In his book Good Strategy, Bad Strategy, the Difference and Why it Matters , the strategy ‘guru’ Richard Rumelt pointed that “the core strategy work is always the same: discovering critical factors in a situation and designing a way of coordinating and focusing actions to deal with those factors”. Most pathology industry insiders will agree that the critical strategic challenge for cellular pathology in the UK is a growing chasm between demand and capacity, facing a crisis of divergent demand and supply. We would, however, add here a caveat, that this is true for the current cellular pathology service model. We believe that there are ways to address this challenge, but it will require the change of the current service model for the discipline. There is another key message: the mentioned change of the service model is not the intervention primarily focused on the (short-term) financial outcomes. It is not about saving another 5% or so per year within the cellular pathology cost centre. We advocate creating future-proof service and averting pending implosion which would have significant adverse clinical and financial effects on the system as the whole, and especially on co-dependent cancer pathways. We do the not doubt that apart to better clinical outcomes, clinically and operationally effective and sustainable cellular pathology will also come with the positive net financial effects for the entire healthcare ecosystem. In this article, we will look into the fracture lines within the current cellular pathology service model, and in the next one, we will share with the audience our thoughts about some possible solutions, contextually within our Pathology 3.0 paradigm.
The demand for cellular pathology services is growing. This growth is manifested as the increase in the absolute number of cases and more complex workload. The former is mainly reflecting the general increase in demand on acute hospital services due to incidence and changes in the management of conditions associated with the ageing population. The latter is due to a number of factors. The evolution of good clinical practices and compliance with new patient management guidelines consumes more laboratory, reporting and postanalytical time and specialist expertise because the knowledge and skill requirements for each subspecialty domain have expanded. Cellular pathologists assess and report cases in more detail. With the expansion and scaling-up of molecular pathology, genomics and precision medicine, the proportion of cases that require iterative and time-demanding incorporation of multiple facets of diagnostic information into integrated reports, has risen and will continue to grow. The time needed for preparation for and presentation at cancer multidisciplinary team meetings (MDTM), and keeping up to date is also directly proportional to the complexity of workload. There is also a sporadic demand to introduce new or split the existing cancer MDTMs and other clinicopathological meetings that impact on already stretched cellular pathology resources.
The growing demand similarly affects the workload of the ‘wet’ laboratory operations. In addition to the increase in the absolute number of cases, individual cases now frequently comprise more samples than before. This generates more paraffin blocks, and more slides need to be cut and stained. More sophisticated diagnostic and precision medicine algorithms imply more immunohistochemical or molecular tests per case and more complex preanalytical and tissue handling routines. For example, we expect routine handling of fresh tissue, extraction of nucleic acids and elaborate logistics arrangements for the transport of samples to centralised genomics laboratories to grow. There is a similar effect on administrative and clerical support. The new layers of non-clinical workload required for compliance with accreditation or targets, participation in the national and local service improvement and transformation impacts all grades of staff.
Similarly, the insufficient capacity is the synergism of circumstances and legacies that have not been adequately addressed for decades. As pointed in the Royal College of Pathologist Census Report, approximately a quarter of the established Histopathology consultant posts is vacant, the age profile of cellular pathologists is bending to the right, and workplace stress combined with pension changes is pushing more consultants to retire in their mid-50s. The training posts are unfilled. As the short-term ‘sticking plaster’, NHS spends nearly £30M annually on cellular pathology locums or outsourcing. Around £50M is paid locally to the consultants on the top of their existing contracts to undertake additional work. As per outsourcing, our unverified observation indicates that the cumulative capacity of the outsourcing sector, which primarily relies on NHS consultants offering extra evening or weekend time, is reaching saturation, especially when it comes to complex, time-consuming and high-risk cases.
Challenges with recruitment and retention and unfavourable demographic profile are equally affecting the scientific workforce. The resources, HR policies and practices are not geared to facilitate succession, skill-building and mentoring proactively and effectively. The recruitment is cumbersome, with a long time to fill even if the suitable candidates are available. Burnout of the workforce at all levels is threatening to plateau or diminish productivity. Workforce development is generally lagging at all levels, and the proverbial ‘vertical skill-shift’ has not been equally successful across the patch. For example, Advanced Biomedical Scientist-Practitioner (ABMSP)-led specimen dissection may have been conceptually endorsed, but has not been rolled-out consistently between, the organisations and often, between specialties within the same departments. The cumulative capacity of the existing consultant workforce to supervise ABMSP training and development of new scientific roles is limited.
The niche, low-volume areas of cellular pathology (e.g. renal pathology, endocrine pathology, cervical cytology or medical liver pathology) or those that may be perceived as stressful or high-risk (e.g. urological pathology) may have additional difficulties to recruit. Interest in autopsy pathology has declined. The academic pathology, as currently structured, is not a realistic choice for the majority of the cellular pathologists. In our opinion, this has significant but not necessarily well-understood long-term consequences, because of their intangible nature. We believe that cellular pathology significantly benefited in the past when generations of pathologists have had the opportunity to be more intimately exposed to the academic environment and methodology early in their careers, even if their further career path subsequently diverged. It has also been recognised that "… developing the genetic competence of both new and existing NHS staff is a huge undertaking …” and, with the increasing volume and significance of integrated reporting by cellular pathologists, this can soon create additional bottlenecks. In addition to genomics, other -omics are going to add to the cornucopia of methods and information that mostly lies outside of the comfort zone of the current cohort of cellular pathologists.
There also seems to be geographically convenient and popular, as well as inconvenient and less-favourite places to live and work, reflecting a range of career choice and personal circumstances in the cellular pathology workforce, leaving services outside of the major metropolitan areas along the ‘vertical axis’ of the country disadvantaged. All these workforce issues have not been confined to cellular pathology only, and they also exist overseas. The anatomic and clinical pathology is the only specialty in the USA with a decrease in the workforce since 2010. The situation with cellular pathology is even bleaker in the developing world.
The additional key, system factor diminishing the capacity of cellular pathology is the current, fragmented, service model. Cellular pathology, with its two-tier, ‘District General Hospitals’ (DGH) and ‘Cancer Centre Teaching Hospital’ organisational model and two-tier ‘generalist’ and ‘specialist’ consultant workforce model is counterintuitive to the very notion of ‘getting-it-right-first-time’ approach. It causes duplication of work, operational, HR and financial inefficiencies, unwarranted variations, avoidable delays and inequity of access to cellular pathology service.
Due to the nature of the exposure to the available case mix, size of the establishment, and the current inconveniences of meaningfully sharing cases across the larger geography, departments within District General Hospitals and some smaller teaching hospitals have continued with the the ‘generalist’ or, at best, ‘a partial generalist’ model. A ‘generalist’ in principle means that a consultant reports most, if not all, types of cases going through their departments. The larger units, typically large teaching hospitals associated with the regional cancer centres have developed full or almost full specialisation. This means that cellular pathologists practising in these departments report one or a few areas of pathology, hence the respective terms “monospecialist” or “oligospecialists”. Having narrowed the scope of practice, and having more comprehensive exposure due to the centralisation of clinical services in their centres, specialists can develop and maintain in-depth expertise in the chosen areas of interest. Also, being part of the larger histopathology department facilitates the exchange of knowledge and skills, through easy access to consultation with other colleagues from their own or other specialties.
In each region, a very significant proportion of cancer cases is initially reported by generalists in District General Hospitals. Most of these cases, as prescribed by the current sets of national guidelines, are then referred for the specialist review and MDTM discussion to the regional teaching hospital cancer centres with specialised clinical and cellular pathology services. This partial duplication of activity consumes significant resources. It is difficult for us to put its precise financial impact at this stage, but assuming that approximately 10% of cases are reported twice as the consequence of this fundamentally inefficient process is probably not far off the mark. Further inefficiencies are also incurred by ad-hoc, legacy-laden operationalisation of MDTMs which contributes to the unnecessarily wasteful postanalytical phase of cellular pathology. For example, a large number of jiffy-bags with slides or blocks travel between DGH and cancer centres, with the labour intensive and expensive logistics and handling, additional tests requested by the specialists to further refine diagnosis introduce avoidable delays etc. We hope that the pending initiative for implementing Cancer Taskforce recommendation38 and streamline cancer multidisciplinary team meetings will contribute to improving operational effectiveness.
Last but not least, cellular pathology has been slow in capitalising on opportunities to improve operations by endorsing information technology. Some of these are the consequence of slow developments and implementations of cellular pathology-friendly Laboratory Information Management Systems (LIMS). Most LIMS have primarily been designed for high volume pathology disciplines (e.g. blood sciences) and developing cellular pathology modules or addressing idiosyncrasies of the discipline (e.g. templates, automated cancer registry reporting …) have never been the top priority, especially when upgrading the old LIMS products, still in use in many departments. Since the exploitation cycle of LIMS is very long, replacement expensive, time-consuming and resource-hungry, in most regions there are no unified LIMS across the organisational boundaries and, at best, there is limited interconnectivity between organisations. For various local reasons, many cellular pathology services still lag behind blood sciences or microbiology in relation to electronic requesting, tracking etc. Also, endorsement of other IT efficiency enablers, such as voice recognition, to compensate for ‘rightsizing’ of the administrative support to consultants, has not been universally successful.
How did cellular pathology end up in this situation? Dissecting the past would probably end as a pyrrhic argument. The bottom line is that we have to come up with a solution which will positively shape the future of the discipline for quality and sustainability. This solution will require much more than introducing ‘new technology’, process improvement and silo optimisation. A Pathology 2.0 solution - the old service model ’on steroids’- will not do the trick. Some early attempts to introduce consolidation in the old manner backfired as the spreadsheet-anticipated financial gains from centralising proved to be a long shot.
Nevertheless, we are optimistic about the forthcoming journey because three significant factors can work in synergy and help create momentum for the transformation. First, the current NHS strategy aims to address the fragmentation of health services. As Simon Stevens recently said, this is about “putting an end to entrenched, siloed working”. Pathology is already a part of existing integration initiatives, such as Sustainability and Transformation Partnerships and Integrated Care Systems, Pathology Networks, Genomic Laboratory Services, the rollout of primary HPV testing or Cancer Strategy. Second, there is a technological game-changer; whole slide imaging technology that underpins digital pathology transformation has become sufficiently mature and fit for purpose, and more affordable. Third, assuming that the integration and digital pathology are fully endorsed and their implementation going forward, there is a number of transformative workforce development and process re-engineering interventions that can change service model to increase the capacity, reduce operational waste in the whole system and cut down transactional costs. We will discuss them in our next article.
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