The suggestion that “local services will develop according to the skills of local workforce and service need” (DOH 2010) poses a potential challenge for radiology departments where there is a skills gap in their workforce which differs vastly from high demand service need. The challenge to overcome the lack of appropriately trained radiologists, radiographers and nurses is a major constraint to developing interventional radiology services within a department.
The Royal College of Radiologists (2009) reported a rise in the number of trainee radiologists and although numbers in practice appear to have risen (30 radiologists per million population) since 2002 to (38 per million) 2008 the figure remains much lower than in many European countries where, on average, the ratio is significantly higher (38 per million) (European Society of Radiography 2009). The significant difference infers that, although figures are rising, UK is failing to meet demand. This potentially will be compounded by the increased numbers of radiologists leaving which is expected to double this year (RCR 2010) (see figure 2 appendix 1). The potential impact on radiology departments is a failure to expand provision beyond a 9am to 5pm service to meet service user’s needs.
The Royal College of Radiologists (RCR) workforce census (2010) identifies a significant regional variation in the numbers of radiologist per million populations. This suggests that the potential impact may therefore be limited to certain regions. Networks as described in the Interventional Radiology: Guidance Service Delivery (2010) document in theory could minimise the impact of regional variation in 24hour service delivery.
A recent survey of Interventional Radiology Service Provision - NHS England (2011) requested Trusts to self-assess their status on whether a formal on-call consultant rota and pathway of care is in place in respect of 24hour interventional radiology services. The results of this survey (see figures 3 & 4; appendix 1) show, in terms of all interventional radiology centres, that around 50% of centres do not have a core service provision with network pathways. Specific Interventional centres show a varied degree of provision. Trauma centres (see figure 4) have appropriate provision (core services with formal rota / network) in the vast majority of regions. However the survey does not explicitly extract information based on the recommendations previously reported in ‘Emergency Admissions: A Journey in the Right Direction? (2007) which insisted that “Hospitals that admit patients as an emergency must have access to plain radiology and CT scanning 24 hrs. per day with immediate reporting”. From the information available this standard can only be assumed.
Implementing the self-assessment process, which is to be repeated, should result in further involvement of Trusts, encouraging them to reflect on their provision and set targets (at both Trust and departmental level) for improvement. On the other hand self-evaluation has a risk of presenting a bias view point; this risk is minimised by the standardised and carefully constructed questions presented on the self-assessment questionnaire. The impact of resulting changes will provide a safe emergency service, where costly open surgical treatments are reduced in favour of less invasive procedures.
The British Society of Interventional Radiology Quality Improvement Initiative aims to improve access to quality provision across all aspects of interventional radiology in the UK by developing a wider network of sites. . There are several benefits to patients, that improved access and a quality interventional service brings:
Interventional radiology is less invasive than traditional surgery, which in turn, means that patients will recover more quickly and need less time off work. There is a huge range of procedures now offered using interventional radiological techniques, most requiring only local anaesthetic, so the hospital stay is minimal; in fact following many procedures patients can go home on the same day.
With policy drivers increasing and improving service provision, the needs of more patients will be met as more patients will benefit from these advantages. However, like conventional surgery, there are always risks attached to any procedure but these risks generally are less significant. The increased use of interventional radiological procedure increases the risk of cancer due to the high radiation levels used.
A study undertaken by O’Brian and van der Putten (2008) aimed to quantify the risks of radiation exposure, when balanced against benefits and viable alternative procedures. The study found that the risk due to radiation exposure was small compared to the overall benefit of the interventional procedure reviewed.
Although this study was limited to the uterine fibroid embolisation procedure, and the benefits identified do not necessarily transpose to other interventional procedures, the method described in the study, to calculate the ‘quality-adjusted life years’ (QALY), could easily be adapted to other procedures. Using the ‘QALY’ indicator, assesses the ‘value for money’ against quality gained. The method of ranking interventions, on grounds of their cost per ‘QALY,’ is controversial because it implies a quasi-utilitarian calculus to determine who will or will not receive treatment (Schlander 2010). However, since health care resources are limited, and Trusts are pressured to make budgetary savings, this method arguably enables resources to be allocated in the way that optimises patient benefits. The study attaches no value to quality indicators identified by patients and therefore suggests patient needs were not considered.
It is clearly indicated in the ‘IRGfSD’ that Health Care Resource Groups have revised “counting and costing” activity of IR to incentivise provision; there is no mention of using the ‘QALY’ indicator; but stating that Health Care Resource Groups “provide a means of categorising the treatment of patients in order to monitor and evaluate the use of resources” is ambiguous.
The ‘Next Stage Review’ stressed that improving quality must be “the basis of everything we do in the NHS”(Darzi 2007). Quality indicators obtained from patients, via questionnaire returns, focus on their needs and are used to inform practice. Patients are able to express their needs and concerns in consultation with health professionals, empowering them to make informed choice about their care and treatment. “No decision about me without me” (NHS 2010).
Patients will be more aware of their rights and what to expect from a quality service; for example, to discuss their imaging examination with the radiographer or radiologist. Patients may also expect their images and reports to be accessible instantaneously, if not nationally, placing a high demand on the Information Technology Strategy. The Image Exchange Portal enables secure transfer of digital images between the NHS and other health care providers, strengthening radiology reporting. It is reported that streamlining data transfer, often carried out by radiographers, frees up their professional time to clinical tasks. The impact on patient experience enables rapid access for a second opinion from speciality centre, images are available at tertiary centres for multi-disciplinary team meetings and urgent transfer of images and reports for emergency care.
The health minister, quoted by Scott (2010) said “ Improving IT is essential to delivering a patient –centred NHS. But the nationally imposed system in neither necessary nor appropriate to deliver this.” Responsibility for IT systems will be given local control to meet local need. Locally managed IT system could be problematic if system cannot interface in order to ensure effective data communication transfer between areas.
“Information systems used for report recording outside radiology departments must interface with the hospital’s RIS to allow linking of the report and images to support patient care and audit” (RCR 2011). Required interfaces have now been developed and is live at Doncaster who use the Mckesson RIS (NISN 2011). This will be essential for staff working between interventional radiological network areas.
Working across networks can pose other risks such as the spread of health care associated infections. Whatever the risk, patient safety needs have a major role in informing practice. Serious untoward incidents will need to be reported and lessons learnt from such unfortunate events will be used to develop action plans to avoid repeated incidents. Safe practice in IR requires safe use of equipment. The IRGfSD acknowledges that cross network working for radiographers would be impractical given that equipment used is complex may differ from one network area to another.
Each network area will require a sufficient and suitably qualified radiography staff workforce to ensure quality of service delivery. The RCR have previously highlighted national shortages of trained radiographers in the NHS. This coupled with a lack of advanced practitioners infers it may prove difficult in some areas to provide 24hr coverage.
There is a likelihood that the role of the radiographer will develop further to release workload pressure of radiologists. Advanced practice, such as reporting is already established and is likely to continue growing in a wider range of clinical areas. However skills development has not been without tensions. The transference of responsibilities is well documented as concerning. In the opinion of the College of Radiographers (2010) “medical image interpretation is legally and legitimately within the regulated practice of radiographers, and has been for many years”.
Brealey et al (2005) reported no significant difference between the reporting accuracy of clinical specialist radiographers and consultant radiologists when reporting on plain radiographs requested from GPs or accident and emergency departments. A meta-analysis of 12 studies found that radiographers report plain film radiographs in clinical practice with 92.6% sensitivity and 97.7% specificity compared with radiologists. With selective training of radiographers in image interpretation, there was no significant difference in their reporting accuracy compared with that of radiologists (Woodford 2006). This evidence reliably supports radiographer reporting since meta-analysis presents significant data analysis to reliably support the findings.
Specific to Interventional Radiology, radiographers have been specialist trained and performing unsupervised peripheral angiographic examinations since March 2000 at Manchester Royal Infirmary without incident. It is estimated that this practice has halved waiting times which had stood at over a year for some patients (Conway 2010). Several other case studies validate similar role extension which illustrates the potential in future duties of the radiographer within Interventional Radiology.
Where there is a skills shortage a consideration may be to out-source image interpretation; patients need to be informed and in agreement of such arrangements (RCR 2011).
Skills extension must be underpinned by suitable education and practice must be clearly agreed within agreed protocols and the clinical governance frameworks. Therefore cross network protocols and agreements should be sound. The ‘IRGfSD’ compounds the effect of the Agenda for Change on Career Progression of the Radiographic Work force (2009) which stresses the importance of the advanced practitioner playing as an integral member of the radiography team in ensuring delivery of high quality, effective care and interaction with relevant multidisciplinary teams. Other expectations of a radiographer will be to undertake and contribute to research, management and academic roles within specialist domains. The four-tier multidisciplinary model (DOH 2003) was designed to shape the clinical radiography team around client and care requirements rather than professional boundaries.
The impact of radiographers providing 24hour cover will place an increasing demand for on-call places and a reliance on existing staff to cover for colleagues during periods of absence. Resorting to the use of locum radiographers may be necessary to provide cover given that European Working Time Directives (1998) is a significant issue. The directive sets limits on working time to ensure staff rest in order to deliver a quality safe service. Fatigue is cited by the Health and Safety Executive as a contributory factor in incidents at work. It is essential therefore that an appropriate cover rota is designed to ensure adequate cover within departments that considers the best skill mix of staff from all four-tiers that will complement wider multi-disciplinary team working requirements.
Appendix
Figure 1: RCR UK data provided in 2011 on percentage increase on examinations between 2007 and 2010.
Source: RCR UK data presented in 2011 based on returns form 35 hospitals
Figure 2: Retirements 2010 and expected retirements 2011
Figure 3: Interventional Radiology Centres as at 31/10/11
Figure 4: Existing and proposed Trauma Centres as at 31/10/11
The following feedback from the RCR (RCR, 2011b) states further factors contributing to a significantly increased workload in Clinical Radiology. For example, Multi Disciplinary Team (MDT) meetings in 2010 were typically three hours in duration (taking into account the preparation and attendance time required), representing an increase in duration by almost a third (30 per cent) since 2007. The frequency of MDT meetings also rose by almost a quarter (23 per cent) over the same period. The increased complexity of individual examinations requires longer reporting times. Previously a large number of Computerised Tomography (CT)or Magnetic Resonance Imaging (MRI) examinations could be reported per session, but this number is now considerably reduced due to the large number of images per examination and the need to frequently perform complex post-processing image manipulation e.g. 3D rendering, for diagnostic purposes. The ability to ensure that the quality of work is maintained whilst rising to the challenges of increasing complexity and throughput may force some radiology departments to compromise, potentially leading to problems such as those reported in Northern Ireland below where lung cancers were not reported on plain films.
At present the radiology department remains predominantly the domain of the radiologist, but this is changing and there is no specific reason why imaging facilities should not be used by other clinical specialists trained in imaging, and images produced in these departments may also be reported remotely.
Maximising the use of resources
There has been a tendency in teaching and large regional hospitals for subspecialty services to pursue the development of satellite departments isolating radiologists from each other. While this may be essential in some clinical situations such as emergency departments, it potentially reduces the interaction between sub-specialist radiologists to the detriment of their wider knowledge and technological development. It may also reinforce the desire for clinicians to set up their own units and encourages the concept of radiologists working in clinical groups rather than providing a comprehensive imaging service. Radiologists should work towards a single strong well-staffed and funded department which is able to accommodate those clinicians who justifiably need prompt access to expert imaging [3].
Brealey S, Scally A, Hahn S, et al. Accuracy of radiographer plain radiograph reporting in clinical practice: a meta-analysis. Clin Radiol 2005; 60: 234-241.
Krestin GP (2009)Maintaining identity in a changing environment: the professional and organizational future of radiology. Radiology 250: 612-7.
Interventional radiologists are doctors who specialise in performing image guided minimally invasive surgery. Many of these procedures can replace traditional surgical operations. This can result in reduced complication rates and shorter stays in hospital
Examples of some procedures;
Femoral angiograms – dye is injected into the main artery of the body (aorta) via catheters. As the dye flows down the arteries in the legs x-rays are taken to show any abnormalities.
Angioplasty – This is a way of relieving a blockage in an artery without having an operation. A fine called a catheter is inserted through the blockage in the artery and a special balloon is then inflated, this opens up the blockage to allow more blood to flow down the artery.
Stents – Metal or plastic stents can be inserted into arteries or veins to keep them (functioning correctly). This can relieve any blockage that’s in the vessel.
Stents can also be positioned in the gut to relieve any blockage and this aids the digestion of food. This procedure is done under sedation and avoids surgery along with any associated risks.
Embolisation – A small bleeding artery can be embolised (blocked or sealed). Fluid, containing thousands of tiny particles, is injected through a catheter into the small arteries. This silts up small blood vessels and blocks them.
Percutaneous Nephrostomy – urine from a normal kidney drains through a narrow tube called a ureter into the . If this tube becomes blocked for example, by a stone, the kidney can not drain and can become infected. It is possible to relieve the blockage by inserting a catheter through the skin into the kidney allowing urine to drain from the kidney into a collecting bag outside the body. Patients may no longer need surgery.
References
Conway B (2011) Interventional News; accessed on-line @
Darzi, A (2007).Our NHS, Our Future, The NHS Next Stage Review. Department of Health. London
DOH (2010) White Paper Equity and Excellence; Liberating the NHS. NHS 2010
DOH (2003) Radiography Skill Mix, A Report on the Four-tier Service Delivery Model. DOH June 2003
O’Brian B and van der Putten W (2008) Quantification of risk-benefit in interventional radiology. Oxford Journals; Volume 129, issue 1-3 p59-62
Strauss K J. (2006). Interventional suite and equipment management: cradle to grave. Pediatr Radiol. 2006 September; 36(Suppl 2): 221–236. Published online 2006 July 22. doi: @
National Confidential Enquiry into Patient Outcome and Death (2000) Interventional Vascular
Radiology and Interventional Neurovascular Radiology. NCEPOD, London
Reekers J A (2011) Interventional Quarter Issue 5 December 2011; Intervention IQ; Trauma Interventions @
Medimaging staff writers (2011); High Equipment Costs in Interventional Radiology and Cardiology, Present Key Deterrent to Uptake. Medimaging Daily Radiology News Posted 10th August 2010. Last accessed on 17th December 2011 @
17. National Confidential Enquiry into Patient Outcome and Death (2007) Trauma: Who cares?’ NCEOPD, London
18. National Confidential Enquiry into Patient Outcome and Death (2009) Acute Kidney Injury: Adding Insult to Injury, NCEPOD, London
NIB (2009) Interventional Radiology (IR): Improving Quality and Outcomes for Patients; A Report from the National Imaging Board. DH Gateway ref. 12788 last accessed online 28.12.11 @
NISN (2011); Image Exchange Portal Newsletter April 2011. Last accessed online 30.12.11 @
Scott J 2010 NHS IT Strategy Goes Local, IT Pro, IT Analysis Business Insight. Last accessed on-line 30.12.11 @
Schlander, Michael (2010-05-23), "Measures of efficiency in healthcare: QALMs about QALYs?", Institute for Innovation & Valuation in Health Care
Woodford AJ. An investigation of the impact/potential impact of a fourtier profession on the practice of radiography: a literature review. Radiography 2006; 12: 318-326
