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Results, discussion and conclusions

Interviews were conducted at two sites at which the CPF had been introduced. They explored the background to introduction of the CPF, the way in which the roles had been introduced and the outcomes of these changes. The main points emerging from the interviews are summarised below.

The benefits

  • Overall benefits. Benefits had been observed at both case study sites and no negative impacts were reported.
  • Increased capacity and patient throughput. The changes brought about by introduction of the CPF, and in particular the consultant and advanced practitioner posts, had facilitated an increase in throughput of patients. 
  • Improved use of medical staff time.  There was evidence that the introduction of the consultant and advanced practitioner posts had led to radiologists’ time and effort being used to greater effect. 
  • Interprofessional working. Inter-professional working had been improved, leading to service improvements.
  • Cost containment.  Where the consultant radiographer role had been introduced in place of a radiologist, the service expansion had been achieved at less cost than if a consultant radiologist had been appointed.
  • Improved teamworking. Introduction of the consultant radiographer posts had had a beneficial impact on teamworking, both within the imaging service and across departments/professions.
  • Improved departmental performance. Departmental performance had improved at both case study sites following introduction of the consultant radiographer posts. The consultant radiographers had been instrumental in redesigning patient pathways and services.
  • Increased flexibility. Introduction of the consultant posts had led to more flexibility in responding to patients. More clinics were scheduled and appointments could be offered at a wider and more convenient range of times for patients.
  • More fulfilled staff. Introduction of the CPF had led to more fulfilled staff at all levels, with radiographers being able to utilise their full range of skills to the benefit of the patients.
  • No change in errors or complaints. No increase in errors or complaints had been experienced since introduction of the consultant posts and their introduction had allowed service ‘gold standards’ for double reporting to be achieved.

Issues

  • Energy and effort. Introduction of the consultant posts takes a lot of time and effort.
  • Ad hoc nature of developments. Introduction and design of the consultant posts was an ad hoc process, driven either opportunistically, through highly talented and individuals being in post and driving the development and approval process; or through service need, where the consultant grade is introduced in an attempt to resolve a service difficulty.

In the following sections issues identified in the case studies are explored.

A strong rationale and business case

Each trust viewed the adoption of the CPF as a means of modernising service development and bringing about change to meet service needs.  The need for careful planning was evident at both sites but the development of a strong rationale and business case had been more dominant in Case Study 1. As part of that strategy it had been seen as essential to gain the support of key people from the directorate management team and clinicians outside radiology who would be using the service. 

In Case Study 2, leading change was viewed as the most important aspect of the rationale. Here, introduction of the consultant posts appeared to have been more of a ‘natural progression' from the situation that had already been established: there had been a clinical specialist in the department since 2002. The consultant role was seen (at least in part) as developing from that and building on the existing strengths within the department and allowing additional talent to be recruited. Nonetheless, approval at Strategic Health Authority (SHA) level had been sought and gained prior to introduction of the posts.

The way in which developments unfold may therefore impact on the extent to which a business case needs to be developed over and above a service rationale. The situation itself may also influence the ultimate decision: in one site, failure to recruit a radiologist (and recognition that difficulties in recruitment of radiologists were likely to continue in future) was a factor leading to the decision to plan these changes.

It should be noted, though, that awareness of changes that had been introduced at other sites was influential in local decision-making in both these cases. Therefore, any additional publicity that the SCoR can give to sites at which the CPF has been introduced and where service outcomes/benefits have improved would provide useful supporting evidence for departments seeking to make similar changes in future.

Similarly, while a strong business case may be less of an imperative at some sites than others, any further evidence of potential cost savings that can be provided may be of value to departments considering implementing one or more consultant posts and the four tier career progression framework.  However, we acknowledge the current challenges in providing data on cost-savings and return to this point later in this chapter.

Service benefits and improvements

In each of the case studies those interviewed were convinced of the benefits accrued and the improvements in service delivery that have resulted. Although it is true to say that robust data on the adoption of the CPF were not collected per se (as data related to the performance of the departments as a whole), in each case targets were being met and there were accounts of service improvement.

In one of the case studies the number of examination appointments for mammography had been increased following introduction of additional clinics after the consultant appointment was appointed.  Attainment of the ‘gold standard’ of double reporting of mammograms and hot reporting of radiographic images had also been achieved at that site.

Interviewees were also convinced of the service benefits arising from introduction of lower grades within the CPF. Introduction of the assistant practitioner role had significantly freed up the time of more senior staff and aided capacity/throughput of patients. Together with the advanced practice and consultant radiographer roles, introduction of these posts can significantly free up radiologist time and/or increase clinic capacity and flexibility.

While these aspects of the consultant role can be directly linked to improvements in patient care, there had also been indirect benefits, through the contributions made by consultants to professional leadership, management of staff development and clinical governance.

Interviewees were persuaded of the service benefits and improvements but did not necessarily have access to robust relevant data.  While the objective costs and benefits were difficult to ascertain clearly, interviewees pointed to a range of clinical and non-clinical benefits including:

  • flexible, patient centred GI service and breast service and improved patient pathways
  • greater clinical capacity
  • robust clinical governance
  • service improvement programme leadership.

In addition, at one site there had been introduction of induction and preceptorship programmes together with work experience and increased engagement with local schools.

Cost Savings

It was difficult for interviewees to identify any direct cost savings except for reduced salary costs. Where the consultant radiographer had been appointed instead of a consultant radiologist, there were readily identifiable cost savings arising from the difference between an AfC Band 8b salary and a medical consultant’s salary. 

However, the broad view was that the main focus had not been on saving salary costs but on service improvement. While interviewees could point to savings and cost efficiencies they had not costed these benefits. The data to support such calculations appeared difficult for departments to isolate from overall statistics. 

In the longer term, cost-efficiencies may prove more relevant within the NHS setting than savings. For example, changed work arrangements that meant that individuals were working all of the time at the appropriate level for their salary, rather than just part of the time, may lead to sustained improvements in value for money, while hypothetical savings to expenditure may disappear if NHS budgets are cut across the board.

However it should be borne in mind that improvement to clinical governance and enablement of the double reporting ‘gold standard’ potentially could lead to additional savings in the long term, for example, from reduced risks of litigation.

Calculating cost benefits

While sites believed there were benefits, they had not attempted to calculate the direct cost benefits; furthermore they felt that there could be problems with making these calculations. At one site, it was believed that because the department had not only introduced the posts but had also re-configured the working arrangements and work practices (both initially and once the consultant had taken a lead on service development) this meant that it was not possible to calculate the cost benefits associated with introducing the posts because of the extent of change.

However, given that first, it is inevitable that an organisation will have to change its practices to accommodate new roles, and second, the intention in introducing these posts is to bring about change to service delivery, then organisational change should not really constitute a barrier to calculating cost-benefits. A rough estimate could be obtained by considering total imaging department income divided by imaging/interventional events (although this would not be appropriate where an individual is employed in one department but performs their duties in another, as in the Emergency Department scenario). It should be possible to collect and compare departmental operational and performance data for a period preceding introduction and for an equivalent period following implementation and then to calculate:

Mean of ∑ examinations and/or interventional processes
Mean of ∑ all staff plus operational costs

Operational costs would include recruitment, training and development costs for the period across which the costs and events are being summed and averaged.

This would provide an average cost per imaging event. If the proportion of examinations or modalities or interventional processes used shifted significantly during that time, some correction would need to be made for this.

If there is a benefit, then we would expect to see either an increase in the number of imaging events for the same total envelope of funding or reduced funding producing the same or greater number of events.

There was a feeling that issues around funding ‘following the patient’ had not been sufficiently resolved to allow throughput of patients to be incorporated into calculations yet, but this will presumably be more feasible in future. At that point, issues of greater throughput, brought about by the operation of parallel clinics, or shorter waiting times, will start to play a part in the cost-benefit analyses.

A full health economics benefit would of course take into account far more sophisticated calculations than these. The total cost per patient per procedure for the different types of skill-mix team before and after the changes, could be attempted, but again, we would point to the difficulties that departments appear to have in identifying and collating the relevant data. Future analyses are likely to include the value to the patient of faster diagnosis and treatment. However, it was not our aim to provide a detailed cost-benefit analysis in health economic terms in this preliminary study.

Conclusions

This small-scale pilot study has pointed to many benefits arising from implementation of the Career Progression Framework. There were no reports of negative outcomes for patients, and many apparent benefits.

On the basis of this work we make the following recommendations to the SCoR:

  • information on precedents in establishing consultant posts is clearly useful to sites considering making an application to introduce this role and/or the CPF. It would be helpful if the SCoR could undertake further case studies of the ways in which sites have introduced the CPF to promote more widely the evidence for the improvements in practice that can result.  The resulting case studies should be publicised via the SCoR website.
  • departments have not tried to undertake cost benefit analyses of the changes they have made.  In addition, they appear to have difficulty in understanding the types of data that could be used and the calculations that could be made. Given the continuing difficulty in obtaining consistent data across sites to support economic or cost-benefit analyses of introduction of these posts, we suggest that the SCoR produces a set of guidelines advising department managers on how to undertake a basic cost-benefit assessment.
  • evidence points to improvements in both service delivery and clinical governance at sites where the consultant posts have been introduced.  Subsequent to the work, questions have been asked about patient safety where radiographers undertake extended role tasks4.  Although safety was not an issue raised in either of the case studies we recommend that the SCOR considers auditing safety records at sites with consultants and the CPF in place and at comparison sites where these posts/this framework are not in place, to determine whether there is any real evidence for either a) safety concerns at sites with consultant and advanced grade posts in place; or b) improvements in safety and governance at sites where consultant radiographers lead the service.
  • the SCoR should develop guidance for departments to help them identify individuals suitable for development as trainees/consultants and identify education programmes appropriate as development routes to consultant positions.

 

 

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