The Role of the Community Liaison Expert Radiographer Practitioner: Guidance for Radiotherapy and Imaging Service Managers and Commissioners

President

The Society and College of Radiographers (SCoR) has pleasure in publishing this guidance document which has been developed to support the implementation of a new role of Community Liaison Expert Radiographer Practitioner. This role was first described in 2006 by SCoR as one of the three expert roles to enhance patient care across cancer pathways(1). Whilst the focus of this work has been the development of therapeutic radiographers, it is acknowledged that the role could be equally applicable to expert diagnostic practitioners working within cancer pathways. 
 
This guidance supports recommendations made within the Cancer Reform Strategy(2) and supports the need for enhancement of care strategies for the patient across multiple interfaces along their cancer pathway. The guidance describes how the role of radiographers can be developed to enhance care for patients with cancer and outlines the role  of the community liaison expert radiographer practitioner. The role builds on the core skills of the radiographer trained in cancer care from pre-registration. It is very much envisaged that this role will be at consultant practitioner level.

SCoR recognises the importance of providing individualised care packages across the often complex cancer care pathway and recognises this as being a solution to integrate support packages specific to the patients' local need and place of residence.

The role of the Community Liaison Expert Practitioner was first defined in the College of Radiographers’ document Positioning Therapeutic Radiographers within Cancer Services: Delivering Patient Centred Care(1). 

The aim of this new guidance is to provide commissioners and providers with information about this role in order to support the local implementation of this role to meet local service needs. 

The guidance describes what an expert radiographer could offer, both within and beyond the traditional boundaries of the Cancer Centre, if higher level posts at consultant levels were to be developed and then commissioned.

The Community Liaison Expert Practitioner will undertake:

• liaison with teams and individuals involved in the disease management and case management levels
• supply of information and support to patients both waiting for and after radiotherapy
• advice to primary care teams regarding the management of side effects of radiotherapy
• liaison with palliative care teams. 

(College of Radiographers, 2006, Positioning Therapeutic Radiographers within Cancer Services: Delivering Patient Centred Care.)(1)

A number of recent developments have highlighted the importance of improving the patient experience of cancer services within the area of information, liaison and support.

The Integrated Cancer Care Programme Report(3)  identified the lack of patient information, integration and communication across services, the variability of specialist support available for patients and the desire from General Practitioners (GPs) for more information about treatment plans, courses of treatment and response to treatment for their patients.

The recently published Cancer Reform Strategy(2) highlights that more must be done to support and empower patients throughout their cancer journey. The report highlights the importance that commissioners must place upon developing robust systems to ensure patients have good continuity of care and timely information and support across the pathway for the patient with cancer. 

One way to achieve this is to ensure that co-ordination of all these elements of information, support and liaison is led strategically by an expert lead practitioner who will develop strategies across all sectors in order to ensure integration of care by those delivering all aspects of the cancer pathway. This is particularly important in the current climate of more complexity across and between pathways of care. New service models are also being advocated, to improve both the access for patients and to improve treatment outcomes for patients.

It is inevitable that some services will be more readily accessible to patients and located closer to where they live whereas other more specialist services will continue to be delivered at specialist centres(4).This may mean that many patients will have to access different treatments across their treatment pathway at differing geographical locations which will be determined by their particular treatment pathway. To continue to deliver and develop high quality services across changing service models, considerable work has been undertaken by the Department of Health (England) in developing a commissioning framework for radiotherapy services(5). High quality care and information and support are essential components of this framework.

The Cancer Reform Strategy acknowledges that although the patient’s experience of care has improved in recent years, more can be done to support and more must be done to empower patients through their cancer journey. To achieve this we need expert co-ordinated care led by an expert.  With the rapid growth of radiotherapy services as a result of the recommendations for service expansion outlined in the Cancer Reform Strategy(2) there will be an increase in new satellite centres providing treatment closer to patients’ homes. Establishing standards across and maintaining links between new and existing centres across Cancer Networks will require co-ordination across all aspects of care; Information and support service co-ordination is a critical part of this care.

To fulfil the educational requirements of this role, SCoR has advocated the need for accreditation of higher level skills at post registration level. Accredited post registration programmes must be agreed and developed locally to support the development of this high level role and in line with the key outcomes described within the SCoR Learning and Development Framework(6). The need to achieve consistency of practice and to support transferability of expert roles between employers has been underlined further by the College of Radiographers, which is developing accreditation processes for higher levels of practice.

A wide range of current information, liaison and support (ILS) activity has been identified by radiographers working within the traditional radiotherapy centre setting(7)(8) including:

One to one care and support of patients and carers

• Detailed information and advice on treatment reactions and side effects prior to treatment
• Gaining consent to treatment planning and delivery
• Information and support to individual patients/carers in the planning/treatment room setting
• Telephone information and support for patient/carer between first appointment with oncologist and first visit to department
• One to one psychological support sessions for patients and carers (often crisis intervention)
• Radiographer-led holistic treatment review clinics in the department
• Radiographer led follow-up at peripheral clinics
• Telephone help line particularly for patients receiving chemo-radiotherapy
• Follow-up phone calls to patients when treatment is finished
• Routine telephone review clinic one week post treatment
• Support in recovering from acute side effects post-treatment
• Development/maintenance of protocols for radiographer-led review clinics
• Responsibility for Patient Group Directives
• Development/monitoring of patient information leaflets
• Special needs information provision e.g. Braille or language specific
• Psychological support for nurses and radiographers in relation to clinical case load

Liaison with health professionals and groups

• Referral to other health professionals within the acute setting
• Provision of education and information sessions, open mornings for pre-radiotherapy site-specific patient groups, patient support groups or other health professionals
• Input to cancer network  meetings, such as information and patient liaison groups 
• Liaison with local cancer information and support centres
• Referral to community palliative care team, social worker, benefits adviser etc
• Liaison with patient’s GP practice team
• Expert advice on skin care and dressings to district nurses and GPs
• Responsibility for discharge letters to GPs related to treatment reactions
• Provision of web-based information and phone contact with GPs/District Nurses

All radiotherapy practitioners are involved in certain routine ILS activity as part of their role. In addition, identified therapeutic radiographers specialise in the provision of ILS within the setting of the radiotherapy centre. 

Historically a number of these posts were pump-primed by Macmillan Cancer Relief in the late 1990s, leading to the title of Macmillan Radiographer or Information Specialist.

Similar appointments have been funded by employing authorities such that most radiotherapy centres have a senior radiographer, supernumerary to the treatment team, specialising in the provision of this type of service. 

Traditionally ILS posts were ‘grown’ around individuals who had achieved qualifications in support services such as counselling and complementary therapies. In this way, posts evolved or were opportunity-driven by available money or an acute service gap.

It is acknowledged that service need and the capacity to deliver that service should now be the driver for a recognised career framework in the field of ILS.

The workforce profile within the centre, particularly in relation to cancer nurse site specialists, is an important factor in how therapeutic radiographers are deployed. In some departments cancer nurse specialists and ILS radiographers deliver very similar services. In others where there are no nurse specialists, radiographers take on a much broader scope of practice.

ILS is delivered not only by information and support radiographers but also by site specialists and treatment and review radiographers working at advanced practice level.

Some departments are developing protocols for routine assessment of the need for information and support for every patient during the radiotherapy phase of the patient pathway. This does not appear to be current routine practice, highlighting the potential for the inclusion of radiotherapy experience within the overall cancer pathway.  

Although the above scope of practice may appear very broad, it should be noted that not all services are provided in every centre; neither are services provided for every patient.

The scope of ILS  practice can be seen to operate throughout the career progression framework from assistant to consultant.

The potential for improvement of the patient experience would be increased considerably by a strategic role that takes an overview of the provision of ILS; identifies gaps in the transition between services and provides a radiotherapy educational strategy for health professionals within the wider community.

The role of the community liaison expert radiographer practitioner is envisaged as operating at a strategic level based within the cancer network, across a group of Primary Care Trusts and in the community setting. 

This post would potentially reduce calls on medical staff time, improving waiting time targets and improving the service for patients.

The role would focus on liaison outside the Cancer Centre to promote effective working with other health professionals involved in the patient pathway, taking an overview on the timeliness of patient information throughout the radiotherapy pathway to dovetail with patient care either side of the pathway.

The community liaison expert radiographer practitioner may have overall responsibility for ILS services delivered by the radiotherapy team within the department but would not be expected to maintain an individual case load.

They would be responsible for maintaining currency in relation to radiotherapy practice to ensure the delivery of up to date patient information and information about treatment regimes for professionals outside the radiotherapy department. 

The maintenance of high quality care for patients can only be achieved by accurate and current information for both patients and staff involved in their care. Myths and misinformation about radiotherapy outside the profession often persist as new techniques and practices outstrip knowledge acquired during initial training. The provision and implementation of an educational strategy would be a key aspect of the role.
 
A network-wide educational strategy would also have the potential to promote the uptake of radiotherapy for the increasing number of patients who could benefit from this form of cancer treatment but who do not currently receive it(2).

The consultant role would provide an expert resource to other health professionals in terms of radiotherapy service provision, co-ordinating advice on acute and long term radiation reactions as more patients survive cancer as a long term condition.

The potential exists for joint working with professionals such as community pharmacists, occupational therapists and physiotherapists to maximise quality of life during treatment and beyond for the cancer survivor.

One consultant role is envisaged operating at lead PCT level / cancer network level, though networks with more than one radiotherapy centre may wish to consider additional roles to respond to the specific geographical needs of the service.

The graduate therapeutic radiographer will have received post registration education and training in the appropriate provision of information and support, together with referral to the multi-disciplinary team. In the past, specialised training has been provided for Macmillan funded radiographers, though specialists funded by alternative means have often sought courses outside the field of radiotherapy. 

The following topics have been proposed to meet the breadth of practice for radiographers working specifically as community liaison expert radiographer practitioners and should be viewed in conjunction with the SCoR Learning and Development Framework(6).

Expert practice

• Advanced communication skills
• Information provision
• Patient assessment and review
• Management of short and long term side effects including wound care
• Pharmacology particularly in relation to toxic regimes, such as chemo-radiotherapy
• Palliative care
• Pain management
• ‘End of life’ skills
• Health education
• Cancer therapies and innovative treatments
• Cancer networks and the primary care team; NHS structures, roles and the opportunity to shadow other cancer care professionals

Strategic expertise

• Study with other health professionals is recommended to broaden horizons beyond radiotherapy and to engender the strategic expertise required for the expert/consultant level role.
• Coaching and mentoring
• Teaching skills
• Identifying service need
• Time management
• Project management
• Leadership skills - identified as crucial for the consultant role

Academic capability

• ‘Advanced practice' should relate more to a state of mind than simply an ability to practice in a specific area of expertise. 
• Study at Masters Level should be a pre-requisite.
• Knowledge of research methods and the ability to plan and deliver research is essential to identify the potential for research within the field.

The role of the community liaison expert radiographer practitioner is seen as essential in ensuring the quality of the patient experience before, during and after radiotherapy. 

Existing information and support specialist radiographers currently operate at the level of advanced practitioners, mainly providing individual patient care and building upon that provided by the generalist radiotherapy practitioner and assistant practitioner.

The strategic role of the consultant/expert practitioner appears undeveloped at this stage, reducing the potential to improve the patient experience and increase knowledge about radiotherapy in the wider community. Without specific focussed work and identified resources, it appears unlikely that the potential will be realised.

It is recommended that:

1. Service managers review practice in relation to information, liaison and support; identifying specific roles and means of extending links into the community to improve the patient experience,
2. the College of Radiographers support the development of a network to provide a good practice forum in the field of information, liaison and support,
3. commissioners identify resources to enable the role of the community liaison expert radiographer practitioner to be developed further. Current financial restrictions have been focussed on waiting time targets and have capped expenditure on this type of activity within radiotherapy departments,
4. Strategic Health Authorities consider funding three year secondments to explore the potential for the strategic role in a range of different cancer network structures,
5. the pilot roles should be developed with academic input co-ordinated across pilot sites, incorporating formal evaluation with yearly milestones.

1. The College of Radiographers Positioning Therapeutic Radiographers within Cancer Services: Delivering Patient-Centred Care SCoR March 2006
2. Department of Health Cancer Reform Strategy DH Dec 2007
3. UnitedHealth Europe Final Report of the ICCP 2004-2006 May 2007
4. Professor the Lord Darzi of Denham for Department of Health High quality care for all: NHS Next Stage Review final report DH June 2008
5. Department of Health Contracting framework toolkit for radiotherapy (teletherapy) services

   (accessed Jan 2009)

6. Society and College of Radiographers Learning and Development Framework for Clinical Imaging and Oncology SCoR Feb 2008
7. Sheffield Hallam University The Role of the Community Liaison Expert Practitioner - Focus Group Report June 2007
8. Society and College of Radiographers, On-line Survey Dec 2007

The Society and College of Radiographers would like to thank the members of the SCoR Radiotherapy Advisory Group - Community Liaison Sub-group 

Margaret Abrahams -  Radiotherapy Services Manager, Rosemere Centre for Cancer, Preston, Lancs
Charlotte Beardmore -  Professional Officer for Radiotherapy, SCoR, London
Angela Duxbury – Principal Lecturer, Radiotherapy and Oncology, Faculty of Health and Wellbeing,  Sheffield Hallam University
Lorraine Fulman -  Information and Support Radiographer, Nottingham University Hospitals Trust
Margaret Le Beau (Chair) – Senior Lecturer, Radiotherapy and Oncology, Faculty of Health and Wellbeing Sheffield Hallam University
Julie Massey -  Radiotherapy Services Manager, Clatterbridge Centre for Oncology, Wirral

Thank you to those who have taken part in consultations and discussions regarding the Community Liaison Expert Radiographer Practitioner Role.
 
Sheffield Hallam University Focus Group Members:
Margaret Abraham - Radiotherapy Services Manager, Rosemere Cancer Centre, Preston, Lancs
Angie Craig - Head of Radiotherapy, St James's Institute of Oncology, Leeds
Carole Downs - Superintendent Radiographer, Northern Centre for Cancer Treatment, Newcastle
Angela Duxbury - Principal Lecturer, Radiotherapy and Oncology, Faculty of Health and Wellbeing,  Sheffield Hallam University
Angela Eddy - Course Leader: MSc Advanced Practice (Radiotherapy and Oncology) Sheffield Hallam University
Lorraine Fulman - Information and Support Radiographer, Nottingham University Hospitals Trust, Nottingham
Margaret Le Beau - Senior Lecturer, Radiotherapy and Oncology, Faculty of Health and Wellbeing Sheffield Hallam University
Sue Lewis - Hull
Fiona Milnes - Radiotherapy Services Team Leader, James Cook University Hospital, Middlesbrough
Julie Owens - St James's Institute of Oncology,  Leeds
Moira Tomlinson - Radiotherapy Services Manager, Sheffield Teaching Hospitals NHS Foundation Trust
Angela Turbin - Operational Lead for Radiotherapy, United Lincolnshire Hospitals NHS Trust, Lincoln

With additional input by
Jane Head - Addenbrookes Hospital, Cambridge
Charlotte Beardmore - Professional Officer for Radiotherapy,  SCoR  London

SCoR Public Patient Liaison Group

SCoR On-line Survey Contributors

Members of the Macmillan Radiographers Group via SCoR email contact group.