NHS0004

Written evidence submitted by Royal College of Pathologists

The College welcomes the opportunity to contribute to this consultation on how the pandemic has led to more people waiting for treatment and waiting for longer.

Following disruption caused by COVID-19, the Royal College of Pathologists (RCPath) has serious concerns over preparations to deal with the backlog of non COVID-19 related illness, especially cancer care, and the related surge of demand for pathology services, particularly for cancer diagnosis and treatment.

More investment and resources are needed across pathology services if we are to alleviate workforce pressure and meet increased demand which has been compounded by the effect of the pandemic. To manage the backlog and the expected rise in referrals it will be vital to have the right number of health staff in the right places.

We welcome the announcement from government of £5.9bn to tackle the backlog of people waiting for crucial diagnostic tests. This funding will be a significant boost for the NHS in England struggling to catch up with the delivery of services that has been exacerbated by the pandemic.

It is absolutely crucial however, that pathology services are allocated a portion of the new funding to help further workforce expansion, investment in IT and digital solutions. Without it, it will not be possible to tackle the backlog irrespective of how much is invested in other types of diagnostic centres, such as imaging. Increasing the latter, whilst necessary, will ultimately lead to significant increase in referrals to the already stretched pathology services for additional investigative tests, necessary for patient management.

Cancer services

Cancer will affect half of us all at some time in our lives. It is a devastating and terrible disease, but modern treatments coupled with early detection and monitoring offer us hope that we can beat it. Pathology is central to this early diagnosis and ongoing monitoring, as well as being vital for cancer prevention and screening, but pathology is facing a workforce crisis which must be addressed if we are to win the fight against cancer.

Pathology is key to prevention, screening, and early detection of cancer. It saves lives and it saves money. If we are to beat cancer, we must invest in pathology.

From current January cancer waiting times, there are 37,000 fewer people who have

commenced a first treatment for cancer from the start of the pandemic, compared to 2019

data. To get through this backlog, Macmillan Cancer Support project that this will take up to 15 months to address only if the system operates consistently at 110%.

NHS England and Improvement have announced (13 May) a £160 million initiative to fund `accelerator sites’  to tackle waiting lists. The College welcomes this extra funding but it must be targeted effectively.

Pathology workforce challenges

Pathology workforce shortages highlighted ‘pre-COVID’ remain. Although recruitment into histopathology has increased, there remains a 25% shortfall in staff able to report results, with some regions having even higher shortages.

Workforce pressures across the four UK nations are being compounded by the pandemic. There have been reductions in patients seeking help for their symptoms, including a significant decline in referrals from primary care leading to substantial delays in diagnosis and a significant backlog of cases.  

Building the cancer workforce, not just in histopathology, but also in haematology and other areas of pathology, has to be a key investment priority for government. Without this investment there will be no capacity for pathology to deal with any increase in workload associated with efforts to overcome this backlog.

The expertise of haematologists is central to patient management and care; for example, by advising GPs and doctors in other specialties on the best tests to perform and interpreting and communicating the significance of the test results.

Clinical biochemists play a key role in diagnosing patients with a wide variety of illnesses – from high cholesterol to rare genetic diseases and bowel cancer.

Pathologists are key to reducing the backlog, especially in cancer diagnosis. More investment is needed across pathology services to alleviate workforce pressure, tackle the backlog and meet increased demand. There needs to be more training places, better IT for day-to-day work and capital investment to implement digital pathology more widely, so staff can work more efficiently and flexibly.

A report from Cancer Research UK in 2018 Estimating the cost of growing the NHS cancer workforce in England by 2029 shows that for the histopathology workforce, without targeted action and investment, the number of histopathologists is set to reduce from the existing shortfall by an additional 2% by 2029. To have a chance of meeting 45 per cent growth ambition, the report analysis estimates the profession would require 580 more staff at a potential maximum cost to HEE of £118 million. It is estimated that this figure could now have increased to £150 million over the next ten years.

There are shortages across most pathology specialties with vacancies for 290 consultant pathologists in the UK. Pathology is also facing a retirement bulge, with, for example, 40% of virology medical consultants expected to retire in the next five years.

It is important to remember that the staff who are going to be dealing with the backlog of cases are also the staff who are exhausted after over a year of dealing with COVID-19. That’s not just pathology staff; it’s nurses, doctors, porters, cleaners, canteen staff – everybody. We need to workout the most efficient way to overcome the backlog without overwhelming people.

Training and recruitment

As well as more investment to recruit and retain more pathology staff, the College would also like to see more training places, better IT for day-to-day work and capital investment to implement digital pathology more widely, so staff can work more efficiently and flexibly.

• NHS England and Improvement have announced (13 May) a £160 million initiative to fund `accelerator sites’  to tackle waiting lists. The College welcomes this extra funding but it must be targeted effectively.

IT and infrastructure

Rapid IT infrastructure transformation, hardware to replace the nearly 30% of Laboratory Information Management Systems (LIMS) that are virtually obsolete, connectivity to link systems, and, for histopathology and haematology, digital imaging will be key to making services more stable and efficient. There have been some good examples of single LIMS roll outs in Wales that have made patients’ test results more accessible, and able to be reported across the country. Similarly, some regions have good systems that link many hospitals and indeed some acute and primary care systems. These models need to be widely adopted. LIMS are vital to effectively manage samples, and associated data and automate workflows.

Digital pathology

One area the College is keen to develop as a profession is to harness technology to achieve the best possible outcomes for the workforce and patients. Digital pathology has the potential to improve patient care and support the pathology workforce by making the diagnosis and monitoring of disease much more efficient. However, in order to transform pathology services and support patient care and safety, we need investment in IT infrastructure, staffing and training.

Digital pathology also facilitates remote working in several ways which are useful during the pandemic and going forward will help with staffing issues - home reporting, avoiding the need to be physically in the same space as a colleague giving a second opinion, and facilitating trainee pathologists in learning.

Any investment should also build on the initial investment of the NHS to develop centres of excellence in digital pathology nationally. These centres can help with any further expansion of the technology across the NHS, by sharing knowledge and standards. It is the view of the College that digital pathology should be centrally funded and rolled out nationally in a similar way to digital radiology.

Genomics in medicine

Genomic medicine provides an incredible opportunity for faster, accurate diagnosis and tailored treatment for people with cancer, and with inherited diseases. However, it is essential that there is equity of access to tests and the associated treatment(s).

Developments in genomics will require significant investment – staff need to be equipped with knowledge, and laboratories with necessary equipment. Pathologists are at the heart of these developments and hence must be involved throughout the programme, because of their vast experience in tissue handling, processing and reporting.

The College is concerned that there is no planned resource provision for the significantly increased workload that the Genomic Medicine Service will create for pathology, which will grow over time. Without this being addressed there will be issues in providing the quality and level of service desired.

Community Diagnostic Hubs

We welcome the move to introduce easier access to diagnostic services centred around patients. Quicker, easier access through a ‘one stop shop’ will lead to earlier diagnoses which leads to better outcomes for patients and can save lives. 

These new diagnostic hubs need to be introduced with sufficient resources, in terms of staffing, IT provision and connectivity with other systems (such as GP practices).

Pandemic pressures in the devolved nations

Wales

• The COVID-19 crisis has highlighted pre-existing problems facing rural areas in Wales. Our members tell us that this means patients wait longer for a diagnosis in these areas. It can be hard to recruit and retain doctors and nurses who are willing to work in smaller hospitals, which means health boards rely more heavily on agency staff to fill gaps in rotas. This has a knock-on effect on patient care, with patients travelling long distances.

Scotland

• The pandemic has underlined the importance of having well-connected and collaborative networks delivering laboratory services across Scotland, underpinned by a distributed services model. The laboratory diagnostic networks were primed to react when the pandemic hit and rapidly developed a potent, nationally coordinated service for COVID-19 testing and surveillance studies.

• Data collection by the existing National Demand Optimisation Group (NDOG) for laboratory services was able to switch its attention towards monitoring the impact of the pandemic on non-COVID-19 testing. These observations can give metrics for healthcare pathways such as cancer diagnosis and chronic disease monitoring. For example, huge reductions in diabetes diagnosis and monitoring can be identified for each health board area and targeted appropriately.

Northern Ireland

• Workforce pressures in Northern Ireland are being compounded by the pandemic. The College recommends more investment in laboratory staff in Northern Ireland, who are under-resourced and under-valued, to enable more effective diagnosis and monitoring. Too much funding is wasted by inappropriate testing or send-away testing due to geographic restraints.

About the Royal College of Pathologists

The Royal College of Pathologists is a professional membership organisation with more than 11,000 fellows, affiliates and trainees, of which 23% are based outside of the UK. We are committed to setting and maintaining professional standards and promoting excellence in the teaching and practice of pathology, for the benefit of patients.

Our members include medically and veterinary qualified pathologists and clinical scientists in
17 different specialties, including cellular pathology, haematology, clinical biochemistry,
medical microbiology and veterinary pathology.

The College works with pathologists at every stage of their career. We set curricula, organise training and run exams, publish clinical guidelines and best practice recommendations and
provide continuing professional development. We engage

a wide range of stakeholders to improve awareness and understanding of pathology and the
vital role it plays in everybody’s healthcare. Working with members, we run programmes to
inspire the next generation to study science and join the profession.

November 2021

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