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The Royal College of Pathologists

NHS clinical biochemistry


‘A profession under siege’

A report on consultant staffing in NHS clinical biochemistry


from the Task Force established by the
Association of Clinical Biochemists (ACB) and
The Royal College of Pathologists (RCPath)

May 2002
Association of Clinical Biochemists The Royal College of Pathologists
130–132 Tooley Street 2 Carlton House Terrace
London London
SE1 2TU SW1Y 5AF
Registered charity no. 261035

www.acb.org.uk www.rcpath.org

© 2002 The Royal College of Pathologists

Further copies of this publication can be obtained from the ACB and College websites
NHS clinical biochemistry
‘A profession under siege’

CONTENTS
Foreword.............................................................................................................................................. 1

1 Executive summary and recommendations ................................................................................. 2


1.1 Introduction....................................................................................................................... 2
1.2 Executive summary............................................................................................................ 2
1.3 Recommendations ............................................................................................................. 5

2 Introduction ................................................................................................................................ 7
2.1 Background to study.......................................................................................................... 7
2.2 Remit of Task Force.......................................................................................................... 7
2.3 Method of working ........................................................................................................... 7
2.3.1 Review of publications
2.3.2 Analysis of membership databases
2.3.3 Benchmarking
2.3.4 Open workshop
2.3.5 Questionnaire to consultants
2.3.6 Questionnaire to chief executives
2.4 Response rate from consultant questionnaire.................................................................... 8
2.4.1 Return rate
2.4.2 Demographics of responding departments
2.4.3 Demographics of responding consultants
2.5 Response rate from chief executive questionnaire............................................................. 9
2.5.1 Return rate
2.5.2 Analysis of respondents

3 Workload in clinical biochemistry ............................................................................................ 10


3.1 Departmental workload................................................................................................... 10
3.1.1 Total workload
3.1.2 Out of hours workload
3.1.3 GP workload
3.1.4 Repertoire
3.2 Consultant workload....................................................................................................... 10
3.2.1 Hours worked
3.2.2 Out of hours
3.2.3 Typical working week
3.2.4 Origin of clinical work
3.2.5 Origin of non-clinical work
3.2.6 Secretarial support
4 Staffing in clinical biochemistry ............................................................................................ 14
4.1 Total staffing ................................................................................................................... 14
4.1.1 Medical staffing
4.1.2 Clinical scientist staffing
4.1.3 Biomedical scientist staffing
4.1.4 Other staff
4.2 Consultant staffing .......................................................................................................... 14
4.2.1 Total consultant staffing
4.2.2 Medical consultant staffing
4.2.3 Clinical scientist consultant staffing
4.2.4 Consultant staffing and demographics
4.3 Audit of minimum senior staffing model......................................................................... 16

5 Pressures in clinical biochemistry.............................................................................................. 18


5.1 Clinical governance pressures.......................................................................................... 18
5.1.1 Laboratory accreditation
5.1.2 Turnaround times
5.1.3 External quality assurance
5.1.4 Blunders
5.1.5 Meeting clinical governance targets
5.2 Laboratory pressures....................................................................................................... 21
5.2.1 Workload and staffing
5.2.2 Scientific and technical workforce
5.2.3 Clinical demand
5.2.4 National service frameworks
5.3 Consultant pressures........................................................................................................ 23
5.3.1 Stress assessment
5.3.2 Absence cover
5.3.3 Research and development and scientific publications
5.3.4 Planned age of retirement
5.3.5 Workforce planning
5.3.6 Consultant staffing assessment

6 Changing practice in clinical biochemistry................................................................................ 28


6.1 Introduction..................................................................................................................... 28
6.2 Changing laboratory practice.......................................................................................... 28
6.2.1 Pre-analytical and analytical functions
6.2.2 Post-analytical practices
6.3 Changing consultant practice .......................................................................................... 29
6.3.1 Multi-site working
6.3.2 Changing consultant functions
6.3.3 Perceived need for additional consultant functions ........................................... 30
6.3.4 Metabolic medicine
7 Action plan for clinical biochemistry........................................................................................ 33
7.1 Priority areas for action................................................................................................... 33
7.2 Consultant staffing .......................................................................................................... 33
7.2.1 Medical consultants
7.2.2 Consultant clinical scientists
7.3 Model to predict the number of consultants in clinical biochemistry.............................. 34
7.3.1 Assessing the need for and basis of the model
7.3.2 A model to predict the number of consultants in clinical biochemistry
7.3.3 Validation of the model
7.3.4 Implementation of the consultant staffing model
7.4 Non-consultant staffing................................................................................................... 38
7.4.1 Trainee medical and clinical scientist staff
7.4.2 Grade B clinical scientists
7.4.3 Biomedical scientists
7.4.4 Medical laboratory assistants and administrative and clerical staff
7.5 Publicity and promotion of the Task Force report .......................................................... 40
7.5.1 Consultation document
7.5.2 Final report
7.5.3 Executive summary and recommendations
7.5.4 Promotion of the findings of the Task Force
7.6 Review of progress with the Task Force recommendations............................................. 41

8 Feedback from senior Trust management................................................................................. 42


8.1 Introduction..................................................................................................................... 42
8.2 Workload in clinical biochemistry................................................................................... 42
8.3 Staffing in clinical biochemistry....................................................................................... 42
8.4 Pressures in clinical biochemistry .................................................................................... 43
8.5 Changing practice in clinical biochemistry...................................................................... 45
8.6 Summary of feedback from senior Trust management.................................................... 47

9 References................................................................................................................................. 48

10 Acknowledgements ................................................................................................................... 50

11 Appendices................................................................................................................................ 51
A1 Membership of the joint ACB/RCPath Task Force.......................................................... 51
A2 Consultant questionnaire................................................................................................. 52
A3 Freehand comments on consultant questionnaire............................................................ 63
A3.1 Part 1– departmental comments........................................................................ 63
A3.2 Part 2 – consultant comments............................................................................ 65
A4 Chief executive questionnaire.......................................................................................... 70
A5 Freehand comments on chief executive questionnaire ..................................................... 74
FOREWORD

Dear Reader,

This report contains the results of a comprehensive study of consultant staffing in NHS clinical
biochemistry, which was commissioned jointly by the Association of Clinical Biochemists (ACB) and
the Royal College of Pathologists (RCPath). The main findings of the report are of a large increase in
both the quantity and complexity of workload over the past five years, with no increase in consultant
staffing. NHS clinical biochemistry truly is ‘a profession under siege’.

The ACB and RCPath recognise that 2002 is a time of great change in health care, and especially in
laboratory medicine. Although evidence of the impact of this change is only now beginning to
accumulate, the recommendations in the report have been designed to be capable of implementation in
this changed environment, enabling the new NHS to maintain modern, responsive and high-quality
clinical biochemistry services which are matched to the needs of the patient.

At national level, the introduction of national service frameworks and managed clinical networks need
to be accommodated. The NHS Plan challenges us to look closely at the roles of medical practitioners
and Making the Change offers the prospect of an integrated team of healthcare scientists, many of
whom work in clinical biochemistry laboratories.

At NHS Trust level, the introduction of the new strategic health authorities in England calls for
flexible but comprehensive service provision and staffing for populations of around 1.5 million. As
part of this reconfiguration, there is a substantial programme of pathology modernisation which
clinical biochemists are helping to lead. A properly staffed and consultant-led service is essential to
deliver the improvements envisaged by the modernisation programme.

Within clinical biochemistry itself, the pattern of requesting is changing and there is greater emphasis
on quality standards necessary to ensure proper clinical governance, including interpretation and
clinical guidelines. The new sub-specialty of metabolic medicine will also have a major impact on the
role of medical consultants in clinical biochemistry.

The ACB and RCPath are keen to work with the four Departments of Health, Strategic Health
Authorities and their Workforce Development Confederations, NHS Trusts (including Primary Care
Trusts) and other professional bodies to implement the recommendations in the report, in the firm
belief that these will deliver the clinical biochemistry services that the NHS and the patient will require
in the years ahead. We hope that you find the report informative and useful.

Yours sincerely,

Professor John S Lilleyman Professor Alan Shenkin


President, RCPath President, ACB

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1 EXECUTIVE SUMMARY AND RECOMMENDATIONS

1.1 Introduction

This report was prepared by a Task Force established jointly by the Association of Clinical
Biochemists (ACB) and the Royal College of Pathologists (RCPath), in response to the
concerns of their members about the growing pressures on consultants in clinical
biochemistry and their impact on quality, risk management and the ability to meet clinical
governance targets for the patient, the service and the profession. The Task Force was
established in February 2001 with the following remit: “to produce an evidence based report
which recommends the optimal number of consultant level staff currently required for NHS
clinical biochemistry departments in the UK, together with a model which may be used to
predict future consultant staffing requirements.”

The Task Force consulted widely in its work. An essential part of the investigation was the
preparation of a detailed questionnaire, which was distributed to every consultant in an NHS
clinical biochemistry department.

A second questionnaire was distributed to every NHS Trust Chief Executive, in order to
provide initial information and seek the views of senior NHS managers about the current
state of clinical biochemistry.

A summary of the main findings of the Task Force is given in Section 1.2. The specific
recommendations arising out of the work of the Task Force are given in Section 1.3.

The full report, together with all the evidence to underpin the findings and justify the
recommendations, is available from the ACB and RCPath, most conveniently from their
websites: www.acb.org.uk and www.rcpath.org.

1.2 Executive summary

1.2.1 The workload of clinical biochemistry departments increased by 56% (requests) and 63%
(tests) over the period 1995–2001. On average, clinical biochemistry departments processed
331 000 requests and 1 839 000 tests in the year to 31 March 2001. Not only did the total
workload rise, but the percentage of that workload delivered outside normal working hours
also rose from 8.7% to 13.4% over the same period. General practitioners now provide the
greatest contribution to the workload, with this share rising from 30.9% in 1995 to 36.7%
in 2001. The repertoire also increased between 1995 and 2001, with an average of ten
additional analytes available within normal working hours and 6.5 analytes out of hours.
Although there are important differences between district general hospitals and teaching
hospitals, the same major trends are evident.

1.2.2 The number of staff working in clinical biochemistry departments has declined during the
period 1995–2001. The number of consultant staff has remained static, whilst the number of
grade B clinical scientists and specialist registrars has each fallen by approximately 10%. The
number of biomedical scientists in post has also declined, in part due to the difficulties of
recruitment and retention.

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1.2.3 The net effect of a rising workload and falling staff is increased pressure and stress within
clinical biochemistry departments, with consultants having to absorb the management
consequences of this additional burden. In 1995, 82% of departments considered their total
staffing to be adequate or better, but by 2001, 89% of departments were struggling to cope.
Unless a solution is found, 98% of departments will either be struggling or unable to cope by
2005.

1.2.4 Against a general background of improving quality standards, early signs of problems may be
detected in areas such as laboratory accreditation, performance in external quality assessment
schemes, turnaround time and blunder rates. Consultants have significantly less confidence in
meeting clinical governance targets than they did in 1995.

1.2.5 All the evidence indicates that the workload of clinical biochemistry laboratories will
continue to rise in line with the growing number of general practitioners and hospital
consultants and the extended roles of other healthcare professionals. Moreover, national
service frameworks for diabetes mellitus, coronary heart disease and cancer are expected to
increase workload by a further 10%.

1.2.6 Many Trusts and departments have introduced a range of measures to try to cope with the
rising workload. Automation and information technology have had some impact, especially
on the pre-analytical and analytical components of the work but, in general, they have failed
to keep pace with the rising workload. In the post-analytical phase of operation, departments
have been forced to introduce steps to manage the interpretation and reporting functions,
often against their better judgement.

1.2.7 Clinical biochemistry is a consultant-led service. Those consultants work long hours. On
average, NHS medical consultants work 47.3 hours each week (excluding on-call cover),
with more than 35% of them regularly working in excess of the 48-hour maximum working
week as defined by the European Working Time Directive. Consultant clinical scientists and
university medical consultants work similar hours. In addition, NHS medical consultants are
on-call for an average of 52 hours each week, with the figures for the other consultant grades
being only slightly less demanding. In total, more than 115 UK consultants in clinical
biochemistry provide a 24-hour, seven-day, single-handed advisory service in addition to
their long working week.

1.2.8 On average, a consultant in clinical biochemistry is now responsible for reporting 630
requests and 3500 test results on each normal working day. There are real concerns,
supported by the Clinical Benchmarking Company, that this workload is too high to
guarantee proper clinical guidance to users of the service – and especially to general
practitioners.

1.2.9 The recent accreditation of the sub-specialty of metabolic medicine will improve the quality
of clinical care in this developing field of medicine. The development is generally welcome
within the profession, but it will generate new work, significantly reduce the amount of time
that accredited medical consultants in clinical biochemistry are able to give to laboratory
related functions and thereby increase pressure on them and other senior staff.

1.2.10 Whilst the clinical demands of the consultant in clinical biochemistry have increased in line
with the workload, there has been an even greater increase in the amount of time spent on
quality issues (laboratory accreditation, audit, risk management, clinical governance, etc.)
and on management within the department and Trust. Research and development has

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suffered badly and is now almost non-existent in many NHS non-teaching hospital
departments.

1.2.11 Evidence from job plans indicates that the roles of medical consultants and consultant clinical
scientists are complementary, with overlapping functions in areas such as reporting, quality
matters and management. Medical consultants will normally undertake some aspects of
direct clinical care and give advice on patient management; this role is likely to grow as the
sub-specialty of metabolic medicine evolves. Consultant clinical scientists generally are
involved in more laboratory-based functions, including research and development. The
decision on whether to appoint a medical consultant or a consultant clinical scientist should
be a local one, based on the detailed duties to be undertaken and the existing staff in post.

1.2.12 Consultants in clinical biochemistry have seen their stress at work increase appreciably
during the past six years, with 36% now admitting to severe stress during the normal
working day.

1.2.13 An additional 78 medical consultants and 70 consultant clinical scientists are required in
clinical biochemistry departments. Whilst these posts are required to meet the deficit
identified in 2001, it is recognised that there will have to be a significant lag phase before
sufficient staff can be recruited and trained. Workforce planning is required to recruit the
necessary additional specialist registrars over a suggested five to six-year period. The problem
for clinical scientists is considerably greater because current trainee recruitment is only
sufficient to meet 50% of the existing need, and a large increase will be required to meet the
additional number of grade B clinical scientists and consultant clinical scientists identified by
the Task Force. Therefore an eight-year period seems a more practical target within which to
expand the recruitment and training of grade A clinical scientists.

1.2.14 There is also an urgent need to increase other grades of staff in clinical biochemistry
departments. In 2001, it has been estimated that 88%, 51% and 49% of departments require
additional biomedical scientists, medical laboratory assistants, and administrative and clerical
staff respectively. A total of 100 grade B clinical scientists require to be recruited to replace
those lost through gradual attrition at NHS Trust level.

1.2.15 A detailed model for assessing the number of consultants in a clinical biochemistry
department has been developed and validated. This model acknowledges the impact of
workload volume and complexity, the problems of single -handed working and maximum
working time and the need for flexibility in the pattern of service delivery, including
operation across sites.

1.2.16 NHS Trust Chief Executives were sent an information sheet of the main findings of the Task
Force and their reactions were sought through a short survey. The senior managers who
replied were split over whether clinical biochemistry is a clinical service or a clinical support
service. In general, they are very happy with the overall quality of service but 25% admit that
the clinical biochemistry services are deteriorating in their Trust.

1.2.17 A majority of the senior managers recognise all or most of the findings in the information
sheet and they acknowledge the pressures that exist in clinical biochemistry. A majority agree
that departments are struggling to cope with current staffing levels and shortages are
acknowledged to varying extents in all staff grades.

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1.2.18 NHS Trusts have clearly invested substantially in automation and information technology
during the past five years, in an effort to manage the rapidly rising workload. Some 74% of
senior managers agree that laboratories in their Trust have been targeted for savings and
virtually all of them have seen an improvement in the cost-effectiveness of their clinical
biochemistry services.

1.2.19 Trust managers agree that a wide range of consultant duties in clinical biochemistry will
increase in the next four years, with 76% expecting service reconfiguration and 91%
expecting extra work related to compliance with clinical governance targets.

1.2.20 Overall, senior managers recognise the range of pressures in clinical biochemistry and see the
need for additional staffing, including consultant staffing. Predictably, perhaps, they do not
view the problems quite so seriously as the consultants in clinical biochemistry – on average
managers see problems to an extent of about two-thirds of that of their consultants.

1.2.21 Senior Trust managers estimate that approximately 100 additional consultants will be
required in clinical biochemistry over the next four years.

1.3 Recommendations

1.3.1 It is recommended that the number of medical consultants in clinical biochemistry be


increased by 78 whole time equivalents (wte) to meet the current needs of the profession and
the introduction of metabolic medicine.

1.3.2 It is recommended that the expansion of 78 specialist registrars in clinical biochemistry


(national training numbers) be achieved by a planned increase of 26 per year, for each of the
next three years.

1.3.3 An expansion of 70 consultant clinical scientist posts is recommended to meet current needs.
In addition, the appointment of 100 principal grade clinical scientists is required to replace
lost posts.

1.3.4 It is recommended that the number of grade A clinical scientist posts must be matched to the
currently identified workforce planning needs and then further expanded by 22 posts per
year for the next eight years.

1.3.5 It is recommended that, as a matter of urgency, the ACB prepare a detailed paper on the
workforce requirements for clinical scientists, which it presents to all relevant national and
regional workforce confederations.

1.3.6 The following six-step model is recommended as the basis for determining consultant staffing
in NHS departments of clinical biochemistry.
(i) Each department should have a minimum of 1.5 wte consultant staff.
(ii) Add 0.1 wte consultant for each increment of 25 000 requests per year above a baseline
of 200 000.
(iii) Add 0.5 wte consultant for each department that operates from more than one
substantial geographical site.

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(iv) Add 0.5 wte consultant for each teaching hospital department, or for each children’s
hospital department, or for other departments that have a lead role in training medical
or clinical scientist staff.
(v) Add 0.15 wte consultant for each 3.5 hour session of direct clinical care above a
baseline of 2 sessions per medical consultant.
(vi) Add 1.0 wte consultant to each department that contains a university professor of
clinical biochemistry.

1.3.7 It is recommended that the 1996 ACB/RCPath minimum senior staffing model be actively
promoted, in conjunction with the new six-step consultant staffing model. For any clinical
biochemistry department, the difference in staffing predicted by the two models may be
equated with the minimum number of principal clinical scientists required.

1.3.8 It is recommended that the findings of this survey be made known to the Institute of
Biomedical Science (IBMS) at an early stage and that the ACB and RCPath offer to work
with the Institute to promote the case for additional biomedical scientist staff in clinical
biochemistry departments.

1.3.9 It is recommended that the ACB and RCPath work with the IBMS to define the roles of
medical laboratory assistants and administrative and clerical staff working in clinical
biochemistry; to determine current and future staffing levels; and to suggest a mechanism for
ensuring that the contribution of these key members of staff is not overlooked.

1.3.10 It is recommended that the full Task Force report be published in professional format on the
websites of the ACB and RCPath.

1.3.11 It is recommended that the ACB and RCPath publish Chapter 1 of the Task Force report
jointly in a hard-copy, professional format that will allow for widespread distribution to the
profession, health service managers and the four UK Departments of Health.

1.3.12 It is recommended that the ACB and RCPath jointly agree a detailed strategy for the
promotion of the main findings of the Task Force report.

1.3.13 It is recommended that heads of departments of clinical biochemistry discuss the findings of
the Task Force report with their Chief Executive Officer, Director of Pathology and Medical
Director, with a view to preparing a local case for action.

1.3.14 It is recommended that the implementation of the Task Force recommendations is the subject
of regular joint review by the RCPath Medical Workforce Department and the ACB
Workforce Advisory Committee.

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2 INTRODUCTION
2.1 Background to study

The ACB/RCPath Task Force to examine consultant staffing in NHS clinical biochemistry
was established in response to growing concerns within the profession that a combination of
increasing workload and other pressures was already compromising the quality of the service
being offered, and that the situation was likely to deteriorate still further in the future. Many
concerns had been expressed, including:
• increasing workload without increases in staffing
• the demand for ever-higher quality standards of practice
• the changing role of consultants in clinical biochemistry
• consultants working excessive hours under growing pressure
• an ageing profession without adequate workforce planning
• a looming crisis in being able to sustain clinical governance targets.

Consequently, the Task Force was jointly established in February 2001 by the Council of the
ACB and the Specialty Advisory Committee on Clinical Biochemistry of the RCPath. The
membership of the Task Force is recorded in Appendix 1.

2.2 Remit of the Task Force

The remit of the Task Force was defined as follows: “to produce an evidence-based report
which recommends the optimal number of consultant level staff currently required for NHS
clinical biochemistry departments in the UK, together with a model which may be used to
predict future consultant staffing requirements”.

2.3 Method of working

The Task Force adopted a broad approach to gathering evidence prior to the analysis phase
of it work.

2.3.1 Review of publications


The Task Force obtained and examined two types of publication. First, it sought publications
from the scientific literature on workload, staffing, changing practice and pressures in clinical
biochemistry. Second, it obtained copies of relevant government publications and reports
from other specialties of pathology and laboratory medicine that addressed similar topics.
These publications are referred to in the text and recorded in Chapter 9.

2.3.2 Analysis of membership databases


The Task Force had access to the membership databases of both the ACB and RCPath.

2.3.3 Benchmarking
The Task Force was granted permission to use the cumulative data collected by the Clinical
Benchmarking Company and the University of Keele (CBC). Clinical Pathology Accreditation
(UK) Ltd (CPA) and the UK National External Quality Assessment Scheme for Clinical
Chemistry (UK NEQAS) also supplied the Task Force with relevant data.

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2.3.4 Open workshop
The Task Force organised an open workshop, which was held in London during Focus 2001
and attended by more than 100 senior members of the profession. The workshop sought to
engage the profession in the work of the Task Force, gather relevant evidence, and influence
the content of the studies undertaken.

2.3.5 Questionnaire to consultants


The Task Force used the information obtained from the sources described in paragraphs
2.3.1–2.3.4 to prepare a questionnaire to gather evidence related to its remit from consultants
working in NHS clinical biochemistry in the UK. The questionnaire sought specific data and
opinion on changes in practice between the years of 1994–1995 and 2000–2001, a relatively
short period chosen to coincide with the time during which the concerns of the profession
have emerged. This questionnaire was divided into two parts: Part 1 sought evidence relating
to the department in which the consultant worked and only one return per department was
analysed; Part 2 sought evidence relating to the work of the individual consultant and all
returns were analysed. A copy of this questionnaire is included as Appendix 2.

2.3.6 Questionnaire to chief executives


Once the consultant questionnaire had been analysed the Task Force designed a short
questionnaire for circulation to chief executive officers (CEOs) of NHS Trusts. The purpose
of this questionnaire was to establish whether senior managers recognised the main
conclusions from the consultant questionnaire in their own environment. A copy of this
questionnaire is included as Appendix 4.

2.4 Response rate from consultant questionnaire

2.4.1 Return rate


The addresses of all consultants working in clinical biochemistry in the NHS were compiled
from lists supplied by the regional representatives to the Council of the ACB and verified by
comparison with the ACB and RCPath membership databases. A total of 414 questionnaires
were distributed to consultants working in 242 departments. Overall, returns were received
from 74% of departments and 64% of individual consultants. Unless otherwise stated, the
data from these returns provides the evidence presented in subsequent chapters of this report.

2.4.2 Demographics of responding departments


A summary of the responses received from the departments is shown in Table 1. Prior to
distribution of the questionnaire it was recognised that changes in NHS Trust structure would
have affected the number and size of several departments in the period 1995–2001.
Therefore, respondents were asked to return like-for-like data (based on the 1995 structure)
together with information on any changes in structure in the intervening period. In a small
number of cases comparative data was not available.

2.4.3 Demographics of responding consultants


A summary of the responses received from individual consultants is included in Table 2. It
had been anticipated that not all consultants would be able to answer all the points in Part 2
of the questionnaire. For example, recently appointed consultants would not be able to
answer questions comparing their roles in 1995 and 2001, and consultants employed by
universities with part-time roles within the NHS would find some questions irrelevant.
Therefore, individuals were invited only to complete those sections that they felt comfortable
to answer. All returned data was included in the analysis.
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Table 1 Analysis of departmental responses to consultant questionnaire

Nature of hospital Distributed Returned %


Teaching hospital 59 45 76
District general hospital 169 122 72
Children’s hospital 9 9 100
Specialist unit 5 4 80
Total 242 180 74

Region Distributed Returned %


Northern and Yorkshire 25 15 60
Trent 16 14 87
South East (incl London) 84 53 63
South West 21 17 81
West Midlands 22 17 77
North West 27 25 93
Wales 14 14 100
Scotland 25 19 76
Northern Ireland 8 6 75
Total 242 180 74

Table 2 Analysis of individual responses to consultant questionnaire

Consultant category Distributed Returned %


NHS medical consultant 172 106 62
NHS consultant clinical scientist 95 131 67
University medical consultant 30 18 60
University non-medical consultant 17 9 53
Total 414 264 64

2.5 Response rate from chief executive questionnaire

2.5.1 Return rate


The Departments of Health in England, Northern Ireland, Scotland and Wales supplied the
names and addresses of the chief executive officers of 229 acute hospitals NHS Trusts. Each of
these was sent the information sheet and survey (Appendix 4). A total of 129 returns were
received by the closing date of 30 November 2001. This represents a 56% return rate. A
further 10 returns arrived after the closing date; these were not analysed but their inclusion as
returns yield an overall return rate of 61%.

2.5.2 Analysis of respondents


The CEO was invited either to complete the survey or to pass it to an appropriate senior
manager for completion. In the event the returns were received from 19 chief executives (15%),
17 medical directors (13%), 45 senior Trust managers (35%), 42 clinical directors of
laboratory medicine (33%) and 6 others (4%).

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3 WORKLOAD IN CLINICAL BIOCHEMISTRY

3.1 Departmental workload

3.1.1 Total workload


Data from Scotland has revealed a 54% increase in the number of clinical biochemistry tests
undertaken by NHS laboratories in the five-year period from 1994–1995 to 1999–2000.1
Data from CBC revealed an increase of 52.7% in the number of requests performed by
participating UK clinical biochemistry laboratories over the same period.2 A summary of the
evidence obtained from the consultant questionnaire is included in Table 3 and this reveals
data that is very much in line with these published trends. Overall, the total number of
requests increased by 56% between 1995 and 2001, whilst the number of tests increased by
63% over the same period. The increase was similar in district general hospital (DGH) and
teaching hospital departments but significantly lower in children’s hospital departments.

3.1.2 Out of hours workload


Not only have clinical biochemistry departments experienced a dramatic rise in total
workload in recent years but the proportion of that workload which arrives outside the
‘normal working day’ (defined as the period with maximum staffing) has also increased from
8.7% to 13.4% (Table 3). This 54% increase almost certainly underestimates the trend
towards ‘around the clock’ services since 52 departments have extended their ‘normal
working day’ during the period under study (see Chapter 6.1.1). A similar finding of a 64%
increase in the out of hours workload over a five year period is available from Scotland.1

3.1.3 General practitioner workload


The percentage of the total workload originating from general practitioners (GPs) rose from
30.9% to 36.7% in the six-year study period (Table 3). In absolute terms, GP requests
increased by 85%, and were the most rapidly growing component of the clinical biochemistry
workload. For DGH departments, GP requests now represent 42.3% of the total workload,
the corresponding figure for teaching hospital departments is 27.2%. It is widely accepted
that requests originating from GPs require more input from consultants and other interpretive
staff at the post-analytical stage than work originating within the hospital.

3.1.4 Repertoire
Not only has the volume of the workload of clinical biochemistry laboratories increased
dramatically, but the repertoire offered has also increased. Within the ‘normal working day’,
94% of respondent departments have seen an increase in repertoire during the past six years
with a mean increase of 10 analytes. In 87% of laboratories the repertoire has also increased
out of hours, by a mean of 6.5 analytes, reflecting the strong move towards more ‘around the
clock’ clinical biochemistry.

3.2 Consultant workload

Four categories of consultant staff work in NHS clinical bioche mistry departments (Table 2).
The Task Force agreed that it would be much more informative to analyse the volume and
nature of the consultant workload by category rather than in total. In one category (university
non-medical consultant), there were few returns and so this category was omitted from
further analysis.

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Table 3 Workload of clinical biochemistry departments

Average departmental workload 1995 2001 % change


Requests (1000s) – all departments 212 331 56
Tests (1000s) – all departments 1128 1839 63
Out of hours (% total) – all departments 8.7 13.4 54
GP origin (% total) – all departments 30.9 36.7 19
Requests (1000s) – teaching 332 522 57
Tests (1000s) – teaching 1824 2882 58
Out of hours (% total) – teaching 8.7 14.5 65
GP origin (% total) – teaching 20.5 27.7 35
Requests (1000s) – DGH 169 263 56
Tests (1000s) – DGH 917 1546 68
Out of hours (% total) – DGH 8.4 12.6 50
GP origin (% total) – DGH 36.3 42.3 16
Requests (1000s) – children’s 110 149 35
Tests (1000s) – children’s 427 539 26
Out of hours (% total) – children’s 13.9 21.1 52
GP origin (% total) – children’s <1 <1 –

3.2.1 Hours worked

3.2.1.1 NHS medical consultants who are employed full time work an average of 47.3 hours per
week (excluding out of hours cover), an average of 8.8 hours above the 38.5h (11 sessions)
that a whole time employee is contracted to work. At least 35% of individuals work an
average in excess of the 48 hours stipulated by the European Working Time Directive 3 –
before any allowance is made for out of hours working. Since 1995, 83% of this category of
consultant has experienced an increase in the average working week, whilst 14% have seen
no change and 3% have seen a decline.

3.2.1.2 NHS consultant clinical scientists work an average of 46.7 hours per week (excluding out of
hours cover), an average of 9.7 hours above the 37 hours that a whole time employee is
nominally contracted to work. At least 32% of consultants work an average in excess of the
48 hours stipulated by the European Working Time Directive3 – before any allowance is made
for out of hours working. Since 1995 66% of this category of consultant has experienced an
increase in the average working week, whilst 26% have seen no change and 8% have seen a
decline.

3.2.1.3 University medical consultants (with honorary NHS consultant contracts) work an average of
48.7 hours per week in total. At least 55% work an average in excess of the 48 hours
stipulated by the European Working Time Directive 3 – before any allowance is made for out
of hours working. Since 1995 59% of this category of consultant has experienced an increase
in the average working week, whilst 29% have seen no change and 12% have experienced a
decline.

11
3.2.2 Out of hours working

3.2.2.1 NHS medical consultants are on-duty out of normal working hours for an average of 52
hours per week. Of these consultants, 31% are available for contact 24 hours per day, 7 days
per week, 52 weeks per year (excluding holidays). The actual number of calls received and the
hours spent in the department vary considerably within this group.

3.2.2.2 NHS consultant clinical scientists are on-duty out of normal working hours for an average of
41 hours per week. Of these consultants, 19% provide total out of hours cover. As with the
previous category of consultant, the actual number of calls received and the hours spent in the
department vary considerably within this group.

3.2.2.3 University medical consultants are on-duty out of normal working hours for an average of 13
hours per week. Once more, the actual number of calls received and the hours spent in the
department vary considerably within this group.

3.2.3 Typical working week


The ‘typical working week’ of each of the three categories of consultant was derived from the
mean of the figures provided and is shown in Table 4. As may have been anticipated, the
medically qualified consultants spend more time on direct patient care than their non-medical
counterparts who, in turn, spend more time on validation of results, providing scientific
insight and departmental management. Predictably, university employees spend more time
teaching and on research and development than their colleagues employed by the NHS. A
sub-analysis of the information returned indicates that NHS employed consultants in teaching
hospital departments, spend more time on teaching and research and development than their
colleagues from DGH departments, who spend correspondingly more time on management-
related tasks (data not shown). It should be stressed that the job functions of each consultant
differ in order to meet the needs of the specific post. Therefore, the breakdown of job
functions for an individual consultant may differ significantly from the mean data shown in
Table 4.

3.2.4 Origin of clinical work


The percentage work for each consultant category that originates from GPs and various
clinical teams within the hospital is shown in Table 5. Children’s hospital departments and
specialist units have been excluded from this analysis. It is clear that GPs generate the biggest
component of clinical work for NHS employed consultants. This finding is most pronounced
for consultants working in DGH departments (Table 3).

3.2.5 Origin of non-clinical work


It may have been expected that the rapidly rising and expanding workload demonstrated in
paragraph 3.1 would have resulted in consultants spending more of their time on this
function. However, it is clear from Table 4 that in 2001 work directly related to clinical
functions accounts for 50% at most of consultant time with management related functions
accounting for the remainder. As will be demonstrated in Chapter 6, the proportion of time
being spent on management functions has increased during the past six years, despite the big
increase in clinical demand.

12
Table 4 Typical working week (excluding on-call)

% working week
Job function NMC NCCS UMC
Direct patient care (inpatient and outpatient) 17.5 0 10.3
Validation and reporting results 23.1 26.3 2.6
Clinical liaison – discussion of results 7.0 7.7 3.0
Clinical liaison – ward visits, etc. 4.8 3.4 1.6
Providing scientific insight 4.8 7.3 7.6
Quality (governance, audit, accreditation) 5.5 8.4 4.6
Research and development 5.5 6.6 20.3
Teaching /training of staff/students 4.3 4.5 7.4
Continuing professional development 4.3 4.8 2.4
Management within the department 11.4 17.9 10.5
Management elsewhere in the Trust 6.8 6.6 4.8
Work for regional, national and other bodies 3.5 4.5 14.2
Other functions 1.5 2.0 10.7
Average hours worked (excluding on-call) 47.3 46.7 48.7

Key
NMC NHS medical consultant
NCCS NHS consultant clinical scientist
UMC University medical consultant

Table 5 Origin of clinical laboratory work for consultants in clinical biochemistry

% clinical work
Referring clinical team NMC NCCS UMC
General practitioners 44.0 36.4 32.9
Physicians 26.0 31.5 34.6
Surgeons 11.2 12.0 9.6
Paediatricians .0 8.2 10.8
Obstetricians .5 6.2 5.7
Psychiatrists 2.5 2.3 3.6
Others 2.8 3.4 2.8

3.2.6 Secretarial support


A total of 72% of individual consultants currently have at least a share of a secretary.
However, there is a sharp contrast between the 90% of medical consultants and the 55% of
non-medical consultants that have secretarial support.

13
4 STAFFING IN CLINICAL BIOCHEMISTRY

4.1 Total staffing

4.1.1 Medical staffing


Data from the questionnaire are summarised in Table 6. Overall, there has been fall of
8.5%from 239.3 wte medical staff in 1995 to 219.0 wte in 2001. This fall is largely
accounted for by a reduction in non-career grade medical staff plus the planned reduction in
the number of trainees. The number of unfilled posts at 31 March 2001 was higher than in
1995 resulting in a reduction of 26.4 (11.5%) staff in post.

4.1.2 Clinical scientist staffing


Data from the questionnaire are summarised in Table 6. Overall, there has been fall of
8.0%from 622.4 wte clinical scientist staff in 1995 to 577.8 wte in 2001. This fall is totally
accounted for by a 13% reduction in grade B clinical scientist staff. The number of unfilled
posts at 31 March 2001 was higher than in 1995 resulting in a reduction of 66.5 (10.7%)
staff in post.

4.1.3 Biomedical scientist staffing


Some 119 departments (49%) returned comparative figures for BMS staff. The results shown
in Table 6 reveal a 1% increase in the establishment but a 1% reduction of staff in post
because of the difficulties of recruiting and retaining BMS staff. This data supports two recent
thorough studies on BMS staffing.4,5

4.1.4 Other staffing


Two other grades of staff work in clinical biochemistry laboratories – medical laboratory
assistants (MLA) and administrative and clerical staff (A&C). No survey of comparative
numbers of these grades of staff was undertaken in this study.

4.2 Consultant staffing

4.2.1 Total consultant staffing


As Table 6 shows, there is an almost 1:1 ratio of medical to non-medical consultant staff
working in clinical biochemistry departments. Neither the total number nor the ratio has
changed significantly between 1995 and 2001.

4.2.2 Medical consultant staffing


Data from the RCPath identified the medical consultant establishment for clinical
biochemistry as being 225 in 1995 and 226 at 30 September 2000. The 2000 establishment
figure included 14 vacant and 19 part-time posts. A total of 202 consultants were identified
as being in post in NHS departments at the commencement of this investigation; these were
each sent a questionnaire (Table 2). Data from the departmental returns from the
questionnaire (Table 6) identified a total of 146.7 wte in 2001 – equivalent to 201 wte for a
100% return. This figure is 2.7 wte fewer than the corresponding figure for 1995. The
conclusion from this evidence is that the number of medical consultants in clinical
biochemistry has remained static during the period 1995–2001.

14
Table 6 Staffing levels in clinical biochemistry: 1995 and 2001

Staff grade Staff numbers (wte)


31/03/1995 31/03/2001
Medical consultant 144.9 (4.5) 140.3 (6.4)
Non-career grade medical 15.4 (0.0) 7.2 (0.0)
Trainee medical 69.2 (5.3) 55.6 (9.5)
Total medical 229.5 (9.8) 203.1 (15.9)
Consultant clinical scientist 153.9 (4.0) 156.8 (3.0)
Grade B clinical scientist 415.5 (1.5) 350.2 (13.9)
Grade A clinical scientist 50.5 (2.0) 46.4 (7.5)
Total clinical scientist 619.9 (7.5) 553.4 (24.4)
Total consultants 298.8 (8.5) 297.1 (9.4)
Biomedical scientists (all grades)* 2095.3 (47.3) 2076.9 (98.2)

Key
Figures not in brackets relate to occupied posts
Figures in brackets are unfilled posts
* Based on returns from 119 departments (49% of distribution)

4.2.3 Clinical scientist staffing


Data from the ACB identified 230 consultant clinical scientists in clinical biochemistry in
1995 and 217 in 2001. A total of 212 individuals were identified working in NHS
departments and sent a questionnaire (Table 2). Data from the departmental returns
identified 159.8 wte staff in post – equivalent to 219 wte for a 100% return. The data in
Table 6 reveals a 1% increase between 1995 and 2001. Taken together this data is also
consistent with essentially static staffing levels over the period of study.

4.2.4 Consultant staffing and demographics


Table 7 expresses the number of medical consultants plus consultant clinical scientists in
clinical biochemistry as a function of the nature of the hospital, the population served and the
workload of the departments. On average in 2001 there is one consultant in clinical
biochemistry for every 174 000 people. Corresponding figures for other specialties in
laboratory medicine are: histopathology 50 000,6 haematology 100 000,7 and microbiology
150 000.8 In all of the above specialties recent proposals have been made for large increases in
the number of consultants. 6–8 As may be anticipated there are fewer consultants in clinical
biochemistry per 100 000 of the population in district general hospitals (DGHs) than in
teaching hospitals.

The average annual workload per consultant has risen dramatically between 1995 and 2001
from 122 000 to 190 000 requests (+56%), and from 652 000 to 1 063 000 tests (+63%).
Putting this data another way each consultant in 2001 is, on average, responsible for 630
requests and 3500 test results on each normal working weekday. The total work per
consultant is somewhat greater in DGHs than in teaching hospitals – the average number of
tests per weekday per consultant being 3900 and 3200, respectively. An independent body
has already expressed concern about the rising workload in clinical biochemistry and the
impact that it will have on clinical risk and the ability of the consultant to maintain standards
of clinical interpretation and guidance.2

15
Table 7 Consultant staffing in relation to demographics and workload

Department Average population Consultant/ Population/


served department consultant
Teaching hospital 440 000 3.04 144 000
District general hospital 276 000 1.32 209 000
Children’s hospital 2 320 000 1.51 1 536 000
Total 302 000 1.73 174 000

Department Requests/department Requests/consultant


1995 2001 1995 2001
Teaching hospital 332 000 522 000 104 000 172 000
District general hospital 169 000 263 000 137 000 199 000
Children’s hospital 110 000 149 000 70 000 98 000
Total 212 000 331 000 122 000 190 000

Department Tests/department Tests/consultant


1995 2001 1995 2001
Teaching hospital 1 824 000 2 882 000 573 000 948 000
District general hospital 917 000 1 546 000 745 000 1 171 000
Children’s hospital 427 000 539 000 270 000 354 000
Total 1 128 000 1 839 000 652 000 1 063 000

4.3 Audit of minimum senior staffing model

In 1996, the ACB and RCPath jointly published a model to calculate the minimum number of
senior staff required in each clinical biochemistry laboratory.9 The definition of senior staffing
used in this model was consultant level staff plus principal clinical scientists. After five years
of operation the questionnaire provided an opportunity to audit the use and effectiveness of
this model. The results of this audit are shown in Table 8. It is clear that just 52% of
laboratories have had cause to use the model. Where it has been used there is strong
agreement that it is soundly based, straightforward to apply and that it produces valid results.
However, in less than 30% of cases did Trust managers take any action based on the results.
A lack of funding was the reason almost universally offered in free text for management
refusing to acknowledge the results of the model. The reason most commonly offered for not
using the model was a lack of conviction that management would take any notice of the
results!

16
Table 8 Audit of minimum senior staffing model

Criterion % responses
Yes No
Use of model 52 –
Model is soundly based 77 23
Model is straightforward to apply 88 12
Model produces credible results 89 11
Managers acted on the model results 25 75
Department benefited from the model 29 71
Use of model – 48
Department unaware of model 7 93
Occasion did not arise to use model 64 36
Model too complex to use 18 82
Data not available for model 9 91
Model seen as irrelevant 28 72
Model seen as a threat 4 96

17
5 PRESSURES IN CLINICAL BIOCHEMISTRY

5.1 Clinical governance pressures

5.1.1 Laboratory accreditation


There is considerable pressure within the profession, from management and from users of
clinical biochemistry services to see objective evidence of quality standards. This evidence is
most conveniently demonstrated through CPA laboratory accreditation. Data from CPA
annual reports on the status of laboratory accreditation in clinical biochemistry departments
is shown in Table 9. Corresponding data from the questionnaire is shown in Table 10.

Table 9 Clinical biochemistry: CPA laboratory accreditation status: 1995 and 2000

Year Still to apply Unconditional Conditional Referred


approval approval no status
1995 133 105 22 3
2000 31155 38 14

Table 10 Laboratory accreditation status: 1995 and 2001: questionnaire

Year Still to apply Unconditional Conditional Referred


approval approval no status
1995 53 89 28 3
2001 6 109 38 5

Some explanation is needed in the interpretation of the data in Tables 9 and 10. The data
from CPA (Table 9) is restricted to single specialty clinical biochemistry departments.
Although most of these will be NHS departments a small number will be in the private sector.
This data does not include any multi-specialty laboratories. Although most of these will
operate outside the NHS, a few will be NHS departments that have returned questionnaires.
On the other hand the returns from the questionnaire include less data for 2001 than for
1995, perhaps reflecting the current state of transition of many departments. Comparison of
the data in Tables 9 and 10 suggests that the departments that have no accreditation status
(yet to apply or referred) are less likely to have completed and returned a questionnaire.

Overall, three broad conclusions may be drawn from this data:


• a large number of clinical biochemistry departments gained CPA accreditation between
1995 and 2000–2001
• a relatively small number of clinical biochemistry departments have yet to apply for
CPA accreditation
• a small, but growing number of departments are finding it difficult to achieve and/or
maintain unconditional accreditation. For example, data from the survey reveals 15
laboratorie s that had unconditional accreditation in 1995 but only conditional
accreditation after re-inspection.

Evidence that consultants are devoting increased time to achieving and/or maintaining CPA
accreditation is presented in Chapter 6.2 and also in the freehand comments summarised in
Appendix 3.

18
5.1.2 Turnaround times
Data from the questionnaire is summarised in Table 11. A total of 91% of departments have
experienced demands to improve the turnaround time of results in the period between 1995
and 2001. The vast majority of laboratories (84%) have managed to deliver improved
turnaround times despite the growing workload (Chapter 3). However, a significant minority
of laboratories (8%) are delivering a slower turnaround time for results in 2001 compared to
1995.

Table 11 Turnaround times (TAT) in clinical biochemistry: 1995 and 2001

Number of departments
Criterion Unchanged Increased Decreased
Demand for faster TAT 15 147 0
Delivery of faster TAT 13 134 13

5.1.3 External quality assurance


The strategic review of pathology services recommended that all laboratories must participate
in external quality assurance (EQA).10 Data from the questionnaire is recorded in Table 12. A
large number of departments (84%) increased their EQA participation between 1995 and
2001. In 52% of cases an improvement in EQA performance has occurred, with no change in
performance in another 41%. However, 7% of departments have experienced deterioration in
EQA performance. Although the general level of performance remains satisfactory, 53% of
departments have current concerns about the EQA performance for one or more analytes. In
freehand comments these concerns are largely attributable to individual poorly performing
methods on large commercial platforms, where the laboratory cannot influence performance.

Table 12 External quality assessment in clinical biochemistry: 1995 and 2001

Number of departments
Criterion Unchanged Increased Decreased
EQA participation 20 140 6
EQA performance 69 86 11
Yes No
Current EQA concern 84 76

5.1.4 Blunders
A blunder is defined as an error made by the laboratory during the pre-analytical, analytical
or post-analytical stages of laboratory operation. Publications in the scientific literature
indicate that the total blunder rate in clinical biochemistry is of the order of 0.3% with
analytical blunders much lower at 0.04%.11,12 Blunders are most likely to be experienced in the
pre-analytical stage, during specimen collection and reception.13 Departments were asked to
comment on their comparative blunder rates for 1995 and 2001 and to distinguish between
minor blunders (identified and corrected within the laboratory) and major blunders (incorrect
data issued by the laboratory). The data is displayed in Table 13.

19
Table 13 Assessment of laboratory blunders in clinical biochemistry

% respondents
Criterion Yes No % change
Laboratory records all blunders 90 10
Distinguishes minor and major events 77 23
Laboratory investigates all complaints 93 7
Increase in minor events 1995–2001 88 12
Increase in major events 1995–2001 78 22
Increase in total events 1995–2000 87 13
Estimate of change in total events +46%

This data shows that the vast majority of departments now have a secure system for recording
and investigating blunders. Several laboratories felt unable to offer an assessment of the
change in blunder rate because they were not recording data in 1995 and yet more
respondents commented that the increase may be more apparent than real because of
improvements in recording. Therefore, the average increase in blunder rate of +46% is at best
an estimate, but it is interesting to note that is a similar increase to the total workload.
Assuming that the published blunder rates apply,11,12 the data from the questionnaire indicates
that in 2001 the average clinical biochemistry laboratory will make approximately three
blunders of any kind every day and approximately two analytical blunders each week.

Two other estimates of changing blunder rate were obtained as part of this investigation.
Firstly, one department which has been keeping detailed records of blunders for several years
was able to demonstrate a gradual fall in the blunder rate over the period 1992–1999, only
for it to double in the year 2000 (41–99 events), during a period when three departments
merged in a single Trust [personal communication]. Secondly, data from UK NEQAS for
clinical chemistry in Birmingham reveals that the non-analytical error rate (transcription
errors etc) doubled between 1995 and 2000 from 0.48% to 0.98% of returns to identical
EQA schemes [personal communication].

5.1.5 Meeting clinical governance targets


As part of the questionnaire consultants were asked to assess their confidence in the
performance of their laboratory and themselves in meeting clinical governance targets
expected by professional colleagues and the general public for the years 1995 and 2001.
Respondents were given a sliding scale from 1 (totally confident) to 9 (expecting a letter from
the lawyer). The results, shown in Table 14, reveal that all three categories of consultant have
lost confidence in all four targets areas. Overall, the average figures indicate a service in
control but gradually deteriorating. However, Table 15 shows the same data analysed in a
different manner. It records the number of total consultants recording scores in the range 7–9,
which may be interpreted as showing a marked lack of confidence in meeting clinical
governance targets. It is interesting to note a sharp increase between 1995 and 2001 in two
areas. The pre-analytical area of activity is concerned with the correct reception and labelling
of specimens and is the greatest source of laboratory blunders.13 The increase in concern
amongst some consultants in the area of direct clinical care may be interpreted as a
combination of increased pressure on the consultant coupled with increased patient
awareness.

20
Table 14 Confidence of consultants in meeting clinical governance targets

A v e r a g e s c o r e f r o m s c a l e r a n g e 1– 9
NMC NCCS UMC
Target area 1995 2001 1995 2001 1995 2001
Pre-analytical 3.5 4.0 3.2 4.4 2.8 4.2
Analytical 3.1 3.3 3.0 3.2 2.3 3.3
Interpretation 3.1 3.5 3.3 3.8 2.8 3.4
Direct clinical 2.8 3.6 – – 2.2 3.0

Key
NMC NHS medical consultant
NCCS NHS consultant clinical scientist
UMC University medical consultant

Table 15 Consultants with concerns in meeting clinical governance targets

Number of consultants scoring 7–9


Target area 1995 2001
Pre-analytical 7 23
Analytical 5 8
Interpretation 9 9
Direct clinical care 1 13

5.2 Laboratory pressures

5.2.1 Workload and staffing


Chapter 2 revealed a rapidly rising workload, compounded still further by an increase in the
proportion of GP requests and pressure to deliver more services, more quickly for more of the
24-hour day. Chapter 3 revealed that consultant staffing levels have remained static over this
period of rapid expansion, that there are less biomedical scientists in post, and that the
number of non-consultant medical and clinical scientist staff fell by ~10%. Departments were
asked to assess the adequacy of their total staffing to cope with the workload received in
1995 and 2001. Furthermore, they were asked to comment on the ability to cope in 2005,
assuming continued growth in workload at the same rate and no change in staffing.

The results, shown in Table 16 reveal the most alarming set of data from this whole
investigation. Put simply, in 1995 82% of departments thought staffing was adequate or
better for the workload, but by 2001 89% of departments were struggling to cope and, unless
there is a change in staffing, 98% of departments in 2005 will either be struggling or unable
to cope – with 72% in the latter category.

As a follow-up to this question, departments that had recorded that they were either
struggling to cope or unable to cope were asked to identify the staff grades required to correct
the problem. The results of this analysis are shown in Table 17. What is revealed is the need
for an increase in all grades of staff, with biomedical scientists and consultants at the top of
the list.

21
Table 16 Adequacy of total staffing to cope with laboratory workload

Number of departments (%)


Assessment of staffing 1995 2001 2005
Staffing satisfactory or better 21 (13) 1 (<1) 0 (0)
Staffing adequate 113 (69) 14 (8) 3 (2)
Staffing struggling to cope 30 (18) 48 (89) 40 (26)
Staffing unable to cope 1 (<1) 4 (3) 111 (72)

Table 17 Staffing shortage in departments struggling or unable to cope

Number of departments
Staff grade 1995 2001 2005
Consultant 14 85 104
Grade B clinical scientist 11 60 72
Biomedical scientist 26 133 138
Medical laboratory assistant 15 86 88
Administrative and clerical 14 74 81

5.2.2 Scientific and technical workforce


Although the purpose of this investigation is focussed on consultant staffing, the pressures
within the scientific and technical workforce deserve a mention, since these staff are essential
members of the team that deliver clinical biochemistry services (Table 17).

The data in Table 6 demonstrates the increase in unfilled posts between 1995 and 2001. In
recognition of the problems being experienced with retention and recruitment the government
recently published a strategy document, aimed at raising the profile and increasing career
prospects of this section of the workforce14 and the NHS recruitment and retention unit has
targeted this workforce for special support. The problems are especially acute for biomedical
scientists 4,5 and it is apparent from Table 17 that a solution must be found if the pressure in
clinical biochemistry laboratories is to be reduced.

5.2.3 Clinical demand


The increased pressures summarised in paragraph 5.2.1 are very largely the result of increased
clinical demand. Hard evidence for this was obtained by asking consultants to comment on
the changes in clinical users numbers and demand in the period since 1995. Results are shown
in Table 18. Virtually all laboratories recognise that they are providing services for more GPs
and more hospital consultants in 2001 than they were in 1995. Their assessment of the
increase slightly overestimates official government figures for GP expansion of 0.9% pa 15 but
underestimates the hospital consultant expansion of 4% pa.16 The fact that the workload has
expanded by 56–63% (Chapter 2) in the face of a ~15% increase in consultant users must be
interpreted as showing an increase in activity of all consultants.

Although ‘demand management’ is often quoted as highly desirable, and many audits and
guidelines have been produced to address the topic, the evidence for clinical biochemistry
laboratories worldwide is that efforts to manage the demand for services are extremely time-
consuming for consultant level staff and, at best, have a very small impact on the workload.

22
Table 18 Clinical demand for clinical biochemistry services: 1995–2001

D ep a r t m e n t s ( % )
Clinical user Increased Decreased % change
General practitioners 97 3 9.2%
Hospital consultants 99 1 11.8%
Total clinical demand 94 6 13.5%

5.2.4 National service frameworks


A number of national service frameworks (NSFs) (known by different names in different
countries in the UK) are in the process of being introduced to improve the standard of health
care in a number of key areas of public health. From a clinical biochemistry perspective three
NSFs are likely to impact on service demand – diabetes, coronary heart disease, and cancer.17–
20
Departments were invited to comment on the likely impact of these three NSFs both on the
laboratory in general and on consultant time. Results are shown in Table 19.

Table 19 Predicted impact of NSFs on clinical demand

NSF Laboratory services % change


Unchanged Increased
Diabetes mellitus 9 91 3.1%
Coronary heart disease 8 92 2.8%
Cancer 10 90 3.2%
Consultant time % change
Unchanged Increased
Diabetes mellitus 25 75 1.8%
Coronary heart disease 24 76 2.0%
Cancer 32 68 1.5%

Summarising the results it is clear that a very high percentage of consultants believe that the
introduction of these NSFs will each further increase the clinical biochemistry workload, by
~3% in each case. The impact on consultant time would also be increased, especially in
diabetes and coronary heart disease where medical consultants in clinical biochemistry run
outpatient clinics. This trend is likely to increase still further with the development of
consultants in metabolic medicine (see Chapter 6).

5.3 Consultant pressures

5.3.1 Stress assessment


Consultants were invited to assess their work related stress in two areas of activity, both in
1995 and 2001. A sliding scale was available ranging from 1 (unstressed) to 9 (about to have
a nervous breakdown). Results are recorded in Table 20. It is clear that whilst there has been
an increase in both areas of activity for all three categories of consultant, the stress within
normal working hours has risen dramatically between 1995 and 2001. This is even more
marked when the data is analysed to show the number of consultants recording a ‘highly
stressed’ score in the range 7–9 (Table 21).

23
The ten consultants currently experiencing severe stress with out of hours working are all
single-handed and providing 24-hour, 7-day, 52-week cover. Of even more concern is the fact
that 86 consultants (36% of the total response) are experiencing severe stress during the
normal working day.

Table 20 Assessment of stress being experienced by consultants

Average score from scale range 1–9


NMC NCCS UMC
Area of activity 1995 2001 1995 2001 1995 2001
Working day 3.8 5.6 4.0 5.8 3.9 5.4
Out of hours 2.7 3.2 2.9 3.6 2.1 2.5

Key
NMC NHS medical consultant
NCCS NHS consultant clinical scientist
UMC University medical consultant

Table 21 Consultants experiencing high stress levels

Number of consultants scoring 7–9


Area of activity 1995 2001
Working day 10 86
Out of hours 3 10

The scale used for assessing stress was deliberately the same as that used to assess confidence
in meeting clinical governance targets (Section 5.1.5). Comparison of the data in Tables 14
and 20 reveals that the working day stress rating is considerably higher than can be accounted
for by concerns with meeting clinical governance targets. As Chapter 6 and Appendix 3 will
reveal, the main source of stress is increase in management functions for consultants, which
are compounding the increased clinical workload described earlier (Section 4.2).

5.3.2 Absence cover


Consultants were asked how cover is provided for their absence from work during holidays
or through sickness. Results are shown in Table 22. A total of 113 single-handed consultants
were identified who obtain absence cover from a combination of non-consultants (mainly
grade B clinical scientists), consultants from other departments or locum consultants. Five
single-handed consultants volunteered the information that since it is virtually impossible to
get locum cover they take a mobile phone with them wherever they go, so that they are
literally on-call 365 days a year.

Table 22 Absence cover for consultants in clinical biochemistry

Absence cover Number of consultants


Consultant from same department 141
Non-consultant from same department 94
Consultant from another department 44
Locum consultant 21

24
5.3.3 Research and development and scientific publications
As pressure on consultants mounts, ‘something has got to give’. For many consultants in
clinical biochemistry that ‘something’ is research and development. Table 4 reveals that NHS
employed consultants currently only manage to spend 6% of their time on this activity and as
Chapter 6 will reveal this percentage has dropped over the past five years for a large number
of consultants. Detailed examination of the data from the questionnaire reveals that 46
consultants (20%) now do no research and development, even though this activity will be
part of their job description. Absence of research and development is most commonly seen in
single-handed consultants working in DGHs.

Comparing the number of peer-reviewed scientific publications in 1995 and 2001 reveals the
impact of the reduction in research and development by NHS consultants. This data is shown
in Table 23. In effect the strong position that the UK has held in the science of clinical
biochemistry is being eroded.

Table 23 Scientific publications in clinical biochemistry

Consultant category Total number of publications % change


1995 2001
NHS medical consultants 165 119 –28
NHS consultant clinical scientists 183 158 –14
University medical consultants 84 105 +25

5.3.4 Planned age of retirement


The average age and planned age of retirement of consultants is recorded in Table 24. It is
clear that on average NHS consultant clinical scientists are older than NHS medical
consultants, although both groups have been employed for the same time and both intend to
retire at a similar age. University medical consultants are on average older than their NHS
counterparts, have been in post longer and intend to retire one year later. The clear intention
of NHS consultants to retire 2.5 years earlier than the normal retirement age is another
indicator of the pressure under which they are working and has implications for workforce
planning.

Table 24 Age profile and retirement plans for consultants

Consultant category
Parameter NMC NCCS UMC
Mean age (years) 46.5 51.7 52.6
Male (%) 78 75 88
Years as a consultant (years) 10.5 10.1 19.3
Mean age of planned retirement (years) 62.5 62.7 63.6

Key
NMC NHS medical consultant
NCCS NHS consultant clinical scientist
UMC University medical consultant

25
5.3.5 Workforce planning

5.3.5.1 The NHSE workforce national advisory board determines workforce planning for NHS
medical consultants in clinical biochemistry in England and Wales after receiving advice from
the medical workforce unit of the RCPath. Through this mechanism, the number of trainee
posts is agreed and National Training Numbers (NTNs) allocated accordingly. The intention
is to have the same number of specialist registrars gaining their CCST in any one year, as
there are consultant vacancies. The anticipated expansion in NHS medical consultant posts in
the second half of the 1990s did not occur, leading to a reduction in NTNs in recent years (as
evidenced in Table 6) and the number of trainees is now broadly in balance with the
anticipated consultant vacancy rate. Full details of this workforce plan are available from the
RCPath. However, any expansion to the existing number of consultants will require a
minimum of five years to achieve, following agreement to fund the increase in NTNs.

5.3.5.2 Workforce planning for NHS consultant clinical scientists in clinical biochemistry is more
complex for two reasons. Firstly, only a proportion of trainees will become consultants, many
who complete training and obtain MRCPath will remain as ‘high grade B’ (principal grade)
clinical scientists. Secondly, although grade A training posts are supernumerary and centrally
funded there is no equivalent to the NHSE workforce national advisory board and posts are
allocated at regional workforce development confederations in a process that involves several
scientific specialties competing for a limited number of training posts. The ACB workforce
advisory committee has drawn up a detailed annual schedule of the number of grade A
clinical scientists required to match the number of consultant and principal grade retirements,
assuming an eight year interval before entry and eligibility for a post (i.e. period to obtain
MRCPath). Full details of this plan are available from the ACB, but there is a clear shortfall
in recruiting trainees. For example, in the period 2006–2008 some 89 clinical scientists are
expected to retire and yet only 44 grade A clinical scientists were appointed between 1998
and 2000. As Table 24 suggests, the number of clinical scientist retirements reaches a sharp
peak in 2009–2012 (total 147) and there requires to be a dramatic increase in trainees just to
maintain the current number of posts. Paradoxically, it would be easy to achieve rapid
expansion of consultant clinical scientist posts from the pool of trained (MRCPath) principal
grade staff but this would simultaneously reduce the numbers of these staff and further
increase the pressure on the recruitment of grade A clinical scientists.

5.3.6 Consultant staffing assessment


Table 17 records the views of 161 departments of the profession that an additional 85
consultants are required in 2001. This equates to a total of 128 consultants for the whole
profession – an increase of 31%. Table 17 also indicates that the profession will require an
additional 28 consultants (7%) between 2001 and 2005.

The questionnaire also asked existing consultants to compare the need for additional NHS
medical consultant and NHS consultant clinical scientist staffing for the years 1995 and 2001.
The assessment was performed using the sliding scale, with scores ranging from 1 (no need) to
9 (absolutely essential). The results of this analysis are shown in Table 25 and they reveal a
very similar assessment of consultant need by both consultant categories.

26
Table 25 Assessment of the need for additional consultant staff

Average score from scale range 1–9


NMC NCCS
Existing consultant grade 1995 2001 1995 2001
NHS medical consultant 3.0 5.0 3.5 5.1
NHS consultant clinical scientist 2.7 4.3 3.5 4.6
All consultants 2.9 4.5 3.5

Key
NMC NHS medical consultant
NCCS NHS consultant clinical scientist

More detailed analysis of the returns to this question enabled an average assessment to be
obtained for all the consultant returns from each department. An average score in the range
7–9 was equated with the clear need for an additional consultant, whilst an increase of at
least 3 scale points between 1995 and 2001 to a score of 5 or 6 was equated with 0.5 wte of
an additional consultant. Table 26 was constructed from this analysis. It summarises the
assessment of the profession for additional consultant staffing in the three categories shown.
A total of 86 consultants were identified as being required, which endorses the figure of 85
that arose from the analysis described in Table 17. Nineteen departments indicated the clear
need for additional consultant staffing but gave equal scoring to a medical consultant or
clinical scientist – most actually commented that they had no strong preference. By adopting a
policy of balancing medical consultant and clinical scientist numbers in any one department
the 19 could be subdivided into 12 medical consultants and 7 clinical scientists. Thus, in
summary, this investigation has identified the need for an additional 86 consultants – 39
medical and 47 clinical scientists.

Table 26 Assessment of additional consultant requirement by department in 2001

Medical Clinical scientist Either Total


27 40 19 86

The figure of 86 consultants is based on returns from 162 of the 242 NHS clinical
biochemistry departments in the UK. Adjusting the number of consultants for this 67% return
rate yields a total requirement for an additional 129 consultants – 59 medical and 70 clinical
scientists. A figure of 129 additional consultants represents a 31% increase from current
levels. The increase would provide an additional consultant for 53% of NHS clinical
biochemistry departments (assuming that no department would get more than one additional
consultant).

This assessment is based on NHS functions. It is recognised, however, that teaching hospitals
may have good reasons for appointing university consultants with some NHS duties, rather
than full time NHS consultants.

27
6 CHANGING PRACTICE IN CLINICAL BIOCHEMISTRY

6.1 Introduction

From the outset, the Task Force was aware that this investigation was being carried out a
time of great change in NHS clinical biochemistry. Therefore, evidence of this change was
sought as part of the investigation so that it could be considered in devising the action plan
for the profession (Chapter 7).

6.2 Changing laboratory practice

6.2.1 Pre-analytical and analytical functions


Technological development in clinical biochemistry has offered a range of developments in
pre-analytical and analytical laboratory function, which could help to offset the large increase
in workload. Respondents to the questionnaire were asked to indicate which of these they had
adopted. For each change introduced they were also asked to comment on its desirability. The
same questions were also applied to two possible changes in the utilisation of staff working in
these areas. The results of this analysis are shown in Table 27.

Table 27 Developments in pre-analytical and analytical function

Function Number of departments


Introduced Desirable %
Computerised ward requesting 19 18 95
Optical scanning of request forms 12 9 75
Increased automation/robotics 51 40 78
Common analytical platforms 63 45 71
Primary sample handling 63 53 84
Reduction in internal QC 22 10 45
Increase in POCT – hospital 53 31 58
Increase in POCT – community 23 12 52
Extended working day 52 31 60
Overtime payments for staff 29 11 38
Other 10 8 80

The lukewarm response to the introduction of more point of care testing (POCT) reflected the
considerable extra work for laboratories in servicing and quality controlling POCT systems
rather than any fundamental objection to POCT. A number of respondents commented that
although they thought an ‘extended working day’ to be desirable in principle it had been
introduced without additional staff resource and had so increased pressure within the
department. In a similar vein some respondents were satisfied that their staff were being paid
for overtime but they would prefer to have sufficie nt staff to make overtime unnecessary.
Finally, the most common ‘other’ function introduced was a pneumatic tube sample delivery
system.

28
6.2.2 Post-analytical practices
The large increase in workload described in Chapter 3 has encouraged departments to give
consideration to changes in practice in managing the interpretation and reporting of results.
Respondents were asked to indicate which practices they had introduced and comment on
their desirability. The results are shown in Table 28.

Table 28 Changes in practice in post-analytical function

Number of departments
Function Introduced Desirable %
Reporting staff on site longer 38 17 45
Reduced advice out of hours 8 1 12
Restrictions on obtaining advice 2 0 0
Wider limits for telephoning results 32 8 25
Increase in electronic reports 144 117 81
Increase in exception reporting 99 36 36
Reduction in comments on reports 43 6 14
Issue of interpretative guidelines 81 73 90
Other 27 17 63

It is clear that with the exception of electronic reports and the issue of guidelines to assist
with interpretation there is no great enthusiasm for these measures, which are seen as
necessary to help cope with the post-analytical dimension of the increased workload. The
most common practice included in the ‘other’ category was the ability to report from home
using a remote terminal.

6.3 Changing consultant practice

6.3.1 Multi-site working


For many years, the normal structure for NHS clinical biochemistry departments has
comprised one department as an integral part of each NHS Trust hospital. More recently,
however, cooperation and merger between Trusts has commenced in order to provide a
comprehensive range of services across a larger population base. This development is likely to
be consolidated with the creation of ~30 new strategic health authorities in England.21 As a
result, cooperation and merger is also occurring within clinical biochemistry departments.
Respondents to the questionnaire were asked to comment on the number of sites in which
they work as a consultant. The results are shown in Table 29. Although one-site working
remains the largest group, multi-site departments are likely to increase during the next few
years. Several consultants included travel between sites in the ‘other’ category for the
allocation of time in their normal working week (Table 4).

Table 29 NHS departments of clinical biochemistry

Number of sites per department 1 2 3 4


Departments 193 44 10 5

29
6.3.2 Changing consultant functions
Respondents to the questionnaire were asked to comment on changes between 1995 and
2001 in the amount of time that they spent on each of the functions included in their normal
working week (Table 4). The summary of this data for all consultants is recorded in Table 30.
The right hand column is the overall cha nge based on a scoring system of increased = +1,
decreased = -1; unchanged = 0.

Table 30 Changing consultant functions: 1995–2001

Number of consultants
Function Increased Decreased Unchanged Overall
Direct patient care 56 20 102 +36
Validation/ reporting 138 54 33 +85
Clinical discussion 136 29 57 +107
Clinical visits 50 68 98 -18
Scientific insight 74 38 103 +36
Quality 183 8 30 +175
Research/development 34 112 48 -78
Teaching/training 102 38 76 +64
CPD 106 32 84 +74
Management – department 161 17 49 +144
Management – Trust 117 22 71 +95
Outside Trust 87 41 81 +46
Other 18 0 0 +18

In Table 31 the same information is broken down according to the category of consultant.
Overall, it is clear that there has been an increase in far more functions than there has been a
decrease. The single biggest increase is in time spent on quality issues such as laboratory
accreditation, audit and meeting clinical governance standards. Thereafter, the increase in
management related functions is even greater than the increase in clinical functions, despite
the large rise in workload described in Chapter 3. Education related functions show a steady
rise. The big loser is research and development (Section 5.3.3). It is interesting to note that the
only other function to show a net decline is the face-to-face discussion with clinicians in visits
to wards etc – presumably because of pressure of time. A comparison between consultant
categories shows the same general trends.

6.3.3 Perceived need for additional consultant functions


Having identified the changes in consultant functions over the last six years respondents were
then asked to suggest the functions from which their department would most benefit if an
additional consultant was appointed. Different responses were invited depending on whether
the additional consultant was a medical consultant or a consultant clinical scientist. Results of
this analysis are displayed in Table 32. The results clearly reveal that the top priorities for an
additional medical consultant lie in the clinical areas and especially in those requiring
increased patient contact. In contrast, the top priorities for an additional clinical scientist are
seen to lie in strengthening the scientific functions of the department, including further
improving quality standards. Education and management functions are given a much lower
priority for additional consultant functions.

30
Table 31 Changing consultant functions: 1995–2001

O v e r a l l score
Function NMC NCCS UMC
Direct patient care +34 Zero +3
Validation/ reporting +28 +59 0
Clinical discussion +54 +52 +2
Clinical visits +10 -27 +1
Scientific insight +13 +20 +3
Quality +62 +101 +12
Research / development -12 -63 -5
Teaching/training +35 +21 +6
CPD +27 +38 +8
Management – department +51 +82 +9
Management – Trust +42 +42 +9
Outside Trust +22 +13 +11
Other +4 +12 +1
Number of responses 86 123 14

Key
NMC NHS medical consultant
NCCS NHS consultant clinical scientist
UMC University medical consultant

Table 32 Additional consultant functions required

Number of responses
Function Medical Clinical scientist
Direct patient care 179 7
Validation/ reporting 141 180
Clinical discussion 192 169
Clinical visits 210 109
Scientific insight 64 195
Quality 147 198
Research/development 130 201
Teaching/training 145 145
CPD 77 92
Management – department 72 107
Management – Trust 25 24
Outside Trust 22 31
Other 4 6
Number of responses 239 239

31
6.3.4 Metabolic medicine
Metabolic medicine is a developing area that has suffered from a lack of clear identity,
resulting in an inconsistent and variable level of clinical support across the country. In order
to cope with the rising workload and improve professionalism in this area the specialist
training authority recently gave recognition to metabolic medicine as a training specialty. This
recognition occurred after the formation of the Task Force and distribution of the
questionnaire. Trainees from both the RCPath and the Royal College of Physicians (RCP) will
now be able to obtain accreditation in metabolic medicine. Within the RCPath it will be the
medical consultants in clinical biochemistry who seek this accreditation. Once accredited, it is
anticipated that these consultants will have appreciably greater clinical roles, including direct
patient care in one or more of the following areas: diabetes, metabolic bone disease, lipid
disorders, nutrition, adult inborn errors of metabolism. At this point in time it is not clear
what proportion of specialist registrars in clinical biochemistry will seek accreditation in
metabolic medicine. However, this development is very much in line with the priorities
identified for an additional medical consultant (Section 6.3.3).

32
7 ACTION PLAN FOR CLINICAL BIOCHEMISTRY

7.1 Priority areas for action

It is clear from Chapters 3–6 that:


• workload in clinical biochemistry has increased considerably during the last six years,
both in terms of quantity and complexity; all the indications are that this trend will
continue
• staffing in clinical biochemistry has shown an overall slight fall during the
corresponding period. Consultants work long hours
• clinical biochemistry departments have introduced a range of measures, sometimes
against their better judgement, to accommodate the increased demands on analytical
and post-analytical functions
• despite these measures, the increasing pressures are beginning to cause loss of quality
and threaten clinical governance. A majority of departments are now struggling to cope
and unless urgent action is instituted most will be unable to cope within four years.

Therefore, the action plan for clinical biochemistry must have as its priority both increasing
the number of staff working in clinical biochemistry departments, and also ensuring that
workforce planning for the specialty acknowledges this need at the earliest possible
opportunity.

The Task Force was established with a specific remit for consultant staff and so this will be
the main focus of the action plan. However, it would be wrong of the Task Force to neglect
the very clear evidence of the need for action to increase other staff grades. Therefore, some
recommendations must be made for action that will address these grades.

The Task Force recognises that it is relatively easy to make plans. It is much more difficult to
implement them, especially when that implementation relies on securing funding. Therefore,
an essential feature of the action plan must be to suggest ways to publicise the present plight
in the profession to those in a position to influence its implementation.

7.2 Consultant staffing

7.2.1 Medical consultants


Section 5.3.6 produced evidence for an additional 59 medical consultant posts in the current
year, with that number rising with increased workload and changing roles. That evidence did
not include the formal recognition of the need for greater clinical support in the new sub-
specialty of metabolic medicine (Section 6.3.4). Even the conservative estimate of 50% of
medical consultants increasing their work by 1 session of metabolic medicine per week is
equivalent to an additional 19 wte staff. Therefore, it is recommended that the number of
medical consultants in clinical biochemistry be increased by 78 wte to meet the current needs
of the profession and the introduction of metabolic medicine. The Task Force recognises that
there is a minimum five to six-year delay between recruiting a specialist registrar and
appointing a consultant with metabolic medicine training. The Task Force also recognises
that the profession cannot train an additional 78 specialist registrars simultaneously and that
with demand for medical graduates in many specialties there is likely to be a recruitment
issue. Therefore, the Task Force recommends that the expansion of 78 specialist registrars in
clinical biochemistry (NTNs) be achieved by a planned increase of 26 per year for each of the

33
next three years. The Task Force appreciates that this programme will only complete the
expansion of consultant by the year 2009, at the earliest. By this time other factors will
almost certainly have come into play and a robust system of workforce planning is essential,
which is linked to a model for predicting the need for medical consultants (Section 7.3).

The Task Force understands that a proportion of these new consultant posts will be based in
teaching hospitals. Whilst it will be a matter for local decision as to whether any individual
post will be a full time NHS medical consultant or a shared university medical consultant, the
Task Force is keen to stress the need to maintain an academic base to the specialty with
sufficient staff to teach and train the next generation of medical students and specialist
registrars.

7.2.2 Consultant clinical scientists


As evidenced in Section 5.3.6 the Task Force recommends an expansion of 70 consultant
clinical scientist posts to meet current needs. A proportion of these posts will be capable of
being filled by principal grade staff with MRCPath. These posts could be filled earlier than
the eight years that it normally takes a grade A clinical scientist to achieve the MRCPath
qualification. However, any individuals appointed from principal grade posts would require
to be replaced in that grade and so there would still be a need to increase the number of grade
A Trainee posts by 70 to meet the consultant requirement. In addition, however, evidence is
produced in Section 7.4.2 to appoint a further 100 principal grade clinical scientists to replace
lost posts. Taking these two figures together means that there is a requirement for an
additional 170 grade A clinical scientists. To further compound the problem, Section 5.3.5
indicates that the current number of trainees is only 50% of that required to meet the needs
of the profession in eight years time and that there will be a large rise in retirements in 2008–
2012.

Therefore, the Task Force has identified a major problem in the recruitment and training of
clinical scientists to meet the needs of the profession. It recommends that the number of grade
A clinical scientist posts must be matched to the currently identified workforce planning needs
and then further expanded by 22 posts for each of the next eight years. In order for this
requirement to have any chance of success it is recommended that, as a matter of urgency, the
ACB prepares a detailed paper on the workforce requirements for clinical scientists, which it
presents all relevant national and regional workforce confederations. The Task Force believes
that it would be very helpful if the RCPath medical workforce unit could add its support to
this paper.

An eight-year implementation period means that other factors will almost certainly have come
into play in the interim and a robust system of workforce planning remains essential. This
requires to be linked to a model for predicting the need for consultant clinical scientists (see
Section 7.3).

7.3 Model to predict the number of consultants in clinical biochemistry

7.3.1 Assessing the need for and basis of the model


Respondents to the questionnaire were invited to express their views on the need for a model
to predict the number of consultants in clinical biochemistry. They were also asked to
comment on a range of criteria upon which the model might be based. The results of this
analysis are shown in Table 33.

34
Table 33 Assessing the need for a model to predict consultant numbers

Question Yes No
Is there a need for a model? 251 0
Model based on 1 consultant /DGH 34
Model based on 2 consultants/DGH 32
Model based on 1NMC + 1 NCCS /DGH 147
Model based on 3 consultants /DGH 15
Model linked to population served 78
Model linked to laboratory workload 141
Model linked to complexity of workload 165
Model linked to GPs + clinical consultants 116
Model linked to consultant level functions 108
Workforce plan based on 1995 as a baseline 66
Workforce plan to optimise staffing by 2005 150

There was unanimous recognition of the need for a model to help predict the level of
consultant staffing. Of the four options for a baseline consultant staffing level in the ‘average
DGH’ the overwhelming majority favoured the model of one medical consultant and one
consultant clinical scientist. Interestingly, the ACB and RCPath first proposed this model
jointly some 20 years ago,22 although it has never been fully implemented. Of the suggested
components to any model there was much less clarity of thinking, which perhaps confirms
that this is not a straightforward matter. However, a model that encompassed elements of
laboratory workload quantity and complexity would meet with the support of the majority of
respondents. There was strong support for the idea of a model that aimed to optimise staffing
by 2005 – even though this is unrealistic in practice (Section 7.2).

7.3.2 A model to predict the number of consultants in clinical biochemistry


Using all the information gathered by the Task Force, including the data that emerged from
the analysis of the questionnaire, the following key factors were recognised as being necessary
for the model.
• An increase of ~128 consultants from the 1995 baseline.
• Assistance for the single -handed consultant plus recognition that the majority of
consultants are already working in excess of the European Working Time Directive.
• Recognition that workload volume must be linked to staffing.
• Recognition of the complexity of service delivery.
• Recognition of changing patterns of service delivery.
• Recognition of the likely impact of metabolic medicine.
• The need to maintain the academic core of clinical biochemistry.
• A model that is simple to understand and implement.
• A model that can accommodate changing patterns of service delivery.

35
These factors have been accommodated into a six-step model, as follows.
(i) A minimum of 1.5 wte consultants per department to overcome single-handed working
and excessive consultant working hours.
(ii) A formula to recognise the incremental need for increased consultant staffing as
workload rises above threshold levels.
(iii) Recognition of a growing number of multi-site departments and that the complexity of
a department operating from more than one site increases the need for consultant
staffing.
(iv) Recognition that teaching and children’s hospitals, and departments with a lead training
role have need of relatively more consultant staff.
(v) A formula to recognise the incremental need for greater consultant staffing as the
amount of direct patient care rises with the growth of metabolic medicine.
(vi) Recognition of the need to protect the academic base to clinical biochemistry.

The following six-step model is, therefore recommended as the basis for determining
consultant staffing in NHS departments of clinical biochemistry.
(i) Each department should have a minimum of 1.5 wte consultant staff.
(ii) Add 0.1 wte consultant for each increment of 25 000 requests per year above a baseline
of 200 000.
(iii) Add 0.5 wte consultant for each department that operates from more than one
substantial geographical site.
(iv) Add 0.5 wte consultant for each teaching hospital department, or for each children’s
hospital department, or for other departments that have a lead role in training medical
or clinical scientist staff.
(v) Add 0.15 wte consultant for each 3.5 hour session of direct clinical care above a
baseline of 2 sessions per medical consultant.
(vi) Add 1.0 wte consultant to each department that contains a university professor of
clinical biochemistry.

This model is capable of application to any configuration of service delivery, including the
current proposals for strategic health authorities that serve populations of ~1.5 million.21

It is recognised that for most current departments this model will not provide a whole number
of wte consultants. Two solutions are offered to this problem. Firstly, the opportunity of
sharing consultants across neighbouring departments should be examined. Thus, two adjacent
departments both with an establishment of 1.5 wte consultants could choose to employ 3.0
wte between them. This option is very much in line with current thinking on different
patterns of service delivery.21 Secondly, if sharing is not an option the rounding to the nearest
whole number should be considered.

7.3.3 Validation of the model


A total of 156 departments provided sufficient information in the questionnaire to enable a
comparison of current staffing and staffing as suggested by the model. Furthermore, a
comparison could also be made between the staffing suggested by the model and that assessed
from the returns in the questionnaire (Section 5.3.6). A summary of the overall figures is
given in Table 34 and correlation of the three sets of data is shown in Figures 1 and 2.
Extrapolating a change of 80–81 to the whole profession (242 departments) would suggest an
overall increase of 124–125 consultants, a figure very close to the target of 128 yielded by the
analysis in Section 5.3.6.
36
Table 34 Comparison of consultant staffing levels

Assessment method This study Change


Current staffing levels 297.5 –
Figure from returns to questionnaire 377.5 +80
Figure from model 378.5 +81

Figures 1 and 2 reveal strong correlations between current staffing and staffing predicted by
the model (R2 = 0.72) and between the staffing predicted by the model and the staffing
assessed from the returns to the questionnaire (R2 = 0.74). There are few outlying laboratories
in either analysis, suggesting that the model is soundly based and that the analysis from the
returns to the questionnaire was also realistic. Significantly, the second correlation analysis
has a gradient of 1.04, with an intercept of -0.10, suggesting parity between the model and
the returns from the questionnaire.

Figure 1 Validation of consultant staffing model

37
Figure 2 Consultant staffing model versus assessed staffing

7.3.4 Implementation of the consultant staffing model


Implementation of the staffing model will require acceptance both by the profession and by
hospital managers. Acceptance will only be forthcoming if the model is judged to be
scientifically sound, practical to use and capable of yielding valid and practical outcomes. The
first stage in acceptance by the profession must be for the Councils of the ACB and RCPath to
give their approval. Thereafter, a description of the model, together with its validation,
should be published. Acceptance by hospital managers will only occur if they can be
convinced of the validity of the case for additional staff based on consideration of increasing
clinical need, quality standards and clinical governance in their own Trust. Recommendations
on how this may be achieved are given in Section 7.5

7.4 Non-consultant staffing

7.4.1 Trainee medical and clinical scientist staff


The supply of appropriately trained staff to occupy medical consultant and senior clinical
scientist (consultant plus Principal grade) posts is inextricably linked with the recruitment of
the appropriate number of trainees (Section 7.2). At a time when a substantial increase in

38
consultant staffing is being proposed a robust system of workforce planning is essential.
Although these systems are in place for both medical and clinical scientist staff there has, until
now, been no joint oversight of the senior staffing requirements of the profession. The
Council of the RCPath has recently recognised the need for better communication on this
matter and has recommended that the membership of its medical workforce unit be expanded
to include someone who has responsibility for clinical scientists. The Task Force welcomes
this initiative, on the understanding that the appointed individual will liase closely with the
ACB workforce advisory committee.

7.4.2 Grade B clinical scientists


Table 6 reveals a 13% fall in the number of grade B clinical scientist posts during the period
of study. This reduction has occurred in an unplanned manner with individual NHS Trusts
taking the decision not to replace a vacant post as a cost saving measure. This development is
most unwelcome at a time of rapid expansion in the workload. principal grade clinical
scientists (with MRCPath) fulfil a vital role in clinical biochemistry departments. They have
responsibility for scientific oversight of specialist areas of service delivery and development
and they usually take the largest share of routine results interpretation and reporting. In both
these roles they contribute to quality standards whilst relieving some of the pressure on
consultant level staff. Table 17 reveals that 36% of departments have an immediate need to
increase grade B clinical scientists, with that figure rising to 47% in 2005. Assuming that the
demand for grade B clinical scientists in any one department equates to 1 wte staff member
these figures suggest the need for an additional 87 grade B clinical scientists in 2001 rising to
113 by 2005. To put these numbers into context Table 6 (when corrected to a 100% return)
demonstrates an unplanned loss of 95 posts of this grade since 1995. In effect, therefore, the
study has revealed the need to return the number of grade B clinical scientists to 1995 levels.

The ACB/RCPath minimum senior staffing model, published in 1996, was designed to
determine the number of senior staff, defined as consultants plus principal clinical scientists,
required for clinical biochemistry departments.9 It emerges from Table 8 that in only 13% of
NHS Trusts have managers used and acted on the results yielded by this model. This figure
contrasts with the 89% of departments who used the model and found it to yield credible
results for senior staffing levels. Therefore, it is recommended that the 1996 ACB/RCPath
minimum senior staffing model be actively promoted in conjunction with the new six-step
consultant staffing model. For any clinical biochemistry department, the difference in staffing
predicted by the two models may be equated with the minimum number of principal clinical
scientists required.

7.4.3 Biomedical scientists


Table 17 reveals that of the 167 departments that responded 133 (79%) identified an
immediate need for BMS staff. By 2005, the percentage of departments that report that they
will require additional BMS staff has risen to 90%. It was not the role of the Task Force to
examine BMS staffing in any detail, especially since there have been recent reviews of this
topic.4,5 However, the strength of evidence in favour of additional BMS staffing is
overwhelming. It is recommended that the findings of this survey be made known to the
Institute of Biomedical Science (IBMS) at an early stage and that the ACB and RCPath offer
to work with the IBMS to promote the case for additional biomedical scientist staff in clinical
biochemistry departments.

39
7.4.4 Medical laboratory assistants and administrative and clerical staff
With no professional body to represent their interests the changing role of MLA and A&C
staff in clinical biochemistry departments has gone largely unnoticed. MLA staff have
traditionally worked with specimen reception and basic processing, whilst A&C staff have
usually dealt with the input of patient details into the computer and routine administration.
However, there is increasing flexibility within this workload and the potential for an
expanding range of competences in line with current government policy.14 Information on
numbers for these staff grades comes from Scotland1 and from the CBC.2 In both cases the
data suggests a rise in MLA staff and a corresponding fall in the lower grades of A&C staff.
Table 17 reveals that the percentage of departments requiring additional MLA and A&C staff
in 2001 is 51% and 44%, respectively. With current workload trends these figures will rise to
57% and 52% by 2005. It is recommended that the ACB and RCPath work with the IBMS
to define the roles of MLA and A&C staff working in clinical biochemistry; to determine
current and future staffing levels; and to suggest a mechanism for ensuring that the
contribution of these key members of staff is not overlooked.

7.5 Publicity and promotion of the Task Force report

7.5.1 Consultation document


The full report will be circulated in draft form to a cohort of the profession who have
expressed an interest in reviewing it. The amended report will then be submitted formally to
the Councils of the ACB and RCPath. It is hoped that this second stage will occur during the
first two months of 2002.

7.5.2 Final report


Once approved by the ACB and RCPath it is recommended that the full Task Force report be
published in professional format on the websites of the ACB and RCPath.

7.5.3 Executive summary and recommendations


Chapter 1 of the report represents a concise summary of the main conclusions from the
investigation together with all the recommendations. This has been written in a format that
allows it to be published as a standalone document. It is recommended that the ACB and
RCPath publish Chapter 1 of the Task Force report jointly in a hard-copy form that will
allow for widespread distribution to the profession, health service managers and the four
Departments of Health.

7.5.4 Promotion of the findings in the Task Force report


It is recommended that the ACB and RCPath jointly agree a detailed strategy for the
promotion of the main findings of the Task Force report. An essential part of the promotion
of the findings will have to be at local NHS Trust level with existing consultants taking the
lead role. Therefore, as part of the detailed promotion strategy it is recommended that heads
of departments of clinical biochemistry discuss the findings of the Task Force report with
their chief executive officer, director of pathology and medical director with a view to
preparing a local case for action. As part of this process the attention of the chief executive
should be drawn to the dramatic increase in work from GPs, much of which is related to
national service frameworks.

40
7.6 Review of progress with the Task Force recommendations

The Task Force believes that the recommendations outlined in this report are essential for the
future viability of NHS clinical biochemistry. The recommendations to increase staffing
numbers are especially important and there should be careful monitoring of progress against
the defined targets. Furthermore, the relevance of the recommendations needs to be reviewed
in the light of changing circumstances. Therefore, it is recommended that the implementation
of the Task Force recommendations is the subject of regular joint review by the RCPath
Medical Workforce Department and the ACB Workforce Advisory Committee.

41
8 FEEDBACK FROM SENIOR TRUST MANAGEMENT

8.1 Introduction

This chapter summarises the responses received from the information sheet and survey
(Appendix 4), which was sent to NHS Trust chief executive officers. The respondents were
from a range of senior managers (Section 2.5.2). The feedback has been grouped into four
areas, which correspond to Chapters 3–6. Free comments were also invited and these are
summarised in Appendix 5.

8.2 Workload in clinical biochemistry

Senior managers were invited to select a category to define how clinical biochemistry is
regarded in their Trust. The results are shown in Table 35. Only 36% of senior managers
regard clinical biochemistry as a clinical service, even though more than 50% of departments
contain medical consultant staff.

Table 35 Clinical biochemistry: classification by senior Trust managers

Category % classification
Clinical service 36
Clinical support service 64
Support service 0
Other 0

Senior managers were then asked to categorise the change in clinical biochemistry workload
in their Trust for the period 1995–2001. The results are shown in Table 36.

Table 36 Change in workload 1995–2001: classification by senior Trust managers

Increase in workload % classification


Increase of <20% 3
Increase of 20–40% 26
Increase of >40% 71

These results confirm that senior managers recognise the large increases in workload
experienced by clinical biochemistry departments over the period (Section 3.1).

8.3 Staffing in clinical biochemistry

Staffing issues were probed in a two different ways. Firstly, senior managers were asked to list
the change in staffing in their Trust over the period 1995–2001. The results in Table 37
confirm that in the large majority of departments any increase in staffing has lagged well
behind the increase in workload.

42
Table 37 Change in staffing 1995–2001: classification by senior Trust managers

Increase in staffing % classification


Increase of <5% 69
Increase of 5–10% 27
Increase of >10% 4

Secondly, a specific question was asked in relation to the change in consultant staffing in
clinical biochemistry over the same period. The results in Table 38 confirm that there has
been very little overall change in consultant staffing. However, the small net increase does
contrast somewhat with the hard data in Section 4.2, suggesting that the Trusts responding to
the survey were, if anything, slightly more representative of those that had increased rather
than decreased consultant staffing. Given the nature of the survey this finding is not
surprising.

Table 38 Clinical biochemistry consultants 1995–2001: classification by senior Trust managers

Change in numbers % classification


Increased 16
Unchanged 76
Decreased 8

8.4 Pressures in clinical biochemistry

A significant proportion of the survey sought the views of senior managers on the current
pressures in clinical biochemistry. Trusts were asked to classify the overall quality of the
service provided by their clinical biochemistry department as judged by feedback from users
and ability to meet clinical governance targets. As a supplementary, Trust managers were
asked how the position has changed over the last five years. The results in Table 39 reveal
that the vast majority of senior managers regard their clinical biochemistry services highly.
Whilst there is clearly an effort to improve these services still further it is significant that 25%
of senior managers are willing to report deterioration in the quality of clinical biochemistry
services over the last five years.

Table 39 Quality of clinical biochemistry: classification by senior Trust managers

Quality % classification
Excellent 50
Satisfactory 46
Less than satisfactory 4
Poor 0
Improved in last five years 36
Unchanged in last five years 39
Deteriorated in last five years 25

43
Senior managers were asked if they recognised in their Trust the summary of data found from
the consultant questionnaire that was included in the information sheet (Appendix 4). As
Table 40 reveals a majority of senior managers recognise all or most of the main findings,
only one Trust claimed to recognise none of the findings. This confirms that senior managers
are generally well briefed about the pressures in clinical biochemistry departments.

Table 40 Recognition by senior Trust managers of main findings from consultant questionnaire

Criterion % classification
Recognise all or most findings 58
Recognise some findings 41
Recognise no findings 1

Chief executiv es were specifically asked if laboratories in their Trust had been targeted for
cost savings during the period 1995–2001, and what had been the impact of the various
pressures on the cost effectiveness of clinical biochemistry. The results in Table 41 show that
a remarkable 74% of Trusts have targeted laboratories for cost savings, and that almost all
laboratories have demonstrated an improvement in cost-effectiveness.

Table 41 Cost pressures in clinical biochemistry sought by senior Trust managers

Cost parameter: 1995–2001 % response


Yes No
Target for cost savings 74 26
Increased cost effectiveness 98 2

The final questions relating to pressures within clinical biochemistry were linked to an
assessment of the adequacy of the current staffing to cope with the workload and other
pressures in the department. The results in Table 42 reveal that whilst the majority of senior
managers regard current consultant and grade B clinical scientist staffing as ‘adequate or
better’ a significant minority acknowledg e that these grades of staff are either struggling or
unable to cope. These results paint a rather more optimistic picture than the corresponding
results from the consultant questionnaire (Section 5.2). The results for biomedical scientist
staff are also more optimistic than in Section 5.2, although they still show a strong majority
of laboratories that are struggling or unable to cope with the current number of BMS staff in
post. Table 42 also confirms that there are a significant proportion of departments that are
understaffed for both MLA and A&C staff, although the percentage of such departments is
again a little lower than suggested by consultants. (Section 4.1.4).

Table 42 Adequacy of staffing in clinical biochemistry: classification by senior Trust managers

% classification
Staff grade Satisfactory or better Adequate Struggling Inadequate
Consultant 31 40 21 8
Grade B clinical scientist 25 37 22 16
Biomedical scientist 8 30 48 14
MLA 10 50 31 9
A&C 8 55 30 7

44
Table 43 is especially revealing since it compares the assessment of adequacy of total staffing
in the opinion of the senior managers and the consultant(s) in clinical biochemistry in the
same Trust. Although senior managers do have the more optimistic view it is highly
significant that 50% of this group consider that total staffing in their clinical biochemistry
department is struggling or unable to cope. The corresponding figure for consultant opinion is
78%.

Table 43 Adequacy of staffing in clinical biochemistry: senior managers and consultants

% classification
Group making assessment Satisfactory or better Adequate Struggling Inadequate
Senior manager 7 43 50 0
Consultant 2 20 75 3

8.5 Changing practice in clinical biochemistry

A number of approaches were used in the survey to assess the views of senior managers on
this topic. First, Trusts were asked if within the past two years there had been a meeting
between senior management and the consultant(s) in clinical biochemistry to review the
impact of workload and other pressures on staffing. It is rather disappointing to note that
37% of Trusts no such meeting has taken place.

Senior managers were much more positive about non-staff investment into their clinical
biochemistry departments over the past five years. As Table 44 reveals a high percentage of
departments have received investment in fabric, automation and IT. This data agrees with
that reported by consultants (Section 6.2).

Table 44 Non-staff investment in clinical biochemistry: 1995–2001

Investment % Trusts confirming investment


Laboratory fabric 38
Laboratory automation 71
Laboratory IT 62

Trusts were invited to predict which of a range of consultant functions they thought would
increase in their clinical biochemistry department in the next four years. The results in Table
45 demonstrate that a majority of departments expect to see increased activity in each of the
areas of consultant activity. These results are in good agreement with those from the
consultant questionnaire (Section 6.3). Of particular interest is the finding that 76% of senior
managers anticipate service reconfiguration during this period.

45
Table 45 Anticipated increase in consultant clinical biochemistry functions

Functions % Senior managers expecting increase


Direct patient care (metabolic medicine) 51
Result interpretation and clinical liaison 83
Meeting quality standards 88
Providing scientific insight 55
Compliance with clinical governance targets 91
Reconfiguring service delivery 76
Teaching, training and CPD 74
Management in department or directorate 55

Crucially, senior managers were asked directly if they thought it likely that an additional
consultant in clinical biochemistry would be appointed within the next four years. If this was
certain or probable, the Trust was asked to indicate if the appointment would be of a medical
consultant or a consultant clinical scientist. Otherwise the Trust was asked to give the reason
for not appointing. The results in Table 46 are for the actual number of responses. They
demonstrate that 55 Trusts (43%) are likely to appoint a consultant in clinical biochemistry
within four years. Correcting for the 56% return rate of the survey this equates to a total
figure of 100 new consultant appointments across the UK.

Table 46 Likelihood of appointing an additional consultant in clinical biochemistry

Action/reason Number of responses


Likelihood Appointment No appointment
Will appoint 22
Probably will appoint 33
Don’t know 38
Will not appoint 32
Medical consultant 24
Consultant clinical scientist 23
No preference 11
Not justified on clinical/ service grounds 11
Not a priority compared to other disciplines 46
Funding not available 15
Other reason 5

It is interesting to note that once again the split between medical consultants and clinical
scientists is almost exactly equal and so the conclusion from senior managers is that NHS
clinical biochemistry will probably wish to appoint 50 medical consultants and 50 consultant
clinical scientists over the next few years. This figure of 100 must be compared with the total
figure of 142 derived from the consultant questionnaires and derived from the consultant
staffing model (Sections 7.2 and 7.3).

46
The final question for senior managers related to the consultant staffing model. Trusts were
informed that the ACB and RCPath has produced and validated a simple model which gives
guidance on the minimum number of consultant staff required in any clinical biochemistry
department based on the clinical and laboratory workload and the complexity of the service
provided. Trusts were also informed that the model is applicable to departments operating
from more than one site and senior managers were asked if they would be prepared to assess
the relevance of this model. The answers to this question are in Table 47 and they show a
high level of interest.

Table 47 Trust senior manager interest in consultant staffing model

Response % responses
Interested in assessing model 70
Not interested in assessing model 5
Don’t know 25

8.6 Summary of feedback from Trust management

Overall, the feedback from senior managers is in good agreement with the findings from the
consultant questionnaire. A large majority of Trusts recognise all or some of the main
findings from the questionnaire. Senior managers acknowledge the pressure in clinical
biochemistry departments and half of them concede that their department is struggling to
cope with the staff in post. There is a difference of degree in that the senior managers take a
view that is somewhat more optimistic than their consultant clinical biochemistry colleagues.
This is to be expected, and may, in part, be explained by a difference in the spectrum of
returns between the consultant questionnaire (more likely to return if problems exist) and the
CEO survey (more likely to return if the service is going well) (Section 8.3).

The Task Force was established with a brief to concentrate on consultant staffing and this
report produces strong evidence in favour of 142 additional consultants in clinical
biochemistry. Without assuming any appointments from the ‘don’t know’ category senior
managers see the need for ~100 such posts (70%) and this suggests that the Task Force
calculations are fairly realistic as well as evidence based.

It is interesting to note that of the reasons given for not appointing another consultant senior
managers put ‘not a priority compared to other disciplines’ and ‘funding not available’ ahead
of ‘not justified on clinical or service grounds’.

47
9 REFERENCES

1 Laboratory statistics: clinical chemistry. Information and Statistics Division, Scottish


Executive Health Department, 1995 and 2000.

2 Clinical biochemistry feedback report. London: The Clinical Benchmarking Company, 1995,
1999 and 2000.

3 European Working Time Directive. Council of the European Union Directive No 93/104/EC
1993. http://www.incomesdata.co.uk/brief/wtimedir.htm.

4 Survey on recruitment and retention of biomedical scientists employed in the National Health
Service. London: The Institute of Biomedical Science, 2000. http://www.ibms.org.

5 The recruitment, training and retention of medical laboratory scientific officers. Scottish
Medical and Scientific Advisory Committee. Edinburgh: Scottish Executive Health
Department, 2001. http://www.show.scot.nhs.uk.

6 Addressing workload and staffing issues in UK histopathology and cytology laboratories.


Institute for Employment Research, University of Warwick for Clinical Pathology
Accreditation (UK) Ltd, 2000. http://www.cpa -uk.co.uk.

7 Consultant haematologists’ manpower 2000. Joint Intercollegiate Committee on


Haematology. London: British Society for Haematology/Royal College of Pathologists, 2001.

8 Consultant workload in medical microbiology and virology. London: Royal College of


Pathologists, 2001.

9 A model for determining minimum senior staffing in departments of clinical biochemistry


(chemical pathology). Association of Clinical Biochemists and Royal College of Pathologists.
1997.

10 Strategic review of pathology services. London: Department of Health, 1995.

11 Lapworth R and Teal TK. Laboratory blunders revisited. Ann Clin Biochem 1994;31:78–84.

12 Moore A and McQuay H. Blunders. Bandolier 1998;5(1):6–7.

13 Blumenthal D. The error of our ways (Editorial). Clin Chem 1997;43:1305.

14 Making the change. A strategy for the professions in healthcare science. London: Department
of Health, 2001. http://www.doh.gov.uk/makingthechange.

15 Statistics for general medical practitioners in England: 1990–2000. London: Department of


Health. http://www.doh.gov.uk/public/sbo104.htm.

16 Hospital, public health medicine and community health services medical and dental staff in
England: 1990–2000. London: Department of Health.
http://www.doh.gov.uk/public/sb0102.htm.

17 Key features of a good diabetes service. Health service guideline HSG(97)45. Department of
Health, London 1997. http://tap.ccta.gov.uk/doh/coin4.nsf/page/HSG-(97)45.
48
18 Diabetes draft standards August 2001. Clinical Standards Board for Scotland. Edinburgh:
Scottish Executive Health Department, 2001. http://www.clinicalstandards.org.

19 Health service circular HSC 2000/012. National service framework for coronary heart
disease. London: Department of Health, 2000.
http://tap.ccta.gov.uk/doh/coin4.nsf/page/HSC-2000-012.

20 Health service circular HSC-2000/021. Improving the quality of cancer services. London:
Department of Health, 2000. http://tap.ccta.gov.uk/doh/coin4.nsf/page/HSC-2000-021.

21 Shifting the balance of power within the NHS – securing delivery. London: Department of
Health, 2001. http://www.doh.gov.uk/shiftingthebalance/index.htm.

22 Manpower working party. Report to Council. London: Association of Clinical Biochemists,


1983.

49
10 ACKNOWLEDGEMENTS

The Task Force gratefully acknowledges the assistance of the following.

• The staff of the Association of Clinical Biochemists for access to the ACB database and
for keeping us fed and watered during Task Force meetings.

• The staff of the Medical Workforce Department of the Royal College of Pathologists
for access to the RCPath database.

• Professor R Dyson and the staff of the Clinical Benchmarking Company for access to
the clinical biochemistry reports for 1995–2000.

• The staff of Clinical Pathology Accreditation (UK) Ltd for data on clinical biochemistry
laboratory accreditation.

• Dr D Bullock of the UK National External Quality Assessment Schemes for information


on the non-analytical error rate.

• Mrs R Lapworth and Mrs T Teal of the William Harvey Hospital, Ashford, Kent for
information and advice on the causes and recording of laboratory blunders.

• The ~100 consultants who contributed to the workshop on this topic at Focus 2002.

• The 16 consultants who read and commented on the draft of this report.

• The 261 consultants from 177 departments that completed the consultant
questionnaire.

• The 129 NHS Trust senior managers who completed the chief executive questionnaire.

50
11 APPENDICES

A1 MEMBERSHIP OF THE JOINT ACB/RCPATH TASK FORCE

Dr Graham H Beastall
Consultant Clinical Scientist
Department of Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF
gbeastall@gri-biochem.org.uk
Member of RCPath SAC for Clinical Biochemistry

Professor Alan Shenkin


Professor of Clinical Chemistry, Honorary Consultant Chemical Pathologist
Royal Liverpool University Hospital, Duncan Building, Liverpool L69 3GA
shenkin@liverpool.ac.uk
President, Association of Clinical Biochemists

Dr David Stansbie
Medical Consultant in Clinical Biochemistry
Bristol Royal Infirmary, Marlborough St, Bristol BS2 8HW
david.stansbie@bris.ac.uk
Chairman of RCPath SAC for Clinical Biochemistry

Dr Howard Worth
Consultant Clinical Scientist
King’s Mill Hospital, Mansfield Rd, Sutton in Ashfield, Nottinghamshire NG17 4JL
Worth@KMC-tr.nhs.uk
Chairman, ACB Workforce Advisory Committee

51
A2 CONSULTANT QUESTIONNAIRE

How many consultant level staff are required in NHS clinical biochemistry?

Questionnaire from the Joint ACB/RCPath Task Force: June 2001

Introduction

The ACB and RCPath have established a joint Task Force with the following remit: “To
produce an evidence based report which recommends the optimal number of consultant level
staff currently required for NHS Clinical Biochemistry Departments in the UK, together with
a model which may be used to predict future consultant level staffing requirements”. For the
purposes of this study consultant le vel staff are defined as Consultant Chemical Pathologists,
Grade C Clinical Scientists in Clinical Biochemistry, and University employees of equivalent
status who undertake significant amounts of NHS service work.

An integral part of the work of the Task Force is the gathering of evidence from practising
consultant level staff in our specialty. Therefore, this questionnaire has been prepared, which
is being distributed to all consultant level staff in the UK. The purpose of the questionnaire is
to determine trends in workload and staffing over the period 1995–2000 and to document
indices of quality, both within the department and in the capacity of the individual
consultant, which are required to manage the current and future service demands.

The questionnaire is in two parts. Part 1 relates to the department in which you work. A code
number has been attached to this section in order to allow collation of the returns from the
same department so that only one outcome per department is analysed, irrespective of the
number of consultants in that department. Part 2 relates to you as an individual consultant.
There is no code attached to this section because it is intended to include all returns in the
final analysis. All returns will be regarded as confidential and anonymous.

Three kinds of response are required to the questions asked. The inclusion of a box indicates
that a ‘tick’ answer is required. The inclusion of a line indicates that specific information is
requested. An incline asks you to express your opinion by circling a number on a on a sliding
scale of 1–9. Please take care to give the correct response to each question.

This is a very important questionnaire. It is not overstating the case to suggest that the future
shape of our profession will be influenced by the findings from it. Therefore, please find the
time to complete it in as much detail as you can. We are hoping for a very high return rate. If
possible, please work with your colleagues in multi-consultant departments to ensure that you
submit an identical return to Part 1 of the questionnaire.

Please return your questionnaire, by mail or fax, no later than July 31st 2001, to:
Graham Beastall, Department of Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF
Fax: 0141 552 3324

Graham Beastall, Alan Shenkin, David Stansbie, Howard Worth


(Members of the Joint ACB / RCPath Task Force)

52
Part 1: Questions relating to the department in which you do your NHS work

Code Number:__________________________

Q1 Describe the department in which you work (tick as appropriate):


Teaching Hospital England
NHS District Hospital N Ireland
Children’s Hospital Scotland
Specialist Unit Wales

Q2 Detail the approximate size of the population and the number of inpatient be ds which are
directly supported by your department:
The local population served by the department ______
Number of local inpatient beds served by your department ______

Q3 Give the laboratory accreditation status of your department on March 31st 1995 and on March
31st 2001: 1995 2001
Unconditional accreditation
Conditional / Provisional accreditation
No accreditation – Referred
No accreditation – Yet to apply

Q4 List the numbers of specified NHS staff (wte) working in your department on March 31st 1995
and on March 31st 2001. For staff employed by bodies other than the NHS (e.g. University)
estimate the wte contribution made to NHS work and include them in the most appropriate
NHS grade. For joint Biochemistry and Haematology departments include only the staff
working in Clinical Biochemistry:
1995 2001
In Post Unfilled In Post Unfilled
Consultant Chemical Pathologist _____ _____ _____ _____
Non-career Grade Medical staff _____ _____ _____ _____
Trainee Medical staff _____ _____ _____ _____
Grade C Clinical Biochemist _____ _____ _____ _____
Grade B Clinical Biochemist _____ _____ _____ _____
Grade A Trainee Clinical Biochemist _____ _____ _____ _____
Total Biomedical Scientist staff _____ _____ _____ _____

Record the changes in the actual number of wte staff working (in post plus unfilled) in your
department between March 31st 1995 and March 31st 2001:
Increase Decrease
Total Medical staff _____ _____
Total Clinical Scientist staff _____ _____

53
Q5 List the overall workload of your department for the years ending on March 31st 1995 and
March 31st 2001 (or March 31st 2000 if these are the latest figures available). Record these
figures both as Requests and Tests using the following definitions as recommended by the
Clinical Benchmarking Company:

“A Request is work received from a single patient at one time usually, but not always on a
single specimen”.
“A Test is a result produced by an analytical process on a single specimen. Calculated results
and comments describing a test or result should not be counted as tests.”

1995 2001
Total Requests _____ _____
Total Tests _____ _____

Express the change in workload between 1995 and 2001 as a percentage of the 1995 figure
and record the results below:
Increase Decrease
Change in total Requests ___% ___%
Change in total Tests ___% ___%

Q6 Estimate for the years ending 31st March 1995 and 31st March 2001 the percentage of the
workload of your department that was processed outside your ‘normal working hours’ (defined
as the hours when you have maximum staff working) and the change in this percentage over
the six-year period:
1995 2001
% Workload processed outside
‘normal working hours’ ___% ___%

Change in % workload processed outside ‘normal working hours ‘ between the years of 1995
and 2001:
Increase Decrease
____ ____

Q7 Estimate for the years ending 31st March 1995 and 31st March 2001 the percentage of the
workload of your department that originated from General Practitioners and the change in this
percentage over the six year period:
1995 2001
% Workload from GPs ___% ___%

Change in % workload from GPs between the years of 1995 and 2001
Increase Decrease
____ ____

Q8 Comment on any change in the repertoire of tests offered by your department during the
period between March 31st 1995 and 31st March 2001:
Unchanged Increased Decreased
The total laboratory repertoire is
The ‘out of hours’ repertoire is

54
Estimate the number of analytes involved in any change to your repertoire during the six-year
period Increase Decrease
Change in total number of analytes ___ ___
Change in analytes offered ‘out of hours’ ___ ___

Q9 Comment on any demand to improve turnaround times for key results in the period between
March 31st 1995 and March 31st 2001 and on the success of the laboratory in meeting that
demand:
Unchanged Increased Decreased
Demand for faster turnaround time

Unchanged Improved Deteriorated


Delivery of faster turnaround time

Q10 Estimate the adequacy of your total staffing to manage the workload at each of the three time
points specified. For 1995 and 2001 make your estimate on actual staff numbers and
workload. For 2005 assume a similar trend in workload and staffing to that experienced
between March 31st 1995 and March 31st 2001:
1995 2001 2005
Staffing satisfactory or better
Staffing adequate
Staffing struggling to cope
Staffing unable to cope

If you ticked any of the boxes that indicated that your staffing ‘was/is/will be struggling to
cope’ or ‘was/is/will be unable to cope’ please indicate the staff grade(s) affected:
1995 2001 2005
Consultant (Medical and Grade C)
Grade B Clinical Biochemist
Biomedical Scientist (all grades)
Medical Laboratory Assistant
Administrative and Clerical

Q11 Which of the following practices have you introduced during the past six years to help with
managing the pre-analytical and analytical functions of your department? For each practice
that you have ticked please indicate if you regard its introduction as a desirable change in an
ideal laboratory-working environment. Do not complete the ‘Desirable ’ column unless you
have first ticked the ‘Introduced’ column:
Introduced Desirable
Computerised ward requesting (‘order comms’)
Optical scanning of request forms
Extended working day
Overtime payments for staff
Increased automation / robotics
Common analytical platforms for more of repertoire
Primary sample handling
Reduction in internal quality control
Increase in point of care testing in hospital
Increase in point of care testing in community
Other (specify) ____________________________

55
Q12 Which of the following practices have you introduced during the past five years to help with
managing the reporting function of your department? For each practice that you have ticked
please indicate if you regard its introduction as a desirable change in an ideal laboratory-
working environment. Do not complete the ‘Desirable’ column unless you have first ticked the
‘Introduced’ column:
Introduced Desirable
Reporting staff on site during a longer working day
Reduced advice from interpretive staff ‘out of hours’
Restrictions on contacting laboratory for advice
Wider limits for telephoning abnormal results
Increase in % of electronic reports
Increase in % of reports not seen by interpretive staff
Reduced % of reports with interpretive comment
Issue of guidelines to assist interpretation of results
Other (specify) ____________________________

Q13 The recording of blunders, errors or complaints is part of Clinical Governance. Minor events
may be defined as within the laboratory, whilst major events include the issuing of incorrect
results or advice that may influence patient management:
Yes No
Does your laboratory formally record these events?
Do you distinguish between minor and major events?
Do you formally investigate all complaints?

Increased Decreased
Over the past six years the total of these events has
Over the past six years minor events have
Over the past six years major events have
Estimate the percentage change in total events in 5 years ___% ___%

Q14 Participation in external quality assessment (EQA) is a requirement for laboratory


accreditation. Comment on the level of participation and performance of your department in
EQA schemes in the period between March 31st 1995 and March 2001 and indicate if your
laboratory has any analytes that give you cause for concern in meeting EQA target
performance criteria:
Unchanged Increased Decreased
Overall EQA participation is

Unchanged Improved Deteriorated


Overall EQA performance is

There is current concern about EQA performance for one or more analytes from the
departmental repertoire: Yes No

Q15 In 1996 the ACB and RCPath jointly published a model for assessing the minimum number of
senior staff in a Clinical Biochemistry laboratory:
Yes No
Has this model been applied to your department?

56
If the answer to the above question was ‘Yes’ then assess the following statements:
Agree Disagree
The model is sound in derivation and validation
The model is straightforward to apply
The model gave a credible result for the department
Managers took notice of the results from the model
The department benefited from using the model

If the answer to the first part of Q15 was ‘No’ then assess the following statements:
Agree Disagree
The department is unaware of the model
The occasion to use the model did not arise
The department considered the model too complex
The department could not get the data for the model
The department saw the model as irrelevant
The department saw the model as a threat
The department did not use the model because
_________________________________________________________

Q16 Before moving to Part 2 of the questionnaire (which deals with your role as a consultant)
please include any information or comment about the functioning of the department which you
feel may be of value to this exercise:

57
Part 2: Questions relating to your role as a consultant

Q17 Indicate the grade of your employment:


Consultant Chemical Pathologist
Grade C Clinical Scientist
University contract (Honorary Chemical Pathologist)
University contract (Honorary Grade C Clinical Scientist)
Number of departmental sites in which you work as a consultant ___

Q18 Answer the following personal questions:


Your sex M F
Your age ___ years
Number of years employed as a consultant ___ years
Year in which you anticipate retirement ___ years
Whole time equivalents worked each week for the NHS ___ wte

Q19 Assess the total hours and percentage of your working time that you currently spend in an
average week on each of the following activities (excluding time on-call):
Total hours % Total
Direct patient care (inpatient + outpatient) ___ ___%
Validation and reporting of results ___ ___%
Clinical liaison – discussion of results ___ ___%
Clinical liaison – ward visits, face-to-face meetings ___ ___%
Providing scientific insight / judgement ___ ___%
Quality (Clinical Governance, audit, accreditation etc) ___ ___%
Research and development ___ ___%
Teaching / training of students / staff ___ ___%
Continuing professional development ___ ___%
Management within the department ___ ___%
Management elsewhere in the Trust ___ ___%
Work for regional, national, international bodies ___ ___%
Other (specify)________________________________________________________

Q20 Record the changes in the percentage of your working time since March 31st 1995 that have
been spent on each of the following activities:
Unchanged Increased Decreased
Direct patient care (inpatient + outpatient)
Validation and reporting of results
Clinical liaison – discussion of results
Clinical liaison – ward visits etc
Providing scientific insight
Quality (governance, audit, accreditation)
Research and development
Teaching / training of students / staff
Continuing professional development
Management within the department
Management elsewhere in the Trust
Work for regional, national, other bodies
Other (specify)__________________________________________________________________

58
Q21 Comment on the average number of hours that you currently work in comparison to the time
for which you are contracted to work (use diary information if possible).
Hours
Time contracted to work each week ___
Average time currently worked each week (excluding on-call) ___
Average time currently worked each week on-call ___

Unchanged Increased Decreased


Since 1995 my working week is
Yes No
Do you have personal secretarial support?

Q22 Explain how your duties are covered adequately when you are on annual, or sick leave:
Duties covered by consultant in the same department
Duties covered by a sub-consultant in the same department
Duties covered by a consultant in another department
Duties covered by employment of a locum consultant

Q23 Estimate the proportion of your current workload that comes from:
General practitioners ___%
Physicians ___%
Paediatricians ___%
Surgeons ___%
Obstetricians and gynaecologists ___%
Psychiatrists ___%
Others ___%

Q24 Comment on any change since 1995 in the number of consultant level clinical staff who
regularly use your consultancy service:
Increased Decreased % Change
Since 1995 the number of GPs is ____%
Since 1995 consultant clinicians are ____%
Since 1995 total clinical liaison is ____%

Q25 Estimate the likely impact of National Service Frameworks on the workload of the department
and the time that you personally will be required to work:

Unchanged Increased % increase


NSF for diabetes – workload ___%
NSF for cardiovascular – workload ___%
NSF for cancer – workload ___%
NSF for diabetes – your working time ___%
NSF for cardiovascular – your time ___%
NSF for cancer – your working time ___%

Q26 Compare the research output in peer reviewed journals, of the department and you personally
in 1995 and 2000:
1995 2000
Number of peer reviewed publications – department ___ ___
Number of peer reviewed publications – you as author ___ ___

59
Q27 Give an assessment of the work-related stress that you experience in the two areas specified.
Circle a number a s appropriate from the scale below, both for 1995 and for the current year:

Unstressed About to have a nervous breakdown

1 2 3 4 5 6 7 8 9

My assessment of stress during normal working hours


1995 1 2 3 4 5 6 7 8 9
2001 1 2 3 4 5 6 7 8 9

My assessment of stress working on-call


1995 1 2 3 4 5 6 7 8 9
2001 1 2 3 4 5 6 7 8 9

Q28 Indicate your confidence in meeting clinical governance targets expected by professional
colleagues and the general public in the four areas specified. Circle a number as appropriate
from the scale below, both for 1995 and for the current year:

Very confident Expecting a letter from the lawyer

1 2 3 4 5 6 7 8 9

Confidence regarding pre-analytical functions:


1995 1 2 3 4 5 6 7 8 9
2001 1 2 3 4 5 6 7 8 9

Confidence regarding analytical performance;


1995 1 2 3 4 5 6 7 8 9
2001 1 2 3 4 5 6 7 8 9

Confidence regarding interpretative comments on reports:


1995 1 2 3 4 5 6 7 8 9
2001 1 2 3 4 5 6 7 8 9

Confidence regarding direct patient consultations and work in clinics:


1995 1 2 3 4 5 6 7 8 9
2001 1 2 3 4 5 6 7 8 9

Q29 If you had an additional Consultant Chemical Pathologist in your department indicate which of
the following functions you would like the department to give more attention to:
Direct patient care (inpatient + outpatient)
Validation and reporting of results
Clinical liaison – discussion of results
Clinical liaison – ward visits / face-to-face discussions
Providing scientific insight / judgement
Quality (Clinical Governance, audit, accreditation etc)

60
Research and development
Teaching / training of students / staff
Continuing professional development
Management within the department
Management elsewhere in the Trust
Work for regional, national, other bodies
Other (specify) ________________________________________________________

Q30 If you had an additional Grade C Clinical Scientist in your department indicate which of the
following functions you would like the department to give more attention to:
Direct patient care (inpatient + outpatient)
Validation and reporting of results
Clinical liaison – discussion of results
Clinical liaison – ward visits / face-to-face discussions
Providing scientific insight / judgement
Quality (Clinical Governance, audit, accreditation etc)
Research and development
Teaching / training of students / staff
Continuing professional development
Management within the department
Management elsewhere in the Trust
Work for regional, national, other bodies
Other (specify)_________________________________________________________

Q31 Indicate your perception of the requirement for additional consultant staffing in your
laboratory. Circle a number from the scale below, both for 1995 and for the current year.
Indicate whether any increase should be in Medical Consultant or Clinical Scientist staff:

No need Absolutely essential

1 2 3 4 5 6 7 8 9

My perception of the need for increased Medical Consultant staff in my laboratory


1995 1 2 3 4 5 6 7 8 9
2001 1 2 3 4 5 6 7 8 9

My perception of the need for increased Consultant Clinical Scientist staff in my laboratory
1995 1 2 3 4 5 6 7 8 9
2001 1 2 3 4 5 6 7 8 9

61
Q32 Based on your knowledge of the profession in the UK and likely future trends please indicate
which of the following statements would have your support as a the basis of a staffing model
aimed at optimising Consultant staffing by the year 2005:

Support
A minimum of one Consultant in each DGH
A minimum of two Consultants in each DGH
A minimum of one Medical + one Grade C Consultant in each DGH
A minimum of three Consultants in each DGH
A formula linking Consultant staffing to population served
A formula linking Consultant staffing to laboratory workload
A formula linking Consultant staffing to workload complexity
A formula linking Consultant staffing to the number of clinical consultants
A formula linking Consultant staffing to Consultant level functions
Acceptance of 1995 as starting point for any Consultant workload model
A detailed workforce plan to optimise Consultant staffing by 2005
No recommendations for Consultant staffing

Q33 Please add below any additional information or comment about the role of the Consultant in
Clinical Biochemistry and/or the pressures being experienced, which you feel may be of value to
this exercise:

Conclusion

Congratulations on completing this questionnaire. The Task Force is extremely grateful to you for
taking part in this very important exercise. Please mail or fax your completed questionnaire to Graham
Beastall at the address shown on the front page of this document to arrive no later than July 31st 2001.

This questionnaire will be analysed both confidentially and anonymously. The outcome of the
questionnaire will be used to inform the content and recommendations of the report from the Task
Force. If you are interested in receiving and commenting on a draft of the report from the Task Force
please send an email message to Graham Beastall at gbeastall@gri-biochem.org.uk to request this
opportunity. It is hoped that the draft report can be put out for consultation the autumn of 2001.

62
A3 FREEHAND COMMENTS ON THE CONSULTANT QUESTIONNAIRE

A3.1 Part 1: departmental comments

A total of 156 comments were received in response to the following request: “Please include any
information or comment about the functioning of your department which you feel may be of value to
this exercise.”

Comment area Number

There is a need for capital investment in IT 5

There is a need for capital investment in buildings and fabric 7

Increases in clinical consultants and GPs is not matched by increased resources


for laboratories 9

The increasing intensity of modern medicine weighs heavily on laboratories 2

Clinical biochemistry is a demand led service. Nowhere in the world has demand be
contained over a sustained period 1

There is pressure from management for laboratories to be ever more cost-effective


when they are already amongst the most efficient and cost-effective parts of the Trust 4

Resources must be forthcoming to match the rising workload 2

The link between workload and workforce has been lost and must be restored 5

Essential service developments (e.g. troponins) must attract new funding 3

The NHS plan will empower more people to get involved in diagnostic work.
They will require support and this will mean more work for laboratories 1

Evidence based medicine is to be applauded but there must be concern


about the impact of clinical protocols on the non-pay costs of laboratories 1

The introduction of the new CPA standards is to be welcomed but it must be


matched by additional staff resources 2

Equipment replacement is cumbersome and haphazard 1

Trust managers are unsympathetic to the problems in laboratories, preferring


to concentrate resources on more visible clinical services 9

Trusts and laboratories require better managers 1

In joint departments the clinical biochemistry service tends to be given the lowest
priority by managers 2

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Comment area Number

The distinction between urgent and routine work is diminishing as more and more
of it is regarded as urgent 11

Extended working is supported but it must be resourced with additional staff 3

Not only is the volume of work increasing but the complexity of that
work is also increasing 8

Not only is there is an increasing need for point of care testing but also
for having the laboratory closer to acute units 1

Recruitment and retention of biomedical scientists is a serious problem 11

Recruitment and retention of MLA and A&C staff is a problem 4

Greater flexibility is required in the roles of scientific and technical staff 1

The European Working Time Directive is driving the introduction of shift systems
which lead to less staff being present during the normal working day 11

There is an increase in staff turnover, largely due to early retirements 1

The lack of trained staff is compromising the ability to provide an out of hours service 2

Training is a significant additional pressure on overstretched staff 2

There is a serious problem with workforce planning for clinical scientists,


especially in specialist areas 9

The contribution of Grade B biochemists is poorly understood and underestimated


by management 8

Changes to departmental structure and management are ongoing with an


uncertain outcome and consequent pressure on staff 2

Further laboratory mergers seem inevitable with a consequent reduction of senior staff 1

Staff are resistant to change 3

The company responsible for private management of the laboratory has changed hands
three times with considerable problems for staff and continuity of service 1

Increased pressure on staff is compromising quality 2

It is ironic that the increase in workload is reducing quality at the exact


time that clinical governance demands increased quality 1

Closed analytical systems are reducing quality standards for some tests 2

64
Comment area Number

Despite automation demands in the last five years have outstripped human
resources – something has to give. The result will be a poorer service 1

Repetitive strain injury is a real problem for interpretative staff 1

Management have realised the hard way the clinical governance risks
from single-handed consultants 1

Instrumentation and IT developments assist the pre-analytical and analytical


phases of the work but do little to assist the post-analytical phase 3

Email has both advantages and disadvantages for consultant staff 1

The questionnaire was difficult to complete because of changes to the


departmental structure in the period between 1995 and 2001 9

The completion of questionnaires now takes a significant amount of


time and everyone believes that theirs is vital 1

A3.2 Part 2: consultant comments

A total of 167 comments were received in response to the following request: “Please include any
information or comment about the role of the consultant in clinical biochemistry which you feel may
be of value to this exercise.”

Comment area Number

Change in Trust and laboratory structure and management adds


appreciably to consultant workloads 13

Working on >1 site increases pressure on consultants 11

With Trust mergers a strategy for improved consultant support is


required or the profession will not survive 2

Consultants are spending much more time in management meetings,


reducing the time available for clinical biochemistry 6

Management seems to increase exponentially with size, multi-site


laboratories create more problems than they solve 1

Although spending much more time on management the responsibility of the


consultant for management decisions is being reduced to the role of advisor 1

Consultants who take on Trust-wide roles put additional pressure on other


senior colleagues and may compromise their own professional standing 6

65
Comment area Number

The increase in time spent on quality issues such as accreditation, audit,


clinical governance etc has greatly increased pressure on consultants 19

Implementation of the new CPA standards will further increase pressure on consultants 2

Statutory training (e.g. health & safety) increases pressure on consultants 2

Supporting POCT is demanding of consultant time 3

Single handed consultants work under increasing stress 3

Being constantly on-call is stressful 1

Increased teaching commitments demand consultant time 2

Long and often deliberate delays in replacing senior staff put


great pressure on to consultants 1

Pathology modernisation is necessary but the process demands a


great deal of consultant time 1

Increasingly consultants and other senior staff find themselves doing


routine jobs to cover for shortages of other staff 4

A more professional approach to business planning is essential and


consultants must be part of this 1

Consultants must receive training support to equip them for the new roles
that they are expected to undertake 1

University consultants are often expected to do two jobs for the price of one 2

Academic clinical biochemistry is being marginalised 1

The role of the consultant in clinical biochemistry is under appreciated 3

The role of the consultant in the provision of specialist clinical biochemistry


services is not always appreciated 2

There is a need to separate clinical and management consultant functions


so that both can be properly resourced 1

Clinical biochemistry is a clinical service not a factory 3

The consultant in clinical biochemistry has a vital role at the clinical


interface, which is hard to maintain because of other demands on time 3

The consultant must be an integral part of the clinical team not an


anonymous individual in a distant laboratory at the end of a telephone 1

66
Comment area Number
The role of the medical consultant in clinical biochemistry has been
undermined, there should always be one in each department 4

Metabolic medicine is to be welcomed, as long as it is resourced 2

The uptake of metabolic medicine is difficult to predict, not all


existing consultants are in favour 4

Medicine does not need 200 half-baked ‘lipidologists’ 1

The quality of candidates applying for SpR posts is a concern for the future 1

The disappearance of the experienced SR means that the number of


out of hours enquiries to the laboratory has increased 1

Training in clinical biochemistry is too packaged it delivers people with


identical skills who are expected to do different jobs 1

Time is the resource that has most been eroded 1

The job has contracted to simply keeping the core service intact, there is
no time for ward rounds, visits, audit or research 3

We have no time to follow up results so that the data may be used to


the best advantage of the patient 1

There are demands for consultants to be seen more outside their laboratories. This can
only be achieved by putting more pressure on already dedicated senior colleagues 1

We are constantly fire fighting there is never time to stand back, review and plan 1

Stress largely results from external factors that you cannot control 1

One result of the increased pressure is that we must accept that we can now
only meet minimum rather than optimum quality standards 1

Different people can cope with different levels of stress, we must target a reasonable
average rather than pushing each individual to the point at which they will break 1

Increased stress is evidenced by the increase in sick leave 1

Consultants spend more time dealing with personnel issues within their staff 1

Despite extreme pressure job satisfaction still exists in the scientific and
intellectual challenge 1

Research and development has virtually ceased 5

Anticipating the opportunities of technological developments, such as


nanotechnology, ought to be an important part of the job but there is no time 1

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Comment area Number

Many Grade B clinical scientists are doing the jobs of consultants, but
without the recognition or the remuneration 5

The cut back in Grade B clinical scientists has increased pressure on consultants 1

Pay for consultant clinical scientists lags well behind that of their medical counterparts 3

Pay for university non-clinical consultants is extremely poor 1

Consultant clinical scientists should receive intensity payments 1

Extended working by consultant clinical scientists deserves remuneration 1

Time has to be found for CPD – otherwise we will make mistakes 1

I am spending increased amounts of time dealing with formal complaints 1

We live in a society where the threat of litigation is growing 1

Increased public expectation is healthy, as long as the resources are available


to deliver on that expectation 1

Clinical governance is essential but we are not doing it properly


because we have neither the time nor the resource 1

The demands of clinical governance must be translated into more consultant


staff or serious failures will occur 2

This department has never had an established consultant and so it has never
been accredited. It serves a population of 240K. No one seems to care! 1

Automation may help with the analytical phase but it does nothing for
interpretation – we need more consultant staff 1

A simple model must be found to relate consultant staffing to workload 1

Minimum standards for consultant staffing must be defined and adhered to 1

In an era of changing Trust and departmental structure a flexible model


for determining consultant staffing is required – such as a federation that
will preserve critical mass and specialty skill 8

The increased demands from GPs, more protocols, and more integrated care pathways
means that the original senior staffing model has been superseded by events 1

Increases in clinical biochemistry workload far outstrip those of other


laboratory disciplines, and yet they get more consultants 2

Clinical Biochemistry could learn from histopathology in how to present


a case for more consultant staff 5
68
The impact of the histopathology model has been damaging for other
laboratory disciplines 1

Privatisation will only produce expensive laboratories which offer a


minimum of clinical liaison 1

There has been little professional guidance at national level on the future
direction and delivery of the service 1

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A4 CHIEF EXECUTIVE QUESTIONNAIRE

Review of NHS clinical biochemistry services


Information sheet and survey of senior NHS Trust managers

Introduction

This document has been prepared especially for senior management in NHS Trust Hospitals.
It is in two parts.

The first part is a very brief summary of the main findings from a detailed investigation into
the current state of NHS Clinical Biochemistry services, which has been undertaken by a Task
Force jointly established by the Association of Clinical Biochemists (ACB) and the Royal
College of Pathologists (RCPath). Whilst the investigation considered all aspects of the NHS
service its focus was on the role of the consultant in Clinical Biochemistry – defined as both
Medical Consultants and Grade C Clinical Scientists.

The second part is a short survey, which seeks to determine the views of senior NHS Trust
managers on their Clinical Biochemistry services, in order that a complete and balanced final
report may be prepared. The Task Force regards the feedback in this second part as an
essential component of its work and so would appreciate the cooperation of senior NHS
Trust managers.

Part 1: Brief summary of the main findings of the Task Force

In the period 1995–2001, Clinical Biochemistry departments have, on average, experienced:


• A ~60% increase in total workload
• A ~50% increase in the proportion of that work received out of normal working hours
• A ~20% increase in the proportion of that work received from GPs.
• An increase in the repertoire of tests offered both within and out of normal working
hours

During the same period Clinical Biochemistry departments have seen:


• Zero expansion of consultant staff (both Medical Consultants and Grade C Clinical
Scientists)
• A ~10% decrease in sub-consultant Medical and Clinical Scientist staff
• A ~1% decrease in Biomedical Scientists in post
• Variable investment in automation and IT, which assists the pre-analytical and analytical
work but not the post-analytical work of the department

In addition to the large increase in workload over the period 1995–2001, consultants in
Clinical Biochemistry have also had to accommodate:
• A significant increase in direct patient care (Medical Consultants only)
• A very large increase in time spent addressing clinical governance targets such as
laboratory accreditation, clinical audit, quality assurance etc
• A large increase in time spent on management within the department and Trust
• A sharp decline in time available for research and development.

70
As a result of these developments, during the period 1995–2001 consultants in Clinical
Biochemistry are, on average:
• working ~48h per week, with a high percentage in breach of the European Working
Time Directive
• responsible for the validation and reporting of 630 requests and 3500 tests per
working day
• less confident of meeting clinical governance targets
• seeing early signs of a loss of quality as measured by blunders, laboratory accreditation
status and performance in External Quality Assessment Schemes
• experiencing a considerable increase in work-related stress, especially during normal
working hours

Consultants were asked to assess the adequa cy of the staffing levels in Clinical Biochemistry
departments to cope with the workload received in 1995 and 2001. They were also asked to
extrapolate the current annual increase in workload to 2005 and comment on the adequacy
of the current staff complement to cope. Results showed:
• in 1995 82% of departments felt that staffing levels were adequate or better
• in 2001 89% of departments are struggling cope with the workload
• by 2005 98% of departments will be struggling to cope or unable to cope, with 72% in
the latter category
• in 2001 the following percentage of departments identified the need for additional
staffing – consultants 51%; Grade B Clinical Scientists 36%, Biomedical Scientists 80%;
Medical Laboratory Assistants 51%, Administrative and Clerical staff 44%.

The Task Force has prepared a detailed report, which provides the evidence to support all the
above statements, and which also includes several other insights into the current state of NHS
Clinical Biochemistry services. A copy of this report may be requested, please see the end of
Part 2 of this document for details.

Part 2: Association of Clinical Biochemists / Royal College of Pathologists


Consultant Staffing in Clinical Biochemistry: Survey of NHS Trusts

Please complete the survey by checking appropriate boxes. Add freehand comments as you think
appropriate. The returns will be received and analysed in an anonymous manner.

Q1 The person completing this survey is:


An NHS Trust Chief Executive
An NHS Trust Medical Director
An NHS Trust Senior Manager
A Clinical Director of Laboratory Medicine
Other (specify): _________________________

Q2 In your Trust Clinical Biochemistry is regarded as:


A clinical service
A clinical support service
A support service
Other (specify): _________________________

71
Q3 How do you react to the brief summary of the main findings of the Task Force, which are
summarised in Part 1 of this document?
I recognise all or most of the findings in this Trust
I recognise some of the findings in this Trust
I do not recognise any of the findings in this Trust

Q4 How would you describe the overall quality of the service provided by your Clinical
Biochemistry department as judged by feedback from users and ability to meet clinical
governance targets? How has this position altered over the last five years?
Excellent Improving
Satisfactory Unchanged
Less than satisfactory Deteriorating
Poor

Q5 Which of the following statements apply to Clinical Biochemistry in your Trust for the period
1995–2001 (tick any that apply)?
Total workload has increased by: <20% 20–40% >40%
Total staffing has increased by: <5% 5–10% >10%
Consultant staffing is: Increased Unchanged Decreased
We have invested in: Fabric Automation IT
Laboratories have been targeted for cost savings: Yes No
The cost effectiveness of the laboratory has: Increased Decreased

Q6 Has your Trust reviewed staffing and workload in Clinical Biochemistry during the past two
years in conjunction with a consultant from the department:
Yes No Don’t know

Q7 How does the Trust assess the current level of staffing of each of the following grades of staff
in the Clinical Biochemistry department:

Satisfactory Adequate Struggling Inadequate


Consultant
Grade B Clinical Scientist
Biomedical Scientist
MLA
A&C staff

Q8 How do the Trust management and the Consultant(s) in Clinical Biochemistry regard the
adequacy of the total staffing in the department to meet the current demands put upon it:

Trust Management Consultant Biochemist


Satisfactory or better
Adequate
Struggling to cope
Unable to cope

72
Q9 Which of the following consultant Clinical Biochemist functions are likely to increase in your
Trust over the next four years:
Direct patient care (Metabolic Medicine)
Result interpretation and clinical liaison
Meeting quality standards (accreditation ,audit etc)
Providing scientific insight
Demonstrating compliance with clinical governance targets
Reconfiguring service delivery
Teaching, training and CPD
Management within the Department / Directorate

Q10 Does your Trust accept the need for additional consultant staffing in Clinical Biochemistry
during the next four years:
Yes Probably Don’t know No

If the answer to the above question was ‘Yes’ or ‘Probably’ indicate which type of consultant
you are more likely to appoint:
Medical Clinical Scientist No Preference

If the answer to the above question was ‘No’ or ‘Don’t Know’ indicate the reason for your
decision:
Post not justified on clinical / service grounds
Post not a priority compared to other disciplines
Funding will not allow for the post
Other (please specify): _____________________

Q11 The ACB and RCPath has produced and validated a simple model which gives guidance on the
minimum number of consultant staff required in any Clinical Biochemistry department based
on the clinical and laboratory workload and the complexity of the service provided. In
recognition of the changing pattern of delivery of Clinical Biochemistry services this model is
applicable to departments operating from more than one site. Is your Trust prepared to assess
the relevance of this model?
Yes Don’t Know No

Q12 Please comment on any aspect of the Clinical Biochemistry service provided by your Trust,
which you feel may be of assistance to the Task Force.

Thank you for reading this document and for completing this survey. Please post the
completed survey using the attached self-adhesive label to Graham H Beastall to arrive no later than
November 30th.

If you would like to receive a copy of the report on Clinical Biochemistry produced by the ACB /
RCPath Task Force please send an email to gbeastall@gri-biochem.org.uk indicating whether you wish
to receive the full report (70 pages) or the Executive Summary and Recommendations (5 pages). If you
wish to receive the full report please include your postal address in the email.

73
A5 FREEHAND COMMENTS ON THE CHIEF EXECUTIVE QUESTIONNAIRE

A total of 59 senior managers responded to the following invitation:


“Please comment on any aspect of the clinical biochemistry service provided by your Trust, which you
feel may be of assistance to the Task Force.”

Comment area Number

Clinical biochemistry services are provided to the whole health economy and
are essential to seamless patient care across interfaces. 1

Because clinical biochemistry services are used by all parts of the healthcare
system it is difficult to assess their true value and fund them accordingly 1

We have to invest in diagnostic services generally 1

We are organisationally inefficient and the patient pathway is inhibited by


the inability of diagnostic services to keep pace with clinical demands 1

The primary care sector must support further investment in diagnostic services 1

The increase in requests from primary care sector is very evident 4

Dramatic increases ha ve been seen in both the analytical and interpretative


elements of the service 1

Increasing numbers of clinical consultants contribute to rising laboratory workloads 1

Increasing out of hours service demands create pressure for laboratories 1

The European Working Time Directive, 24/7 working and defensive


medicine all increase demands on clinical biochemistry 5

Working time directives and on-call commitments are incompatible for


single handed consultants 2

Meeting the demand for ever more rapid turnaround times is a challenge 1

Expanded point of care testing will generate extra management work for
clinical biochemistry 1

Near patient testing creates major problems related to high staff turnover
and inadequate training 2

The devolution of former specialist tests increases the need for consultant staffing 1

Extra laboratory activity is required to meet clinical governance commitments 2

The new more stringent laborator y accreditation standards will require


additional staff resource 1

Support for benchmarking of workload and clinical activity 4


74
Comment area Number

Biochemistry consultants are often ‘forced’ to take on additional management


roles because, unlike their histopathology colleagues they do not have a stack
of slides to report. This reduces their effectiveness in their primary role. 2

Biochemistry consultants provide added value, e.g. support for research 1

The shortfall in consultants and sub-consultant clinical scientists is a constraint


on research and development, clinical liaison, audit and governance 1

Clinical biochemistry departments are preserving the service to users at the


expense of research and development, clinical governance etc 1

Considerable consultant time is required for service reconfiguration 1

The future for biochemistry is as part of an integrated laboratory sciences department 1

The service is reviewed regularly to assess its value to users 2

Clinical biochemists must work better with clinicians to develop protocols


for the appropriateness of requesting 1

The problems highlighted in this survey are also largely applicable to other specialities 1

Advantage is taken of technological innovation to keep pace with demand


and maintain and improve service quality and response times 4

There is a need for major investment in IT, which is unlikely to be found


from within individual Trust capital budgets 1

The clinical biochemistry service is hampered by poor IT infrastructure 1

IT investment does assist the post-analytical phase of work 1

Order communications will be introduced shortly and this should circumvent


many of the current IT shortcomings 1

Laboratories have been given fair savings targets – the same as all services 1

Clinical biochemistry staffing is under current review 4

Increments in consultant staffing are difficult and will most effectively be


achieved as joint appointments with a neighbouring Trust 1

Consultants may work on more than one site but it not without problems 1

Consultants should regularly review and re-prioritise their tasks in order


to cope with changing work patterns 1

Clinical biochemistry has an ageing staff with no obvious workforce plan 1

75
Comment area Number
There is a shortage of specialist-trained staff (paediatrics) 1

Staff are awaiting with interest the outcome of the pathology modernisation
plan 1

Clinical scientists are increasingly involved in day to day issues at the


expense of development 1

Biomedical scientists need to be developed to encourage more efficient working 1

There is a severe problem of recruiting laboratory staff, mainly because


salaries are not competitive 1

The consultant assessment of the adequacy of staffing levels is meaningless 1

There are problems of tribalism between medical and scientific consultants


which do not benefit the service or the patients 1

The workload has doubled with no increase in staff. We rely on an adjacent


Trust to provide cover for our single-handed consultant 1

We buy in consultant cover from adjacent Trusts to cover sickness and annual
leave for our single handed consultant 1

We have an excellent clinical and laboratory service but it relies on a single


handed consultant who is also clinical director. Additional staff are needed 1

Medical cover is provided on the basis of one consultant session. This is not satisfactory 1

We have an excellent service but it is beset by the problem of ‘higher priorities’


elsewhere for senior appointments 1

Space is very tight for clinical biochemistry in our Trust 1

We refer on a greater proportion of our clinical biochemistry to third party laboratories 1

Rationalisation, modernisation and reconfiguration across 4 hospital sites and


within a 3 counties framework poses the greatest challenge for us 1

There is a plan for reconfiguring pathology services for 4 Trusts to create one
central laboratory and 3 ‘hot labs’ 1

A virtual laboratory has been created from five departments. This has
improved efficiency, consultant cross-cover and development work 1

We operate the hub and spoke model for clinical biochemistry. A workload
and manpower review are underway 1

With increasing pressure on beds the provision of on-site clinical biochemistry


services is essential 1

76
Comment area Number
There has been little leadership in reorganising work patterns to cope with
the pressure – this initiative would command Trust support 1

We have a very successful joint service/academic department, which is of great value


to both the university and the Trust. We will continue to support developments in the
next few years 1

We have an academically led service, which provides a busy clinical service


whilst maintaining bench research 1

We have a patient focussed rather than a laboratory focussed consultant. This


is easier to support given the pressure on all patients focussed services 1

We have a single-handed medical consultant covering two sites and running


clinics for lipids and endocrinology 1

We are developing clinical networking with neighbouring Trusts. This will


facilitate improved quality but will require additional consultant time 1

We have a good working relationship between senior managers / consultants


in clinical biochemistry and Trust senior management 1

We have a PFI laboratory service, we share space between laboratory disciplines,


we are moving on the modernisation agenda, we have good IT links and excellent
public relations with the PCT 1

Laboratory services are provided through a private company who employ


the technical but not consultant staff 1

The Community Trust reports a perceptive drop in the quality of clinical


biochemistry services 1

We currently have a development bid to introduce a 24-hour service to one of our sites 1

This Trust is currently involved in a sector wide review 1

This Trust is very happy with the clinical scientists in post and regards them
as good value for money. We are not sure how the directorate of medicine
would react to the appointment of a medical consultant 1

Our clinical biochemistry service is under great strain 1

We wish you success in highlighting this vital area within overall health service 1

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