This document was archived on 4th December 2018. Advice on independent practice can be found at https://www.sor.org/sites/default/files/document-versions/scor_bmus_guidelines_final.pdf Section 1.21.
There is also information at https://www.sor.org/career-progression/independent-practitioners/independent-practice-and-independent-practitioners
The term Independent Practitioner encompasses all those members of SCoR who are healthcare practitioners (whether registered with a regulatory body or not) and who are not directly classed as employees. They provide services to Healthcare Commissioners, Trusts and Health Boards, corporate medical companies and, in some cases, directly to members of the public who may self-refer. These services include diagnostic imaging, screening, Dual Energy X-Ray Absorptiometry (DEXA), therapy and education. Independent practitioner members may, for example, be self-employed, partners, company directors, franchisors or franchisees. The SCoR supports the role of the independent practitioner and recognises the need for policies to enable them to provide highly professional standards of care. This document provides guidelines for professional practice for members who are working within the definition stated above; it does not directly apply to employees of independent providers.
1.1 The term Independent Practitioner encompasses all those members of The Society and College of Radiographers (SCoR) who are healthcare practitioners (whether registered with a regulatory body or not) and who are not directly classed as employees. They provide services to Healthcare Commissioners, Trusts and Health Boards, corporate medical companies and, in some cases, directly to members of the public who may self-refer. These services include diagnostic imaging, screening, Dual Energy X-Ray Absorptiometry (DEXA), therapy and education. Independent practitioner members may, for example, be self-employed, partners, company directors, franchisors or franchisees.
1.2 There is increasing demand on diagnostic imaging and therapy services to meet the requirements of the various national screening programmes, local and national targets for diagnosis and treatment as well as new initiatives on early cancer diagnosis. Following implementation of the coalition government’s Health and Social Care Act (2012),1 General Practitioners (GPs) have a leading role in commissioning services in England which can include provision by ‘Any Qualified Provider’ (AQP). This has accentuated the need for alternative high quality specialist services providing services to the NHS who may also be able to offer provision closer to where people live. The SCoR has published jointly with the Royal College of Radiologists and the Royal College of General Practitioners a good practice guide for delivering services in primary care.2
1.3 The SCoR supports the role of the independent practitioner and recognises the need for policies to enable them to provide highly professional standards of care. This document provides guidelines for professional practice for members who are working within the definition stated above; it does not directly apply to employees of independent providers.
1.4 Following the publication of the ‘Francis’ report into the Mid-Staffordshire NHS Foundation Trust failings, it is essential that all members, whether working independently or not, are aware of their responsibilities in ensuring that poor standards of care that they may encounter are addressed. It is the professional responsibility of every member to take action where there is concern or, indeed, evidence of unacceptable or substandard care. The SCoR response to the ‘Francis’ report can be found at https://www.sor.org/news/scor-publishes-response-francis-report
1.5 This document does not advise on legal and internal revenue matters for independent practice, or on the setting up of private companies. Additional advice on these matters should be sought from appropriate sources.
1.6 At the 2013 Annual Delegates Conference motion No. 49 3 was passed that tasked UK Council with publishing guidance on maximising opportunities for radiographers within GP commissioning and service provision, and support members in identifying how to plan for their futures, including access to information and support on the impact on their NHS pension. Council has as a result published information and guidance which can be accessed via https://www.sor.org/career-progression/independent-practitioners. Independent practitioners as well as those considering setting themselves up as independent practitioners are advised to read the information and guidance provided.
1.7 There can be frequent changes affecting Independent Practice and practitioners are advised to ensure that they regularly monitor websites such as those run by the Care Quality Commission (CQC) and local and national commissioning organisations in particular. It can be helpful to receive RSS feeds if these are available and to sign up for any electronic information or newsletters those individual organisations may produce. It is the intention of the Department of Health that central support for the AQP commissioning process in England will cease in 2014 and be transferred to local commissioners and commissioning support units. The SCoR maintains an informal e-list of independent practitioner members that it is possible to join by contacting the Professional Support team via www.sor.org/contact-us. Joining will help the SCoR identify members practising independently and can be used to disseminate information between group members and from and to the SCoR.
Independent Practitioners are encouraged to have their services independently assessed by the United Kingdom Accreditation Service (UKAS) against the Imaging Services Accreditation Standard (ISAS), jointly established by the Royal College of Radiologists and the College of Radiographers. ISAS covers all the guidance and standards set out in this document and provides strong and independent confirmation that high quality services are being delivered. Details on ISAS and how to apply can be obtained from http://www.isas-uk.org/
3.1 The aim of an independent service is to provide both the patient and the client (clinician, commissioner or purchaser) with a high quality of service. The service must ensure safe and effective patient care which complies with relevant statutory instruments and clinical governance policies. Of particular relevance are current regulations and advice controlling the use of ionising and other radiations and registration with the Care Quality Commission in England, or, if applicable, its equivalent in Scotland, Wales and Northern Ireland.
3.2 Independent practitioners practice in a number of settings ranging across NHS Trusts, Health Boards, local communities and the private sector. Clinical governance will play a key role and places particular emphasis on lifelong learning, professional self-regulation, and the setting, delivering and monitoring of standards. The Ionising Radiations Regulations 1999 (IRR99)4 and the Ionising Radiation (Medical Exposure) Regulations and amendments 2005,5 20066 and 20117 will also impact significantly on practice and procedures for ensuring safety. There are fully discussed in SCoR documents relating to radiation protection. 8, 9
3.3 It is in the interest of patients, commissioners and professional staff that the service is of the highest quality. Individual independent practitioners have an over-riding duty to their patients to have due regard to their professional code of conduct in their practice and it is vital that an independent practitioner is not compromised in his/her professional role when dealing with a patient. Indeed, independent practitioners must work within the statutory obligations placed on all healthcare professionals and it is no defence to claim that certain working practices remove professional responsibility from the individual. Independent practitioners must recognise and avoid conditions and practices that are inappropriate and ensure they develop and maintain high quality services at all times.
4.1 Independent practice may take any of the following forms:
4.2 Members are advised to seek advice from appropriate sources as to which model is suitable for their own particular practice. Further information on business models can be found at www.businesslink.gov.uk. This site is large and the ‘starting up’ page may be of particular help to those new to independent practice.
5.1 This document should be read in conjunction with the following documents:
Together, these documents set out the underpinning values and principles required to promote, maintain and disseminate the highest standards of professionalism including responsibility and accountability, thereby enhancing the good standing and reputation of the members of the SCoR.
All independent practitioners in England are at least potentially required to register with the Care Quality Commission (CQC).
The registration requirements do not apply to employees, only to the legal entity or organisation that is delivering a service or services. The ‘Scope of Registration’ can be found via the CQC website14 and should be read through carefully.
If you are in any doubt as to whether you will need to register, the SCoR advice is to contact the CQC as the onus is on the provider of services to register. There is, however, a very wide variety of ways in which services are delivered by providers; the CQC may not be able to advise in advance as to whether registration is required in every case and may request that the application form is completed so that a full assessment can then be made.
The CQC has advised the SCoR that ‘keepsake’ or ‘souvenir scanning’ ultrasound providers in pregnancy do come within the ‘Scope of Registration’ under the Diagnostic and Screening category.15
Registration application forms are available from the Care Quality Commission. Contact details including e-mail enquiries and telephone advice numbers are available via the CQC website.
Please note that CQC registration applies to England only. There are equivalent bodies to the CQC in Scotland, Wales and Northern Ireland and members in the above countries are advised to make enquiries with them as to whether there are plans to register diagnostic, therapy or screening services as in England. The SCoRs understanding is that the CQC is the first health and social care services regulator to expand the scope of service provider regulation. Web links to the regulators in all four countries are below.
There may be cross border issues if practising in Scotland, Wales or Northern Ireland but also providing independent diagnostic, screening or therapy services in England. Advice should be sought from the CQC if you believe you fall into this category.
England: Care Quality Commission
Scotland: Healthcare Improvement Scotland
Wales: Health Inspectorate Wales
Northern Ireland: Regulatory and Quality Improvement Authority
It is proposed that in 2014 Monitor (England) will regulate independent providers of NHS funded services for the first time through the expansion of its licence provider regime. There are exemptions and a licence may not be required in all circumstances. Independent Providers are advised to confirm with local commissioners and with Monitor as required. Information can be obtained via the Monitor website.
Independent practitioners in England must meet the comprehensive requirements of the Fetal Anomaly Screening Programme (FASP) 16 when undertaking screening examinations that form part of the FASP remit. These are first trimester Down’s syndrome screening and the second trimester 18 weeks to 20 weeks 6 days fetal anomaly scan. There are equivalent organisations to FASP in Wales and Scotland. Web links to the various programmes are as follows:
England: http://fetalanomaly.screening.nhs.uk/
Scotland: http://www.nhsinform.co.uk/Screening
Wales: http://www.antenatalscreening.wales.nhs.uk/public/home
9.1 A healthcare professional such as a radiographer or sonographer, as with any professional person, is liable in common law for any injury caused to a patient or client through breach of contract and acts of wilful or professional negligence whilst carrying out his or her professional duties. This is in common with all persons who hold themselves, and the services they offer, out to the public as having special skills.
9.2 The above makes it imperative that all independent practitioners ensure that they are covered in terms of professional and vicarious liabilities and third party insurance.
9.3 The SCoR provides Professional Indemnity Insurance (PII) to its members but it is important that the advice is followed. Details are available from
http://www.sor.org/members/membershipcentre/profindemn.htm
From early 2014 it will be a legal requirement for all statutorily registered healthcare professionals to hold Professional Indemnity Insurance.17
It should be noted that the SCoR PII only covers individual members and not companies.
9.4 Independent practitioners will need to ensure that they are also covered for ‘third party’ liability, equipment damage or loss, transport of equipment and corporate insurance when running a company or business. Other forms of insurance to cover for personal illness or disability may also be advisable.
9.5 This document does not cover legal matters. Independent Practitioners are strongly advised to seek legal advice from appropriate sources to clarify the full extent of their own particular legal position and liabilities.
10.1 Independent practitioners are required under health and safety legislation to have a written operational policy which embraces all aspects of their work.
Suitable and sufficient risk assessments must be undertaken. The working environment must be safe and must comply with all statutory health and safety requirements under the Health and Safety at Work Act (1974),18 the Management of Health and Safety at Work Regulations (1999) 19 and the Ionising Radiation Regulations and amendments.5-9 The following section identifies areas that need to be covered.
10.2 All work must be monitored and verified in order to provide an efficient audit system.
10.3 A dose reduction policy, specifying appropriate mechanisms for ensuring that the dose to the patient is kept as low as reasonably achievable (ALARA principle), must be established when ionising radiation is being employed. Similarly with ultrasound, the British Medical Ultrasound Society safety statements should be followed: http://www.bmus.org/policies-guides/pg-safetystatements.asp
For magnetic resonance imaging (MRI) scans, independent practitioners should follow the advice given in the SCoR document entitled ‘Safety in Magnetic Resonance Imaging’ (2013).20
Supply, administration and prescribing of medicines (including contrast agents) must be done within the current legislation and reference should be made to published SCoR advice.21
10.4 Where independent practitioners have a direct role in the procedure, there should be a protocol for reporting and interpretation of images and a framework of supervision for advice and guidance.
10.5 There should be recognition of agreed referral sources.
10.6 Practice should be evidence-based.
10.7 There should be protocols concerning all aspects of health and safety for patients, staff and members of the public, including those pertaining to the safe use of ionising and non-ionising radiation to ensure personal safety.
10.8 There should be due regard to quality assurance including safety, inspection and testing of equipment and the appropriate quality assurance procedures.
10.9 There must be a comprehensive training and development strategy. Independent practitioners must be aware of their professional responsibility to keep their practice current with respect to equipment/techniques and dose reduction/minimisation methods. Independent practitioners should record all relevant continuing professional development (CPD) activities in accordance with the CPD policy of SCoR and the statutory requirements of the HCPC or other regulatory bodies.
10.10 There should be a clear policy on the information to be issued to patients.
10.11 There should be a regular review of all equipment and an equipment replacement programme should be established.
10.12 There should be declared, unambiguous and acceptable levels of care for patients including statements on relationships, standards and facilities.
10.13 Patient/client confidentiality must be maintained at all times.
10.14 There should be due regard to ethical standards.
11.1 Clinical governance was defined in the 1998 consultation document ‘A First Class Service: Quality in the New NHS’ 22 as:
‘a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.’
11.2 The ethos of clinical governance has been embedded throughout this document. However, the key components and themes that promote good clinical governance are stated here for clarity. These components and themes are aimed at sizeable healthcare organisations but are nevertheless relevant themes that every independent practitioner and small independent practice will need to consider to ensure they have relevant policies and procedures in place.
Independent Practitioners are expected to develop, implement and monitor policies embracing the standards below. This will serve to assure patients and commissioners that the service offered by the Independent Practitioner is of a high quality. If wishing to bid for AQP contracts detailed requirements will be provided by the commissioning authority.
Specific objectives of independent services should be laid down in writing and are likely to include:
Health records are confidential. They should be shared only on a need-to-know basis. Information governance ensures necessary safeguards for, and appropriate use of, patient and personal information. There should be systems in place to protect the confidentiality and security of patient information and provide access to relevant information only to those who need it. In practice, this is addressed through three fundamental principles - confidentiality, integrity and availability.
Confidentiality - Information must be secured against unauthorised access.
Integrity - Information must be safeguarded against unauthorised modification.
Availability - Information must be accessible to authorised users at times when they require it.
In order to maintain these principles, the following standards must be observed:
Patients’ medical records and reports from imaging examinations must be stored in a secure place within a specified time and a duplicate record kept. This may be in paper or digital format such as Picture Archiving and Communications Systems (PACS). A report should be produced for all examinations.
Independent practitioners may only accept requests for examinations involving ionising radiation from Registered Health Care Practitioners (ie they must be registered under a statutory regulatory body in the UK). Requests must be properly authorised in accordance with established criteria, national guidelines and evidence based practice and the examination requested must be of benefit to the patient.24 The request must contain sufficient clinical information to justify the examination and the Ionising Radiation Regulations and its amendments followed. Independent practitioners may carry out alternative or additional examinations where, in their professional judgement, these are appropriate to the patient’s condition.
Independent practitioners may, however, accept self-referrals for relevant examinations that do not involve ionising radiation; ultrasound examinations would be an example. It must be noted that there is no mechanism for self-referral under the Ionising Radiation regulations and subsequent amendments. SCoR advice on self-referrals was published in 2010 and is available from the document library.24
For ultrasound examinations, a verbal self-referral from the patient themselves is acceptable but the reasons for the request should be recorded on the report and the sonographer must be able to justify the examination.
Independent practitioners must use their own professional judgement and not carry out any imaging (whether referred or self-referred) where, in their professional opinion, the risk to the patient is greater than the benefit obtained by the procedure. It is good practice to go back to the referrer in cases where this is in doubt.
The independent practitioner should ensure that the patient or client has been assessed appropriately prior to undertaking the examination and has given their consent.
The National Screening Committee has issued Public Guidance on Screening which links with this section on referrals (October 2010). Independent practitioners should be aware of this advice and how it may affect their practice. “Thinking of having a private screening test?” can be downloaded from http://www.screening.nhs.uk/private-screening
It is imperative that all independent practitioners are aware of the issues surrounding the gaining of consent from patients and others attending for diagnostic imaging or radiotherapy. Radiographers and sonographers have professional duties and responsibilities in terms of conduct, performance and ethics including a requirement to only undertake those tasks in which they are competent and for which appropriate patient consent has been obtained. The principle of consent to an examination carried out by a healthcare professional is the right of patients to determine what happens to their bodies. The radiographer or sonographer who does not respect this principle is potentially liable to both legal action by the patient and by a regulatory body such as the Health and Care Professions Council. SCoR advice can be found within ‘Consent to Imaging and Radiotherapy Treatment Examinations’ (2007). 26
The service must have dated, written policies and procedures to provide the framework for the service being provided. These must be based on current knowledge and principles. To achieve the standard the following must be observed:
Good documentation and record keeping are synonymous. Effective patient care requires documentation of diagnosis, treatment and future plans so that there is sharing of communication for all practitioners for the benefit of the patient. Many civil cases arise after an initial event and records are essential in terms of providing clarity, content, style, accuracy and comprehensiveness.
Records must:
Advice on reporting is contained in the following documents:
Standards for the Reporting and Interpretation of Imaging Investigations, RCR, (2006)29
The Scope of Practice, SCoR, (2013)30
United Kingdom Association of Sonographers (UKAS) Guidelines for Professional Working Standards: Ultrasound Practice (2008).31 UKAS merged with the SCoR on 1st January 2009.
‘Team Working in Clinical Imaging’ published jointly with the RCR in 2012.23
The service must be properly directed and staffed to achieve its stated goals and objectives. Practitioners are responsible for identifying, developing and maintaining the necessary skills and competences relevant to the service and its objectives and to ensure the provision of high quality care.
To achieve the standard, the following must be evident:
There should be suitable space, equipment and adequate supplies for the safe performance and delivery of all services provided.
To achieve the standard the following must be observed:
Health professionals should be able to assess the care they provide against established clinical standards by means of clinical audit. This will involve identifying and building on good practice, the assessment and minimising of risk and the investigation of problems and learning from that investigation. The service must assure the provision of high quality care by its involvement in evaluation activities. AQP contracts will stipulate what evaluation is required and the Standards against which the service is to be evaluated.
To achieve the standard, the following policies are observed:
13.1 SCoR, within its Code of Professional Conduct10 allows for the practice of independent practitioners advertising their services provided that any advertisement conforms to the British Codes of Advertising Practice and Sales Promotion. To achieve the standard, the following criteria apply:
13.2 The health care practitioner/patient relationship is important, therefore due regard should be paid to the maintenance of the highest ethical standards in any advertising. Direct appeals to patients, either face to face or over the telephone, should be avoided. It is undesirable to use too many abbreviations which can be confusing to patients and clients. Comparative claims with other practitioners should not be made in respect of superiority of skills, equipment and/or facilities. The term ‘specialist’ should be restricted to those who have a defined specialist skill. While it may be correct and proper for Independent Practitioners to be able to publicise their service and practice, they should act in a restrained and professional manner at all times.
Further information can be obtained from the Advertising Standards Authority (ASA) at www.asa.org.uk/asa/codes
13.3 Independent Practitioners who are registered with a regulatory body such as the HCPC or NMC must also comply with their requirements.
13.4 It is important that claims made about the performance of specific imaging modalities or methods for screening for various types of pathology are accurate (see also section 12.3, Referrals, for National Screening Committee advice).
(All links in above text accessed 28/1/14)