Bulletin October 2019 Number 188

As I visit labs all over the UK as part of the #labtours visits, and speak to members at our very many events, the pressures on staffing are apparent everywhere.

Workforce issues in pathology across many of our disciplines have formed a major part of our work supporting members. We know how hard things are, and have been doing an enormous amount on this. We know that some of you may not be aware of the full scope of what has been going on – hence this update. This piece will focus largely on the NHS, but we have worked with colleagues internationally and we know that many of the same issues are present in every area. The international shortage of doctors is a reality. We do not have enough doctors as a country, or as a global health system, to fill all the roles we need. The US alone is short of 50,000 doctors, with a deficit of 90,000 predicted over the next few years. Other nations have similar problems. The Republic of Ireland trains more doctors per head of population than any other country, but still has pathology and other healthcare workforce shortages.

The key areas of College work have been getting data, attracting people into the profession, retaining and supporting people in their roles, and influencing policy to get investment in and for the workforce, including advocating for both medical and clinical scientist expansion and investment in scientists more generally. Our College Workforce team, along with Assistant Registrar Dr Esther Youd, the College Learning department and Professor Shelley Heard, have been working tirelessly for all of us on this.

One of the key things we have done is to document the state of play. The College collects and analyses the workforce census data, and publishes it in a readable report; no one else does. Shameful as it is, the electronic staff record systems in health services are not accurate or structured so as to be able to collect data on the workforce. So we do surveys to provide hard data on which we can campaign for our members. Getting data from some of your departments has not always been easy, and we do need you to help us with this – do make sure your data is being submitted!

Attracting people into our specialties has also been no small effort. We work right from raising awareness among the public, highlighting what we do so that people think about pathology, working on curriculum input for universities (the new undergraduate curriculum was published on 17 September, with many many thanks to all involved!), undergraduate ‘pathology schools’ and foundation doctors. The events (that you help pay for through your subscription), such as the recent Foundation taster day held on Saturday 29 June, and the two-day Summer School, are a real draw for young doctors, and they have been a great success in helping us increase interest in what we do across our specialties. I have never read more uplifting sets of feedback than from these events (any good feedback makes my day better, and this certainly kept me smiling for the whole day!).

Attracting people in has also involved lots of work on making the jobs as attractive as possible and we were pleased to see a commitment to this in the interim NHS People plan. Campaigning to get a salary uplift for trainees by using the histopathology workforce census data, highlighting pathology as a shortage specialty, and trying to address the disparity in earnings for histopathology trainees across the UK has been part of our work, and we have been successful in most elements of this. This makes us more attractive.

So, the full recruitment this year into histopathology (actually over 100% counting the academic posts), from a previous rate of 72% over the last few years, has not come easily, and the College has been a major player in making this happen. We have also had recent indications of increases in applications for training in several of our areas, including combined infection, haematology and immunology – all really good signs that we may be making a difference. We will get official figures across all our disciplines later, and I will let you know when the news comes out.

We were also successful in working together with colleagues in the Academy of Medical Royal Colleges to get the cap on tier 2 visas lifted, and to get doctors, nurses and scientists recognised as shortage professions at government level. This helps with the ease of recruitment from overseas, but is another short-term tactic while we expand the medical student population further. A second phase of expansion in UK medical students following the recent increase in medical student numbers is greatly needed – we have pushed very hard for this and have got it into the NHS commitment. At one of my two recent meetings with Simon Stevens, Chief Executive of NHS England, he reiterated his determination to help expand these numbers by a significant amount, so we are very pleased that this message is being heard.

In terms of supporting and retaining people who might leave, the key area is in relation to pensions. This is a fiscal policy-produced problem for everyone, but it is creating particular problems across all of healthcare, and is producing a significant disincentive for a great number of senior professionals. We have been raising this with the NHS directly, and also through the Academy. You may have seen from my twitter feed (@JoMartin_ path) that I met Simons Stevens to discuss this, and I have also talked to the Secretary of State for Health and Social Care about it. We have been working with the other Colleges on this also. More recently there has been the offer of a choice of how much you contribute to your pension, which is a temporary fix. It was raised directly in our meeting with the new Director of People for the NHS. We are collecting examples of ‘lost sessions’ because of this situation to help make the national case, together with our fellow Colleges. We continue to raise this at every opportunity, and campaign to get at the very least an exception for the NHS. I honestly do not believe that we could have done more on your behalf. We know it is being taken very seriously by all those in health policy, including Simon Stevens, but how soon a long-term resolution can be found is not yet clear.

The investment in digital pathology and LIMS systems, especially as the pathology networks come into existence, have the potential to help take some of the pressure off some departments, and make sharing workload and specialist referral easier. Good examples are seen in the clinical biochemistry community, where acute cover is being shared across a wide geographical area, linked by one LIMS system.

Digital pathology systems help histopathologists to be more efficient (there is debate as to how much more efficient it is, but 15–20% is the published figures. I believe it is probably nearer 10% in practice, but this is an entirely personal view, and I do believe we urgently need this help). Digital pathology also helps retain people, since it allows flexible working, including working from home for some sessions, which is very attractive for many people. We know that some people would have retired completely had it not been for the option of digital reporting. And retaining people is key.

We have had some good success over the last year in getting commitments from NHSI and Cancer Alliance networks to invest in digital. At least 12 digital pathology systems are being implemented over the next year, and we have been active in getting £20m of additional funding for digitisation. In terms of other IT improvements there has been £38m for LIMS systems generally, with another £12m just announced for the Yorkshire region.

We have also been doing some work through the English regional council, to feed back to NHS Improvement some of the impact of the 29 new pathology networks. We have successfully argued for specialist networks to protect some of our key supra-network expertise, and advised on how communications might be improved. Making sure that changes don’t drive people away is something we continue to emphasise in all our dealings with national bodies.

In terms of influencing policy, we use data to support better investment in the workforce. We use it to call for more medical students, more trainees, more support staff and better IT. We use the reports to highlight the shortages in the press, with MPs, with fellow pathology organisations in the UK and abroad, and with those who make decisions about how many trainees we need, and what investment in IT support we need. We work with charities such as the Blood Cancer Alliance, CRUK and Bowel Cancer UK to highlight the need for more pathologists, using that data. My colleagues and I meet the leadership of the devolved nations across the UK, with education bodies such as HEE, Cancer Leads, NHSE, NHSI and PHE and we all use the data to argue for more investment. I do tweet about some of these key meetings, and have recently taken Sir David Behan, Chair of HEE, on a lab tour to show him exactly how things stand, reinforcing the intellectual argument with a more personal touch.

You may rightly say, though, that this will take several years to make a difference to the current situation. So in addition to the digital investment push, we have been doing a lot to promote support for all our members and trainees in all our disciplines, and were very pleased to see the focus on making the NHS a great place to work in the People Plan drafts from the NHS.

We have been doing a lot on independent reporting. We already have produced good guidelines in this area. We know that even senior trainees in histopathology are not always being offered the opportunity to report on their own. There are some centres where even post FRCPath trainees are not independently reporting. We have tried to encourage this through sharing examples such as the Leeds model (independent reporting by post ST3 trainees on a (paid!) sessional basis, within their scope of approved practice). We are also supporting competence assessment and accelerated learning in a digital structured online learning tool (a year away, but in development). We also know that this may not help you if you don’t have trainees, but it may help elsewhere, and it may be a means of expanding our training pool.

Our clinical scientists and our biomedical scientists are key to our services. We all calling for expanded training numbers and training budgets for these. We know that the application rates of appointable candidates for clinical scientist training posts are very high (in one area, for example, 50 candidates applied for one post, with a shortlist of ten, all of whom were potentially appointable).

We are also supporting the change in legislation to allow clinical scientists to prescribe (for example, the very many skilled clinical scientist practitioners in lipids could run clinics independently if this was legalised, as happens for therapists and nurses). This multidisciplinary approach is workforce policy internationally, not just in the UK.

Advanced roles in dissection have been very helpful in stemming some of the pressure on medical pathologists. We have had reporting scientists in cytology as advanced practitioners for many years, and (oddly enough!) also in ophthalmic pathology. Advanced practitioners who have qualified in histopathology reporting (and there are still tens rather than more of them) are appointed to consultant scientist posts, but with a much-reduced scope of practice compared to a medical consultant. For more information about these posts and programmes, the web pages are all open to members, so do check them out, or speak with members of the conjoint training board. We have been asked by members to also look at more niche reporting for scientists (placenta to help the paediatric pathologists, bowel screening samples, etc.). We are working with NHS England and Health

Education England to get more training support for these professionals, because without their help we will be looking at even more deficits and stressed pathologists. In histopathology we are 25% down now, with an 8% rise in demand each year due to general pressures, and specific pressures around bowel screening expansion also. We are all too aware that you, and all of us, need all the help we can get.

So, apologies for the extended workforce update, but I wanted you to be aware of quite how much is going on to support you in this. Do foray into Twitter to check out @RCPath and @JoMartin_path to see a more ‘real time’ stream of what we are up to. There are also some excellent pathology resources for updates for all our specialties – and a very polite and helpful pathology community!

As regards to your membership value more widely, there is a list on the website. What they haven’t included is that you do get a President, and really excellent Honorary Officers and skilled College staff, who actually care!