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Appendix 1 - the Case Studies

Case Study 1

The Hospital
This was undertaken at a large district general hospital in the south of England which had been granted NHS Foundation Trust status.  It provided a full range of services in addition to being a regional centre for three specialties.

Interviewees
Those participating were the radiology specialty manager, the directorate manager and the consultant radiographer. Three interviews were conducted; two were conducted face-to-face but because of a difficulty of arranging a suitable time for the third, the interviewee completed the question template on-line.

Radiography Profile
There is one consultant radiographer in post who specialises in gastrointestinal imaging (GI).  The consultant had been in post for two years and was appointed on Agenda for Change (AfC) band 8b which remained unchanged at the time of interviews.  

The ‘four tier system’ Career Progression Framework began to be implemented pre-2005 and became fully implemented on the appointment of the consultant radiographer in 2008.  

There are 12 advanced practitioners in post whose specialities comprise barium enemas, ultrasound, urodynamics and skeletal reporting and nuclear medicine reporting. The introduction of these posts began before 2005. The advanced practitioners are banded at AfC band 7.  

There are four assistant practitioners in post but one assistant is studying to become a radiographer.  Posts were introduced about 10 years ago and those currently employed are employed at AfC band 4. The assistants’ fields of practice are general radiography, trauma, dentals, DEXA and screening (general not interventional). Shortly their scope of practice will be extended to include theatre radiography.

Rationale for adopting the CPF
The main rationale for adopting the CPF was as a service improvement to reduce waiting times and increase flexibility of the service.

Assistant practitioners
The introduction of assistant practitioners, although meeting a service need, was also seen to be important as a way of introducing career progression for helpers. Increasing their scope of practice would be beneficial to the department by contributing to spreading the radiography workload as well as providing a financial benefit.  Some years ago, before accredited training was introduced, it was felt that that as the overcouch imaging of barium enema patients was very repetitive, the ‘helper’ working in screening could probably be trained to carry out this activity under supervision.  A risk assessment was undertaken and the helper was trained to carry out this task. This then meant that there was increased job satisfaction for the helper and patient lists could be managed with fewer staff, with those not required being deployed to areas where there was a shortage. This proved to be very successful and when a foundation degree started, the helper was one of the first to register for the programme, having already gained an NVQ level 3 in the interim.

Currently there are three assistants at AfC band 4.  There have been as many as five but one retired, another took a post in another hospital and a third is undertaking a radiography degree.  

Practice areas are general radiography, trauma, dentals, DEXA and screening (general, not interventional) and shortly to be in-theatre.

The case for more assistants was made by the consultant who was of the view that:

“It is the way that the staffing of departments has to go in the present financial climate. We need a lot more assistant practitioners as there is scope to use them in many more areas in the department. With appropriate training there is a role in ultrasound, mammography, theatre, nuclear medicine, CT and MRI.”

Training is provided by a local university to provide an academic content but the trust trains assistants on the job to carry out particular screening procedures that run strictly to protocol; this is felt to have obvious benefits to theatre and the department.

Advanced practitioners
Advanced practitioner posts were introduced to bring about service improvement by reducing waiting times and increasing flexibility of the service.  

The advanced practitioner as a title has not been introduced but radiographers in particular areas with an interest in a speciality were encouraged to develop so that they could take on some of the work carried out by radiologists (eg barium enemas, skeletal reporting). Some universities offered courses that gave academic support to their clinical training. This gave the role development process credibility to sceptical radiologists and to the risk management team.

This was straightforward in ultrasound because of the many precedents elsewhere. With regard to skeletal reporting a business case had to be made.

Consultant post
The rationale for seeking to appoint the consultant posts was service need. At times there was not full radiological cover, especially for lower GI imaging and radiographers were already working at an advanced level in that field at the trust.  There was a recognition that this approach to appointing a consultant radiographer had taken place elsewhere in the UK and it was seen as a logical progression to pursue in the trust.  The role was included in the departmental strategic plan but the case for the role had to be put to the Directorate Management Team.

In addition to the service need there were issues of professional leadership and educational development on which it was considered important for the consultant to take the lead.  

The development of the consultant post was led by the radiology speciality manager and the clinical director.  The first step was to review the service need and once this had been established the strategy was to look at consultant appointments elsewhere in the UK.  The precedents from other trusts provided for a process of cross-fertilisation in coming up initially with several job plans.  There were a number of consultations within radiology and with consultants outside radiology in the trust.  The development team emphasised that the necessity was to provide evidence to justify the post and ensure it was not viewed as simply a job that was being designed for a specific individual. Therefore the post had to reflect a role that would meet the needs of the service.

When the post was approved it was advertised both within the trust and externally. There was an external enquiry but this did not lead to an application. There was, however, an internal candidate who applied and was successful.

Role Content
The job description was put together after studying similar posts in other trusts and by taking advice from sources within and external to the hospital.  It was agreed by the speciality manager, the lead radiologist and the directorate management.  The core elements were agreed as primarily GI radiography/radiology with responsibility for leading on barium enemas; other elements included membership of the multidisciplinary team (MDT); CT colonography; professional lead in radiography; membership of the departmental management team and educational lead including responsibility for ensuring staff CPD needs are met.  

Post appointment negotiations took place between the speciality manager and the consultant radiographer as it was recognised that the role would develop.  The consultant explained that:

‘These [requirements] have changed as the job has evolved. When the job description was written, the emphasis was very much on the clinical side: professional lead, education, clinical governance and audit. Now I am very involved in all of the above plus service improvement and skill mix within the department.’

Although the consultant cannot quantify the percentage of time spent on each element as they are continually in flux, four clinical sessions are routinely undertaken per week plus the reporting requirements arising from those. However if there are radiologists away who have GI lists the consultant covers those in order that the waiting times remain on target.

The initial job description reflected the clinical need but the managerial and leadership roles have developed subsequently. The consultant and managers agreed that the benefits have been greater than anticipated.

Selection criteria
Criteria adopted for assessing and selecting applicants for the consultant post were based around qualifications and experience relative to the job description.  The applicant was marked against a scoring grid matched to the job description.

The panel was the speciality manager, the lead radiologist and an external member who was a consultant radiographer.

The consultant has two lines of accountability; on a non-clinical basis to the speciality manager and clinically to the lead radiologist in the same way as other radiologists.

CPD arrangements are in place for the consultants and for advanced practitioners. This is based around a performance management programme using a dial system where performance is scored on a scale 1-10 with 5 being the optimum score, less than 5 demonstrates an underperformance and over 5 an over performance on a particular task type.

Impact and benefits
There have been a number of impacts on the clinical side including freeing-up radiologists’ time from some specific types of examination, improving the use of their training time and enabling increased demands elsewhere to be met. For example, prior to the consultant radiographer appointment, the need for barium enemas was not being met to the required level.  The radiographer-led barium enema service and radiographer involvement in CT colonography has had a positive impact on service capacity in these areas.  The trust is very satisfied in the way the service is run. In particular, the importance of the professional lead role was emphasised which included developing the work force and undertaking a training needs analysis for radiographic staff.

The anticipated benefits of the appointment have been realised but the overall effect is one which is different to what was expected in that there have been advances in areas other than those planned. These have been improvements in clinical governance within radiology which is now much better organised; improvements to staff development and training and improvements in planning and recording. Clinically, there has been an impact on service capacity since introduction of the consultant post.

It was difficult to determine whether there had been any direct impact on proportion of patients meeting 18 weeks targets pre-and post-implementation of the consultant post as there have been so many modernising projects. But it was clear that if the consultant radiographer had not been appointed the department would have to have done things differently.  However, the patient waiting-list length pre- and post-implementation has reduced. The trust meets its 6 week target for imaging and 2 weeks for cancer. Overall, there was a strong view that the key benefits are around patient care and timely radiology.  Lists are no longer cancelled because of holidays or sickness and, if required, the capacity is increased by extending lists or running extra lists.

As radiologists are normally involved in a range of modalities, they are therefore not always readily available. Because of this, the consultant radiographer is now the named person for contact by referrers on aspects of GI imaging and plays a key role within the multi-disciplinary team.

“I have a part to play within the multidisciplinary team and as such can communicate findings straight to referrers and also arrange any examinations that they may require at short notice. We also discuss service provision, patient information etc.”

Likewise in the case of advanced practitioners, their involvement in ultrasound, urodynamics and with referrers and multi-disciplinary teams has produced similar benefits.  

For assistant practitioners, their benefit is exemplified by operating the DEXA service under the responsibility of a band 6 radiographer. The manager recommended that the SCoR extend the scope of practice of assistant practitioners.

In summing up the benefits of the consultant post, the speciality manager stated:

“There have been clinical benefits, certainly, but with the development of the managerial and leadership roles, the benefits have been better than planned.”

The consultant radiographer identified the benefits as:

“Service improvement and programme leadership. A flexible, patient centred GI service. A robust Clinical Governance Agenda. High level of student support. The introduction of induction and preceptorship programmes together with work experience book and engaging with schools to organise visits as part of their science programme.  I do not think that we envisaged that the role would evolve in the way that it has and for that reason the benefits are different. We had thought that they would be mainly to the clinical side of things but the other parts of my role have made a bigger impact on the department”.

Monitoring the service
Activity is measured on a monthly basis and waiting times on a weekly basis for both financial and service planning reasons.  In 2006 there were 125,304 examinations and in 2008 it was 147,866.  For fluoroscopy following the appointment of the consultant radiographer in the first year there was a 24.8% increase in activity; in the second year it was a 7.8% increase but activity is continuing at this higher level.

Figures are reported internally to the directorate management.  They are used to measure performance, comparison with previous returns and are used for strategic planning. Year on year comparisons are made and are noted at Board level. This does impact on departmental income as money is transferred into the budget based on activity.

The figures are also reported externally to the primary care trust and they are compared against national tariffs in relation to funding.  

With regard to complaints, the department would investigate any against the consultant if any had been made but to date there have not been any.  Where complaints are made against the department the consultant radiographer investigates these.  There has been no change in the number of complaints overall since the year in which the consultant the post was introduced.

Consultant costs
Overall, the cost to introduce the consultant post has been salary (Band 8b) plus development and training.  There was no additional funding to resource the post; the start-up costs had to be found from within the department’s budget. Now the post is established it sits within the department’s budget on a recurrent basis.  There is no data that directly demonstrates the cost-benefits or could be used to calculate cost savings except the self- evident difference in salary between a consultant radiographer and consultant radiologist.   These were produced when ‘selling’ the concept to the directorate management and featured as part of the ongoing discussions.

Succession planning
There are no robust succession plans in place should the consultant move on. However, the future of barium enemas are under discussion but the consultant radiographer also performs CT colonography and the role would develop to meet new requirements.  

If the consultant did leave, following the initial panic, the trust would seek to reappoint as the post is valued but a new person would have to have the same clinical skills and be at the appropriate level.  

The department is now discussing a consultant radiographer post in nuclear medicine and has identified potential for introducing radiographer consultants in ultrasound and breast imaging.

The trust fully endorses the CPF but the development and implementation process has to be rigorous; there are a lot of key people to persuade in radiology as well as the wider trust.

Case Study 2 

This was undertaken at a large trust in the north of England.

The Hospital
The hospital was a large trust formed from the merger of three hospitals in the north of England. Imaging services are provided across the three sites.

Interviewees
Interviews were undertaken with four individuals: the director of clinical services (a radiologist), two consultant radiographers (one of whom had been involved in writing the original proposal to introduce consultant posts and the other having come through the trainee consultant route) and a radiologist. 

Radiography Profile
The CPF had been in place for around three years by the time at which the interviews were conducted, in late 2009. 

There are two consultant radiographers and two trainee consultants at the hospital, along with an extensive cohort of advanced practice radiographers and sonographers. If the scope for and justification (through a business case) for a consultant post is established, a post will be developed and the trainee is eligible to apply, but the posts must be nationally advertised as per Department of Health guidance. Consultant radiographers are employed on AfC band 8b and the trainees are on 8a.

A considerable number of advanced practitioners were in post: two in breast imaging, 20 in ultrasound, two in CT reporting, 9 in film reporting, one GI practitioner, and four in barium studies. Advanced practice radiographers are employed on AfC band 7.

In addition, six assistant practitioners were employed.

Rationale for adopting the CPF
There had been a radiographer clinical specialist role within the hospital since 2002 and this was seen as a precursor to the consultant role: the roles were 50 per cent clinical and 50 per cent non-clinical and had been introduced with the aim of developing advanced practice. This had led into discussions about advanced/consultant practice and the possibility of a radiography role in leading on service development rather than simply leading advanced practice within a focused area.

One key driver had been discussions around the emergency care and critical care agendas which were at the forefront of NHS policy at that time; a further factor was the need to meet the four hour target in Emergency Departments/A&Ea. Considerations regarding service cover and service development also played a part. 

There was some existing history of extended practice: radiographers had been reporting on plain films in the hospital for over 12 years. However, this had been a somewhat ad hoc arrangement, with some appropriately qualified radiographers not reporting at all. Introduction of the consultant post to lead on service development was therefore seen as an opportunity to extend and formalise the role extension that already existed.

Given that much of the role was envisaged as focusing on leading and changing practice, a significant additional factor in the decision to take forward the proposal for consultant radiographers was the fact that the managers also felt that they had in post an individual who not only had the required talent, drive and ability to do the job but also – and more importantly at the planning stage - to lead on gaining approval for the consultant posts.

Two consultant posts were originally planned: one in the ED and one in GI. Planning for the GI post was largely prompted by screening requirements aligned with the cancer service agenda and largely focused on addressing key clinical service needs for which there was not necessarily any radiologist leadership. Rather than the focus for the changes being on issues that needed to be tackled and which radiologists were not or could not tackle, it was about changing how the imaging services department looked at things in total and in particular worked across disciplines.

Regarding introduction of the advanced practice radiographers, while the intention was for these individuals to take on some of the radiologists’ role this was seen as potentially filling a gap in service provision and releasing some of the radiologists’ time for other activities rather than being about cutting costs.

Therefore, there had been a combination of factors. ”It wasn’t just a cynical move to plug holes, [and] it wasn’t singularly because we thought it was a good idea; it was multi factorial”.

One comment is worth noting. The clinical service director stated:

“My view is that for the extreme role extension [ie to consultant level] in radiography you need to have suitable people in post before you plan it. And there are not huge [numbers] of people out there. I think that’s one of the constraining factors [and] the most interesting bit.”

Assistant practitioners
There are six assistant practitioners in general radiography and one assistant in a partner managed MRI service, with that development being supported by the trust. The trust had recently recruited one person to start as a trainee assistant practitioner for mammography but the individual had then decided against continuing in this post, so there was no assistant in mammography at the moment but it is planned to appoint an assistant practitioner in this area at some point in the future.

The trust first developed just one assistant practitioner; this individual was already a very experienced clinical support worker. A second assistant practitioner was appointed two years later. A further four had been trained in the last year in plain film radiography. The trainee assistant practitioners undertake the first year of the radiography degree to qualify for the role.

These last four posts had been planned with a view to providing the additional staff that would be required when the department moved into new premises in the near future. A key factor influencing this decision had been the fact that the SHA still provides backfill funding, which enabled the department to recruit two trainee assistant practitioners internally and two externally. The trust was looking at introducing assistant practitioners in a number of other areas, mainly in radiographic practice, with some discussion regarding the possibility of their introduction into CT, too.

The assistant practitioners work the same extended days as other staff and the same rotations too. They work as part of the team, under direct supervision, but as integrated, flexible, members of the team. Their work is varied, although for the majority of their time they may take x-rays under supervision; at other times of the day they will work as a support worker.

Advanced practitioners
The general radiography posts had been developed and reconfigured by the consultant to make best use of their time. Radiographers in plain film were now being used as reporters the majority of the time; previously these radiographers had only been plain film reporting for one or two sessions a week and yet often had been employed in a band 7 post. Following the role reconfiguration 60 per cent of their time is dedicated to advanced practice, clinically, and the remainder of their time is clinical, so that now they are involved in work that is appropriate to their banding all the time. The change had also meant that radiographers were now providing services 12 hours a day and at weekends on one site and 9-5 at the other two sites and at the same time radiographers had taken on a large proportion of the radiologists’ reporting workload.

The advanced practitioners are clinically accountable to the Consultant but are line managed by the radiography manager. All advanced practitioners are expected to hold a postgraduate certificate and be working towards a master’s degree. All of the sonographers are advanced practitioners.

Consultant post
One of the consultants (one of the case study interviewees) had been employed within the trust prior to introduction of the consultant posts. They had been tasked with writing the proposal for the introduction of the consultant posts and then subsequently had been appointed (following an open recruitment process) as a consultant, at band 8b, in 2004. The second consultant had been appointed initially to a trainee post at band 8a and then, once qualified and following advertising and open competition for the post, was appointed consultant at band 8b in 2006. It should be noted that the original proposal had proposed two posts, with one being in GI imaging. However, a failure to recruit had meant that this post was effectively frozen and the second consultant post had arisen from a subsequent proposal for service support in breast imagingb.

There were several reasons for seeking to appoint the consultant posts. One was service need. On occasions there was not full radiological cover, especially for lower GI imaging. There was also an acute shortage of suitable consultant radiologists making recruitment challenging and the desire of incoming radiology consultants to focus on their chosen area of subject specialisation meant that a lot of bread and butter radiology work was not being done; as the consultant radiologist stated:

“There was no space in people’s work plans, so things like plain film reporting, ultrasound, etc. were being left by the wayside, and there was a need to get it reported and sorted”.

At the same time, several radiographers were already working at an advanced level in the trust when discussions first took place.  There was a recognition that the appointment of consultant radiographers to improve imaging services had already taken place elsewhere in the UK and it was seen as a logical progression to pursue within the trust.  In addition to addressing the service delivery needs, appointment of a consultant was also expected to provide professional and educational development and leadership.

The development of the consultant post was led by the radiology speciality manager and the clinical director.  The first step was to review the service need and once this had been established the strategy was to look at consultant appointments elsewhere in the UK. The precedents from other trusts provided for a process of cross fertilisation in coming up initially with several job plans. There were a number of consultations within radiology and with consultants outside radiology in the trust. The development team emphasised the necessity of providing evidence to justify the post and not a job that was being designed for a specific individual. Therefore the post had to reflect a role that would meet the needs of the service.

Role Content
The job description had been written to fit the framework that would get approval. However, the head of service had had a significant say in making sure that the balance was right. The basic structure for the consultant post was around six-tenths clinical, three tenths development support of others and leadership and one tenth research. However, the ED role had changed since the consultant had been appointed and it was now felt to be closer to a quarter research, a quarter service leadership and development and slightly less clinical. It was felt that over time the role would become less clinical as that individual moved into more of a leadership role alongside the Clinical Director and the radiography manager.

There are indications that, in the case of the two successful appointments, the role had been developed with the strengths of the eventual appointee in mind. The priorities within the two posts allowed the consultants to play to their strengths.

Regarding the consultant post based in ED, while the post is employed through imaging services, the role sits within ED; this post is therefore involved in implementing change more widely within the trust, rather than being constrained to implementing change within imaging services. The consultant had looked at how imaging services integrated with other areas and at how pathways could be changed and new pathways introduced, in collaboration with the management team.

The consultant post in the breast imaging service was also largely focussed on service development. While the role was being defined, the eventual appointee was seen as the person most likely to be appointed to the post. Although this individual has a clinical role, they also enjoy implementing systems and have a strong network of contacts externally. The role now requires this individual to collaborate with outside services across directorates.

Research has been a central part of the role. For example, in the breast imaging service, the referral pathway for mammographic surveillance had been changed based on a study undertaken by the consultant (while in the trainee consultant post) which culminated in the recognition that patients should be stratified according to risk and their surveillance regime determined from that.

There is also evidence of changes to patient pathways. In the ED, direct access for trauma patients through GPs and through the walk-in centre had been introduced. The big issue had not been access to imaging but access to report.  Now, radiographers not only report but can also give the patient advice and instruction regarding their injury, which normally the GPs would do. The immediate availability of reporting means that patients can now also be referred directly into the appointments system, whereas before they would have had to wait for a referral from their GP. This means that patients are managed better and it has increased capacity in the ED.

Selection criteria

The key issues for the posts were seen as being able to work autonomously and confidently and being able to drive their own agenda, to drive change and challenge practice both within the department and across boundaries.

The criteria used for assessing and selecting applicants for the two consultant posts were based around qualifications and experience related to the job description.  However, the two trainee consultant posts had not been advertised externally; they had been given to people who were viewed as particularly appropriate because of their previous experience, as the consultant radiologist indicated:

“The trainee posts are only secondments at the end of the day. If they don’t prove that they’ve got potential for a consultant post in their area then they’ll go back to their old job.”

The trainee consultants are required to go through a Masters’ programme and to prove during the secondment that they have the potential to take on a consultant post in their area: if they do not, then they return to their old job. Where the business case for the post is justified, the post is advertised nationally and the trainee will be eligible to apply for the post at that point.

Impact and benefits

A number of clinical and capacity benefits were identified:

At various points in time, the trust had found themselves with gaps in the service; this was attributed largely to the rapid development of complex imaging, with, as a result, the more basic and routine imaging being left behind. There had also been problems with reporting in ED, with radiologists sometimes not reporting for up to 14 or 15 days after the patient attended. The developments in radiography had meant that they now had a 12 hour radiographer-led hot reporting service for the ED which was likely to be extended to a twelve hours seven days a week service in the near future. Recently this had been extended to include radiographer discharge of patients from ED under protocol and these innovations around discharge have freed up clinical time.

Across the imaging service, the consultant and advanced practitioner posts were seen as having plugged gaps, supported service delivery and innovation and/or freed up radiologists’ time. Introduction of these grades had also allowed for double reporting of barium enemas and, in the breast scanning service, introduction of the consultant post has allowed the double reporting of mammograms. The interviewees believed this would not have been feasible before the introduction of the advanced practice posts. Although the actual throughput of patients remained the same the trust had been able to bring the added benefit to the patient of double reporting, which is the ‘gold standard’ for mammography.

Having the consultant radiographer permanently based in the department meant that the timings for stereotactic core biopsies could be more flexible, which in turn meant that they have been able to reduce the waiting times for patients for that procedure. The consultant radiographer had been responsible for stereotactic core biopsies since 2004 (when they were an advanced practice radiographer prior to being appointed to the consultant post); previously it had only been radiologists who undertook this job and they did just one session per week. The trust did not hold records on this, but the interviewee believed that previously they were doing “probably two stereo cores a week”. Now they could accommodate eight a week.

“It’s been a godsend. It has freed up consultant radiologist time to do more intricate cross sectional imaging. In my world of breast work it’s made up for the fact that we haven’t been able to recruit to posts. It’s provided additional hands in one-stop clinics and in the second reporting of films. And certainly for A&E and for the outpatient, hospital based stuff, that’s been expanded; it’s definitely taken a huge load off the consultant radiologists to allow them to develop additional services.”

The radiologist confirmed this point, saying that they felt that there had been improvements across the board: introduction of the consultant posts had enabled the trust to adhere to the RCR guidance that everything should be reported and to meet the radiology 6-week (and soon to be two-week) targets for the breast service.

The breast service had one consultant radiographer and one and a half whole time equivalent advanced practitioners in place and this had allowed the service to increase the numbers seen in clinic. The radiologist in charge of the service was unable to provide figures relating to the increase but commented:

“We lost one consultant radiologist, were unable to secure a locum and could not re-recruit. We had [these advanced personnel] in place and training up when the crunch came. We had this ‘before’ scenario, and then we put them in place, and immediately after, we had a service that was ticking along and it would have fallen apart had they not been there, so it’s not really that easy to quantify [but] the clinic numbers and smooth running of clinics have been down to having these multi-skilled people, including the consultant and advanced practitioner, able to work with a minimum of supervision.”

One of the biggest impacts of introduction of the consultant role has been the introduction of hard evidence-based practice and change in systems. The change to the referral pathway for mammographic surveillance was reported in an earlier section. There had also been changes made to the referral pathway because previous research had revealed extensive slippage in patients and that some were not getting mammograms until nearly nine months after they should have. In the breast service, then, there is evidence that the consultant has been able to put research into practice, “to implement it, put the systems in place so we can improve the patient pathways”.

When the department moves to new premises it will be possible to have two simultaneous symptomatic one-stop clinic lists running. The proposal on the table at the time of the interview was for the consultant radiologist and the consultant radiographer each to have their own list within that clinic. This would increase the patient throughput significantly. With their present arrangements they have only 16 patients per clinic. With the new arrangements they will increase to 24 patients per clinic, with five clinics per week. In addition, the consultant radiographer was able to undertake interventional guided ultrasound; previously it was only the radiologists that could do this procedure. Although the service was not yet at a point where they could really increase the patient numbers (because they were constrained by the existing site and were waiting to move to the new premises), those patients who were seen in the clinic at present did not have to wait so long to be seen because of the additional personnel available.

More widely there were felt to have been benefits for referrers with a more responsive service and better access. There were also thought to be benefits arising from the improved relationship with a number of areas, primarily the emergency department, GI practice, ultrasound, breast and neurological (because of the CT reporting). In ED, as was reported earlier, the consultant radiographer had worked with colleagues to change and improve patient pathways. A large part of these improvements had arisen from their being able to offer immediate reporting – delays in reporting had been a particular weakness previously.

Introduction of the advanced and assistant practitioners in imaging services meant that virtually all patients were now being imaged within two weeks. On a typical day the department conducts a thousand examinations with around half being radiographic and the other half requiring more complex imaging. Looking at the extent of change by modality, radiology is the area in which radiographers have had the biggest single impact by their contribution to reporting. Virtually all images were being reported within five days.

While there had been improvements to capacity arising from introduction of the ED consultant post, the increase in capacity did not relate to the imaging service more generally but to ED itself and, indirectly, with other hospital departments (eg through the new referral processes). Introduction of the consultant had helped the service meet the four hour target. In terms of actual throughput of patients, there was negligible impact because by nature of its role an ED department sees everybody presenting on a day. However, in a report published in 2004c on the impact of this site’s introduction of the ED consultant post, it was reported that journey times through the ED had been cut (although no data/figures were provided) while ED recalls because of misinterpretation had decreased by approximately 50 per cent.

A complication in demonstrating the cost benefits of introduction of such roles is that they do not occur in a vacuum; neither does the department remain unchanged around the new posts. One of the consultant radiographers stated:

‘’It’s very difficult [trying to] tie it down to [the impact of] one person because it’s more that it’s been a gradual change, although some have been quicker than others. It’s very difficult to pin down specific cost-benefits. I’ve looked to see if historically we can and it’s very difficult to say ‘we saved that money’….[and there is] research income both in terms of through backfill or additional money.  The secondments of the two trainee consultants are being funded out of backfill research money, which in turn is funded by a backfill component of a DH research grant that funds my time. And the best way for them to backfill me is for other people to take on some of the strategic things that I do.’’

The research is conducted through patient recruitment to trials, so that brings in direct organisational income and although this does not necessarily come in to radiology it is one of the areas where the money can be positively identified. Some of the cost savings may arise through release of workforce (primarily the more expensive radiologists). But this can be difficult to estimate in the ED. Looking at reporting, cost-benefits may centre on the fact that the trust is are gaining more complex work from radiographers than they had been previously, so that is more about value for money than savings per se.

The trust had not attempted to calculate the savings made, or other cost-benefits (e.g as in value for money) arising from the changes made.

Monitoring the service

The department had developed a report tracker and that allows the managers to see activity levels for all the modalities of reporting. They monitored and had graphs giving historical data on total activity, but had now moved to this system which allowed active management of each individual modality. In general their level of activity had grown by 5 - 8 per cent each year for the last 8 – 10 years, with faster growth in areas such as MR and CT but this was not entirely attributable to the introduction of the new posts. Performance data are reported to the SHA and at national level and the Service Board receives a report internally. Figures are recorded internally for the number of complaints, but these are not recorded against individual members of staff.

A record of the number of reports that are made is compiled every month, categorised by reporter and an annual report is produced. While it would be possible to calculate an overall departmental report rate before and after the introduction of these posts, this had not been done.

Consultant costs

Overall, the main costs in introducing the consultant posts had been their salary plus the cost of training (for those who had come through the trainee consultant route). Very little cost was involved. This was partly because they had vacancies at the time. For the ED consultant, the only cost was advertising and selection, plus the cost of the upgrade of the appointee’s post to 8b. If the selection process had resulted in an external recruitment, then the trust would have used money saved from existing vacancies. The trust will not allow departments to advertise a job unless they have the money available to recruit to it. Funding for the first consultant posts came from money that had originally been intended for radiologists. In addition, they had not directly replaced the post of the radiographer that was upgraded to consultant. The same situation pertained when they appointed the consultant radiographer for the breast service. However, interviewees – including one of the radiologists - were keen to emphasise that the developments had not been planned and had not been intended as a way of getting ‘a radiologist on the cheap’:

“They [consultant radiographers] can hold their own with any consultant radiologist quite happily and should be allowed to. They are not a replacement or a threat but a…just another colleague. I wouldn’t want trust finance people to see it as a radiologist on the cheap.”

Part of the training process requires the trainee consultant to justify their employment by demonstrating cost-efficiencies. The interviewee who had been through the consultant training process had identified new funding streams as part of the training and had looked at the current systems and how these could be made more efficient. In addition, by enabling double reporting, introduction of the consultant radiographers has reduced the chance of litigation; this may feed through into cost savings.

Succession planning

The trust does not have a succession plan as such but is trying to develop more of these specialist roles and to grow the service. Another person in a similar role to the clinical specialist had now become a trainee consultant. Regarding succession planning in ultrasound and breast imaging they had a clinical specialist team that works alongside the consultant, so in terms of succession planning they would expect someone from that cohort of people to be appropriate for development.

By the time that the current two trainee consultants finish their training, the department aims to be considering their next steps: whether to look at recruiting two more trainees in other areas, that’s for discussion. Although they recognised that finances were likely to be challenging in the future, they did not anticipate remaining with just five consultants in post. Increasing the number of consultant radiographers was part of their substantive workforce plan at the time of the interview.

Whilst costs were not seen as a real constraint on developing the consultant radiographer posts, one limitation however is finding the time to provide the training and mentoring needed. With limited numbers and limited staff, it is difficult for the radiologists to spare the time to train up consultant radiographers because of the lack of available time in the working day. This could constitute a barrier to the introduction of further posts.

 

a. A four-hour target in emergency departments was introduced by the Department of Health for National Health Service acute hospitals in England that required trusts to ensure that, by 2004, at least 98% of patients attending an A&E department must be seen, treated, admitted or discharged in under four hours.

b. Trainee consultants for GI and fluoroscopy were subsequently appointed following the original case study interviews.

c. NHS Modernisation Agency (2004) Radiology: Supporting the Delivery of Emergency Care

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