Documentos de Académico
Documentos de Profesional
Documentos de Cultura
May 2002
Association of Clinical Biochemists The Royal College of Pathologists
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www.acb.org.uk www.rcpath.org
Further copies of this publication can be obtained from the ACB and College websites
NHS clinical biochemistry
‘A profession under siege’
CONTENTS
Foreword.............................................................................................................................................. 1
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
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,
1
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.
1.2.1 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.
2
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
3
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.
4
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
1.3.3 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.
5
(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.
6
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.
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”.
The Task Force adopted a broad approach to gathering evidence prior to the analysis phase
of it work.
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.
7
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.
9
3 WORKLOAD IN CLINICAL BIOCHEMISTRY
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.
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.
10
Table 3 Workload of clinical biochemistry departments
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.
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
% 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
13
4 STAFFING IN CLINICAL BIOCHEMISTRY
14
Table 6 Staffing levels in clinical biochemistry: 1995 and 2001
Key
Figures not in brackets relate to occupied posts
Figures in brackets are unfilled posts
* Based on returns from 119 departments (49% of distribution)
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
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
Table 9 Clinical biochemistry: CPA laboratory accreditation status: 1995 and 2000
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.
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.
Number of departments
Criterion Unchanged Increased Decreased
Demand for faster TAT 15 147 0
Delivery of faster TAT 13 134 13
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].
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
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
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
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.
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%
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).
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.
Key
NMC NHS medical consultant
NCCS NHS consultant clinical scientist
UMC University medical consultant
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).
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.
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.
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
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.
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).
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.
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.
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.
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.
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
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
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.
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.
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).
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).
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.
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.
37
Figure 2 Consultant staffing model versus assessed staffing
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.
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.
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.
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.
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.
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.
These results confirm that senior managers recognise the large increases in workload
experienced by clinical biochemistry departments over the period (Section 3.1).
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
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.
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.
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.
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).
% 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%.
% classification
Group making assessment Satisfactory or better Adequate Struggling Inadequate
Senior manager 7 43 50 0
Consultant 2 20 75 3
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).
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
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.
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.
Response % responses
Interested in assessing model 70
Not interested in assessing model 5
Don’t know 25
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
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.
11 Lapworth R and Teal TK. Laboratory blunders revisited. Ann Clin Biochem 1994;31:78–84.
14 Making the change. A strategy for the professions in healthcare science. London: Department
of Health, 2001. http://www.doh.gov.uk/makingthechange.
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.
49
10 ACKNOWLEDGEMENTS
• 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.
• 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
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
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?
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
52
Part 1: Questions relating to the department in which you do your NHS work
Code Number:__________________________
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
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 ___% ___%
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
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 ___
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:
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:
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:
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:
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
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.”
Clinical biochemistry is a demand led service. Nowhere in the world has demand be
contained over a sustained period 1
The link between workload and workforce has been lost and must be restored 5
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
In joint departments the clinical biochemistry service tends to be given the lowest
priority by managers 2
63
Comment area Number
The distinction between urgent and routine work is diminishing as more and more
of it is regarded as urgent 11
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
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
The lack of trained staff is compromising the ability to provide an out of hours service 2
Further laboratory mergers seem inevitable with a consequent reduction of senior staff 1
The company responsible for private management of the laboratory has changed hands
three times with considerable problems for staff and continuity of service 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
Management have realised the hard way the clinical governance risks
from single-handed consultants 1
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.”
65
Comment area Number
Implementation of the new CPA standards will further increase pressure on consultants 2
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
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
The quality of candidates applying for SpR posts is a concern for the future 1
The job has contracted to simply keeping the core service intact, there is
no time for ward rounds, visits, audit or research 3
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
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
67
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
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
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
There has been little professional guidance at national level on the future
direction and delivery of the service 1
69
A4 CHIEF EXECUTIVE QUESTIONNAIRE
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.
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.
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.
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:
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:
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.
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A5 FREEHAND COMMENTS ON THE CHIEF EXECUTIVE QUESTIONNAIRE
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
The primary care sector must support further investment in diagnostic services 1
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
The problems highlighted in this survey are also largely applicable to other specialities 1
Laboratories have been given fair savings targets – the same as all services 1
Consultants may work on more than one site but it not without problems 1
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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
We buy in consultant cover from adjacent Trusts to cover sickness and annual
leave for our single handed consultant 1
Medical cover is provided on the basis of one consultant session. This is not satisfactory 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
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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 currently have a development bid to introduce a 24-hour service to one of our sites 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
We wish you success in highlighting this vital area within overall health service 1
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