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4.0 Potential additional workforce development pathways

There are several additional routes to the development and acquisition of a stable sonographer workforce in the UK, as follows:

4.1 First degree direct entry, leading to BSc (Hons) Medical Ultrasound

The establishment of a primary, direct entry degree has the potential to attract a wide range of applicants and there is evidence that there would be strong demand. Such programmes would be delivered by established universities and students may be eligible for bursaries as are diagnostic and therapeutic radiography undergraduates.

Advantages of this development route are:

  • Likely to be popular with a wide range of applicants;
  • Potential to allow for a large number of graduates (but depends on the availability of clinical placements);
  • Direct costs to Trusts and Health Boards are limited and are as for other healthcare students;
  • No ‘back-fill’ problems;
  • Would fit well with ‘four tier’ career progression structure. Postgraduate level courses would be able to develop advanced and consultant level skills;
  • Highly comparable with ‘direct entry’ midwifery approach which has been successful.

Problems that would need to be addressed include:

  • Potentially narrow education and training that does not provide a wide range of core imaging skills. The broad general curriculum associated with a BSc (Hons) degree should help to mitigate this, as would ensuring an interprofessional approach to curriculum design and learning. 
  • Concerns regarding musculo-skeletal injury if this is seen as an inevitable consequence of practising in ultrasound.
  • Training places will be required in the NHS Trusts and Health Boards; in the early phase at least, it will be clinically challenging to support a sonographer student without any prior healthcare knowledge through to graduation.
  • Direct entry at this level assumes establishment of a ‘practitioner’ level of sonographer but as yet no consensus exists as to what ultrasound examinations can be carried out by this level of practitioner.
  • There is, at least, a three year lead-in period as no programmes are approved currently, so this is not a short term solution.
  • Sonography is not currently a regulated profession and ‘Sonographer’ is not a protected title. In October 2009 the Chief Executive of the Health Professions Council wrote to the Secretary of State for Health recommending regulation, subject to consideration being given to two points arising from a report for the
  • Department of Health (England) on the extension of professional regulation. It could still be several years before the legislative process is completed, if it proceeds.  Although sonographer regulation is desirable, it is not a pre-requisite to the establishment of direct entry first degree programmes in ultrasound and such developments may proceed regardless.
  • Employers must be able to demonstrate that they will employ primary degree, direct entry qualified sonographers.
  • A preceptorship year as for direct entry midwives is likely to be required (and would assist employers and the existing workforce to develop confidence in this new element of the sonographer workforce).
  • In England, Strategic Health Authorities must be willing to support both the programmes themselves and the underlying principles.
  • Many in the existing ultrasound workforce will need to be convinced that this is an acceptable way forward.

4.2 Postgraduate direct entry, leading to PGC/PGD/MSc

In reality, this option exists already but is under-recognised and under-utilised.

Advantages include:

  • It is likely to be popular with a wide range of primary degree qualified applicants.
  • It has the potential to allow for a large number of graduates (but depends on the availability of clinical placements)
  • Direct costs to NHS Trusts and Health Boards are limited.
  • No ‘back-fill’ problems.
  • Applicants will be more ‘mature’ as they will already hold a primary degree, with many holding this is in a health or healthcare related subject.
  • Such a pathway is available currently. In particular, CASE accredited vascular programmes have students following this pathway.
  • The programmes can be accredited following established CASE procedures so giving confidence to employers and the existing ultrasound workforce.

Problems that would need to be addressed include:

  • Training places will still be required in the NHS Trusts and Health Boards, and it will be clinically challenging to support students with limited or no healthcare experience through to completion.
  • In England, Strategic Health Authorities must be willing to support both the courses themselves and the underlying principles.
  • Funding of students is likely to be a problem as some will have considerable debts from their first degrees, and may be ineligible for further support through the bursary system.

4.3 Distance Learning

Distance learning programmes should be considered as options for delivering both direct entry first degrees and higher degrees to develop the sonographer workforce and in the past have been used by some universities to deliver sonographer education and training at higher degree level.  It will still be necessary for all students to have a clinical placement(s) for the duration of the programme. These could be commissioned alongside more traditionally delivered programmes that may themselves utilise a wide variety of innovative learning methods.

4.4 Radiology Academies, and Computer Based Simulators and Learning Aids

In England, there is also potential for universities to link with the three Radiology Academies in the delivery of ultrasound education. Facilities in the academies would be particularly helpful in the early stages of sonographer training, and in developing reporting skills.

It would also be important to exploit innovative learning technologies to assist in skills development and to ease some of the training burden on clinical departments, particularly those related to equipment and probe handling and hand-eye co- ordination. Such technology is in development currently.

4.5 ‘Focused’ ultrasound courses

These are courses that prepare a trainee for a fairly narrow scope of ultrasound practice, for example first trimester examinations, early pregnancy assessment, third trimester techniques, carotid ultrasound, gynaecological brachytherapy. Increased use of these should be considered as they offer the opportunity to diversify and grow the workforce undertaking ultrasound examinations while ensuring that practice is aligned to a set standard of competence and award/academic credit. (See Appendix 2 for the College of Radiographers position statement on ‘focused’ courses).

Advantages of focused courses are:

  • They can be delivered in a relatively short timescale, typically three to six months.
  • Assist in meeting demand with limited training costs.
  • The courses can be specially designed, or could form part of a wider CASE accredited PGC/PGD. 
  • They extend an individual’s existing scope of practice in other imaging or treatment techniques or other professional activities (e.g. midwife undertaking first trimester scans; radiographer undertaking carotid artery scanning; physiotherapist scanning shoulder joints)
  • CASE now accredits focused courses to standards similar to full programmes.

There are disadvantages, including: 

  • Narrow experience in a limited area of practice may lead to missed pathology in adjacent organs/structures; for example, an adnexal mass missed on first trimester examination as the individual scanning was trained to examine only the uterus and fetus.

4.6 Overseas recruitment and registration

Sonography is listed (2009-2010) as a shortage specialty by the UK Government Migratory Advisory Committee (MAC) making it easier for NHS organisations to employ sonographers who are not from within the European Union/European Economic Area where there is already legislation covering the free movement of workers. The problem for UK employers is that as sonography is not regulated it can be difficult for them to judge the suitability of overseas applicants. Although the academic equivalence of an applicant’s educational qualifications can be assessed via UK Naric (http://www.naric.org.uk) this is not helpful as far as an applicant’s clinical competence is concerned. The education and training arrangements in other countries
can be very different to the UK; for example, sonographers in some countries are trained to carry out the ultrasound examinations but are not required to report them. This ‘third party’ reporting scenario is not considered good practice in the UK.

Registration with one of the UK’s statutory healthcare professions regulators is often asked for by employers but for many overseas sonographers practising in the UK this is not possible and is not a legal requirement at present. The SCoR has specific information relating to this issue which can be found in appendix 3. Some European Union/European Economic Area and overseas sonographers may be able to register but this will be via another professional route such as radiography, nursing or midwifery.

The Society and College of Radiographers maintains the Public Voluntary Register of Sonographers (PVRS) and sonographers practising in the UK, whether from the UK or overseas, are encouraged to apply. Acceptance on to this voluntary register does not in itself constitute an endorsement of employment suitability and this responsibility must remain with the individual employer. The Society and College of Radiographers stance on registration and the PVRS is articulated in its ‘Scope of Practice in Medical Ultrasound’ document published in 2009.

4.7 Assistant Practitioners

The SCoR supports the use of assistant practitioners in ultrasound although their role is necessarily limited as good ultrasound practice requires the person performing the ultrasound examination to issue and take responsibility for the report. Ultrasound examinations currently considered suitable for assistant practitioners are given below (see also The Scope of Practice of Assistant Practitioners in Ultrasound, published in 2008 by the Society of Radiographers):

  • single measurements, single conditions or routine screening examinations; for example, obstetric dating scans* where the task is limited to making a single measurement followed by recording the associated gestational age that has been automatically calculated by the machine software from standard data charts/tables.
  • abdominal aortic aneurysm screening where a single organ is scanned and measurements taken and recorded.
  • calculating bladder volumes and ankle brachial pressure indices using dedicated or specialised single purpose equipment and automatic calculation software.
  • routine surveillance examinations to monitor anatomical dimensions where a baseline scan has been performed by a registered healthcare practitioner routine daily quality control of imaging equipment.

* In England, the combined test has been recommended as the first trimester screening test for Down’s syndrome. This involves measurement of the nuchal translucency and is not considered an appropriate procedure for assistant practitioners.

4.8 Local Initiatives

There are a small number of local or regional initiatives that merit investigation and replication where appropriate. Examples are:

  • The work done by the West Midlands SHA to increase the number of sonographers in that SHA (following a proposal from the West Midlands Perinatal Institute, West Midlands SHA Workforce Deanery has funded sonographer training, supporting a co-ordinated regional approach that will provide 18 additional training places over three years). 
  • The Essex Cardiac and Stroke Network have provided funding (July 2009) to increase the number of sonographers able to carry out carotid Doppler examinations. 

However, by their nature, these are local approaches to workforce development and the funding may only be available for a short period of time. It is also the case that sonographers developed through such initiatives may move to other NHS Trusts and Health Boards outside of the original funding area. 

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