Averting a Histopathology Crisis

There is a well-established histopathology workforce crisis in the UK. It’s a critical situation caused by an ever-increasing demand on services without a corresponding rise in appropriately trained staff. Because only 3 percent of diagnostic laboratories currently have enough staff to deliver their reporting workload (1), backlogs and case outsourcing are increasingly commonplace. The shortage can lead to longer turnaround times that leave patients waiting for results, ultimately impacting their treatment plans – and potentially even their outcomes.

Histopathology dissection and reporting has traditionally been conducted by medically qualified practitioners who have completed the recognized national training scheme. But, over the last 15 years, healthcare scientists have begun to take on some of these advanced clinical practice roles in the same way that nurses and other non-medically qualified practitioners have assumed new responsibilities in other specialties. For example, consultant-level practice in cervical cytology is well-established for healthcare scientists – as is histological dissection, although the latter practice is still sporadic within UK laboratories. In some departments, scientists lead almost all dissection; others, in contrast, continue to see dissection delivered only by medically qualified pathologists. Laboratories are increasingly seeking to transform their workforce with a more varied skill mix (2) – and assigning new duties to healthcare scientists has been identified as a way to improve pathology services across the board. Faster turnaround times and lower financial burden (3) release pathologists to focus on reporting and other crucial roles, leaving healthcare scientists to deliver the higher-volume, less specialized work.

Piloting the future

In 2012, a small cohort of healthcare scientists began training in histopathology reporting as part of a collaborative pilot project between the Royal College of Pathologists and the Institute of Biomedical Science (IBMS). Although training was modeled on the existing medical histopathology curriculum, the program took a modular approach and offered only gastrointestinal or gynecological pathology as initial options. These specialties were chosen because they were judged to have the greatest burden of high-volume, low-complexity work. The scientists undertook the training alongside their existing clinical, scientific, and managerial roles within the laboratory and, after they had completed at least one year of training, took a competency exam. If they passed this initial test, the scientists’ training continued for at least another two years before they were permitted to attempt an exam – at an equivalent level to FRCPath part II – in their focus area. Successful candidates then entered the final stage of training, akin to that undertaken by medical pathologists, which developed independent practice at consultant level. This stage lasted around a year and preceded the Certificate of Completion of Training, which then provided a route into formal posts.

By 2017, the first two healthcare scientists had started practicing independently at consultant level alongside medical consultants within specialty histopathology teams. The success of the pilot scheme saw it transformed into a formal training program and, with the addition of dermatopathology as an option, more and more healthcare scientists began training. Today, there are many fully qualified and substantive Consultant Healthcare Scientists in England, all of whom dissect and report a wide range of specimens alongside medical pathologists as part of the clinical histopathology workforce. Although their roles are, in many ways, similar to those of their consultant medical pathologist colleagues, these scientists practice within specialist areas and do not perform post-mortem examinations, interpret frozen sections, or report diagnostic cytology specimens.

Bolstering the workforce

The benefits of increasing the pool of staff able to provide a clinical histopathology service are clear. Most importantly, it enables continued provision of a safe, effective, and high-quality histopathology service to the patient. It also has the potential to maintain or decrease turnaround times in the face of increasing demand, which can no longer be satisfied purely by training more medical pathologists. Medics are in short supply globally – and the situation is only predicted to worsen. Changing the skill mix is of huge benefit to departments and is in line with UK policies, such as the National Health Service Long Term Plan (2) and Pathology Networking in England: State of the Nation (3), which recommend new ways of working to meet demand, improve services, and make financial savings.

For healthcare scientists, there is also the opportunity to develop another full clinical role in the histopathology laboratory. Historically, the only senior career development available was management – and, for many scientists seeking work that made full use of their scientific expertise and extensive education and training, this was not the most desirable pathway. When those working at junior levels can visualize a clear clinical career pathway to consultant-level practice for the first time, team morale hits a record high. And so the recruitment and retention of healthcare scientists is set to improve as a result.

Expanding roles and opportunities for healthcare scientists also widens the experience of the team providing the clinical service. Medics may excel via their clinical knowledge, whereas scientists can bring strong laboratory and management expertise to the table. Individuals can educate and advise each other according to their strengths, further enriching the dynamic and expertise of the team.

Healthcare scientists who undertake training in reporting experience a fundamental change in their roles and responsibilities, with increased clinical responsibility for cases and the ability to provide leadership for histopathology within the multidisciplinary team (MDT). They increasingly represent histopathology at local and regional MDT meetings – and this is beneficial because it helps to develop relationships between clinical and pathology teams, gives greater job satisfaction for scientists, and releases time for medical pathologists to focus on more complex work.

New opportunities

There are many benefits for the department and organization when reviewing the skill mix of staff providing the clinical histopathology service. Fundamentally, healthcare scientists cost less than their medically qualified counterparts, whether working at Advanced Clinical Practice or Consultant level. In the UK, histopathology dissection and reporting training is overseen by the College and IBMS and is of a high standard, with structured training and assessments set at appropriate levels for the qualifications being undertaken. The use of healthcare scientists in reporting provides a way for histopathology departments to manage increasing workloads while maintaining or even decreasing turnaround times. If the workload can be managed successfully, cases will no longer require outsourcing – an expensive option that can lead to reporting delays. As pathology networks continue to develop in the UK, the presence of reporting healthcare scientists can even provide flexibility by reporting cases for any departments in the network with a backlog, keeping the task within the geographical network and reducing costs.

Since the publication of the Royal College of Pathologists’ workforce census in 2018 (1), there has been greater interest in addressing issues around the delivery of histopathology services. A national working party has been established to scrutinize wider training for healthcare scientists from the start of their career up to consultant-level practice. The working party will review all existing qualifications and pathways, including the histopathology curricula established in 2012 by the National School of Healthcare Science as part of the Scientist Training Program.

Until now, histopathology reporting training for healthcare scientists has not been nationally funded, leaving many cohorts of interested and engaged staff to complete the training alongside their existing laboratory duties – not the optimal way for any new qualification to be successful. As a result, there are still only small numbers of healthcare scientists in training; even fewer have completed the training and gained the ability to work at Consultant level. Recently, for the first time, Health Education England offered the opportunity for two healthcare scientists within each English pathology network to embark on funded dissection or reporting training within histopathology. And though it is a positive step forward to meet existing and future demand for histopathology services, it is important that more extensive, fully funded clinical training opportunities are available for healthcare scientists across the UK. Only then will there be sustainability within the workforce, safe and timely delivery of the workload across the entire UK, and improved pathways and outcomes for our patients.