Introduction

In this issue ...
· Farewell and Welcome
· Workload and Staffing in Histopathology and Cytology
· CPA in Italy

At the Annual General Meeting of CPA on 6 October 2000, Professor Brian Edwards stepped down as the inaugural Chairman of the Board of CPA, having served in that capacity from day one of CPA’s existence.  He was also a key figure in nurturing CPA in its fledgling years, funding the initial pilot study in Trent when he was Regional Administrator.  He has been a constant source of sound advice, often challenging accepted dogma.  His network of contacts has meant that CPA has always been able to get its message through at the highest levels.  CPA owes a great debt of gratitude to Brian Edwards, reflected in his honorary Fellowship of The Royal College of Pathologists and honorary Membership of The Association of Clinical Pathologists, and this was fully acknowledged at a short presentation to him following the AGM and Board meeting in October.

 At the AGM, CPA also welcomed Professor Sir Duncan Nichol CBE, MA, FHSM, Dip HSM as independent Chairman of the Board of Directors.  One of us first met Sir Duncan on his starting day as Consultant Immunologist in Salford in 1980.  Sir Duncan, then plain Mr Nichol, was Area Administrator of Salford Area Health Authority before going on to become Regional Administrator, and then Regional General Manager of Mersey Regional Health Authority.  In the mid-eighties, be became a non-executive director of the NHS Management Board until being appointed to the “top job” (aka “poisoned 

chalice”) of Chief Executive of the NHS Management Executive from 1989-1994.  Since 1994, he has held various positions as Professor of International Healthcare Management and Systems Development in the Health Services Management Unit of the University of Manchester.  During this period, he has held many national, honorary and non-executive posts, including non-executive directorship of HP Prisons Board and of BUPA Ltd.  He is currently President of the Association of Quality in Healthcare and has gained experience of accreditation systems as the current Chairman of the Home Office National Accreditation Panel for Offending Behaviour Programmes of the Prison and Probation Services.  You might think this an appropriate introduction to working with CPA but we couldn’t possibly comment.  There is no doubt, however, that Sir Duncan’s vast experience and contacts will stand CPA in good stead during his period as Chairman

 So, while we bid a fond farewell to Professor Brian Edwards, we give a warm welcome to Professor Sir Duncan Nichol.
 
Mansel Haeney
Chief Executive (Accreditation)             

David Goldie
 Chief Executive (EQA)

ADDRESSING WORKLOAD
AND STAFFING ISSUES 
IN UK HISTOPATHOLOGY AND 
CYTOLOGY LABORATORIES

It is a well-known fact that Histopathology and Cytology departments have been struggling, for some time, to meet the demands placed upon them. This has been very apparent to CPA, where the reports of laboratory inspections over the last two years have made increasingly gloomy reading. More departments have been referred, while many more than in the past have conditions on them. Much of the problem is related to the imbalance between workload and staffing that has become more acute in the last few years.  CPA therefore decided to commission, and fund, a research study into the current state of Histopathology departments in the UK. In order to gain some insight into potential future changes the study also sought information about the trends in the previous 5 years.

In order for the results to be seen to be unaffected by professional interests, an independent organisation, the Institute of Employment Research at Warwick University, was retained to carry out the study. The Institute has considerable experience in this type of research, and the researchers in this study were Drs. Rob Wilson and Ruth Shackleton.

They obviously needed advice on the particular problems of Histopathology departments, including the possible workload measures available for use and the nature of the staffing structure in NHS laboratories in the UK. Cheryl Blair and Georgina Pyle of the Headquarters staff and myself, as Chairman of the Histopathology SAC provided this from CPA.

The postal survey was done, as many of you who participated will know, in May and June 2000, and the response was extremely good. Of the 300 laboratories who were approached replies came from 191 (64%). This is regarded as a high response rate to such a survey and we are very grateful to all those who took the time to complete the questionnaire.

The results of the survey have been published and are available in full from the CPA office.

Table 1
Average Number of Staff per Grade in Histopathology and Cytology Laboratories in the UK 1999/2000

1.   Staffing in Histopathology and Cytology Laboratories in 1999/2000      

Table 1 (which is extracted from table 21 in the report) shows the average number of staff in each grade in terms of the actual number of employees, together with the number of WTEs in post and the Funded Establishment.   The average laboratory had 3.7 WTE consultants in post, 8 qualified Bio-Medical Scientists (BMS), 2.1 Medical Laboratory Assistants (MLA) and 1.6 Cytoscreeners.

103 of the responding laboratories (53.9%) had no establishment in the BMS 4 grade, 58.6% had no establishment for trainee BMSs and similarly 86.4% lacked established posts for trainee Cytoscreeners. There is obviously a serious deficiency in posts at the top and bottom of the BMS grade and this does not bode well for the future.

2. Workload Measures in 1999/2000

These average staffing levels can be compared to the average workload shown in Table 2 (table 31 in the report). The average laboratory received 12818 Histology requests, 23630 Gynaecological Cytology, 2993 non-gynaecological cytology requests, and did 532 PMs.

We can thus compare these workload to staffing ratios with those recommended by the Royal College of Pathologists and those used as broad guidelines for Bio-Medical Scientists. The College recommended number of Consultants for a DGH laboratory with this workload would be 5.1, whereas the actual number of WTEs in post is 3.7. This is a 27% shortfall. Even if we accept that the recommended numbers are slightly on the generous side it is still obvious that the average department is significantly understaffed at Consultant level.

Table 2
Average Workload Measures for UK Histopathology and Cytology Laboratories 1999/2000

Turning to the trends in staffing that were revealed by the survey, it is apparent that has been an overall increase in staff numbers over the past 5 years. The average laboratory had 20.7 staff of all grades in 1994/95 and this had increased to 24.8 WTEs by 1999/2000. Included in this overall increase there were increases in the average number of Consultants from 3 to 3.9, of Grade 2 BMSs from 2.2 to 2.8, of MLAs from 1.7 to 2.2. , and of clerical and secretarial staff from 3 to 3.6. Other grades remained largely unchanged.

Trends in the workload over the same 5 year period are shown in Table 3 (table 41 in the report).

t is clear from this table that the Histology requests have increased by 12.6% over these 5 years, but that does not tell the whole story. The number of Blocks is up by 12,2%, Slides by 27.9%, and Immunohistochemistry by 84.4%. The increased complexity of the work done, is the crucial factor in placing stress on Histopathology departments and that has not been previously documented. Using the simple number of Histology requests as a measure of workload may be no longer adequate.  As expected gynaecological cytology numbers are static, non-gynaecological cytology increased by 12.8% and Hospital post -mortems show a continuous downward trend.

he survey also sought information about vacancies in the workforce. The average number of Consultant vacancies per laboratory was 0.6 (16% of employment) with the average duration of a vacancy being 10.9 months.

Similar figures for BMS 1s are 0.8 (21%) with an average duration of 8.3 months, and for cytoscreeners are 0.4 (17%) for an average of 9.2 months.

For all grades of staff the number of people in post was below the funded establishment.

Table 3
Workload Measure Trends 1994/1995 to 1999/2000

The reasons for the problems with staffing in Histopathology departments are shown by the responses to the "Important issues questions". These are shown in Table 4(table 51 in the report). Recruitment, retention and retirement are key issues particularly for Consultants. With Bio-medical Scientists these matters are also significant but pay levels are cited as the most important issue.

There is much more detail in the full report for those who wish to read it, but the overall conclusion is that Histopathology and Cytology laboratories face an ever increasing workload and a greatly increased complexity of the work done. This has not been matched by a commensurate increase in the workforce, at any level, and therefore departments are under considerable stress.   This is reflected in the difficulties in recruitment and retention of staff at all grades in the laboratory.

We have now, from an independent body, as accurate a picture as we can obtain of the state of the Histopathology service in the UK. , and it is not a reassuring one. The current workforce is not sufficient and, as the workload shows every sign of continuing its year on year increase, the situation can only deteriorate unless there is urgent and significant action. 

K.W.M. SCOTT
Chairman of the Histopathology SAC

Table 4
Important issues affecting Different Grades of Staff

CPA in
ITALY MAY 2000

Following on from the successful CPA trips to Italy in October 1998 and February 1999 a third inspection team went out in May 2000.  On this occasion the executive manager Cherubino Blair was accompanied by Dr Jim Murray (haematology), Dr Mark Hastings (microbiology), Mr John Wood (chemistry) and Dr Tim Wallington (immunology).

 The purpose of the trip was to conduct CPA inspections of the departments in Lecce, Rome, Rieti and Padua.  The CPA team were joined by Italian colleagues for some of the visits.  The outward flight to Southern Italy involved a transit stop at Rome airport where the inspectors sat down briefly and planned their trip over a cold beer.  In common with most air travellers they then realised they were drinking cold beer at 10.30 in the morning.  On arrival in Brindisi they were met by Dr Pignatelli who escorted them to his laboratory.  On the way he informed us that the laboratory was several hundred years old.  Although this sounded like most NHS institutions the CPA team were then shown round a converted royal palace with a magnificent chapel as the temporary CPA office.  It was hard to imagine a more splendid environment in which to work.  Inspection completed the inspectors were whisked off to the airport in the evening for a flight back to Rome.  They were then collected by their hosts in Rome and taken straight to the restaurant for a typical roman meal.  The team stayed in the recently opened accommodation of the University Hospital (once again 

the term hospital accommodation took on a new meaning).  The next morning saw Cheryl Blair accompany John Wood and Dr Mario Plebani to inspect the clinical chemistry department in Rome (University Hospital del Sacro Cuore) Dr Giardina.  Jim Murray and Mark Hastings were joined by Dr Giovanni Bonadonna from Verona for the trip to Rieti.  Meanwhile the Pope arranged an audience with Tim Wallington.  Another fascinating and intensive days inspecting ended with the drive back to Rome and an evening meal by the Trevi fountain.  Any tendency to exhaustion around midnight was dissipated by the magnificent surroundings of Rome as we were driven round the city by our hosts.

Another early morning start for the flight to Venice from where we were driven to Padua.   Our trip here was to conduct a second cycle inspection of Dr Mario Plebani’s lab.

As with the earlier trips the communication difficulties did not prove a major barrier and we were aided by first class interpreters provided by our hosts.  A number of major differences in practice were very apparent.  Consultant medical staff participating and supervising phlebotomy seems not uncommon in Italy as Italian law requires the presence of a medical attendant.  Differences in the approach to health and safety are also very clear and in this respect it is difficult to apply CPA (UK) standards to Italian departments.  Although in the UK we may complain about our national Royal College of Pathologists

and our national Institute of Biomedical Science our lives are made much easier by the provision of these national structures.  In Italy the situation is very different with clear regional differences throughout the country.

 Every CPA inspector knows that every visit is a learning experience.  On these visits we learnt that our Italian colleagues face many of the same problems that we do.  It was enlightening to see such close and integrated working between the medical and the scientific staff, something we rarely see now in UK departments.  We were impressed by the dedication, the enthusiasm and the commitment to quality shown by all the staff we encountered.  The quality of the hospitality we received was simply marvellous.  It was an ambitious exercise to take on so many inspections in departments ranging from one end of