J Clin Pathol 1988;41:1141-1147Association ofClinical Pathologists Presidential Address, Exeter 1988

Occasional articlesCrystal ball gazing and the effects of fate*

In 1981 Duncan Linsell,. the then President of theAssociation of Clinical Pathologists, took as the titleof his presidential address, "Clinical Pathologists-athreatened species".' In it he intimated that he hadbeen persuaded to speak on this topic because of thedecline in the number of young doctors in training,and particularly in the number of applicants forconsultant appointments, and the emergence of anumber of "threat factors" in our professionalenvironment, coupled with the gloomyprognostications of his contemporaries.Among the "threat factors" he discussed were the

occurrence of management disputes in laboratoriesand the advent of trade unionism into the hospitalenvironment which threatened consultant control oflaboratories, the changing public attitudes to theprofession resulting in an anti-authoritarian trend ofchallenge, and the financial decline of the countryresulting in the exchange of the 10% annual increase toone ofdefensive rearguard action further complicatingthe pathologist's role. In looking at other factors foroptimism, Dr Linsell came to the conclusion that in thefuture his successors would look back on hispresidential address and say, "a threatened species,who said so?"

Since that address, the speed of change hasaccelerated enormously with the appointment ofgeneral managers at regional, district, and unit levelsof the National Health Service (NHS), consequent onthe implementation of the report by Griffiths,2 whowas invited by the Department of Health and SocialSecurity (DHSS) to review the management of thehealth service. This has resulted in the drawing up ofstatistical guidelines by which the efficiency, orotherwise, of a laboratory can be judged. Functionaland clinical budgeting has been introduced, witheffects on the laboratory repertoire and its staffinglevels, while complicating factors such as fast changingtechnology have added further unknowns to thecomposite practice of the laboratory of the future. Inlooking back to the "rosy-hue" days of my earlymedical career, and also forward to the undoubtedchanges and challenges which await the doctor in thelaboratory, I am conscious of the enormous changeswhich continue to take place.

*Abridged versionAccepted for publication 21 July 1988

In the absence at that time of the availability of aformal qualification in pathology it was necessary toacquire "laboratory experience" after obtaininggeneral medical experience. It was also usual to obtaina doctorate in medicine (MD) to show one's researchexperience. Having obtained general medicalexperience, fate took a hand when I heard that one ofthe lecturers in the department ofpharmacology in theUniversity of Liverpool had been granted two years'leave of absence to obtain what in those days wasknown as the BTA qualification (Been to America). Iapplied, was accepted as an assistant lecturer, and waspromised that I would be able to complete an MDdegree.

It was during this period thatmy interest in chemicalpathology was stimulated, because I worked on therole of choline in the pathogenesis of myastheniagravis. Having obtained the MD, I was determined topursue further biochemical studies and arranged tospend two years in the University of Rochester'sbiochemistry department on a research fellowship toobtain an American Master of Science (MS)qualification. Again, fate took a hand in my future,when I was invited to accept an appointment as"lecturer in charge" of the department ofpharmacology in Trinity College, Dublin. Anxiousnot to miss my trip to America, it was subsequentlynegotiated that I would spend one year before takingup the appointment in Dublin as a researchpharmacologist with one of their graduates in theUniversity ofCalifornia at Los Angeles. Working longhours I completed all of the practical work for an MSdegree in 10 months. It was on the pharmacologicaleffects of various extracts of a liana known assciadotenia toxifera, thus giving me further basicchemistry experience in methods of separation andidentification and the subsequent award of the MSqualification.

I was within 10 days of leaving America when Ireceived a telegram from Dublin requesting me to callin on the New York State Racing Laboratory to learnall that I could about the detection ofdrugs in the urineofracehorses. I was subsequently asked to set up a unitin Dublin to detect drugs in the urine and saliva ofracehorses, and incidentally proving a source ofrevenue for the newly founded department.During my time in Dublin, in addition to my

pharmacological appointment, I became the official1141

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analyst to the Irish TurfClub-thus adding toxicologyto my learning curve in chemical pathology.My interest in hormones resulted in the

establishment of a hormonal analytical service forpatients of the Dublin Federated Hospitals. TheCollege ofPathologists had by this time been born andbecause ofmy biochemical background and interests Iapplied for and was offered Founder Membership ofthe College.

I reflect on this history to emphasise how fateintervenes at important points of life and how ourattitudes to consultant apppointments in pathologyhave changed. May I venture to suggest that becauseof the more formalised training now available, aperson with such a background today would beunlikely to be considered for a consultantappointment in this country, and yet I believe that Ibrought to chemical pathology, albeit in a restrictedaspect ofthe subject, a different approach from that ofmany ofmy contemporaries who had gone through amore formal hospital, laboratory based apprentice-type training.

This type of background has, I think, moulded myown views of the future of pathology and thepathologist. In these roots I can discern the fashioningofmy own pragmatic approach to our discipline, and Iwould encourage all of our junior membersoccasionally to be unorthodox in the manner in whichthey gain their experience of pathology.May I emphasise that I am not advocating a training

in pathology which might not equip the aspiringconsultant for independent practice. I freely expressmy concern over the possible effects of the proposedchanges in the Royal College of Pathologistsexamination structure, which might have the effect ofshortening the bench and interpretative training of thewould-be pathologist.As I now reach the point at which retirement looms

on the horizon, it is opportune to speculate about thepathology of the future and about the pathologistswho may or may not control it, and to speculate if fatewill again take a hand. We face enormoustechnological and administrative changes, and this,combined with the ever increasing efforts to containcosts, will undoubtedly have profound effects onpathology and pathologists.

Technological changesTechnological changes will undoubtedly change theway in which pathologists currently practise. Testingnear the patient has been developing for many years,initially because of the need to have instant results inintensive care and special care baby units, andsubsequently elsewhere with the development ofdesk-top analysers and other simple-to-use instruments inall disciplines of pathology. Recent work has shown

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that there is little difference in the results produced bysuch instruments, when they are operated indecentralised sites by nurses, secretarial staff, orjuniordoctors, compared with the results produced in thelaboratory.3

It seems doubtful whether expensive laboratoryday-time and on-call services will continue very longinto the future for many common analyses, especiallyas machines are developed that allegedly need minimaltechnical expertise. Such developments are not onlyconfined to the disciplines of chemical pathology andhaematology; instruments based on biosensortechniques are already available for the rapiddetermination of bacteriological growth. These desk-top instruments are fast-they can be operated- byinstructed personnel to produce results in two minutesor less-and they have shown great uniformity indetecting several varieties of organisms.

In histopathology nuclear magnetic resonance andcomputor axial tomography are becoming so accuratethat the need for examination of biopsy specimens bythe consultant is likely to diminish rapidly.Microbiology and cytological histology will probablybe the next disciplines to lend themselves toautomation by reagent and instrument makers in thenext decade, and it is possible to visualise desk-topautomatic readers of cervical and other smears; inother disciplines the application of biosensors at thebed-side with the development of instruments todetermine many medically important biochemicalanalyses will not be long delayed.Whether at the bed-side or in the laboratory, the

demands for non-invasive methods will increase. Thisis not only because people naturally tend to wish tolimit their exposures to painful medical assaults of allsorts, but also because their lawyers will have less ofanaxe to grind if nothing enters the skin to causeiatrogenic injury. The inexorable rise into four figuresof defence society subscriptions will add extra weightto this consideration.The patterns of disease within our communities are

also changing. In the United States of America theprevalence of acute illnesses has declined from 70% to20% of all illness but chronic diseases have increasedfrom 30% to 80%. It is in this group of patients thatthe development ofself-testing programmes is likely toincrease considerably, and where a consumer can starttreatment without visiting a doctor, money and timecan be saved by avoiding unnecessary clinic visits. Thegreater the use of self-testing programmes, coupledwith the development of biosensors and automaticdesk-top analysers, the less the need for a routinepathology laboratory and the subsequent need for thepathologist to look at the future ofthe specialty and todetermine his or her place in that future.

All laboratories continue to be interested in

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Crystal ball gazing and the effects offatesubstituting labour for capital and are thus receptiveto further automation. It seems likely that we are goingto have to use a less skilled workforce for the mundanelaboratory work and there may no longer be a need forthe medium sized laboratory in all hospitals as theimpact of new technologies, far removed from thelaboratory, become evident. In non-urgent areaswhere results are not needed at once, it seems hardly aflight of fancy to imagine the development of a few"super" laboratories servicing several hospitals ordistricts with resultant economies of scale, even whenexpensive commercial "kit" type assays are used. It isessential, however, to have an efficient samplecollection system, a suitable data network to feed theresults back to the base hospital, and the willingness ofpathologists to recognise that every hospital cannotoffer an entire range of analyses and treatments forevery disease. It seems inevitable that health servicechiefs must seriously consider such moves, perhapseven by developing a private sector service for this typeof assay. The recent appointment of managementconsultants by the Manpower Planning AdvisoryGroup of the DHSS certainly points in that direction.

But hospitals are the second line of defence againstillness. The first line is the general practitioner (GP)and events taking place there could again reduce thedemands on hospital laboratories. It is interesting tospeculate how the GP would cope with the advent of"instant pathology". From one drop ofblood a deviceakin to a microchip could read out a veritablecatalogue of biochemical and haematological valuesfrom haemaglobin, through a host of electrolytes, tomore arcane variables such as serum zinc and folic acidconcentrations.The technology for this process is well established. It

forms merely one side-shoot of that most prolific ofhuman engineering-the silicon chip. Interestingly,the pharmaceutical company British Drug Houses(BDH) has already announced that it hopes to sell itslatest clinical analysers directly to GPs despite the factthat NHS doctors have no means of obtainingreimbursement for the reagents used. This is in linewith recommendations of the all-party UnitedKingdom Social Services Committee that GPs beencouraged to provide diagnostic tests on their ownpremises. Although the Government have currentlyrejected the idea, if implemented, it would have aprofound effect: in some laboratories more than 30%of the workload comes directly from GPs-the effectsof such a change would be enormous.With the pressures to save money there will

inevitably be a decline in inpatient admissions,coupled with a decreasing length of stay asperformance indicators in the clinical spheres becomemore frequently used. Despite these pressures todiminish the amount of work of the hospital

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laboratory it is evident that we might be on thethreshold of a new technology based on recombinantdeoxyribonucleic acid (DNA) research. Thesetechniques are bringing the medical scientist muchcloser to an understanding of the pathogenesis ofimportant diseases, such as cancer, autoimmunedisease, and atherosclerosis, and may well result in anentirely new set of diagnostic procedures.

Administrative changes

The more important of the managerial changes nowaffecting pathology within a national framework arethe result of the Griffiths report, for it is the discretionpermitted in the DHSS document HC(84)134 that hasled to a diversity of management practices withinpathology.

There are different types of staff working withinlaboratories, each with its own associated structure.Under the terms of the 1974 DHSS eireularHSC(IS) 16, a consultant is identified as the head of thedepartment and is responsible for the properfunctioning of that department. The only variation inthis arrangement is the recognition that the head ofthedepartment could also be a "non-medical scientist" ofequivalent standing. This was later defined by theRoyal College of Pathologists as a top grade scientistof the Whitley Council Professional and Technical (A)Scientific grade. This was, I believe, a situation whichshould have been resisted forcibly at that time. Itimmediately suggested that the top-grade scientistcould carry out all the functions (clinical,technological, and managerial) of the medicallyqualified consultant pathologist, and hence today weobserve the claims of top grade scientists forequivalent pay for doing (what they allege is) the samejob, while their professional organisations activelyseek those conditions of service currently available todoctors within the NHS. Although their work may becomplementary, I do not believe that consultantpathologists and top grade scientists do the same job,and perhaps the time is now opportune to define moreaccurately the functions of each.The other main staffing structure in the laboratory is

that of the medical laboratory scientific officer(MLSO). The terms and conditions of this group oflaboratory workers are controlled by the WhitleyCouncil 'B'. In the absence ofany type of review body,the MLSOs have lost out considerably in financialterms during the past five years. The Whitley Councilregulations for MLSOs prescribe a hierarchy of postsin departments from junior to senior chief MLSO.There is also the potential to appoint a higher gradeMLSO, who will be graded as a principal chief if thereare 63 or more MLSOs employed, or as senior chief ifthe laboratory has fewer than 63. This appointment is

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1144not mandatory on the employing authority, which hasdiscretion to refuse to appoint a "floating" MLSO, butif they do so, the Whitley Council agreement requiresthat he or she has "overall technical charge of thelaboratory"-the definition of this phrase is less thanclear. Dyson' has pointed out that it does not refer tomanagement control because the request for that titlehas so far been refused by the management side of theWhitley Council-yet it must imply some technicalcontrol over the work of the department.

It is the relationship between the medical andMLSO structure which has been responsible for manyof the management difficulties that have arisen inNHSlaboratories. This has been compounded by theappointment of Griffiths-type managers, as it isultimately the health authorities' responsibility toproduce an acceptable formula for an efficient andreliable pathology service.The initiative of the Griffiths proposals to introduce

management budgets for clinicians has now progres-sed to the stage of third generation pilot experiments.Inevitably, this could have enormous implications forthe consultant laboratory manager. Budgetary man-agement is becoming more complex and time consum-ing, and consultants must either allocate time to suchmatters, or inevitably the most senior MLSO orscientist will undertake this function with the loss ofanimportant part of his or her management respon-sibility. The consultant who escapes this chore in thisway or believes that he or she should devote the wholeof his or her time to clinical work to the exclusion ofmanagement functions will be responsible for themore rapid demise of the medical pathologist in theNHS laboratory.One of the problems which the consultant-manager

of the laboratory will have to cope with is the growingpressure to change the current staffing structure. Asindicated earlier, pressures for labour substitution willbe great, for staffare the major financial burden ofanylaboratory. Highly skilled staff are often not requiredto operate automatic or semiautomatic machines, andthere will be a need for unskilled and semiskilledassistants, working under the overall control of a fewfully trained people.With the present intention of devolving man-

agement to the peripheral unit, many solutions to theproblems of the laboratory will probably becomeevident. That all of these will not be favourable to theposition of the consultant pathologist is an inevitableconsequence ofthis freedom to manage at a local level.Of the other changes arising from the Griffiths

management report, one of the logical implications ofsuch reforms of the NHS is that doctors, bothconsultants and GPs, could eventually be placed onshort term contracts with review before renewal toestablish good quality of care and a continuing need

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for the services ofthe doctor in each locality. Maynardhas pointed out that this could be achieved either by adirect or indirect approach.6 The direct approachwould necessitate a move to short term contracts-say, from 1 April 1990, offering zero pay increases tothose retaining their existing contract and generouspay settlements to those who are prepared to move toshort term contracts. Possible reactions to this mightinvolve a trade union type of reaction from the BritishMedical Association. Entrepreneurs in the privateinsurance industry may also react with aggressivemarketing of their policies if the threat of resignationfrom the NHS became a possibility.The alternative to the "head on" approach is a

Fabian gradualist approach-a policy that essentiallyuses consumer and competition policies to underminethe doctors' security of tenure over the next five years.By the end ofthis time short term contracts will appearincreasingly attractive as a source ofgreater security ofincome and employment. Such an approach has, Ibelieve, already been initiated by certain health auth-orities going out to tender for certain radiology andpathology services in hospitals.

Health authorities are already permitted to go out totender for clinical services, and could, if they wished,buy in annually, say 500 hernias, 400 hips, 10 000cervical smears and 200 bypasses from the lowestbidders, public or private. It is not beyond the boundsof possibility to imagine that entire health districtscould be operated by the private sector. There is nodoubt that this creation of an aura of uncertainty inthe future would certainly add to the allure of a shortterm contract. Similar policies already operating in theUnited States ofAmerica are the result of the pressureto contain costs. Health care managers are producingpractice "norms" and costs which are used as yardsticks to control clinical practice.

Breckenridge has pointed out that among thewonders of nature is the way in which many animalsand birds are able to change their appearance or adjusttheir behaviour when the world around them changesand becomes threatening.' The environment isunquestionably changing in pathology, and patho-logists will have to adapt to survive these adverseconditions and developments which now surround us.New technology is changing the nature ofthe tests thatlaboratories undertake, while managerial limitationsof finance demand accountability and the greatestpossible return for the money spent. This leaves thetraditional pathologist in a situation where, in addi-tion to the changing nature of his or her work, thereason for existing is being seriously challenged byfinancially cheaper and managerially more easy tocontrol scientific staff. The attraction of replacing thepathologist by this non-medical challenge must appearincreasingly attractive to the new breed of general

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Crystal ball gazing and the effects offatemanagers.The wind of change is blowing for pathology, and

with respect to the staffing of laboratories threeseparate initiatives are currently taking place. There isthe proposed amalgamation of the Whitley Council'A' (graduate scientists) and Whitley Council 'B'(medical laboratory scientific officer grades) under thechairmanship of professor Roger Dyson. These seemto be making slow progress because of the entrenchedpositions of the participants in the talks-the profes-sions themselves. These obvious stumbling blocks toprogress are not apparent in the initiative of theManpower Planning Advisory Group (MPAG) of theDHSS into a pathology laboratory staffing under-taken by an outside body-Management AdvisoryServices (MAS) ofCheltenham. TheMPAG have usedas a reason for the review the interest of the regionalchairman and the publication of the National AuditOffice Report on professional and technical man-power in December 1986. In this instance the variousprofessional groups are only being used as a "sound-ing board" for the ideas promulgated by the Man-agement Advisory Services (MAS) and gleaned bydiscussion with laboratory workers and visits tolaboratories both in the public and private sector inEngland, and overseas in Germany and America.

In the interim, the Whitley Council responsible forMLSO terms and conditions of service have producedproposals which are remarkably similar to those beingdiscussed and proposed by the other two groups. Itwould seem that the MAS has sought to establish thepurpose of a pathology laboratory service, and toestablish what effect pathology investigations have onthe outcome ofcare for patients. It is ofinterest that intheir preliminary overview of the current services theyhave indicated their belief that "pathologists are at awatershed" and that "defining the role of thepathologists is central to the definition of pathologyservices."

It is important to emphasise that advice on theappropriate investigation, the interpretation of theresult, and the choices for care and treatment can onlybe effectively found in people with medical training,and who are registered with the General MedicalCouncil. There is, however, a difficulty in the recogni-tion by the Royal College of Pathologists that non-medically trained personnel may, on occasion, adviseclinicians on the care and treatment of patients. Iwould strongly reiterate that some clear differentiationof membership and the tasks carried out should nowbe introduced between medical and non-medical mem-bers. This is not meant to denigrate the position of thenon-medical scientist but the consultant and thescientist carry out different tasks, and this should berecognised.

In the future the staffing of NHS laboratories will

1145need to change to encompass changing technology. Itis evident that a minimally trained group to undertakerepetitive tasks is required, together with a smallerhighly trained group of dedicated scientists, trained toundertake tasks requiring discretionary judgement,and controlled by the appropriate Board of theCouncil for Professions Supplementary to Medicine.Interestingly, the Whitley Council have recentlyindicated that the Fellowship of the Institute ofMedical Laboratory Sciences should no longer beessential for promotion within the MLSO structureand that the Council for the Professions Supplemen-tary to Medicine should in future control all of theeducational requirements ofnon-medical staffin NHSlaboratories.

Medical pathologists will assume the role of inves-tigative physicians and, in addition to determininglaboratory priorities, will become more clinicallyorientated. The smaller amalgamated technologistspine would be of degree standard, and could beafforded the opportunity to acquire the MRCPathdiploma. The inevitable increase in non-medical mem-bership of the Royal College could lead to uneasyrelationships with other medical Royal Colleges. Atransfer to a more clinically orientated Royal Collegehas already been seriously suggested by groups ofyounger haematologists who see their future as moreclinically than laboratory based.

Medical pathologists are currently in difficultieswith their technical and clinical skills beingdeprecated, their future uncertain, yet having to dealwith laboratory management and budgeting at a timeofeconomic stringency if the MA's report is accepted.The most likely development for the medically trainedpathologist is an appointment as "director of path-ology", accountable to an appropriate general man-ager, and responsible for setting the direction of theservice, ensuring its cost effectiveness, and managingthe pre- and post-analytical phases. In this scheme alaboratory manager might also be appointed who,although responsible to the director, would managethe analytical phase. It is the relationship betweenthese two which is important, particularly ifHSC(IS)16 is abandoned. The position of the consul-tants in charge ofeach discipline would be particularlyvague, for their technology staffs are likely to be theresponsibility of the laboratory manager. This desirefor change is obviously being pressed by the technicalstaffs of laboratories. This desire is not apparent eitheramong medical pathologists or, more importantly,among the users (clinicians) of the service.

Despite the limitation of monies for laboratoryexpansion, in a wider context we observe around us theburgeoning array of administrators who currentlyinhabit the NHS, with their demands for more andmore data of every possible type. This takes the

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professionals time and effort to collect and there islitttle evidence so far that great use is being made of it.Knott has observed that, "in the corridors of ourhospitals today you are just as likely to bump into anadministrator as you are to a doctor or nurse. What ismore the full-time administrator may be a doctor ornurse-a fully fledged clinically competent individualpushed from the prime ofhis or her bedside career, andthrown into the nightmare jungle of buff envelopesand A4 circulars".8 Not content with invading thehospital service, management seeks to convert some ofour best medical personnel to its cause. This is notmeant to be an attack on administrators; most ofthemare personable, hard-working individuals concernedthat they are doing their job conscientiously-asindeed they may be. It is not the personnel that are atfault, it is the system. Whereas the pathologists of oldhad to be concerned about the accuracy and inter-pretation of the clinical report emanating from theirlaboratories and the clinical well-being of the patient,today they are expected to contribute to operationaland strategic plans, provide information on staffing,test numbers and their complexity, budget, andbalance the laboratory account, and attend numerouscommittees and give opinions on multifarious consul-tation documents-all tasks that inevitably increasethe numbers of supporting administrative staff.The fact that a district can make a logical case for

appointing a director of planning and informationwhen it is crying out for a pathologist to deal with theever increasing backlog of cervical smears illustrates alack of priority in forward planning. Even throwingmoney at the existing state of affairs simply exag-gerates the disparity between those whose main task isclinical and those who support this activity in a myriadof disguises.

The Future

I believe that medical pathology and medical path-ologists are now threatened as never before by thechanges taking place around them, changes which aredifficult to influence. Duncan Linsell's concludingremarks indicated that, in the future his successorswould look back on his presidential address and say,"6a threatened species, who said so?". Seven years onand there is little evidence that he was correct for allthe signs about us indicate that unless we can delineatea new and changing role for the medical pathologist,the future is fraught with danger.What is this new role to be? May I seriously suggest

to you that we should leave the sheltered confines ofour laboratories and venture forth to undertake thoseinvestigatory clinical tasks on patients which the newtechnology will demand-a reversion to the olderfunctions of the "clinical pathologist". This has been

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well shown by the radiologists whose clinical inves-tigative function has increased considerably over thepast 10 years.The haematologists have grasped their clinical

opportunities rather earlier than the other path-ological specialties and perhaps even to the extentwhere laboratory training is now being sacrificed toclinical practice-this is to be regretted.

Histopathologists should be undertaking the col-poscopies and localising tumours or secondarydeposits by the use of tumour markers, even takinginto their repertoire nuclear magnetic resonance andother techniques developed to make a diagnosis at thepatient's bedside. The future of histopathology for themedical pathologist will not be in the traditionalhistopathological diagnosis based on morphologicalcriteria. It will be based on the comparable mor-phology expressed by different markers indicatingdifferences in biological behaviour, metastatic poten-tial, and prognosis. The early stages of this are alreadyseen by the reclassification of some tumour types bysuggesting functional differences between tumourscurrently having a similar histological appearance.

Chemical pathologists will have to emphasise theirclinical roles and will have to ensure that they are theones who control and use the biosensors and suchdevelopments at the bedside. More and more they willhave to apply their knowledge to clinically specialisedareas of their discipline. Fortunately, there is evidencethat this is now occurring with the assumption of fullclinical responsibility for the investigation ofinfertilityand the treatment ofoutpatients with lipid, endocrine,and metabolic disorder, diabetes mellitus andnutritional problems. Flynn has estimated that 40% ofthe 194 NHS and honorary consultant chemicalpathologists in England and Wales have such clinicalcommitments and 13% have charge of inpatients.9

Microbiologists are also witnessing a considerableexpansion of their clinical role into the wards andkitchens of our hospitals and by the control of thespread of plagues such as the HIV virus and hepatitisand the determination of levels of immunity andsusceptibility to disease within the community. Wemust seize the initiative by recognising the changes inour discipline, the lack of finance, probable privatisa-tion and the development ofnew instrumentation anddata processing methods. Petty strife among consul-tants must be minimal in recognising that we mightlose some of our independence in the appointment oflaboratory directors with the financial ability to makechanges to influence the way in which the pathologyservice develops.The forces in medical care are changing rapidly.

Unlesswe as pAthologists stay abreast ofthese changeswe will be replaced by others who are waiting anx-iously to take our place in laboratory medicine. It is

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Crystal ball gazing and the effects offate 1147

vitally important that the clinical director of thelaboratory should have the clear management auth-ority implied within the Griffiths report and spelledout in HSC(IS)16. These issues are not bargainable.'`Let us also seek to enlarge our spheres ofinfluence. AsBreckenridge, the then president of the AmericanCollege of Pathologists has said, "Let us embark on anew venture in an area of medicine that belongs toclinical pathologists"."

Let fate again take a hand as it has with my ownpersonal career. Who knows what the crystal ball willforetell for the new breed of clinical pathologist?Perhaps Sydney Dyke, the father of this Association,will yet see the development of the new clinicalpathologist, and will permit himself to say, "and abouttime too!"

GW PennintonPresident, Association of Clinical Pathologists

1987-88Referes

1 Linsell WD. Clinical pathologists-a threatened species? J ClinPathol 1982;35:249-56.

2 Griffiths MRL. NHS management inquiry report. London: DHSS1983.

3 Nanji AA, Poon R, Hindberg I. Near patient testing usingdesk-top analysers. Comparison of performance by nurses,physicians and medical office personnel. J Clin Pathol 1987;41:223-5.

4 Department of Health and Social Security. Health service man-agement: implementation ofthe NHSmanagement inquiry reportHC(84)13. London: DHSS, 1984.

5 Dyson R. Management tensions in laboratories. Br Med J1987;296:1626.

6 Maynard A. From an ivory tower "Dear John, Yours Margaret."The Health Services Journal 1987;823.

7 Breckenridge RL. Like the Ptarmigan and the herds we willsurvive. Pathologist 1986, May 6.

8 Knott L. NHS cuts must start with penpushers. General Prac-titioner 1987;25.

9 Flynn FV. Joint planning of training grade numbers in chemicalpathology (England and Wales). Bull Roy Coll Pathol1988;61:8-14.

10 Dyson R. Clinical directors of pathology: who are they and whatdo they direct. J Clin Pathol 1988;41:709-10.

11 Breckenridge RL. Serving as a consultant to the physicians officelaboratory. Pathologist 1986, May 6.

Requests for reprints to: Dr GW Pennington, The JessopHospital for Women, Leavygreave Road, Sheffield S3 7RE,England.

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