President of the Royal College of Pathologists, Dr Bernie Croal, speaks to Kathy Oxtoby about the evolving landscape of pathology in the UK, the challenges and opportunities facing this vast specialty, and where he sees the field going next.
Pathology is the glue that holds much of healthcare together and is a prime example of multidisciplinary working at its best. Supporting diagnostic processes, guiding doctors on the right way to treat common diseases, using cutting-edge genetic technologies to treat patients with life-threatening conditions and much more besides, pathologists are the crucial backbone of research, advancing medicine and devising new treatments.
And this is something that Royal College of Pathologists president Bernie Croal has spent his career championing. ‘We talk about pathology involving patients from before you’re born all the way through to after you’re dead – that’s the pathology journey we will all dip into at some point,’ he says.
In fact, he points out that a staggering 95% of healthcare interactions involve pathology in one form or another to optimise patient care. ‘It’s not just about diagnosis, it’s about screening, prevention, treatment – and across the 17 disciplines [of pathology] we’re involved with all of that,’ he says.
New drugs, personalised approaches
The pathology landscape continues to evolve, and there are some exciting developments within the specialty – some of which have already reached patients.
One of the most recent and well known is the emergence of self-injectable glucagon-like peptide-1 (GLP-1) agonists for the treatment of obesity, which chemical pathologists have played an instrumental role in: the research, the clinical trials and now one of the groups delivering and monitoring this therapy across the NHS and the private sector
‘That’s quite a dramatic development and we’re beginning to see potential impacts on large numbers of the population,’ says Dr Croal.
The capacity for GLP-1s to treat a previously underserved patient population echoes another substantial advancement in pathology: genomic medicine.
Dr Croal notes that being able to use the pathology and genomic data together has had ‘a huge influence on practice in the last 10 years’ and is paving the way for more personalised medicine that can support better outcomes for patients, especially in cancer
‘Knowledge about genomic testing and the use of that genomic information to select treatments for cancer, for example, is clearly a significant step forward in how we manage those patients’, he says. ‘We’re now beginning to see treatments become a lot more successful and patient centred.’
He also predicts that further combination of pathology and genomics will lead to many more new cancer treatments, which will ‘significantly alter the outcomes and the survival rates for cancer’.
Automation and connectivity
Technology in a range of forms is playing an increasingly important role in progressing the field. For example, Dr Croal says pathologists are beginning to see a lot more automation in their labs. This has ‘already happened in the blood science labs, but we’re also beginning to see it in the histopathology labs’, he says, which is ‘bringing more efficiency to the whole process’.
In addition, one of the few positive outcomes of the Covid-19 pandemic is the widespread use of online meetings. This has allowed for a new, efficient and collaborative way of working that Dr Croal says is invaluable.
‘Being able to speak to other pathologists around the country – around the world even – has been a big advantage,’ Dr Croal says.
‘All pathologists work not just with other pathologists in other disciplines within pathology, but with a huge variety of other healthcare professions across the whole of healthcare,’ he adds. ‘[Covid] advanced the ability to sit in a virtual room and discuss patients and issues with doctors in, say, surgery, cancer wards and general practice, and do it all remotely.’
Investing in artificial intelligence
An innovation taking this pursuit of efficiency to the next level is artificial intelligence (AI), which Dr Croal says could ‘revolutionise different parts of the pathology journey’.
Research has already shown how AI can be used to drive efficiencies in cancer diagnosis, predict future health risks using AI-enabled ECG and analyse digital images for stroke care – and that’s just scratching the surface of the possibilities. AI has the potential to help make myriad processes quicker, more efficient, and result in better outcomes for patients.
For Dr Croal, AI is currently ‘a real buzzword’, but he says the vision needs to be turned into reality.
He says: ‘Everyone’s talking about it, but the reality is it’s not really happening at the moment.’ It seems that the research is promising but the transition of AI into everyday practice is a little way off.
And the reason is simple. ‘Across pathology we need to improve the IT systems and further implement digital pathology in order for us then to think about how we can use AI to make systems better, more efficient, and ensure that AI can be better for patients,’ Dr Croal explains. ‘There’s a long way to go, but we desperately need investment into pathology services to enable us to take advantage of it.’ AI is very expensive and at the moment, the NHS simply can’t implement or afford to.
The recently published 10 year health plan for England pushes the need for the adoption of new technology, with the shift to digital driving a new way of delivering healthcare. This will however need significant investment in pathology, investment that is not really happening at the moment. Dr Croal says, the Government needs to step up with the necessary investment, and the strategies must be workable amidst current NHS pressures.
Supporting the workforce
According to Dr Croal, the biggest challenges facing pathology in the UK are the same ones facing all of healthcare and in many countries around the world: ‘a workforce crisis and a funding crisis’.
‘Clearly, healthcare in the UK is not doing well at the moment. We don’t have enough money, our infrastructure is crumbling, we don’t have enough staff in the right place, and we’ve got huge waiting lists where people are suffering and dying unnecessarily,’ he says. ‘We’re also seeing some pathology services beginning to fail across the UK.’
In fact, paediatric and perinatal pathology now has a consultant vacancy rate of almost 40%. In major areas like Birmingham, Leicester, Bristol and the whole of Northern Ireland, there are now no paediatric and perinatal pathologists, which means ‘those services have gone’ for those local populations, and alternative plans have to be put in place.
It’s not just paediatric and perinatal pathology that’s being affected, as ‘we’re beginning to see shortages across all of pathology’. This is exacerbated by the number of pathologists choosing to work in the private sector, Dr Croal says. This adds pressure on the NHS because these individuals tend not to be involved in the training of new pathologists.
‘We need to support NHS pathology to ensure we have those training centres, and the presence of pathologists within NHS hospitals,’ he adds.
But that’s easier said than done. Underpinning these issues is a reduction by the Government in the number of pathology training posts available in recent years. Dr Croal estimates that in five to 10 years’ time, there may be a 40% shortage of consultant pathologists to meet the likely workload demand.
As RCPath president, this is something Dr Croal is tackling head on. Earlier this year, the College published a new workforce strategy, ‘which is aiming not only at trying to improve the training part of the equation, but also focusing on retention of the pathologists that we already have’, he says.
This includes plans for how automation, digital, AI and other innovations can be used to manage increasing pathology workloads and generate intelligent solutions to support the imbalance between workforce and workload, but emphasising that “AI will help us do the work, not replace us”.
The overall aim of the strategy is to safeguard future service delivery and eliminate the workforce crisis that threatens the delivery of care to patients.
Pathology’s increasing popularity
While there may be workforce challenges, pathology ‘is more popular than it ever has been’, according to Dr Croal, and part of the appeal is ‘being able to combine science and medicine’.
Younger members of the profession are also increasingly seeing pathology as a specialism offering optimal work-life balance. ‘It enables many of us to work during the day mostly and avoid weekends, and it is better for flexible and part-time working,’ he explains.
For the first time ever, the majority of pathology consultants being trained now are female. ‘It’s been a big shift, since even 10 years ago, and it’s a shift we all very much welcome,’ Dr Croal says. ‘It means we’ve got a better balance of males and females across our disciplines.’
Dr Croal anticipates that ‘there will be huge competition for pathologists’ in the future, and ‘because a lot of the pathologist activity can be done virtually, that will enable pathologists to work anywhere’.
It is hoped that this flexibility, connectivity and efficiency will form part of the solution to the workforce crisis in the UK and across Europe, which, in turn, will better support patient care and outcomes.
‘The best way of investing in healthcare’
Halfway through his three-year presidency, Dr Croal is looking at developing a new pathology plan to take the specialism towards a more technological future. ‘We want to explicitly document what we think pathology needs and what direction it needs to go in, covering important areas around IT, digital and AI, but also around workforce and how we can make that work better,’ he explains.
With the recent publication of the new 10 Year Health Plan for England, Dr Croal is now ‘looking to see how pathology fits into that, and how we can develop our own plan that demonstrates the importance of pathology and what pathology can do – T he plan does not come with much in the way of new funding or a clear implementation strategy – it will be up to the NHS and pathology to work differently and demonstrate importance and value – the latter shifting healthcare budgets towards pathology hopefully’.
With the specialisms being so instrumental across the healthcare spectrum, Dr Croal is adamant that more investment will go a long way.
‘If we invest in pathology, if we improve pathology, then the rest of healthcare benefits,’ he says. ‘It’s the best way of investing in healthcare and improving services for patients.’
