The Recruitment, Training and Retention of Medical Laboratory Scientific Officers

Scottish Medical and Scientific Advisory Committee

Working together for a healthy, caring Scotland

Introduction 1. Clinical laboratory medicine is a specialty in its own right and an integral part of clinical practice. Its essential role is to provide and interpret investigations for the diagnosis, management, early detection and prevention of disease, through specimen analysis and the clinical interpretation of its result. It forms a vital component of the clinical care of patients, (for example, on-going monitoring of treatment), and is used as a resource in both the undergraduate and postgraduate training of medical students and in support of the training of nurses in infection control. Test results and autopsy reports provide valuable information for medical audit. Results provided by the laboratory are often a prerequisite for clinical research and development. 2. Laboratory services are consultant-led and employ medical staff, clinical scientists, medical laboratory scientific officers (MLSOs), medical laboratory assistants, medical technical officers, cytology screeners, phlebotomists and an infrastructure of ancillary staff and administrative and clerical staff. The work, which is mainly carried out in the laboratory, may also be undertaken in near-patient settings such as wards and out-patient clinics, particularly one-stop clinics. The proportion of time spent in these locations will vary according to the particular discipline concerned and to local arrangements for service delivery. 3. Approximately 1,600 MLSOs are employed in NHSScotland. This category of staff makes up the largest group of personnel within the clinical laboratory service who carry out the investigations which are crucial to modern medical care. Without them, the diagnosis of disease, the evaluation of the effectiveness of treatment, and research into the causes and cures of disease would not be possible. As with other health care professionals, many of the tasks which were originally only carried out by medical staff, are now the responsibility of the MLSO working under the direction of the consultant in charge of the laboratory. 4. Each year, some 50 million tests are performed by the clinical laboratory service in Scotland. The expectations of patients and NHS professionals, coupled with the rapid exponential growth in advances in health care, conspire to create a cycle where demand may often exceed resource. 5. MLSOs are recruited from graduates holding an Honours degree approved by the Council for Professions Supplementary to Medicine, (CPSM) and accredited by the Institute of Biomedical Science, (IBMS). After a minimum training period of one year, undertaken in a laboratory approved by the CPSM for training purposes, they can apply to the Medical Laboratory Technician Board of the CPSM to be placed on the State Register. Currently, as well as the academic and training requirements of the CPSM, candidates have to sit and pass an oral examination before becoming state registered. 6. MLSOs may go on to study for a postgraduate degree in order to further progress within their profession. The Institute for Biomedical Science, (IBMS), is the professional body for MLSOs in all fields of work, including that of medical laboratory scientific officers in the National Health Service and related services in the United Kingdom and Ireland. Its aims are to promote and develop biomedical science and its practitioners, and to establish, improve and maintain professional standards.

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7. MLSOs are also employed in the Scottish National Blood Transfusion Service, government, university and forensic laboratories, the Medical Research Council, (MRC), the pharmaceutical industry, and with Her Majestys Forces. 8. The profession has never enjoyed a high public profile. Frequently, the significance of their vital work is lost or, at best, simply taken for granted because the laboratory is hidden away from the public gaze and, in most disciplines, there is little direct patient contact. The Group therefore make no apology for including a brief summary of the vital work of each of the laboratory disciplines in Appendix II. Background 9. This report has been commissioned against the backdrop of the Review of Acute Services1 and increased recognition of the difficulties encountered in the recruitment, training and retention of Medical Laboratory Scientific Officers (MLSOs). The Groups remit is explicit in identifying the need to look at some of the broader issues of changes in laboratory practice taking into account such issues as skill-mix, automation, extended hours of work, near-patient testing, fast-tracking and links with primary care. 10. The laboratory services are demand-driven and the workload has been rising as a direct result of increased clinical activity and the scope of pathology generally. Increasing emphasis on primary care, earlier hospital discharge and more day care means that the laboratory service has to respond to new demands from general practitioners who require assistance with the investigation and management of patients in the community. Method of Working 11. The Group, which met on four occasions between June 1999 and May 2000, sought evidence in the form of a postal questionnaire from all Head Medical Laboratory Scientific Officers / Laboratory Managers in the NHS in Scotland. Nearly a hundred written comments were received with the returned questionnaires. Direct quotations from some of these comments have been placed in italics at the head of each chapter to convey the extent of the problem and the strength of feeling which exists within the profession. The results of the survey (see Appendix III) formed the evidence base on which the Group formulated its recommendations. The Group is grateful to the Institute of Biomedical Science, (IBMS), for collating the responses. 12. During the lifetime of the Working Group, the IBMS conducted a parallel survey2, (see Appendix IV), relating mainly to Trusts in England and Wales (but including eight large Scottish Trusts), with broadly similar results. 13. The composition and membership of the Group is shown in Appendix I

Structure of Report 14. The report sets out the background to the review, identifies the issues involved and puts forward a range of solutions. For ease of reference, separate chapters concentrate on the three main areas under review, namely the recruitment, training and retention of Medical Laboratory Scientific Officers, even though it is recognised that these three areas are

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interlinked. No attempt is made to differentiate between the laboratory disciplines except where the context clearly demands it. A summary of the main recommendations appears in Chapter V.

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II.

RECRUITMENT

Nobody seems to know what an MLSO is, or what he or she does It is becoming increasingly difficult, if not nigh impossible, to recruit qualified MLSOs Recruitment is difficult due to an extremely low starting salary We have lost several highly trained and long serving biomedical scientists in recent months, all of them going to jobs outside the NHS

Introduction 15. The focus of this report relates primarily to MLSOs and the relatively new grade of Medical Laboratory Assistant (MLA). Recruiting MLSOs to work in NHS laboratories is becoming increasingly difficult. These difficulties were first identified in the Review of Acute Services1 and have since been identified by Porter (1998)3 and Johnston and Milne (1999)4. The use of MTO grades, MLAs and the permanent locum are now established employment strategies as shown by a recent survey, conducted by the IBMS2, which has confirmed the extent of the problem throughout the UK. Our own survey, conducted as an integral part of the work of this Group, revealed broadly similar findings (see Appendix III). Current Issues 16. Two main factors dominate the problem of recruitment at all levels of non-medical laboratory staff. These are: low pay competition from industry in the Science and Technology sector.

Possible Solutions

Pay and Conditions of Service 17. According to a recent report from the Association of Graduate Recruiters (AGR) Warwick5, graduates in science and engineering, starting their careers in research and development and other technical roles, are earning median salaries of 17,250, and those with qualifications in information technology and computer science are earning a median of 17,500. 18. By contrast, MLSOs have a training grade with a pay scale ranging from 9,726 to 10,782. This reflects the fact that the starting salary for trainees has been boosted by over 20% in this years pay round in recognition of the fact that low pay has been a factor in ongoing recruitment difficulties. On attaining State Registration (normally within one year), MLSO 1s move on to a salary scale ranging from 13,066 to 17,195.

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19. There is further scope for Trusts to advance the salary of an MLSO1 up to 19,343 if the post carries additional responsibility or if it requires specialist skills which do not justify a higher grade. Nonetheless, the majority of trainee and qualified MLSOs consider themselves to be poorly paid relative to other similarly qualified staff in the NHS, other parts of the public sector and the private sector. 20. The review has identified some practice and potential developments that may go some way to ameliorating this position. While appointments should normally be made to the minimum of the appropriate Whitley Council scale for the grade, employers do have discretion to appoint to any point on the scale, having regard to local conditions, skills, experience and qualifications. There is evidence that some employers have been using this flexibility to offer above the minimum rate of pay in an effort to attract good quality candidates. At best, however, such an approach only addresses issues short term. 21. In the longer term, current UK negotiations on NHS pay modernisation may offer the prospect of some improvement. The development of an NHS-wide job evaluation system should identify whether MLSO posts are of equal value to other similarly qualified posts in the NHS. Issues of equal pay for equal value should therefore be addressed. A further part of the pay modernisation negotiations will cover the possibility of extending the remit of the Nursing, Midwives, Health Visitors and Professions Allied to Medicine Pay Review Body (NPRB). If MLSOs are one of the staff groups which achieve NPRB status this will have a positive impact on recruitment and retention. Key Issues: 22. Present rules dictate that MLSOs must possess a degree in biomedical sciences accredited by the IBMS and approved by the CPSM, the body which is responsible for Stateregistration of MLSO staff. A view has been expressed that current CPSM regulations for registration are too restrictive. Many science graduates who possess a degree that is not in Biomedical Science are required, depending upon the degree content, to attend a top-up day release course at an approved university before they are eligible for State registration. Over the years this has contributed to an inability to recruit staff. The Group therefore believes that 4 year Honours degree courses in Scotland, provided they meet all the statutory requirements, should be tailored more to the needs of a clinical laboratory service. At present, these courses are offered by The Robert Gordon University, Aberdeen; Napier University, Edinburgh; Glasgow Caledonian University and the University of Paisley. 23. The fact that MLSOs increasingly belong to a graduate-only profession is in itself a clear recognition of the high level of qualifications and skills required to carry out laboratory scientific work and the acquisition of such qualifications and skills should be encouraged. Graduate entry requires medical laboratory based training at an appropriate level to fulfil the requirements of state registration and to ensure that the skills acquired are fully relevant in the context of the modern NHS laboratory. 24. In addition, applicants with Highers in science subjects should be given the opportunity to progress to graduate level and state registration. To facilitate this matter, dialogue with those Universities offering courses in biomedical science needs to be opened as a matter of urgency. The re-introduction of part-time courses needs to be explored along with

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the introduction of a link year as part of the 4-year Honours course where students gain the necessary practical laboratory experience. 25. The Group advocates the need for supernumerary posts for trainee MLSOs in Scotland to link in with the rural / urban training initiative, (see paragraph 41). A model to be followed is the NMET Levy System currently being established in England and Wales. Competition from the Science and Technology Sector: 26. The NHS is unable to compete for applicants on an equal footing with outside industry. This problem is likely to increase since commercial science is already an expanding industry in Scotland. 27. In order to attract highly qualified and trained staff it is important that the Nursing Directorate and the Directorate of Human Resources of the Scottish Executive, Universities, employment organisations and professional bodies work together to encourage recruitment and develop career pathways for staff entering laboratory medicine.

Recommendations Although pay and conditions of service lie outwith the remit of this Working Group, the Group welcomes the fact that these issues are being examined in other fora, e.g. the National Pay Review Body, Agenda for Change Pay Modernisation. The Group believes that the inclusion of MLSOs in the National Pay Review Body would have a positive impact on recruitment and retention. 4 year Honours degree courses in Scotland, provided they meet all the statutory requirements, should be tailored more to the needs of a clinical laboratory service. (Paragraph 22). Applicants with Highers in science subjects should be given the opportunity to progress academically to graduate level. (Paragraph 24). The re-introduction of part-time courses needs to be explored along with the introduction of a link year as part of the 4-year Honours course where students gain the necessary practical laboratory experience. (Paragraph 24). The Nursing Directorate and the Directorate of Human Resources of the Scottish Executive, Universities, employment organisations and professional bodies should work together to encourage recruitment and develop career pathways for staff entering laboratory medicine. (Paragraph 27).

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III.

TRAINING

Graduate staff feel aggrieved that we cannot accept their Honours degrees without their attendance at a further top-up course when they realise that the top-up course has little relevance to their everyday work Due to increased workloads, qualified MLSOs have very little time to fulfil training needs Our location away from the major training centres means that staff require much more time off to follow Continued Professional Development. This problem needs to be tackled urgently Due to our geographical position, trainees effectively incur a 16 hour day taking into account the 155 mile round trip to attend classes

Introduction 28. At present, different according to local practice. log books for all who are guidance. The IBMS / DoH approaches are adopted for the training of MLSOs and MLAs In addition, there are approaches such as the mandatory use of in training for State registration and compliance with IBMS training manual for MLAs is currently widely used.

29. MLSOs are required to be State registered and are thereby subject to the rules and governances of the CPSM as administered by the Medical Laboratory Technicians Board. There are four post-registration grades and MLSOs normally require further postgraduate qualifications and training to progress through the grading structure. MLSO in-service training is geared towards ensuring that the registrant gains sufficient practical ability to undertake the duties of the particular discipline. Students generally specialise in one of the main disciplines prior to State Registration. Increasingly, a multi-disciplinary approach to training is being encouraged and the CPSM log books recognise this with the recently revised log books. It is the view of the CPSM that registrants should undergo an appropriate course of training for all the disciplines that they are expected to practice in. 30. At present, there are only 82 MLSO trainees in Scotland which equates to just 4% of the total MLSO workforce. 31. Entry into the MLA grade does not require any school leaving qualifications or indeed any educational qualifications. These staff undergo training programmes to provide them with the practical skills needed to support the routine work of a pathology laboratory. The training programmes do not, however, lead to any qualifications. They always work under the supervision of qualified staff. Current Issues 32. Key issues affecting the training of MLSOs include:

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the difficulties of training staff in-house when having to operate a 24-hour service and shift systems differences between the university education systems in England and Scotland the lack of a formal training programme and career progression structure for MLAs the provision of education and training for staff who are based in remote and rural areas, and no recognition of commitment / resources required to organise training.

Possible Solutions Review of the Core Curriculum: 33. The CPSM and the IBMS should jointly undertake a review with the universities of the core curricula of degree courses to ensure that they reflect modern laboratory practice. Role extension of MLSOs is likely to involve a change in the direction of training to a more widely based concept both in the acute and primary care settings in some of the laboratory disciplines. Many MLSOs already undertake tasks such as film reporting, near-patient clinics for anti-coagulant and diabetic control, peripheral blood stem cell harvesting, histology tissue cut-up, etc. In addition, current trends in laboratory work patterns, including converging technology, have enhanced the capacity for multi-tasking of technical and scientific staff in appropriate circumstances. In most disciplines of clinical laboratory medicine, MLSOs are responsible for validation, quality control and reporting of the laboratory results. Work pressures on pathologists are also extending the professional role of the MLSO. For example, the Royal College of Pathologists and the IBMS have recently agreed the development of an Advanced Practitioners Grade within Cytopathology with a wider range of responsibility and reporting powers. Advances in information technology continue to have a significant impact on the ability of laboratory staff to extend cover to remote and rural areas. It is important that the roles and interface of scientific staff receive critical attention within all disciplines. 34. There is a need to make a clear distinction between requirements for basic education and those for further training. Under the category of further training, appropriate programmes should be designed to accommodate the requirements of multi-tasking in the core section of larger laboratories, (which may provide services on a regional basis), and / or a laboratory in a remote and rural location and these should be appropriately funded. University / NHS Interface: 35. The Group recommends that the IBMS and CPSM should foster closer links with Universities in Scotland. In particular, different styles of teaching modules, e.g. distance and open learning, should be explored. Relevant universities should critically examine, in conjunction with IBMS and CPSM, the course content of biomedical science degrees for its suitability for careers in laboratory medicine. At present there is only a limited number of universities offering suitable courses for part-time education. These are Napier University; Glasgow Caledonian University and the University of Paisley. This has implications both in terms of finance and time for departments in remote and rural areas.

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Training Opportunities: 36. In addition to proficiency in technical skills, MLSOs in many disciplines are required to be proficient in scientific, interpretative, diagnostic and monitoring skills. The IBMS and the CPSM promotes the view that MLSOs should be educated in the clinical aspects of their disciplines. It also requires them to be proficient post-diagnosis so that they can aid in the monitoring of treatment and thereby make a crucial contribution to the clinical management of such patients. Opportunities should be taken to allow MLSO training to take place at the clinical interface. Examples from the acute and primary care sectors could include training for work in lipid and diabetic clinics, anti-coagulant clinics, allergy skin-testing clinics and community health centres. The Royal College of Pathologists and IBMS are currently considering a number of joint initiatives in this area. MLSOs could also be used as much more of a resource in the context of the education of medical and nursing staff. Such activities would help MLSOs to raise their profile, foster a sense of team working and utilise staff to their full potential. 37. Managers will be aware of, and should adhere to, the recommendations set out in the Strategy for Education, Training and Lifelong Learning11 and the opportunity that this affords all NHS staff to develop their skills and to deliver a high quality service. 38. The key aims of this Strategy are to modernise the NHSScotland by promoting: Fitness for purpose: to ensure that all NHS staff are equipped with the skills, knowledge and attitudes to deliver the services patients and their families expect. Improved access and opportunity: to ensure that all NHS staff in Scotland are supported and encouraged to develop and maintain their skills. A flexible workforce: that is capable of responding efficiently to change in clinical practice and new methods of service deliveries. Effective team working: encouraging methods of working and learning which promote an integrated approach to patient care. Recruitment and retention: career progression and job satisfaction which fulfils the needs and aspirations of all NHS staff in Scotland regardless of their social, academic or ethnic backgrounds. Staff development as an investment in quality: by raising awareness among NHS Boards, managers and service planners of the value of education, training and lifelong learning in delivering quality services.

39. The Strategy means that staff throughout NHSScotland will be encouraged to take greater responsibility for their own learning. In return they can expect: Support from their employer in helping them to keep up-to-date and acquire new skills, including access to appropriate learning resources and to induction training.

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The opportunity to sit down with their managers / senior professional colleagues at regular intervals, to discuss their development needs and identify learning opportunities. Help in preparing personal development plans and / or learning portfolios which support their career development using as a model the IBMS PDP plan. Local decisions about investment in education and training activities, including access to funding, based on a recent assessment of learning needs and the service development objectives of the NHS. To take part in team-based learning as well as development activities. To have their skills and competencies recognised as part of the continuous process of lifelong learning.

40. To ensure that NHSScotland has staff with the necessary skills and knowledge, the Working Group recommends that MLSOs, in conjunction with Trusts and with the collaboration of MSF and IBMS, be involved in the preparation of workforce needs assessments so that they reflect the change in need for a fully staffed and appropriately skilled laboratory service. These workforce needs assessments are required to accompany all service change proposals put to NHS Boards. The Group also recommends that MLSOs should ensure that local approaches to Continuing Professional Development, as part of the development of local learning plans, should be channelled through their professional body, the IBMS, with support from their MSF representative. 41. All NHS employers were asked by December 2000 to ensure that all their staff have personal development plans, backed up by the opportunity to discuss their learning needs at regular intervals. Training of MLA Staff: 42. At present there is no programme for the formal training of MLAs or a recognised career structure where achievement is rewarded. A formal training scheme should be introduced which could lead to recognised qualifications. A career structure which recognises the different roles undertaken by MLA staff should be considered. Training for Staff in Remote and Rural Areas: 43. At present, there is no programme of distance learning available in Scotland. The nearest course is available from the Virtual School of Biomedical Science, University of Ulster. The development of a Scottish-based distance learning course would help to train laboratory staff in remote and rural areas without the need to travel long distances and take time off work. 44. The need to support laboratory services in geographically different sites is relevant to a significant number of acute Trusts across Scotland. The support needs to encompass issues wider than that of basic training per se to include, for example, multi-tasking, accreditation and information technology. Opportunities for secondment should be made more widely available to allow a free-exchange of staff from a remote and rural area to central Scotland

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and vice versa. If necessary, financial incentives should be put in place to allow this to happen effectively. 45. A training network, focused on the training needs of MLSOs would help to knit together all the different strands of the service from every part of Scotland. It would also act as a forum to ensure that all staff achieve Continuing Professional Competencies which, it is understood will become mandatory under the proposals of the Health Care Professional Council, (HCPC), and can demonstrate continuing professional development. This might be achieved through the use of supernumerary MLSO training posts or by means of networking training between a rural district general hospital and a teaching hospital which is a CPSM approved training centre with cross-secondment between laboratories. This could either take place within a health board or across health boards. The Remote and Rural Areas Resource Initiative, (RARARI), would seem to be the appropriate body to facilitate the development of this network.

Recommendations The IBMS and the CPSM should foster closer links with relevant Universities in Scotland and jointly undertake a review of the core curricula of degree courses to ensure continuing relevance. In addition, different styles of teaching modules, e.g. distance and open learning, should be explored. (Paragraphs 33 and 35). More opportunities should be taken to allow MLSO training to take place at the clinical interface. Such activities would help MLSOs to raise their profile, foster a sense of team working and utilise staff to their full potential. (Paragraph 36). Managers will be aware of, and should adhere to, the recommendations set out in the Strategy for Education, Training and Lifelong Learning and the opportunity that this affords to all NHS staff to develop their skills and to deliver a high quality service. (Paragraph 37) All MLSOs, in conjunction with Trusts, should be involved in the preparation of workforce needs assessments through MSF and the IBMS- so that they reflect the change in need for a fully staffed and appropriately skilled laboratory service. MLSOs should ensure that local approaches to Continuing Professional Development, as part of the development of local learning plans, should be channelled through their professional body. (Paragraphs 40 and 41). A formal training scheme for MLAs should be introduced leading to an improved career structure.(Paragraph 42). A training network focused on the training needs of MLSOs, would help to knit together all the different strands of the service from every part of Scotland and should be facilitated by RARARI. (Paragraph 45).

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IV.

RETENTION

There is little to offer staff with no prospects of promotion and an escalating workload

Introduction 46. Staff retention is a major problem. This was highlighted in our survey and also in the survey conducted by the IBMS2. Furthermore, the IBMS Annual Report for 199812 singled out the continued decline in the number of MLSO4 grades, (the most senior grade), as a source of particular concern. Current Issues 47. A number of factors affect staff retention. These include: inadequate remuneration little opportunity for career progression a sense of not being a part of the hospital team / absence of direct patient contact in some laboratory disciplines low morale escalating workloads [see Appendix III] competition from outside industry offering career progression and improved prospects for remuneration, and requirements for a 24-hour service.

48. The situation is also exacerbated by the ageing profile of the laboratory workforce. In Scotland, 80% of MLSOs are more than 35 years of age and 37% are more than 45 years of age, (see Appendix III). Possible Solutions New Technology: 49. Over the past thirty years, the development of automated analysers has had a profound effect on medical laboratories. In Clinical Chemistry, several instruments now have the capacity to offer a menu of over 100 general chemistry tests. In Immunology, immunoassays, which previously were only available after days of analytical processing, can now be analysed within hours. Full blood counts and coagulation results are available rapidly and automated analysers are now also available for a range of immunological, virological and antibiotic assays. More recent developments mean that it is now possible to carry out assays from different laboratory disciplines on the same analytical platform, (e.g. clinical chemistry,

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immunoassay and haematology analysers can be bolted together, with a single shared sample processor) as part of a modular approach. 50. The benefits of automation may not always be apparent to laboratory staff, some of whom even view these developments as a threat to their professional skills. However, if the bulk of the routine analysis can be completed easily with minimum intervention from highly trained MLSO staff, time will be freed up for the more challenging tasks of audit, teaching and training, research and development, quality management and improved communications with other health care professionals, all of which enhance job satisfaction. Enhanced Job Satisfaction: 51. In the light of technological development and changing patterns of service delivery, there needs to be a radical re-think about job design, the structure of the grading system and the need to match the expectations of graduates with realistic and rewarding responsibilities. 52. There is no doubt that cross-disciplinary working (i.e. multi-tasking), which makes greater use of core skills to span specialty boundaries, is on the increase. Attempts should be made to enhance job satisfaction through role extension, for example, into the field of diagnosis / reporting of results, provided this is underpinned by appropriate training and approved by the medical head of the laboratory. Flexible working, short-term placements and facilitation of movement between academic and service sectors should also be explored more actively than at present. These proposals should go some way to resolve present problems resulting from rigidly defined professional boundaries and ill-defined career pathways which make movement between different grades difficult. Career Progression: 53. The present grading structure impedes career progression. It is also outmoded and serves no useful purpose in the context of a modern laboratory. The structure of departments means that there is usually only one MLSO4 in any given laboratory and a limited number of MLSO3 posts. The paucity of MLSO 2, 3 and 4 posts, (see Appendix III), means that opportunities to secure promotion are few and far between. Furthermore, MLA grades, with neither a structure nor a formal training scheme, have not been particularly successful in terms of retention. 54. The ability to progress through grades is an attractive one to most employees, with the promise of reward. The Group therefore propose that an integrated career structure with multiple entry points should be introduced for all MLAs and MLSOs. The structure would have entry points from school leavers to graduates with a commitment to lifelong learning and continuing professional education. Progress through the structure would be dependent upon qualifications, ability and aptitude. 55. Certain jobs and skills are common to all disciplines and these should form the basic training for all medical laboratory workers (MLSOs and MLAs). This includes pre-analytical work, health and safety, record keeping, reagent preparation and clinical waste disposal. Techniques common to most disciplines, such as the use and maintenance of equipment, including loading automated analysers, should form the next stage of training. Further stages will include specialisation and training leading to State registration and beyond for postgraduate staff.

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56. The potential for lateral movement into other areas of NHSScotland, should be encouraged. Raising the Profile: 57. It is an unfortunate fact that there is a general lack of awareness amongst both NHS employers and the public about the contribution made by laboratory staff to health care delivery 13. Laboratory staff are perceived by many members of senior NHS management to be remote from the rest of the hospital, resistant to change and unwilling to become involved in management issues. On the other hand, laboratory staff themselves often sense resistance on the part of clinicians and managers to let them become more involved in issues of common concern. The Group recommends that all Trusts should encourage the professional representation of laboratory staff by laboratory staff at Clinical Directorate level within the organisation. The person appointed should be accorded equal status with other lead professional heads. It is known that such an arrangement has already been tried and tested in at least one Trust in Scotland to good effect. 58. There is a need for MLSOs to develop links beyond the confines of the laboratory. To some extent, this is already happening in some of the laboratory disciplines because of increased opportunities for MLSOs to undertake near-patient testing on the ward or in the clinic and to meet the needs of general practitioners working in the community. In addition to this, technological developments such as small analysers for use outwith the hospital laboratory, are likely to result in more interaction between laboratory staff and the users of the service. Control of infection and the public health aspects of laboratory work are prime areas which call for laboratory staff to be interactive with other colleagues in the Service. Staff should build on these opportunities to raise their profile among the general public and other health care professionals. Regulation of a 24-hour Service: 59. A 24-hour service is now more or less mandatory in every hospital laboratory but the type and level of service varies according to the laboratory setting and the subsequent demands that are placed upon the laboratory. The Working Group believes that the voluntary aspect currently attached to this service no longer conforms with the demands of the modern NHS and is increasingly anomalous. The Group believes it is crucial that each laboratory has a sufficient pool of staff to operate a 24 hour service, recognising that not all staff will be willing to participate in the on-call rota at any given time.

Recommendations Attempts should be made to enhance job satisfaction through role extension, for example, into the field of diagnosis / reporting of results, provided this is underpinned by appropriate training. Flexible working, short-term placements and facilitation of movement between academic and service sectors should also be explored more actively than at present. (Paragraph 52). An integrated career structure with multiple entry points should be introduced for all MLAs and MLSOs. The structure would have entry points from school leavers to

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graduates with a commitment to lifelong learning and continuing professional education. (Paragraph 54). The potential for lateral movement into other areas of NHSScotland should be encouraged. (Paragraph 56). All Trusts should encourage the professional representation of all laboratory staff by laboratory staff at Clinical Directorate level within the organisation. The person appointed should be accorded equal status with other lead professional heads. (Paragraph 57).

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V.

SUMMARY OF MAIN RECOMMENDATIONS

Recruitment: 1. Although pay and conditions of service lie outwith the remit of this Working Group, the Group welcome the fact that these issues are being examined in other fora, e.g. the National Pay Review Body, Agenda for Change Pay Modernisation. The Group believes that the inclusion of MLSOs in the National Pay Review Body would have a positive impact on recruitment and retention. (Paragraph 21). 2. 4 year Honours degree courses in Scotland, provided they meet all the statutory requirements, should be tailored more to the needs of a clinical laboratory service. (Paragraph 22). 3. Applicants with Highers in science subjects should be given the opportunity to progress academically to graduate level. (Paragraph 24). 4. The re-introduction of part-time courses needs to be explored along with the introduction of a link year as part of the 4-year Honours course where students gain the necessary practical laboratory experience. (Paragraph 24). 5. The Nursing Directorate and the Directorate of Human Resources of the Scottish Executive, Universities, employment organisations and professional bodies should work together to encourage recruitment and develop career pathways for staff entering laboratory medicine. (Paragraph 27).

Training: 6. The IBMS and CPSM should foster closer links with relevant Universities in Scotland and jointly undertake a review of the core curricula of degree courses to ensure continuing relevance. In addition, different styles of teaching modules, e.g. distance and open learning, should be explored. (Paragraphs 33 and 35). 7. More opportunities should be taken to allow MLSO training to take place at the clinical interface. Such activities would help MLSOs to raise their profile, foster a sense of team working and utilise staff to their full potential. (Paragraph 36) 8. Managers will be aware of, and should adhere to, the recommendations set out in the Strategy for Education, Training and Lifelong Learning and the opportunity that this affords to all NHS staff to develop their skills and to deliver a high quality service. (Paragraph 37). 9. All MLSOs, in conjunction with Trusts and with the collaboration of MSF and IBMS, should be involved in the preparation of workforce needs assessments so that they reflect the change in need for a fully staffed and appropriately skilled laboratory service. MLSOs should ensure that local approaches to Continuing Professional Development, as part of the development of local learning plans, should be channelled through their professional body. (Paragraphs 40 and 41).

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10. A formal training scheme for MLAs should be introduced leading to an improved career structure. (Paragraph 42). 11. A training network, focused on the training needs of MLSOs, would help to knit together all the different strands of the service from every part of Scotland and should be facilitated by RARARI. (Paragraph 45).

Retention: 12. Attempts should be made to enhance job satisfaction through role extension, for example, into the field of diagnosis / reporting of results, provided this is underpinned by appropriate training. Flexible working, short-term placements and facilitation of movement between academic and service sectors should also be explored more actively than at present. (Paragraph 52). 13. An integrated career structure with multiple entry points should be introduced for all MLAs and MLSOs. The structure would have entry points from school leavers to graduates with a commitment to lifelong learning and continuing professional education. (Paragraph 54). 14. The potential for lateral movement into other areas of the NHS should be encouraged. (Paragraph 56). 15. All Trusts should encourage the professional representation of all laboratory staff by laboratory staff at Clinical Directorate level within the organisation. The person appointed should be accorded equal status with other lead professional heads. (Paragraph 57).

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References 1. The Scottish Office Department of Health. Acute Services Review Report. Edinburgh: The Stationery Office, 1998. 2. Institute of Biomedical Science / The Gillett Consultancy. A Survey of Recruitment and Retention amongst Biomedical Scientists employed in the National Health Service. IBMS, London. 2000. 3. Porter A R. MSF Heads of Pathology Departments 1998 Survey. Biomedical Scientist 1998; 42: 707. 4. Johnston P W, Milne G D. A survey of factors affecting the recruitment and retention of Medical Laboratory Scientific Officers in Pathology. Health Bulletin 1999; 57(6): 393-398. 5. Institute of Employment Studies. Graduate Salaries and Vacancies 1999 Survey. Association of Graduate Recruiters, Warwick 1999. 6. Staffing crisis hits testing of patient samples. The Herald 24 January 2000. 7. Laboratory cut-backs [Opinion Leader] The Herald 26 January 2000. 8. Browne A, McSmith A. Cuts force secretaries to diagnose cancer tests. The Observer. 23 January 2000. 9. Laboratory staff lobby Wesminster. Medical Laboratory World. May 1999. 10. Ward S. Down the tubes. Health Service Journal 25 May 2000: 22-23. 11. Scottish Executive Health Department. Learning Together: A Strategy for Education, Training and Lifelong Learning for the National Health Service in Scotland. Tactica Solutions, Edinburgh. 1999. 12. Institute of Biomedical Science. Annual Report: 1998. IBMS, London. 1999. 13. Connolly C, Huckerby D. Test match. Health Service Journal 25 May 2000: 24-25.

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APPENDIX I MEMBERSHIP OF THE WORKING GROUP Chairman: Mr T Cavanagh Laboratory Manager /Senior Chief MLSO Western Infirmary, Glasgow.

Members: Ms M Allardyce Senior Chief MLSO (Haematology) Aberdeen Royal Infirmary. Executive Director Scottish Council for Postgraduate Medical and Dental Education. Consultant Pathologist Western Infirmary, Glasgow. MLSO 4 (Haematology) Falkirk & District Royal Infirmary Pathology Laboratory Manager Borders General Hospital Regional Officer, MSF. MLSO 3 (Immunology) Western Infirmary, Glasgow. Trust Chief Executive Ayrshire & Arran Acute Hospitals NHS Trust. Head MLSO (Regional Virus Laboratory) Gartnavel General Hospital, Glasgow. MLSO 4 (Pathology) Aberdeen Royal Infirmary. Reader in Medical Microbiology Ninewells Hospital, Dundee. Head MLSO / Pathology Services Manager University of Edinburgh Medical School Laboratory Manager Edinburgh and S E Scotland Blood Transfusion Service.

Dr E G Buckley

Dr R A Burnett

Mr J Deans

Mr R Fleet

Mr M Fuller Mr E Galloway

Mr S Greep

Mr R A McCartney

Mr G D Milne

Dr D C Old

Mr J K Rae

Mr J T Scott

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Mr R Singer

Business Manager / Laboratory Manager Ninewells Hospital, Dundee. Senior Chief MLSO (Clinical Microbiology) Western Infirmary, Glasgow.

Mr D Swan

Officers: Dr A Keel DCMO (Management Executive) Scottish Executive Health Department. Health Care Policy Division Scottish Executive Health Department.

Mr J N Leadbeater

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APPENDIX II SUMMARY OF THE MAIN LABORATORY DISCIPLINES Clinical Chemistry Clinical Chemistry (also called Clinical Biochemistry or Chemical Pathology) is the study of the chemical constituents of the human body in health and disease. Most tests are carried out on blood or urine but other body fluids, cells and tissues may also be analysed. It is increasingly concerned with major screening programmes of neonates and adults. The discipline is primarily a hospital-based service but offers a significant service to general practitioners. Staff perform a wide range of tests including routine automated tests, metabolic function tests and endocrine tests in order to determine the diagnosis of metabolic disease and to monitor drug therapy. They may also be required to investigate drug overdoses. The discipline is a highly automated one which has a large volume of work and a wide range of laboratory investigations. Blood Transfusion The Scottish National Blood Transfusion Service (SNBTS) is a division of the Common Services Agency of NHS Scotland and is organised and co-ordinated on a national basis. It is responsible for the collection of voluntary blood donations and for the preparation and provision of an adequate supply of safe blood components and blood products. Staff perform tests to determine blood grouping and antibody identification in order to provide compatible blood and blood products. This service is essential in the acute hospital context where modern medical techniques and treatments rely heavily upon the support of such products being available. Staff also undertake specialised testing for the resolution of grouping and matching problems, the preparation of diagnostic grouping reagents, the provision of rare blood and tissue-matched blood products and the preparation of blood components and plasma fractions in order to supply the needs of acute hospital Trusts.

Haematology Haematology is the study of blood and blood forming tissues. Haematology laboratories provide an investigative, diagnostic and clinical service for the care of patients with anaemia, haematological malignancy, haemaglobinopathies and coagulation abnormalities. Laboratory staff perform a wide range of tests on blood and bone marrow aimed at diagnosing and managing haematological conditions ranging from leukaemia to control of anti-coagulant therapy. Cellular Pathology Cellular pathology encompasses two related but different elements: Histopathology and Cytology.

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Histopathology Histopathology is concerned with the diagnosis and management of disease through the examination of tissue which has been obtained through surgical removal, biopsy or autopsy. Staff prepare tissue removed during surgery or at post mortem using techniques such as microtomy, routine and specialised staining procedures and frozen sections so that they can be examined under the microscope. Nowadays, increasing use is made of Immunocytochemistry and Molecular Biology techniques as an aid to diagnosis. Cytology Cytology is the microscopic study of free cell specimens. It is usually, though not always, closely linked to Histopathology, and refers to the examination of exfoliated or aspirated cells. It plays a crucial role in the national breast and cervical screening programmes. Screening of cervical smears and non-gynaecological cellular material forms a large part of the workload. Fine needle aspiration of abnormal tissue (e.g. breast lumps) is increasingly being used for rapid diagnosis. Laboratory staff are involved in preparatory techniques in cytology and also in studying the cells under investigation to detect abnormalities. Autopsy Post mortem examinations are performed by staff in histopathology departments and are undertaken either on behalf of clinicians or at the request of the Procurator Fiscal. Accurate information on cause of death is a pre-requisite for health service planning and the autopsy provides one of the most direct means of clinical audit and is an accurate measure of quality of care. Medical Microbiology Staff in medical microbiology laboratories in the NHS are primarily concerned with providing a service to clinicians to aid in the diagnosis and treatment of microbial diseases such as meningitis, respiratory tract, enteric and wound infections. They also provide a public health function by assisting in the control of epidemic and sporadic disease. Tests are carried out to isolate and identify disease-causing micro-organisms, fungi, protozoa and parasites. Serum is tested for antibodies to infective agents and for microbial antigens. Specimens commonly examined are blood, urine, faeces, sputum and swabs from various body sites. Virology Virology, together with bacteriology and mycology, is concerned with the study of all aspects of disease caused by infectious agents. Staff in virology laboratories are primarily concerned with the detection and identification of viruses such as herpes, influenza and the human immunodeficiency virus (HIV). Tests include the culture of viruses in living cells, testing of blood samples for antibodies to viruses and the use of specialised techniques for the detection of viral particles in human tissue. These laboratories also have a heavy routine commitment to population screening for

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immunity to hepatitis and rubella and to monitoring the efficacy of vaccines. Molecular biology techniques are widely applied. Immunology Immunology is concerned with the study of the diseases of the immune system. Staff in immunology laboratories specialise in the investigation of abnormalities and disturbances of the immune system associated with, for example, bacterial and viral infections, parasitic infestation, allergy, malignant and autoimmune diseases and immunological deficiencies. Changes are analysed in antibodies and other proteins and leukocytes are identified in conditions such as leukaemia and AIDS. Investigations take place in order to assess responses to vaccination or treatment and, in transplant recipients, to measure the function of their immune system. Histocompatibility / Tissue Typing Histocompatibility / Tissue Typing laboratories provide HLA (tissue) typing services pre solid organ or bone marrow transplantation. Such laboratory tests are a prerequisite to determining whether a potential donor is compatible with the recipient in order to avoid major problems of rejection. Certain tissue types are also associated with specific diseases and histopathology laboratories undertake the tests necessary to determine such links.

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APPENDIX III SUMMARY OF SCOTTISH SURVEY ON RECRUITMENT, TRAINING AND RETENTION OF MEDICAL LABORATORY SCIENTIFIC OFFICERS The Survey Questionnaires were sent to all Head MLSOs and Laboratory Managers in Scotland. Replies were received from 120 out of 143 possible respondents, representing a response rate of 84%. It was not possible to identify or follow up the outstanding questionnaires since respondents had been assured a guarantee of anonymity. Nearly a hundred written comments were received with the returned questionnaires. The questionnaire was conducted during the period 1-30 September 1999. Over the past 2 years, staff vacancies accounted for 25% of the total MLSO complement (50.5 w.t.e.) for Cellular Pathology; 21% (014.73 w.t.e.) for Haematology; 17% (12 w.t.e.) for Virology; 15.5% (71.73 w.t.e.) for Biochemistry and 13% (54.83 w.t.e.) for Microbiology. Over the past 2 years, the average time to fill vacancies amounted to 45 weeks for 2 posts in Immunology; 9 weeks for 9 posts in Blood Transfusion and 8 weeks for 104.73 w.t.e. posts in Haematology. Currently 25% of MLSOs in Scotland are graduates and 8% possess a higher degree. With the move to all-graduate recruitment, these percentages are set to increase dramatically over the next few years.

The accompanying graphs illustrate the results of the survey.

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APPENDIX IV SUMMARY OF IBMS SURVEY ON RECRUITMENT AND RETENTION OF BIOMEDICAL SCIENTISTS EMPLOYED IN THE NATIONAL HEALTH SERVICE The Survey Questionnaires were sent to 1,163 NHS Trust Pathology Managers and Senior Medical laboratory Scientific Officers to ascertain recruitment and retention status in NHS Pathology laboratories in the UK. The survey was conducted between Christmas 1999 and 21 January 2000. Perceptual data was received from 68% of Trusts in England and Wales, with full statistical data from 39%. Data were also received from 8 trusts in Scotland and Northern Ireland, 8 PHLS laboratories and 12 private hospitals. The Workforce 88% of all Trust laboratories were understaffed 62% of all Trusts had unfilled vacancies 66 % of all Trusts considered their MLSO establishment was inadequate There is a calculated 1,255 shortfall in MLSO numbers in NHS Trusts in England and Wales, of which 1,052 are MLSO 1 vacancies Over 20 % of laboratories report the following impacts of these staff shortages (on free expression): -training stopped or suffered -staff under stress -falling service delivery -failings developing in Quality Assurance and Quality Control systems -Difficulties in maintaining on-call services 50% of MLSOs have a degree, 25% having a BSc in Biomedical Science.

Recruitment 89% of Trusts sought to recruit MLSOs in 1999, 54% failed to fill all vacancies and 18% failed to appoint any new MLSO staff 68% of Trusts sought to appoint Trainee MLSOs in 1999. 61% felt fields of applicants were adequate (9.19 candidates per post) 61% of Trusts sought to appoint MLSO1s in 1999. 93% felt fields were inadequate (2.95 candidates per post) and 50% failed to appoint altogether. Where appointments were made these often took protracted periods of time and multiple advertisements

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98% of respondents thought that recruitment problems were getting worse Histology / cytology was the most problematical discipline to recruit to, with 40% of respondents reporting particular difficulties for Histologist recruitment 97% of respondents spontaneously cited pay levels as a key recruitment problem 25% cited poor public image and a similar 25% cited lack of career prospects as problems Training and development issues, and a lack of comparability with other NHS graduate groups were also seen as hindering recruitment.

Retention Over three quarters of laboratories reported highest staff turnover rates for the MLSO1 grade 60% reported highest turnover rates for staff between 20 and 30 years The mean MLSO1 turnover rate was 16.47% in 1999 Reasons for leaving. gleaned from exit interviews were given as: -low pay (61%) -stressful working conditions (19%) -low morale / lack of career status (18%) -career change (10%) Only 21% of resignations were attributed to routine career progressions (promotion, retirement or moving away) A mean of 56% of leavers were reported as leaving the NHS altogether, while one-fifth of Trusts reported that ALL their leavers left the Health Service 40% of Trusts reported offering enhancements to salary terms in order to attract and retain staff, though this was significantly more common in London and least common in Scotland.

Working Practices 76% of all Trusts use inappropriate staff groups to cover Biomedical Scientist duties. Most commonly used substitute staff are Trainee MLSOs (71%), MLAs (59%) and nonState-Registered locum cover (21%) Approximately half the Trusts responding believed that Biomedical Scientist recruitment and retention problems were not recognised by their Human Resources Director. Fewer still (40%) thought their problems were recognised by the Trust Chief Executive and only 10% believed that their Health Authority saw BMS recruitment and retention as a problem

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Regional Education Consortia provided 23% of Trusts with funds for education, 20% with funds for training, 11% with funds for continuing professional development and 4% with funds for personal development planning By far the most significant issue emerging from a free expression invitation to comment on the current state of BMS recruitment and retention was that of low pay (53%). Low morale (14%), wrong career structure (12%) and lack of training provision (10%) also featured prominently.

Reproduced with kind permission from the Institute of Biomedical Science.

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