Pathology Workforce Strategy

Pathology Workforce Strategy

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Strategy noun …a plan of action designed to achieve a long-term or overall aim…

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Pathology Service: Workforce Strategy

Contents:

1: Foreword 2: Introduction 3: Context and Strategic Alignment • What is Pathology • Pathology Networks • Lancashire & South Cumbria Service redesign • ICB priorities • Financial Recovery & 24/25 Operational Planning • People Promise • Sustainable workforce development/wider integrated teams • Service reform/end-to-end/patient focussed and central to system recovery • Digital Pathology/technological change • Leadership, Data and Transformation

4: Visioning the future and defining what is required • Population dynamics and profiles • Activity projections • Wicked problems • Vision • Aims

5: Understanding the current state • Current culture/feelings; staff survey • Staff analytics • Flow • Priority areas and gaps • So what?

6: Planning to deliver – options appraisal and benefits analysis 7: Next Steps – Implementing, monitoring and refreshing 8: References 3

1. Foreword “Diagnostics plays a key role in the treatment of patients providing critical insights that guide and support treatments to improve patient outcomes. I am really pleased that this Network Pathology Workforce Strategy has been produced following extensive consultation and recognises the key issues and opportunities as we continue to develop comprehensive services in hospital, community and primary care.

A robust pathology workforce strategy is pivotal in ensuring the efficient and accurate diagnosis of diseases, which is foundational to effective patient care across Lancashire and South Cumbria. As medical advancements continue to progress, the demand for skilled pathologists grows, highlighting the necessity for a well-structured approach to attract, train, and retain talent in this critical field. By implementing a comprehensive pathology workforce strategy, we seek to address current shortages, enhance diagnostic capabilities, and ultimately improve patient outcomes, driving forward both research and innovation.

The pathology workforce will be central to the adoption of new technologies and the introduction of areas including digital solutions, genomics and artificial intelligence (AI), due to their specialized expertise. Staff in Pathology are uniquely positioned to integrate these new technologies enhancing diagnostic accuracy essential for advancing personalized medicine and improving patient care outcomes.

This workforce strategy for pathology identifies the needs of the service following a comprehensive assessment of current workforce capabilities, workload demands, and future trends in healthcare. This involved analysing data on staffing levels, skill gaps, and the evolving landscape of medical technology and patient demographics.

By understanding these factors, the strategy can pinpoint specific areas where additional training or resources are required. By implementing these measures, the workforce strategy ensures that pathology staff are well-equipped to meet current and future service needs, fostering a dynamic and skilled workforce capable of leveraging new technologies to improve patient care.”

Anthony Rowbottom: Managing Director, Lancashire and South Cumbria Pathology Service 4

“NHS pathology services play a crucial role in supporting patient care across every patient pathway. Ensuring we have the right workforce with the right skills is absolutely key in delivering high quality care. Therefore, this pathology workforce strategy will underpin the vision from the national pathology transformation programme and ensure pathology services are delivered for the benefit of patients long into the future.”

Helen Ligget: Regional Lead Scientist, NHS England NW “This radical step change workforce strategy will provide the blueprint for more collaborative, digitally enabled ways of working. It will put pathology in the centre of our diagnostic capabilities to support our changing population need. It is key to ensure we have a sustained, supported and well recognised workforce, enabled to deliver the pressures and demands on the health care system that face us.

Investment in leadership development across Pathology will support the wider ICB ambition of a One Workforce.”

Andrea Anderson: Director of People, NHS Lancashire and South Cumbria Integrated Care Board

Pathology Service: Workforce Strategy

A note from the authors….

“First of all I would like to thank the members of staff that have engaged in the process of creating this document over the last six months. A strategy for our workforce across LSC has been required for a while and I hope this document provides the strategic direction for us all. We now need to move forward and implement the necessary changes to ensure we have a sustainable, well trained and happy workforce that will move this critical service forward for the population of LSC.”

Gillian Crankshaw: Workforce and Strategy & Transformation Lead, L&SC Pathology Service

“I want to take this opportunity to thank everyone who has supported the development of this workforce strategy. In particular, those that welcomed me into departments and laboratories, were keen to show me the equipment, explain how things work and be open and enthusiastic to share with me what working within Pathology meant to them and their day-to-day experiences. I would also like to acknowledge those who took the time within their busy working days to engage with the events and sessions we put on. To say thank you for staying with me, when the questions I posed and things I asked of you were difficult and maybe felt a little strange. Most of all I would like to say thank you for welcoming me in and enabling me to be a small part of making things better. As a strategic workforce planner, I absolutely endorse the value in taking time to think about the future and what that may mean for staff. I also see how often our efforts are diverted into reacting to the now rather than preparing for what is coming. For me the process of writing a workforce strategy and pausing to lift up our heads to reflect and explore the possibilities of what might be is as important as the resulting product.

Importantly what we commit to writing down and monitoring has the best chance of getting done.”

Fiona Ball: Workforce, Strategy & Education Lead, Lancashire and South Cumbria Pathology Service

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2. Introduction It is critically important for us to prioritise a focus on our workforce. To look after our staff, nurture and develop their aspirations, grow effective and inspirational leaders, build wider integrated teams, embrace digital and technological opportunities and champion the amazing people who work in our Pathology services.

We need to urgently review and reform not just the size, but the shape and skills of our pathology workforce, ensuring we raise the profile of the end-toend patient focussed role pathology plays in improving the health outcomes of our populations and its central contribution to whole system recovery.

This workforce strategy has been developed for the Lancashire and South Cumbria Pathology Service with support from the NHS Lancashire and South Cumbria Integrated Care Board’s People Directorate and NHS England Northwest partners.

In bringing this work together, we have used the Six Step Strategic Workforce Planning methodology and have benefited from pathology subject matter expertise, strategic workforce planning and transformation facilitation skills, and data and analytic support.

In addition, we have visited sites and laboratories and spoken with a wide range of staff, without whose input this strategy could not have been produced. It is an evidence-driven plan, which has worked hard to represent the realities of our current staff, understand the detail of what is currently happening and provide a platform for discussion that can act as a lever for change.

The ambitions of the Lancashire and South Cumbria Pathology Service Strategic Plan for 2024–2027, ‘Delivering Excellence in Laboratory Medicine’, provides a collective commitment to prioritise what needs to be done to build agility and put in place proactive responses to the challenges around us.

This workforce strategy describes some of those proactive responses and explains where we will start.

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Pathology Service: Workforce Strategy

3. Context and Strategic Alignment

Pathology is a part of health provision that affects all stages of a person’s life from birth until end of life.

It impacts all stages of care pathways. It is estimated that Pathology is involved in 70% of all diagnoses made in the NHS. Although often thought of as a back-office function, it is critical in providing direct patient care i.e. Point of Care Testing (PoCT), infection control and as part of multi-disciplinary teams.

WHAT I S PATH OLOGY ?

“…experts in illness and disease. They use their expertise to support every aspect of healthcare, from guiding doctors on the right way to treat common diseases, to using cutting-edge genetic technologies to treat patients with life-threatening conditions.”

What is pathology? (rcpath.org)

STAFF? WHO ARE ITS

Y LOG O H T F PA O E TUR U F E S TH E O TD WHA

IKE? L K LOO

Pathology includes a wide range of staff including Medical Doctors and Consultants; Healthcare Scientists; Clinical Scientists; Clinical Support roles (such as Healthcare Support Workers, Assistants, Associates, Practitioners and Trainees, Mortuary Technicians and Phlebotomists); Admin and Clerical staff; and other Professional Scientific and Technical staff.

These staff sit across a number of disciplines and sub disciplines.

For this workforce strategy, we have defined the groups as either of Core or Aligned disciplines, with the main focus being upon the Core Disciplines.

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The Pathology Modernisation Programme and the Carter Review both recognised the need to scale up pathology services, but also the fact that a focus only on ‘local test production’ misses opportunities to work in different ways to, ‘enhance care pathways, enable patients to take control of their chronic disorders and save resources outside the laboratory and across health economies’.

The National Pathology Programme Digital First report 2 critically describes ‘clinical value chains’ which can only be maximised if pathology services are coordinated with clinical services.

It describes Pathology’s critical place in not only in supporting clinical teams and making results visible and interpretable for patients, but also in supporting innovation to make pathways faster and better.

2 National Pathology Programme Digital First: Clinical Transformation through Pathology Innovation

The key implication of this vision is for ‘pathology to place itself at the centre of self-managed healthcare’.

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Pathology Service: Workforce Strategy

In developing this workforce strategy, one of the early steps we undertook was to research the wider national, regional and local context, to ensure that our work was appropriately aligned to the environments surrounding us.

From this literature research, we discovered five key areas that are either already directly affecting the LSC Pathology Workforce or have the potential to impact our thinking about the future

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National Reports

ICB Priorities

There are many national reports and publications presenting recommendations of change for pathology. Key findings from these are explored in section 3 of the full version of the LSC Workforce Strategy.

The Joint Forward Plan (JFP) lays out four priority aims and six strategic objectives with a centralised vision to create ‘…healthy communities where people are given the best start in life, so they can live longer and healthier lives’. With a specific focus on using our assets differently, embedding a future operating model based on collaborative working, sharing and belonging.

2 Pathology Networks NHS England’s National Pathology Transformation programme includes a Maturity Matrix for Networks and an ask for all pathology networks be ‘mature’ in all domains by the end of 2024/25.

Lancashire & South Cumbria Service Transformation The ambition for the LSC Pathology Service, operating as one service network.

Anticipated to be delivered over a two-year, phased transition period. The future service model is still being defined and as such, this workforce strategy sits within a changing context but aims to build the agility to respond to both currently known or anticipated workforce pressures, as well as being able to flex and adapt to the changing service architecture as that matures.

The ICB 5-year Workforce Strategy promotes the strategic priorities of; Working as one to deliver our One Workforce ethos and approach; Working as one to attract and retain a diverse and skilled workforce and Working as one to train and grow our own workforce.

Financial Recovery and 24/25 Operational Planning The 24/25 Operating Planning Guidance for workforce states that, ‘System workforce numbers must be aligned to service priorities and the financial resources available’, which potentially poses a challenge and a risk for pathology and often sees its benefit realised within other parts of the system.

There is a minimum 2.2% efficiency target set for systems in 2024/25 and requirements to improve workforce productivity and reduce agency spend to a maximum of 3.2% of the total pay bill. For Pathology, agency spend was 4.57% of the total pay bill in 22/23, which has increased 1.38 percentage point since 20/21.

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4 The NHS Long Term Workforce Plan

People Promise

The NHS Long Term Workforce Plan (LTWP) was published in June 2023. It only mentions pathology a total of three times; in relation to AI freeing up clinical time, improving accuracy and efficiency, and in supporting the implementation of new technologies, in which an expectation of increased productivity across pathology services of 10% by March 2025 is proposed.

The NHS People Promise commits to the ambition to work together to improve the experience of working in the NHS for everyone and to look after our people.

The LTWP modelled predictions for healthcare scientists suggest a shortfall of up to 5% by 2036/37, despite the ambitions to increase training intake across the various national healthcare scientist programmes Practitioner Training Programme (PTP), Scientist Training Programme (STP) and Higher Specialist Scientist Training (HSST) by between 31–33% by 2031. The investment and support required to meet these training ambitions will take concerted effort and planning to deliver, as well as ensuring we fully explore alternative solutions to bridging this anticipated shortfall.

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Coding architectures in the National NHS Staff Survey don’t provide visibility of pathology staff, however, the high-level group that includes pathology score lower than other staff groups across all themes. Staff engagement scores are worsening; and the L&SC scores lowest across the Northwest for the themes of ‘We are compassionate and inclusive’, ‘We are a team’ and ‘Staff engagement’.

It would be valuable to explore how we can enhance insights and onward monitoring of our staff experiences.

Across all these five areas four consistent change drivers were present.

Pathology Service: Workforce Strategy

4. Visioning the future and defining what is required

Population by Age Band

Population dynamics and profiles The population of Lancashire and South Cumbria is 1.7 million, which is about 2.5% of the total UK population. The highest proportion of our population is aged between 50–59. We have higher proportions of the population aged 60+; lower proportions of people aged between 20–49; and low proportions of children and young people aged between 10–19 compared to the national picture. This means we potentially face an increasingly ageing population, with a relatively smaller working age population than our Northwest counterparts, and a smaller proportion of people expected to become of working age within the next decade.

Population projections suggest that the overall LSC population will see an increase of 5.3% by 2043. Based on current projections, we could expect to see a 1.4% reduction in people aged 20–64; and a 30.9% increase in people aged 65+.

L&SC sees an average Index of Multiple Deprivation (IMD) score of 28.6 and an average life expectancy age of 79.9. In addition to the above, we stand out as one of the areas of highest deprivation across England and have one of the lowest average life expectancy, being second only to Greater Manchester with Cheshire and Merseyside being 7th lowest.

Life Expectancy vs Deprivation by ICB

Population ethnicity ratios suggest that in L&SC the proportion of the population who are BAME is around 11.6%. The LSC Integrated Care Strategy succinctly describes the challenges facing our populations, and the LSC Joint Forward Plan clearly visualises the variation and inequalities faced across our geographical places and neighbourhoods.

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Activity Projections There are differences between the data sources available for activity baselines particularly between the numbers of tests reflected within Model Hospital data collections and the internal network collections produced by each provider to support the business case development. In terms of the modelling used within the workforce strategy, we have used the locally collected data as a proxy for our projections on future modelled demand scenarios.

According to this data, the total number of tests across LSC have risen from almost 42 million in 2019/20 to just under 45 million in 2022/23, an increase of 7%. During the COVID pandemic, from 2020 to 2021, we see a reduction in activity of around 20% with a corresponding recovery the following year, seeing a growth of 28%, which if we omit the immediate Covid period could equate to an approximate yearly increase of around 3%. We see this annual growth in activity increase again in 22/23 at around a 4% in year growth since the previous year.

Across the LSC Providers, we see similar trends in all Trusts, with the exception of Lancashire Teaching Hospitals NHS Foundation Trust, who have seen reducing activity levels since the immediate post-covid 21/22 recovery. The largest % increases are seen at BTH (15%), followed by ELHT (12%).

Across disciplines, we see the largest proportions of total tests within Blood Sciences, at between 89–91%, followed by Microbiology at between 7–11%, then Cellular Pathology at 1–2%. Over the period 2019 – 2023 we see an average % annual decrease of 1.82 % for Microbiology; a 2.84% average annual increase for Blood Sciences and the largest average annual increases for Cellular Pathology at 4.54%. This suggests that the rate of increase in activity is higher for Cellular Pathology than the other disciplines, but as a proportion of the total pathology testing activity it remains a small element.

Looking across the LSC providers, total testing has seen an average of 2.43% increase per annum, which ranges between -1.64% at LTH to 5.18% at BTH. Using the average % annual increases for LSC, the scenarios could see testing volumes somewhere near to 53 million by 2030.

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Within this activity, direct access tests rose from 19m to 22.5m (17%) between 2019 to 2023. Direct Access Testing shows a different split across disciplines, with the majority of direct access testing being seen within Blood Sciences. As a proportion of total testing, direct access constitutes 50% of all testing in 22/23 and this proportion can be seen to have risen by around 4 percentage points since 2019.

When we use the current levels of total staff in post (WTE) as at October 2023 as a proxy to model future workforce, this could mean the requirement of around 116 additional WTE by 2030. Obviously, this does not account for any efficiencies in service delivery, automation or digitisation but gives a potential flavour of the plausible future.

Using the same methodology to look at what this may mean for each discipline, we see that Blood Sciences have seen an average annual increase of 2.84%; 2.54% for Cellular Pathology and a reduction of -1.82% for Microbiology. Projections could therefore expect to see testing volumes to reach around 940,000 for Cellular Pathology; 3.4million for Microbiology and 49 million for Blood Sciences by 2030. Equating to a potential increase in staff WTE of 64 for Cellular Pathology; a reduction of -14 for Microbiology and 75 for Blood Sciences by 2030.

These scenarios pose critical questions around the capacity of the workforce to meet potential demand, making it all the more important to fully focus on development and transformational options to support appropriate growth and redesign to meet this anticipated rise in demand.

2 Although it is recognised that there is an element of unquantified underutilised capacity on Blood Sciences machines which could potentially make this figure lower. A more extended review of capacity would be required to refine these assumptions.

Pathology Service: Workforce Strategy

Wicked problems is a phrase often used in planning and policy spheres to describe “…a problem that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognise. It refers to an idea or problem that cannot be fixed, where there is no single solution to the problem; …’wicked’ denotes resistance to resolution…(and)… because of complex interdependencies the effort to solve one aspect of a wicked problem may reveal or create other problems.”

Wicked problem-Wikipedia

When we engaged with staff working with pathology within LSC, in the form of laboratory walk-rounds and a staff survey, we heard that retention, training and career development and funding and investment were ranked the most critical problems. Flexible working, increasing workload, and technological changes also stood out. Views were similar across most LSC trusts, with culture and behaviour being an additional highly ranked problem at ELHT.

One aspect that is absent from the local impression, was the ambition of agility and essential positioning of pathology staff to inform and drive wider system transformation and benefits. The local concerns were very much routed in the present, immediate challenges facing staff on a day-to-day, week-to-week basis, but we should remember to place these within the wider strategic direction presented to us by the numerous national publications discussed earlier on.

Across the disciplines, Biochemistry viewed flexible working/ employment options as most important, with Cellular Pathology signalling workload as a higher priority and Microbiology ranking time for leadership, collaboration and improvement higher than other specialisms.

Staff comments from LSC survey

Senior staff (B8a+) /Medical Consultants appeared to consider increasing workload higher than other staff, with Asian staff ranking flexible working; cultures and behaviours and time for leadership, collaboration and improvement higher than white staff.

Male staff appeared to rank fewer aspects important than female staff, focussing on retention, training/career development, and recruitment.

Additional areas identified as wicked problems mentioned the current state of estates and infrastructure, along with overall staffing levels, innovation and quality improvement.

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Vision As part of the LSC Pathology Network, a vision, strategic objectives and set of values have already been set. However, there is still some work to be done in communicating and embedding these across all organisations and staff. Of these strategic objectives the one related to Workforce & Education lays an ambition to “…develop posts with academic partners with roles aligned to innovative practice.

We will work collaboratively.”

Using Kotter’s eight step process for leading change, we have developed a complimentary workforce vision which we hope will be imaginable; desirable; feasible; focused; flexible and communicable and will enable any stakeholders, partners and staff inside and outside pathology and LSC to clearly understand our ambitions for the future.

Critically, this will explain and visualise why we are proposing the recommendations we are and crucially support describing these to wider colleagues and staff in order to facilitate action.

What we heard repeatedly was an uncertainty over the future configuration of Pathology across LSC and within that a despondency over the feasibility and capability to make working within Pathology better.

By richly describing the future workforce environment and values we would like to create it is hoped that we can elucidate and rally a collective understanding and ownership of that future and a collaborative willingness to create it together, even in the shifting and uncertain landscape. By being detailed in our description of what is important from a people perspective, we can incorporate resilience, flex and agility in our ongoing responses to this uncertainty.

This workforce strategy formalises what we heard strongly from staff who described a desired future where everyone is behaving professionally, respectfully, calmly; kind and compassionately.

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In the future Pathology staff will be…..“ working efficiently, as a team; in fit for purpose labs with adequate facilities. They will enjoy the work they do, really feel and see the difference they make to patients, will be encouraged and enabled to make continual improvements; being cognisant and able to respond to the future requirements placed upon them.

Pathology staff within LSC will be valued as skilled and knowledgeable professionals, who provide a core enabling element of patient care, which is a responsive, dependable and quality service for the people of LSC. “

Pathology Service: Workforce Strategy

Aims In order to achieve the above vision for the LSC Pathology Workforce, we have identified five clear aims it will be important to deliver and aligned to these, six specific benefits or outcomes we expect to achieve through the implementation of the recommendations laid out. These have been co-designed by a broad range of participants from across the LSC Pathology Workforce as part of our engagement approach to developing this Strategy and have framed our collective thinking throughout the design process.

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Dorothy Walmsley Diagnostics CBM Lancashire Teaching Hospitals NHS Foundation Trust 16

Pathology Service: Workforce Strategy

5. Understanding the current state Staff analytics Before we describe the current profile, dynamics and trends of staff working within Pathology across LSC, it is important to flag the difficulty, visibility and standardisation of data and recording mechanisms to enable robust analysis and ongoing insight. The Electronic Staff Record (ESR) has been used as the single source of the truth for the pathology workforce, however within this it is worthwhile noting that there is no single service flag which allows easy identification and extraction of staff working within pathology services. Although national guidance provides high level structures relating to occupational codes, staff groupings and areas of work, much is left to individual provider interpretation and internal system architecture. In extracting the insights for this strategy, various assumptions, logical mapping constructs and exclusions have been made to produce a baseline position for the core pathology workforce. These have been checked and validated with lab managers. On ESR, there are variable proportions of staff where we have had to make assumptions on which discipline they are aligned to due to the tertiary area of work coding descriptions. This proportion is highest at LTH but is something that would value further work across all providers.

At the time of writing, we are aware of a national programme of work that has begun to refine and standardise pathology workforce coding within ESR. This is an essential piece of work but will also require subsequent localised cleansing and data quality processes to take place alongside, with an ongoing monitoring and oversight over the compliance and implied quality in order to ensure repeatability and enhanced confidence with the insights provided.

are currently captured by the monthly Provider Workforce Returns (PWRs) [for Bank and Agency usage only] but are not at a granular level sufficient to identify service specific usage. At a local level, bank and agency usage figures have been collected, however these are unstandardised, reflect snapshots from providers at different points in time and have variability in completeness. Equally, there is no mechanism to capture overtime/additional worked volumes, which for pathology staff we expect to be high. Without this element, we are not confidently able to model the entire quantities of staff time currently being used to deliver the activity levels discussed earlier and it is likely that our assumptions of workforce need are an understatement of any actual sustainable future position.

The data used in the following section was extracted from ESR and reflects the position as at October 2023 (apart from trend analysis). The full data analysis pack, including the extraction and mapping process is available separately for further information.

‘The ability to agree a standardised approach to recording and identifying staff as working within pathology services will be a key recommendation.’

There are also some elements that we have been unable to capture as part of this exercise which will need ongoing focussed attention. There is no robust mechanism for collecting levels of Bank, Agency, or overtime/ additional worked volumes for pathology. At a system level, these 17

Size of Workforce LSC has the smallest pathology workforce across the Northwest, which is slightly under the expected proportions compared to weighted population sizes.

Across the disciplines, Blood Sciences see the highest proportion of staff, followed by Cellular Pathology. Proportions vary across the providers, with staff being more equally distributed across the main four disciplines at LTH; little Immunology being seen at ELHT, as activity is delivered by the team at LTH, and smaller proportions of Microbiology being seen at UHMBT.

LSC has lower proportions of Medical and Dental and Admin and Clerical staff than the rest of the Northwest.

There are variable staffing levels between our providers, some of which will be related to local service configurations and coding between pathology and other hospital directorates, as well as the provision of some specialist services on one site.

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BTH and LTH have lower proportions of Healthcare Scientists and higher proportions of Clinical Support and Medical and Dental staff; with ELHT and UHMBT having proportionately higher levels of Healthcare Scientists. There are also variable levels of Admin and Clerical staff, with the highest proportions being seen at ELHT and the lowest proportions seen at UHMBT.

Pathology Service: Workforce Strategy

Growth over time Overall, pathology staff in post growth over the past 5 years has been higher in LSC than within the rest of the Northwest at around 16.8%. However, this is much lower than that of the total substantive workforce across the LSC Acute providers over the same period (around 24–25%).

It is clear from these high-level figures that the feeling on the ground of lack of investment and keeping pace of the Pathology workforce is certainly substantiated.

During 2022/23, LSC has seen an in-year reduction in staff, compared to continued growth seen in the rest of the Northwest. This is compared to a continue % WTE growth seen in total substantive workforce across the LSC acute providers of around 5–6% in the same period.

This is further compounded when we consider the variable levels of growth between the LSC providers and across the main four disciplines.

In the last 12 months, two out of the four providers have seen reductions in staff in post and two providers have seen continual growth at varying levels (4% at UHMBT and 2.5% at ELHT). Across the main four disciplines, growth has similarly been variable, with the highest 12 month % WTE growth seen within Microbiology (14.3%) and reductions seen within Cellular Pathology (-0.4%).

This suggests that the position is worsening in terms of investment in the pathology workforce.

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Working patterns Participation rate describes the proportion of time an individual is contracted to work. LSC sees a lower participation rate within its pathology staff than the rest of the Northwest. There is variance across the LSC providers, with the highest seen at BTH (89%) and the lowest seen at UHMBT (84%); and disciplines [highest levels within Immunology (92%) and the lowest within Blood Sciences (88%)].

Age profiles LSC has a similar profile to the rest of the Northwest. Most LSC providers have highest proportion of staff aged between 35–44.

LSC sees a broadly similar proportion of its staff on Permanent compared to Fixed Term Temporary contracts as the rest of the Northwest. Again, there is variance across providers and disciplines.

It would be useful to understand what is driving this. Does it reflect staff preferences or structural responsibilities, or a reflection of short term, reactionary funding/approval mechanisms. A greater understanding would enable greater insight into any desired improvements or changes of approach.

Cellular pathology, Immunology and Microbiology have a higher proportion of staff aged 25–34.

• LSC Pathology staff have a higher retirement risk than total staff across the acute providers (16.4%).

• There is variability across providers, with the highest risk at LTH. • Risk also varies across staff groups, the highest being within Admin and Clerical roles.

• Blood Sciences have the highest and Microbiology the lowest risk.

This poses a significant challenge, especially combined with the anticipated population projections highlighted earlier, that anticipate a reduction in our working age population. The critical question is where the succession for those staff who will be expected to retire come from and what are we putting in place now to ensure appropriate investment in supply and career pipelines to ensure future sustainability.

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Pathology Service: Workforce Strategy

Skill mix and staffing structures There is wide variability seen around skill mix and banding structures. Whether this is driven by differences in activity, acuity or complexity of testing volumes, or something else is unquantified.

LSC sees a broadly similar split as the rest of the Northwest There is variance across providers and disciplines with the highest mix of qualified staff seen at ELHT (60.7%) and Blood Sciences (64.7%) and the lowest seen at LTH (47.9%) and Immunology (40.5%).

LSC sees larger proportions of bands 5–7 and lower proportions of bands 8a+ and Non-AFC than the rest of the Northwest. Again, we see variance across providers and disciplines. There is a notable low level of Band 4s, with ELHT standing out with the highest proportion to total staff.

LSC has lower proportions of Band 8a+ Healthcare Scientists than the rest of the Northwest; and have higher proportions of clinical support roles at bands 1–4. It is clear from this evidenced variability that significant work is required to understand an optimised staffing structure based on agreed collaborative practices.

Representation and Inclusivity The LSC Pathology workforce has a lower proportion of female staff than the rest of the Northwest (71% CM/ 69% GM) and lower than the mix across the wider LSC total workforce (73.4%).

There is variance across the providers, with ELHT seeing a lower proportions of female staff. There are significantly more female staff within Admin and Clerical (87.5%) and clinical support roles (69.7%), with the highest proportions within Microbiology (69.5%) and the lowest within Immunology (62.8%). Female staff are less well represented within 8a+ (52.6%) and Non-AFC (43.4%) bands.

The majority of the pathology workforce is white (68.7%). Immunology appears to have the lowest proportion of BAME staff (19.0%). Highest proportions of BAME staff are within Band 5 and non-AFC roles, with none showing within the Band 8b-9 senior roles. The proportion of BAME staff who are also female, are low across all banding levels, apart from Band 5 roles.

LSC has fewer disabled staff than the rest of the Northwest.

Non-disclosure rates for disability is higher (16%) than across the wider LSC workforce (11.8%). Microbiology has the highest proportion of disabled staff (8.1%). There are more disabled staff within Band 2–6 roles with an absence of any disabled staff in senior B8b-9 roles.

There are less LGBT+ staff (3.7%) in LSC than the rest of the Northwest (4.8% CM/4% GM). Non-disclosure rates for sexual orientation within LSC Pathology staff is higher (18.7%) than across the wider LSC workforce (17%).

Microbiology has the highest proportion of LGBT+ staff (5.7%) and Blood Sciences the lowest (2.8%).

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The data suggests that representation within the pathology workforce is different to that within our LSC population, being particularly underrepresented in respect of staff with disabilities. Although ethnicity representation at an overall level appears inclusive, we must remember the variance we see within banding and disciplines which may require more consideration.

Absence LSC has a lower sickness absence rate (6.7%) than the rest of the Northwest and compared to the wider LSC workforce (7.1%) as a whole. There is variance with ELHT showing the highest absence rate (10.3%) and UHMBT the lowest (4.9%) and Blood Sciences the highest sickness and Immunology the lowest.

Higher sickness levels is seen within Clinical Support and Admin and Clerical roles, in the 55–64 age brackets, and within the lower banded roles (B1–4). There is an increasing trend in sickness absence since 2021, with the topmost reason for absence across all pathology staff being Mental Health.

Joiners Joiner rates for LSC pathology workforce are very slightly increasing but are the lowest across the Northwest.

LSC pathology workforce recruits the highest proportion of its staff from other NHS organisations (31.43%).

This churn may reflect inefficiencies within our own system, ‘…robbing Peter to pay Paul’.

There is variance across providers with BTH recruiting proportionately more from other public sector sources; UHMBT more from abroad – Non-EU country; and LTH being the only provider recruiting from NQ – First Qualification. Blood Sciences recruit the highest proportion from other NHS organisations; Microbiology the highest proportion from other private sector; and Cellular Path the highest proportion from Education/Training.

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Leavers Leaver rates for LSC pathology workforce are also slightly increasing but remain the lowest in the Northwest.

Staff mainly voluntarily resign with 31% resign citing relocation; 15.9% work life balance; and 4.9% lack of opportunities. We don’t understand why 18% leave.

We do not know where the majority of our leavers go to after they leave (41%). Of those where we do, the majority either to go to another NHS organisation (23.5%) or to no employment (15.7%). This is particularly high within Bands 5–7 (20.3%). Unknown leaving destinations is highest within Microbiology (66.4%), and leavers to other NHS organisations is highest within Immunology. Over the past 2 years, we have lost 31.85 WTE staff who had no future employment at the time of leaving.

In LSC, we have slightly more people joining than leaving. For bands Band 5–7 there are almost equal proportions of leavers as joiners; and more Non-AFC leavers than joiners. There is again variance across the providers, and disciplines with Cellular Pathology seeing more joiners than leavers, whereas Microbiology has more leavers than joiners.

This would suggest that we are doing a lot to stand still.

Pathology Service: Workforce Strategy

Flow To understand which staff were involved in which activities, we met with groups of staff working with each of the core disciplines to explore each pathway more fully.

We used a process mapping approach to help guide these structured conversations.

This process is a simple exercise used in conjunction with other improvement methods to know where to start making improvements that will have the biggest impact for patients and staff.

Within Microbiology we heard that there is variability within processes depending upon specimen type and individual provider preferences, over things for example such as receipt and booking numbering. At the beginning of the pathway, we see mainly Band 3 and Band 4 MLAs [Healthcare Science Associates] booking in, with a BMS [Healthcare Science Practitioner] available for oversight, to check the clinical details are accurate and as support for any questions.

Key skill requirements for this stage is described as understanding and accuracy, decision making; and an ability to work shifts including evening shifts. Current pressures or challenges highlighted were related to the development of staff and the tendency for individuals to be recruited who aspire or are already ready for BMS [Healthcare Science Practitioner] roles but are using these roles as opportunities to step into the workforce. Despite this being a useful way of growing our own, it was reflected that this did result in continued disruption and change within the team.

We also heard that the current rostering and shift patterns were not necessarily aligned to when the work arrived, particularly from GP transfers (6–8pm). Also, the variable quality and completeness of clinical details on forms was raised. In relation to sample processing, we heard that most specimen preparation was being undertaken by Band 3/4 MLAs [Healthcare Science Associates], supported by inhouse courses delivered within each Trust. It was felt that although there were cell count/gram stain automation machines, the advantages of these in comparison

to the effort to implement as well as the concern over potentially de-skilling staff was questioned. Reporting within Microbiology was predominantly undertaken by consultants for clinical validation and BMS [Healthcare Science Practitioner] for technical validation, with additional time from both BMS [Clinical Scientists] and Consultant staff related to providing ongoing advice aligned to the report. The additional pressures on staff time were flagged, as was the increasing workload aligned to quality assurance aligned to UKAS accreditation.

Four cellular pathology porters were cited in transporting deliveries from theatres, however it was mentioned that there is sometimes a reliance on MLAs [Healthcare Science Associates] to collect.

Admin staff then complete the booking in form, with Band 2/3 MLAs [Healthcare Science Associates] checking for missing data. It was flagged that the receipt and booking process for Cellular pathology was a very manual process and labour intensive. In particular, a substantial amount of MLA [Healthcare Science Associate] time was equated to chasing missing information, despite processes for regular monitoring being in place within some providers. A consultant pathologist / senior clinician is then responsible for triaging, however, it was noted that the MLA [Healthcare Science Associate] was responsible for finding the pathologist and physically taking forms to them for them to triage. Admin teams or whoever else is available are noted as having undertaken the send away processes. Consultant pathologist and BMS [Healthcare Science Practitioners] are noted as being involved in cut up, with BMSs being rostered on daily with consultants seeing a small number (estimated at 5%) but more complex specimens which take more time. Band 6/7 BMSs [Healthcare Science Practitioners] are responsible for the quality control checks. It was noted that there was appetite from BMS [Healthcare Science Practitioner] staff to get more involved in cut up, however the main challenges were around availability of space, in terms of cut up benches, as well as time to release staff for BMS [Healthcare Science Practitioner] training and the time of senior staff for supervision of those undertaking training. In 23

terms of reporting, it was flagged that there are still several pathologists who prefer to dictate reports. It was reflected that although this is a small number of individuals who prefer not to use digitisation alternatives, this does impact greatly on the secretary’s workload.

Within Blood Sciences, Biochemistry booking in is generally undertaken by Band 2 HCSA, who also load samples and look after stock. There are no overnight requirements for these staff (7am – 10pm) and training is provided in-house at each provider. It was noted that staff at this level generally support multiple pathology disciplines and can experience challenges of the way departments are configured across the LSC sites. Mostly Band 3 staff undertake the technical processing work, with Band 6 staff utilised where there are single handed shifts. This higher level of banding reflects the need to work out of hours in shifts in order to accommodate later drop off (up to midnight). One of the challenges noted within Biochemistry

was the big gap between levels of responsibility between band 6 and band 7 roles.

It was also reflected that with only the Band 6 staff undertake out of hours work, staff progressing to band 7 roles can experience drops in salary by progressing.

Technical validation is undertaken by BMSs with Clinical validation undertaken by Clinical Scientists during core working hours. Currently, it was reflected that it was mostly Band 7 staff are undertaking staff appraisals. Admin and clerical staff at Band 2 manually enter results.

For Haematology MLAs [Healthcare Science Associates] at band 2/3 are triaging specimens in central reception and B4 MLAs [Healthcare Science Associates] are undertaking rota management, administration, stocktake and ordering duties. MLAs [Healthcare Science Associates] undertake the processing of films within normal range. Any variations on normal range are processed by technicians depending up on their level of training. Training is provided in-house and can take between 6–9 months with maintaining competency requiring at least 10 routine days per year.

BMS [Healthcare Science Practitioner] staff read films and make decisions, with senior BMS Healthcare Science Practitioner] roles undertaking 2nd stage validation.

Outliers are reviewed in stage 2 validation, which is a step valued by the clinical teams, however there was some question raised over the necessity of this stage and a reflection that it is perceived as devaluing technicians.

Transfusion was described as a very busy service with not much space. MLAs [Healthcare Science Associates] undertake checks /telephone calls with registered staff at band 6 undertaking processing. It was noted that there is considerable lone working at this stage which necessitates the higher banding of staff. There are UK transfusion publications which outline the recommendations for staff training and NSH guidelines which are now over 14 years old. One of the challenges raised for

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Pathology Service: Workforce Strategy transfusion staff was around the variation in out of hours payments, which sees much local variation. Similarly, it was raised that an increasing amount of time is spent on UKAS and quality systems, as well as being hands on in the fixing of equipment such as printers and analysers to try and minimise downtime.

Immunology is a specialist service which sees tests the majority of tests directed to LTH, however it was noted that some sites do not currently send to LTH, preferring sites such as Leeds or Wythenshawe. MLAs [Healthcare Science Associates] involved in receiving and booking are in the main band 3s, with BMSs [Healthcare Science Practitioners] retrieving and undertaking tests whilst MLAs [Healthcare Science Associates] support disposal and housekeeping duties. There is a separate specialist portfolio for training and predominantly staff work in a single discipline way. It was flagged how the volume of work had grown but how the workforce had not grown in the same proportions. It was also noted that clinical immunology is expanding, which is affecting capacity within the lab due to increased activity. It was raised that there are some staff who would like career progression beyond band 3 but who are not aspiring towards BMS [Healthcare Science Practitioner] roles. It was also noted that it is very difficult getting bank or agency staff with the right skills within this discipline, leading to support being sought from other immunology labs (Sheffield or Liverpool). Band 5–7 BMS [Healthcare Science Practitioners] enter results and undertake technical validation, with Clinical Scientists /Consultant Clinical Scientists undertaking medical validation. It was reflected that the workforce was relatively stable within this discipline and staff tend to enjoy the hands on “real science” nature of the work.

Within Admin and Clerical teams, there are a mixture of Band 2s, undertaking mostly stockroom and supplies duties, Band 3/4s working as secretaries supporting disciplines (e.g. Histology and Haematology). These teams are mainly responsible for duties including rota coordination, onboarding locums, taking minutes at MDTs and typing reports. There are business admin level 2/3 apprenticeships for training, which now includes a specific pathology unit and this is currently being scoped across the network. Typing skills along with attention to detail is cited as key skills and understanding terminology is noted as a big skill gap. It is felt that pathology secretaries are a different kind of secretary to other medical secretaries, and it was highlighted that it can be difficult filling lower-level roles, particular in IT positions.

It was noted that there are a high level of part time staff within these teams and it reflected that part time staff can feel second best due to their part time status.

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From these conversations, we heard that differences within the disciplines themselves but also within the processes within each provider are driving differences in what is expected of staff.

It appears that across most disciplines there are stratified roles and duties expected of those roles, however it was highlighted that at times of pressure anyone who is available will do.

There are lots of manual processes being undertaken, particularly within the receipt and booking parts of the pathways and within Cellular pathology.

Timing and scheduling of staff does not always align to when work arrives.

We heard that there were some duplication of activities within pathways.

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It was reflected that staff had the appetite to do more but that often physical space was a barrier for developing working responsibilities.

There are different levels of staff within different disciplines, which is justified on grounds of technical requirements of the discipline, ways of working (e.g. shift patterns) and responsibility levels.

Most staff are working within single discipline ways of working and there appeared little appetite to change this.

Lots of training is being undertaken in-house and there can be difficulty in finding cover within LSC for very specialist roles, skills and disciplines.

The admin and clerical teams flagged concerns over part time workers feeling undervalued and overall, there appear to be career gaps and lack of progression opportunities.

Pathology Service: Workforce Strategy

Priority areas and gaps When we combine what we have already discovered about rising activity levels and staff profiles/leaver and joiner rates, we can model a view of what our potential shortfall will look like by 2030. Using the ‘do nothing’ scenario used earlier, we see that our forecasted levels of new joiners is likely to be only slightly above our forecasted levels of leavers. Within this, the amount of effort and potential impact on overall productivity of continual recruitment, churn within and across our organisations, and changing levels of experience impacted by replacing more experienced staff or staff who do not have corporate or embedded memory of systems and processes is not to be underestimated. There are notable opportunities within this changing environment, particularly around transformation, new ideas and enthusiasm to do things differently, however we must ensure we plan and are ready to harness those opportunities and are ready to mitigate the potential for disruption, unsettling uncertainty and effects on productivity and morale.

From the modelled scenario, we can describe how even with continued effort to recruit and attract staff into pathology, it is likely that we will have a shortfall of the volumes of staff required by 2030 to deliver activity in the same way we do now.

Gap analysis for total Pathology Workforce

Gap analysis for Microbiology Workforce

When we consider Microbiology, we see a much higher level of forecasted leavers compared to joiners, which suggests that if we do nothing differently, by 2030 we will have significantly less staff working in Microbiology than we do now. We have already suggested that modelled activity is expected to rise which could mean we see a potential shortfall of around 38 WTE.

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Priority areas and gaps

Gap analysis for Cellular Pathology

For Cellular Pathology, we see the converse, with more joiners forecasted than leavers suggesting that by 2030, we will have more staff than the non-adjusted activity projections suggest we need. Caution should be applied here in that there needs to be more work done on the future need scenarios to ensure we are fully considering all future plausible options including processes becoming more automated and creation of network delivered services.

Blood Sciences forecasts suggest that our workforce will be pretty much standing still between now and 2030. Within this, the levels of effort and change associated with managing the anticipated levels of leavers and joiners should not be underestimated. Again, these ‘do nothing’ scenarios suggest that by 2030 we will have insufficient workforce for the modelled levels of activity.

In the development of this workforce strategy, work has not been done to explore the wider impact of these future scenarios and shortfalls upon the overall pathways and outcomes for the patients and population of Lancashire and South Cumbria. As we explained at the very beginning of this strategy, pathology services are the critical centre of patient diagnosis, treatment, care and outcomes and it is strongly advised that further work be designed in conjunction with the ICB to ensure the potential health economic impact of these workforce future scenarios is fully understood.

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Gap analysis for Blood Sciences Workforce

Pathology Service: Workforce Strategy

So What?

In order to explore and think collectively about what we could do together, we held two face-to-face events and gathered a representation of staff together. In these sessions, we used the Health Education England STAR methodology to work through a number of posed questions based around the workforce challenges we had uncovered. The STAR methodology is a simple, coherent framework to facilitate and guide workforce conversations and guides transformation discussions around the five points of the star focussing on supply; upskilling; new ways of working; new roles and leadership.

The aim of these events was to encourage participants to think about what could be done differently for pathology around the central problems posed.

The sessions asked participants to frame their thinking around the following central problems, whilst keeping the person at the centre of thinking; exploring a range of workforce solutions and exploring transformation not just improvement suggestions.

Challenge 1: Improving the culture and behaviours within pathology.

Challenge 2: Addressing the size of the pathology Workforce (thinking about attraction, recruitment, business cases, growth and new ways of working).

Challenge 3: Changing the shape of the pathology workforce (thinking about retirement risk, succession planning, talent management; absence; qualified/ support skill mix).

Challenge 4: Addressing variation across providers and disciplines (thinking about staff in post, growth, participation rates and banding structures).

Challenge 5: Improving inclusion and representation within the pathology workforce (thinking about gender split, ethnicity, disability, sexual orientation, other protected characteristics, development opportunities and access to education and training).

These were vibrant, enthusiastic events which produced a long list of ‘jolly good ideas’ of 128 things we could do grouped into 29 themed project areas. Although it is clear we are not going to embark on delivering 29 projects and 128 improvement activities all at the same time, no good idea will be lost and will be included within the longer-term roadmap of ongoing improvements this strategy proposes.

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6. Planning to deliver The long list of ideas have been reviewed and scored against how far each one would help us to achieve the list of benefits we agreed at the beginning. This benefit analysis has been used in conjunction with key recommendations from national publications and targets along with the amount of investment, resource, and size and scale it would take to implement the development proposed. These have then been mapped onto impact/effort and system matrices and the following recommendations selected as critical priorities.

This approach has meant that we can articulate for each recommendation and proposed intervention programme how they are expected to contribute to delivering our core aims and also underpin the staging rationale of how we will approach implementation.

As a result, eight key recommended areas of action have been identified as priorities for us to focus on. These include a variety of programmes of work that underpin their delivery, and each area of work is anticipated to require differing levels of resource or effort to achieve the identified benefits, as articulated in the matrix to the right.

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Pathology Service: Workforce Strategy Improving the way we work collectively in order to support our staff and ensure that we have a clear strategic direction, improve the currently perceived disconnection between staff and managers, as well as optimising what activities our staff are undertaking.

Develop the quality, capabilities and capacity for effective leadership and management to address the current challenges and pressures we heard from staff, but also critically underpin how we can develop the required agility to improve morale, job satisfaction and motivation and enable us to work effectively together to support the delivery of a reliable, safe, effective and high-quality pathology service.

Improved data and analytics, reviewing available data sources and intelligence and driving ESR standardisation and coding quality reviews in order to continue to provide insight and learning to support our ongoing decision making, and to enable robust oversight and improve our ability to undertake benefit realisation and monitor whether the actions we are taking are working and having the desired impact.

Focussing on improving the belonging and culture within the LSC Pathology Network to enable us to build an inclusive and representative workforce that works well together with a clear vision, purpose and sense of strategic direction. Improving staff morale, motivation and satisfaction will be critical in delivering the joined-up, cohesive and effective relationships required to work together to achieve our collective ambitions.

One of the key findings has been the amount of variation currently evidenced, which resonates with feelings articulated from staff of a perception of some departments, teams, disciplines or sites having different structures, expectations, developments and opportunities. To support improved internal systems, development of a wider and more inclusive representation and enhanced optimisation of our staff, a critical priority will be to review and redesign our skill mix requirements.

A continued focus on career development and training opportunities, building on the emerging work already started to enhance how we educate and train together as a network. This work has been facilitated by the appointment of a LSC Pathology Network Practice Education Facilitator (PEF) and in order to continue to develop in this area, ongoing and sustainable facilitation and coordination resource will need to be maintained.

Improving the flow and optimising how staff are enabled to work will support creating equality across disciplines and sites, increasing efficiencies and supporting improved staff morale and retention.

Maximising opportunities for greater use of AI and digital pathology solutions which have the potential to release pressures on staff and remove manual working and duplication in processes.

Creating greater connectivity to wider system service changes and recovery and transformation programmes to ensure that wider decision-making is cognisant of the impact on pathology on any service or pathway redesign. Building mechanisms to support early involvement for pathology in service improvement, procurement or commissioning conversations. Reviewing temporary funded posts and undertaking a financial impact assessment to explore and support investment within pathology using a health economic approach and methodology.

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7. Next Steps – Implementing,monitoring and refreshing There is clearly a lot of work aligned to delivering these recommendations and it will not be feasible or desirable to tackle all these priorities at once. The recommendations aim to serve as a strategic, long-term overview of the critical things we need to address to achieve a sustainable, agile and resilient pathology workforce. The next steps we will need to collectively do is to design the architecture in which we can start to implement and work on these priorities.

The following diagram presents a high-level overview of how these priorities fit into a 5-year delivery and improvement programme. This implementation road map starts to break out and phase the recommended actions into deliverable phases.

The proposed scheduling is based on the benefit effort analysis and has considered logical interdependencies in the design of the road map.

And this is where the Workforce strategy ends….. … However, to ensure this document delivers its ambition to be a ‘lever for action’, there will need to be several practical next steps which need to be put in place.

1. There needs to be a devolved workforce steering group and appropriate governance put in place to ensure ownership and accountability to deliver this plan.

2. A series of Task and Finish groups will need to be set up, facilitated and resourced to enable sufficient do-ers aligned to each programme of work to ensure action.

3. There will need to be structure to support development of project initiation documentation and enable responsible owners to be identified and project teams to be created.

4. There will need to be a mechanism designed to monitor progress and impact to ensure we have a way of tracking progress and of assessing whether we are achieving the benefits we set out to achieve. The use of logic models may be desirable to support this ongoing benefit realisation.

It is also worthwhile ending with a reminder that this workforce strategy has used the six-step workforce planning methodology to guide its creation. The delivery of the Workforce Strategy as a document takes us up to step 5.

We have laid the foundations for the beginnings of step 6 in the implementation road map described above, however it is important to end as we began, by reminding readers and all our stakeholders that workforce planning is not a one-off event but a cycle. The final call to action is for the LSC Pathology Service is to consider how it will build capability and capacity to continue to use this approach to continually review the recommendations, re-asking and questioning what is the purpose of what we are doing and why we are doing it? Reaching out and forward to think about the changing context happening around pathology; continuing to monitor and horizon scan to keep the skills and future state requirements live and relevant; maintaining oversight of what we currently have and what gaps that poses; and continuing to adjust and add to the useful interventions, adding in new ‘jolly good ideas’ as they reveal themselves.

Using the words of George E P Box, “…all models are wrong, but some are useful”.

It is now over to the collective will of everyone working within pathology in Lancashire and South Cumbria, along with our aligned partners of the acute hospital trusts, the wider ICS partners and the ICB to ensure that this model or plan is useful.

This summary supports the full LSC Pathology Workforce Strategy which is available on request from LSCPathology@lthtr.nhs.uk

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Pathology Service: Workforce Strategy

Implementation Road Map

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