Background

The Oncology Centre at Addenbrooke’s Hospital, Cambridge, serves a population of 1.5 million. In 2000, like most other Radiotherapy and Oncology Departments across the UK, the Centre was experiencing a serious radiography staffing shortage. A vacancy rate of 27% contributed to a 15-week wait for treatment in the department which had 4 Linear Accelerators (Linacs) at the time with New Opportunities Funding (NOF) for 2 more. The staffing situation at that time compared with subsequent years following service and role re-design undertaken during the period 2000–2006 is outlined in Figure 1. There was one Gynaecological Oncology Specialist Radiographer supporting Gynaecological patients along the radiotherapy treatment pathway. This was considered particularly important following introduction of the use of dilators. The post developed later into the new role of Gynaecological Oncology Advanced Therapy Radiographer Practitioner.

By 2006 the additional Linacs had been installed. Following implementation of new roles, and in particular Advanced and Consultant Radiotherapy Practitioners, the Centre treated 4000 new cases with 40,000 patient attendances per annum. It was fully staffed and had no waiting list.

Currently (2009) the Centre receives approximately 4,500 new patient referrals a year with fractionations increased to 52,500 per annum. Equipment has been increased and stands at:

8 Linacs including 2 with TomoTherapy;
HDR/Pantak;
2 x CT Simulators (ProSoma)

Staffing has changed as indicated in the following table (Figure 1). One additional Consultant Practitioner has been appointed. WTE Radiographers have increased but Assistant Practitioners have decreased as a result of attrition. There are no staffing vacancies and, most importantly, the Centre is meeting the current cancer targets.
 

 Figure 1: Staffing

The Centre implemented all four levels of the 4-tier career structure following its acceptance as one of the nine national pilot sites for the New Ways of Working in Radiotherapy project funded by the Department of Health. All levels of the career escalator are supported by the Knowledge and Skills
Framework (KSF) and the occupational standards for radiotherapy developed by Skills for Health with appropriate professional involvement.

The process of implementation in the Trust is outlined below with emphasis on the Advanced Practitioner in particular and to a lesser extent the Consultant Practitioner role. However, since these cannot be entirely separated out from the Assistant Practitioner and Therapeutic Radiographer Practitioner the process in relation to each of these is outlined briefly also.

Assistant Practitioners

The Oncology Centre determined initially that for each piece of equipment one qualified Assistant Practitioner was required and thus future training requirements would be determined by purchase of new as opposed to replacement units and natural wastage. However, subsequently there were insufficient qualified Assistant Practitioners but graduate radiographers available and it was decided to use the departmental funding required for the 2-year training period for a radiographer appointment instead.

One possible element of natural wastage was identified as progression of an Assistant Practitioner to training as a Radiographer and several have taken this route. Currently all trainee Assistants undertake the Foundation Degree for which the core work-based education and training is completed in the pre-treatment and treatment delivery areas. The Foundation Degree, with appropriate academic bridging, can provide access to the undergraduate programme leading to qualification as a Radiographer. However, the qualified Assistant Practitioner builds an individual portfolio of competencies, determined by the service need and the individual’s requirements (e.g. run up, HDR/Superficial Units outside original scope of practice and weekly checks) which can lead to work in other areas. For example a role for the qualified Assistant Practitioner has been identified in support of the Advanced Practitioner role in specialist areas such as Head & Neck pathway coordination.

Therapeutic Radiographer practitioners

The CoR in the Strategy for the Education and Professional Development of Therapeutic Radiographers(1) included newly registered practitioners, post preceptorship practitioners and established registered practitioners within the ‘Practitioner’ tier, the only division being the preceptorship period which

“… will end when the practitioner and manager agree that goals have been attained. This whole process will be incorporated into the performance management systems already in place.”

This was addressed within the New Ways of Working pilot through development of a preceptorship model that was successfully implemented in all nine pilot sites. The Oncology Centre continues to use this model which forms part of the progression framework from new graduate to senior practitioner.

Progression through Preceptorship

Newly graduated therapeutic radiographers employed by the Oncology Centre enter the objectivesbased preceptorship programme developed by the New Ways of Working in Radiotherapy pilot. A minimum of one year is spent in preceptorship. During this period the radiographer, supported by a nominated preceptor, is expected to meet the objectives set out in the programme and to maintain a portfolio of clinical and professional development evidence. The portfolio is assessed to determine suitability for progression once the radiographer and their preceptor are satisfied that the objectives have been achieved.

Progression Route

New graduate

1. minimum 1 year preceptorship
2. preceptor and radiographer satisfied objectives achieved
3. eligible for grading to Senior 2 Band 6, providing required competencies achieved and responsibilities and requirements set out in Senior 2 Job Description and Person Specification are met.

Progression to Senior 2/AfC Foundation Point
1) evidence gathered – portfolio of clinical and professional development including evidence
of:

• Critical evaluation of their practice;
• Understanding of the Oncology Centre Policies, Procedures and Quality Assurance System ;
• Working area competencies met (see Appendix 2 for an example)
• Competency self evaluation;
• Attendance at practice development reviews;
• Continuing professional development;
• KSF requirements met.

2) The following supporting documentation collated:  

3) Portfolio and supporting documentation submitted to Head of Radiotherapy.

4) Panel (Head of Radiotherapy, operations superintendent and a senior radiographer) consider portfolio to assess ability to work as Senior 2.

5) Interview 2 weeks following submission of portfolio (Head of Radiotherapy and the clinical floor manager). Radiographer informed of outcome:

• Evidence supports application for upgrading to Senior 2; or
• Further evidence required to demonstrate ability to work as Senior 2. Support given to help meet the objectives and radiographer can apply once objectives met.

6) Appeals procedure: if the radiographer fails to meet the preceptorship or progression to Senior 2 objectives and disagrees with the outcome s/he follows the Trust grievance procedure.

Senior Practitioner – Senior 1 Band 7

1) Radiographers given support to identify areas of development through the annual Trust Appraisal Development and Review process.
2) Acknowledgement that not all radiographers will, or wish to, progress to advanced and consultant levels of practice. However, all maintain competence and undertake continuing professional development (CPD).
3) Staff wishing to pursue the continuing education and professional development required to prepare for Advanced Practitioner posts are supported but with recognition that not all radiographers wishing to become Advanced Practitioners may be able to achieve this at Addenbrooke’s - dependent on the availability of appropriate posts.

Implementing advanced and consultant practice roles

Service need identified

The radiotherapy process was mapped and the current staff step identified (Figure 2).

Click to enlarge.

Figure 2: Radiotherapy Process Map

Oncologists were identified as the predominantly occurring group. With patient numbers increasing and a shortfall of both trained oncologists and medical physicists, identification of areas of work requiring higher level skills but which could be undertaken by other groups was identified as the most appropriate way forward.

Although the skils mix approach was used to address waiting time targets other measures were also introduced, including:

• extended hours working
• expansion of the administrative and clerical support for the management of appointments; and
• establishment of planning and review clinic teams

Reviewing the Patient Pathway and Radiotherapy Process two broad areas of expert practice were identified as ways of improving efficiency within the pathway as well as improving patient experience and contributing to technical innovation:

1. cancer site expert practice
2. technical expert practice

Figure 3 illustrates the contributions of the cancer site 'Expert Practitioner' within the prostate patient pathway while Figure 4 demonstrates, within the 'Review' element of Image Guided Radiotherapy (IGRT), one area for future development of participation in the radiotherapy process by the technical Expert practitioner.

Click to enlarge.

Figure 3: Prostate Cancer Pathway

Figure 4: IGRT Process Map

Following this review of the Patient Pathway and Radiotherapy Process the role of the expert practitioner at advanced and consultant level was clarified.

Clarifying the Role.

It was important to be clear that re-designing the way the service was delivered and the development of new roles was not simply a matter of re-naming roles which already existed or, at the other extreme, a matter of "out with the old and in with the new". Rather "advanced practice" was defined in terms of level of responsibility arising from autonomous, evidence-based practice where the individual, working within local and national guidelines:

a. has an 'expert practice' function providing either techinical or cancer site specific expert knowledge and practice;
b. provides professional leadership and consultancy;
c. undertakes an education and training role;
d. develops practice and the service;
e. undertakes research and evaluation.

Listed below are some of the factors taken into account when considering technical and cancer site specific expert practice generally while Figure 5 provides a summary of the role identified for an Advanced Practitioner in Thoracic Radiotherapy as a specific example.

 Figure 5: Role summary - Advanced Practitioner in Thoracic Radiotherapy

In addition generic skills, knowledge and competences at expert practice levels include:

• management and leadership skills;
• clinical governance;
• interpersonal skills;
• research and audit;
• advanced communication skills.

Having identified the need and clarified roles a ‘Case of Need’ for Advanced Practitioner posts, prepared in close collaboration with the multi-disciplinary team, was submitted to the Trust. This included an indication of the impact on service delivery and development as well as on the patient experience. The submission for approval of Consultant posts was prepared in a similar way for submission to the SHA within the guidelines for AHP Consultant posts issued by the DH in Advance Letter PAM(PTA) 2/2001. Copy of a submission made for a Consultant post is included as an example in Appendix 3.

Advanced Therapy Practitioner in Radiotherapy

Advanced Practitioner posts were funded from internal re-distribution of the allocated budget on the basis of a review of the skill mix required to deliver the re-designed service.

There was one Gynaecological Oncology Specialist Radiographer post in 2000. This role was introduced to support Gynaecological patients along the radiotherapy treatment pathway having been considered particularly important following introduction of the use of dilators. The post was expanded later, with an academic framework, to allow inclusion of the consenting of patients, on treatment review and treatment using the HDR (High Dose Rate Brachytherapy) Unit to provide the new role of Gynaecological Oncology Advanced Therapy Radiographer Practitioner.

Further posts have been established now in the following areas:

• Head & Neck;
• Urology;
• Breast;
• Pre-treatment;
• Image Guided Radiotherapy (IGRT); and
• Research.

Consultant Practitioner

The number of Consultant Practitioners is determined by service requirements and the funding available. Two Consultant Practitioners are now in post – one in Gynaecological Oncology and the other in Neuro-oncology.

Job Evaluation and Pay Structure

Job Descriptions were evaluated and pay banding determined accordingly. Examples of Job Descriptions and Person Specifications for both an Advanced and a Consultant Practitioner are appended (Appendices 4 and 5 respectively). Grading and pay band is determined by the experience within the field of expert practice as indicated in the table in Figure 6. However, identifying initial funding for each post at the level of 8a has been found helpful because the possibility of progression is then built in without requiring identification of additional funding.

Figure 6: Expert Practitioner Banding

Education and Training Framework

Expert practice as either an Advanced or Consultant Practitioner is diverse and thus the education and development needs of individuals is also varied and dependent on previous experience and academic development, as well as the specific roles and responsibilities required for service development. For example, MSc modules such as On Treatment Review, Patient Consent, Advanced Practice, Pharmacology and Palliative Care have all been accessed.

An education package designed to provide evidence of both academic skills and expert practice at Masters level was developed in collaboration with a Higher Education Institution (HEI). Close partnership with the whole multi-professional team was fundamental in designing a tool to assess and provide evidence of expert practice. The tool was then validated by a panel from the HEI. An essential component of the tool is a viva assessing the demonstration of autonomy and clinical reasoning.

Multi -Professional Agreement

Radiographers within the Centre were keen to be recognised as working at an expert level after some early reservations were addressed through a series of team meetings. The Multi-disciplinary Teams (MDTs) were key in the development of the initial proposal, including role specifications, approval for practice and the subsequent requirements for the full consenting of patients by the ‘Expert Practitioner’. The proposal was then submitted for agreement by the multi-professional Radiotherapy Standards Group, which has responsibility for governance issues, (an example of the form used to record all activity of the Group is included as Figure 7).

Figure 7: Radiotherapy Standards Group Activity Record

The issue of informed consent was an important one and all of the following were taken into account:

• General Medical Council guidelines (Seeking patients’ consent: the ethical considerations who obtains consent 19
• DH guidelines (Good practice in consent implementation guide)(20);
• Trust Policy and Procedures e.g. BSI ISO 9001 2000, requiring the monitoring of training records to support expert practice and that policies and procedures for clinical work are defined;
• Expert practitioners required to undertake consent for identified groups of patients following appropriate education training and experience (see Figure 8, for an excerpt from the approval document submitted to the Trust);
• The definition of roles under IR(ME)R (Assistants as operators; Advanced practitioners and Consultants as referrers);
• The need for compliance with professional guidance and codes of conduct.

Figure 8: Submission for Trust Approval of Consent Proposal

Trust Agreement

Trust agreement to the proposal that Advanced or Consultant Practitioners obtain fully informed patient consent was gained. Agreement followed submission of: the Advanced Practice Framework;

the educational requirements specified in the extract in Figure 8; competencies identified;
and the training programme established with the agreement of the Standards Group.

Appointment process

Normal appointment procedures are followed with a panel comprising:

• Head of Radiotherapy
• Clinical Oncologist in related area
• Representative from HR
• External Assessor

Applicants for Advanced Practice or Consultant posts are required to produce a portfolio of evidence of expert practice which is assessed against the KSF to determine the Band at which they are appointed (see Figure 6). Applicants with more limited experience at this level may be appointed as a Novice so that they can begin to develop a portfolio of expert practice which will be assessed as above at the appropriate time. A novice is supported in the initial period by an experienced advanced practitioner who acts as a preceptor for a period agreed between them. A similar approach is taken where a practitioner recruited to a Consultant post has the advanced knowledge and skills required to function at this level but may not have developed the clinical expertise in a specific area to the required level.

Assessment of Expert Practice

Expert practice is assessed against the relevant criteria outlined in the CoR document Education and Professional Development: Moving Ahead 19 on the basis of the following evidence provided by the Advanced or Consultant Practitioner:

• Portfolio of evidence-based learning and reflection at MSc level;
• Relevant courses related to Knowledge Specification for area of practice;
• Viva with consultant and peer review of practice yearly with medical staff. 

Appraisal, Clinical Supervision and Continual Assessment of Advanced/Consultant Practice

Clinical supervision for the Advanced or Consultant Practitioner is provided by the relevant clinical or technical expert in the area of practice which if:

• Site specific is generally a Clinical Oncologist ; and
• Technical, such as treatment planning, may be a Clinical Oncologist or Physicist.

Practice is continually assessed and reviewed through the Appraisal process. Appraisal interviews
are carried out jointly by the Professional Head of Service and the relevant member(s) of the multidisciplinary
team (MDT) with consideration given to:

• Agenda for Change and the relevant KSF;
• SCoR accreditation;
• Portfolio of evidence of expert practice supported by competency assessment (details in Appendix 6). A summary of the general framework for staff development and review is included at Appendix 7 for information but the frequency of Appraisal specifically for the Advanced and Consultant posts is indicated in Figure 9 below:

Figure 9: Appraisal Frequency

An informal Advanced Practitioner and Specialist Radiographer Forum provides an additional peer support network for advanced practitioners and those radiographers undertaking roles outside pretreatment or treatment delivery. This has been particularly useful during the development of new roles because possible areas of over-lap can be identified and addressed and best practice shared or established.

Managing Advanced and Consultant Practitioners

Issues are often raised with respect to line management of an individual who may well be on a pay scale higher than the Professional Head of Service. This can be addressed by clarifying two areas of responsibility when it comes to the Appraisal and Development Review and objective-setting:

• Professional issues - Professional Head of Service has responsibility e.g. for: CPD support; working arrangements; and governance.
• Clinical objectives and clinical competencies - responsibility dependent on area of practice

What has implementing advanced and consultant practice roles achieved?

1. Is it cost effective? The cost per patient is low but it is difficult to assess currently whether or not that is totally attributable to introduction of the 4-tier career framework as no formal cost/benefit analysis has been undertaken.
2. Improved patient experience – positive survey results indicating that patient satisfaction is high.
3. Improved access to health care professionals.
4. A reduction in admissions of patients with post radiotherapy complications has followed from implementation of: (a) the AHP Head and Neck clinic (no medical staff involvement) led by an Advanced Therapy practitioner and including dieticians and Speech and Language Therapists; and (b) Therapy Radiographer Practitioners reviewing the care pathway on the ward.
5. Improved implementation of new technologies.
6. Having a dedicated lead role reduces the pressure on the remainder of the Department by providing a single point of contact.
7. Greater consistency with respect to staff seeing a particular patient.
8. Improvement in meeting cancer targets – now 100% - through better co-ordination of pathway.
9. Fully staffed because of improved recruitment and retention as current staff and potential recruits recognise the value of the career development opportunities.

What still needs to happen to fully implement the career framework?

Funding remains a significant issue and in particular the funding and process for commissioning Assistant Practitioner training. Although funding for Advanced and Consultant Practitioners is based on service re-design and role development, some is derived through clinic activity with funding through PCTs.

Recognition of the basic requirement for support by medical colleagues at a local level for implementation of these developments is essential as review of current roles and development of new ones continues.

Any barriers to implementation of the career framework need to be addressed so that it can be used to facilitate the continued improvement in the quality and cost-effectiveness of patient care.