevance
of pathologists as clinicians in the core management of patients.
There will be more and better teaching of pathology in the undergraduate
medical curriculum. Recruitment of high-calibre "home"
trainees into pathology will increase and funding of Consultant
Pathology posts by Trusts and PCTs will be perceived as essential
rather than as being of questionable value in the front-line management
of patients.
8. RECOMMENDATIONS
— Effective Workforce planning in Pathology
urgently requires the commissioning of a dedicated Electronic
Workforce Database (EWD) of the type originally conceived and
initially funded through the DoH. This Database is now available
for use. The proposed Electronic Workforce Record is no substitute
for the EWD since it is insufficiently detailed to capture all
of the information necessary for effective Pathology Workforce
planning. A detailed analysis of the costs of deploying the EWD
are appended [Appendix VIII]. An essential requirement to the
use of an EWD is that it should be a requirement of employment
(individuals and/or Trusts should be mandated) to maintain their
entries at least once, annually.
— Pathology Workforce should be monitored
and planned on a national basis using the proposed Electronic
Workforce Database as a matter of urgency. There needs to be a
greater awareness of the dangers in the predicted loss of expertise
as senior members of the workforce (all specialties) reach retirement.
— Pathology specialties could recruit
nationally to training programmes based around teaching centres
and utilising rotations to other Trusts or trainees to gain specific
expertise in a manner analogous to that currently used by Histopathology
Training Schools. To assist this process, NTNs should be transferred
from locations where no training occurs and relocated to the training
centres.
— Wherever possible, specialist training
could be integrated between medically-trained Pathologists, Clinical
Scientists and Biomedical Scientists for specific areas of the
curriculum. Joint training across specialties and between the
three groups would provide a foundation for role rationalisation
and cross-specialty working, particularly in common fields such
as molecular genetics but would still maintain the unique nature
of each specialty.
— As a generalisation, medically-trained
pathologists should make greater use of their clinical skills
and become more proactive in the management of patients.
— Since establishment of pathology
services involves complex planning over a long term, StHAs, Trusts
and PCTs should ring-fence and protect monies currently designated
for workforce personnel.
Professor Adrian C Newland
President, The Royal College of Pathologists
Professor Christopher S Foster
Director of Workforce Planning, The Royal College
of Pathologists
9. REFERENCED
MATERIAL 1 Health Professions
Council database download—31 March 2006.
2 Department of Health, "NHS Hospital
and Community Health Services, Non-medical Workforce Concensus"—England
30 September 2004.
3 Department of Health, "Pathology—The
Essential Service" (Draft guidance on modernising pathology
services—2002.
4 Department of Health, Modernising Pathology
Services—2004.
5 Department of Health, Modernising pathology:
Building a service responsive to patients—2005.
6 Department of Health, The NHS Knowledge
and Skills Framework (NHS KSF) and the Developement Review Process
(October 2004)— 2004.
7 Department of Health, Agenda for Change
Proposed Agreement (September 2004): Final draft—2004.
8 http://www.wise.nhs.uk/sites/workforce/practitioners/medical/default.aspx
9 http://www.rcpath.org/resources/pdf/TelepathologyMay05.pdf
10 Liebmann R and Foster CS. Workforce—Greener
grass? Consultant histopathologists moving between Trusts—survey
results. The Bulletin of the Royal College of Pathologists
133, 11-13 (2006).
11 http://www.gmc-uk.org/education/undergraduate/tomorrows_doctors.asp
12 John Hutton: £73 million for
junior doctor training programme. MMC Programme, 23 March,
2005.
13 Domizio P and Du Boulay C. Working
smarter—Career Choices And Career Progression In The Pathology
Specialties: National Surveys Of UK Medical Graduates. The
Bulletin of the Royal College of Pathologists 134, 31-35
(2006).
10. SPECIALTY-SPECIFIC
INFORMATION
The foregoing document has provided generic
information with respect to overall trends in Pathology Workforce.
However, Pathology is a complex and heterogeneous subject in which
each of the specialties currently experiences unique and specific
problems and constraints. These are addressed in Supplementary
Documents I containing Appendices I-VIII. The Proformas developed
annually with the NHS Workforce Review Team are contained within
Appendices IX-XV in Supplementary Documents II. [32]
32 Not printed here. Back
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