Putting a price on pathology

The pathology laboratory is undergoing fundamental change. The NHS is being asked to make £20bn of efficiency savings annually by 2015, and according to the 2008 Carter review, pathology could contribute £500m a year.

The rationalisation of pathology’s staff and services with the introduction of blood science is one way to help achieve this. There has always been change, of course, with the introduction of new blood tests and new equipment. But Whitehall’s latest initiative involving laboratory staff - mostly biomedical scientists - and their working practices will be fundamental and long-lasting.

Over time, pathology has evolved into up to eight distinct disciplines, and training has reflected this. But the Department of Health’s Modernising Scientific Careers paper recognises three strands that flow from life science. One of these strands, blood science, combines the established disciplines of haematology, blood transfusion, biochemistry and immunology with the new specialism of genetics and molecular science. This change is being driven not simply by the demands of NHS pathology laboratories, but also by advances in technology and practice.

A second government initiative is pathology modernisation. This advises on how pathology service design, particularly managed networks, can help build the capacity required. Now that blood-based work is becoming increasingly automated, and often based on vacutainer blood tubes, there is an efficiency-led move towards merging departments which have common ground. With overlap of techniques and the development of common methods, the pooling of resources is inevitable in driving down costs.

Therfore, how we train blood scientists also needs consideration. Old courses on the separate disciplines must be phased out, new courses developed and delivered, and students enthused and recruited. Consequently, the providers of these courses in higher education must grasp the nettle and change. 

Blood science in a general hospital

Maidstone and Tunbridge Wells Trust is a large acute hospital trust providing a full range of general hospital services to around 500,000 people. It is part of a wider Kent and Medway Pathology Network where some specialist services are shared.

In the search for economies of scale, rationalisation and centralisation, the departments of clinical biochemistry, blood transfusion and haematology have been reconfigured to form a single blood science department.

Further centralisation of direct access work between the trust’s two acute hospitals has seen non-urgent cold work from the community centralised at the Maidstone site. This has been developed with the support of state of the art robotics which make it possible to process a large number of samples. The Tunbridge Wells site retains an acute service that is structured in the same way, on a smaller scale, to support the acute hospital.

The pre-analytical area is staffed by blood science medical laboratory assistants, who are trained to deal with all sample requests whether their final destination is the clinical biochemistry or haematology laboratory. Traditional automated analytical areas of the haematology and chemistry laboratories are supported by these staff during both routine and unsocial hours. The increased flexibility of these members of staff is a huge advantage to the efficiency of the service.

Reducing the skill mix or numbers of staff further will have a negative impact on the ability to offer safe services round the clock

Significant savings have been made by incorporating lean methods into the new blood science department. Staff have found the process exciting and morale is high. Change is not necessarily an issue, as long as there is good communication and consideration of everyone who is affected. Creative processes capitalising on natural changes in the workforce are essential and give a sound, clear way forward for any new structure.

In contrast, progress on integrating the different strands of qualified staff is limited. Some simple cross-training of biomedical scientists can be taken forward. Theoretically, trainee graduates can be trained for their legally required registration with the Health Profession Council within the blood science setting.

However, until Modernising Scientific Careers is further developed it is difficult to know how formal education will progress. The scientists’ professional group – the Institute of Biomedical Science – offers qualifications in either haematology and blood transfusion or in biochemistry, but not both. This is not conducive to the development of a generic blood science department and a multi-subject qualification is an imperative.

Cross-trained BMSs will increase flexibility by working across traditionally separate laboratories. However, the workload is such that optimum numbers of staff are required to provide a safe service, and this cancels out the impact of cross-training. Reducing the skill mix or numbers of staff further will have a negative impact on the ability to offer safe services round the clock. This must be addressed.

Integration of blood transfusion services in relation to pathology modernisation has also been slow. Blood transfusion is harder to merge into the blood science model as, unlike the diagnostic nature of haematology and biochemistry services, blood transfusion is a therapeutic service requiring different skills.

However, the writing is on the wall and new staff structures must be developed. There is no doubt that specialists are required at senior level and we have yet to see how this will develop within the MSC pathway.

A university perspective on blood science

As MSC gets under way, progressive universities are developing undergraduate courses in blood sciences. Higher education BSc (Hons) Healthcare Science (Blood Science) degrees to facilitate practitioner training programmes must demonstrate key principles and meet key criteria to achieve Medical Education England (MEE) accreditation.

But as things stand now, the regulation of blood science graduates - who would be entering a new career pathway as a blood science practitioner – needs to be developed by the Health Professions Council, who at present register only biomedical and clinical scientists.

As university fees soar and graduate return on investment becomes a more pressing consideration, universities need to address the issue of non-regulation and its possible effects on blood science graduates’ future employability. Most universities are therefore not only requiring MEE accreditation, but also seeking HPC approval and IBMS accreditation for blood science degree programmes. This makes graduates eligible for HPC registration, albeit as a biomedical scientist.

The evolution of undergraduate blood science degree courses appears to be taking place via a metamorphosis from a biomedical science degree to a healthcare science degree. This calls for universities to think creatively and innovate to the necessary requirements.

However, in order to provide blood science graduates with eligibility for HPC registration, the curriculum, accreditation and workplace training requirements for both type of degree must be show to be equivalent and relevant. Furthermore, this has to be delivered within the MEE non-flexible placement schedule of 10, 15 and 25 weeks in Years 1, 2 and 3 respectively. This makes it possible to integrate academic and workplace-based learning within what usually becomes an extended academic year.

Recently a tendering process took place for delivery of masters degrees that underpin the Scientist Training Programme. The universities of Manchester and Nottingham were selected for delivery of MSc Clinical Science (Blood Science) degrees. These are accredited as meeting the requirements of MSC for the STP. Just like practitioner training programmes graduates, there is no regulation for STP graduates. As all laboratory staff are required to be registered with the Health Professions Council, there is an ongoing debate regarding the possibility of STP blood science graduates being eligible for HPC registration as clinical scientists. The less demanding graduate-level practitioners training programme should deliver staff with broad based but less complex skills.

The development of blood science PTP and STP programmes provides universities with a welcome opportunity to strengthen existing partnerships with NHS placement providers. This will help develop the laboratory infrastructure that is needed to support new models of workplace training required by tomorrow’s staff.

The way forward

Blood science is coming, and the astute and forward-looking will be ready for it. Naturally, as in any birth, there will be some pain and possibly some blood loss. Undoubtedly many traditionalists and others with entrenched views will resist change, whereas others will view these changes as an opportunity to develop and continue the evolution of pathology.

Indeed, an extension of the acceptance of loss of traditional speciality barriers is the breakdown in professional barriers, which may see the merging of biomedical scientists, biochemists and clinical scientists into one unified group of laboratory scientists.

Dr Andrew Blann is a consultant clinical scientist and senior lecturer at the University of Birmingham Centre for Cardiovascular Sciences. Jane Dalton is blood science service manager Maidstone and Tunbridge Wells Trust. Jan Martin is senior lecturer in biomedical sciences at the University of Wolverhampton

Find out more

Contact Dr Andrew Blann on a.blann@bham.ac.uk

• Modernising Scientific Careers
• Pathology Modernisation
• The Carter Report