Fewer resources and increasing demands make effective service provision ever harder to achieve. Michele Marshall and George Blair look at the changes one trust implemented in its radiology team to ensure it was able to do more with less
The radiology department at North West London Hospitals NHS Trust changed their care pathway and created new clinical roles to cope with increase demand in services and shortage of resource
How can we meet the growing demand for services with constrained resources? This is a huge challenge for radiology − but one being tackled at North West London Hospitals Trust through innovative thinking, new roles and changing practices.
‘Investment in radiographer training, along with an increase in their numbers, has created a more productive department’
This demand is fuelled by increased patient expectations, a drive to shorten patient pathways and rapid developments in healthcare technology. Department of Health data shows a sustained rise in complex imaging, which is now embedded in a majority of cancer pathways and used to monitor effectiveness of treatments, as well as in primary diagnosis.
A target of six weeks is becoming difficult to sustain with diagnostic waits rising again, particularly for magnetic resonance imaging.
While trying to deliver cost improvement programmes of 5 per cent, radiology departments have looked to workforce reorganisation to maximise productivity. At North West London, computerised tomography scans went up by 30 per cent and interventional radiology workload increased by 29 per cent over the four years to 2012-13.
In contrast, medical staff increased by only 3 per cent. Doing more of the same while faced with the current pressures can lead to a downward spiral of longer delays for patients and a decline in work quality. Increased sickness rates through stress and work related injury has a predictable impact on staff morale, recruitment and retention. Implementing changes to staff roles as a quick fix can lead to disappointing results.
The radiology directorate took a strategic and sustainable approach to developing new roles and changing working practices. Some roles were delegated to non-medical staff and investment in radiographer training, along with an increase in their numbers by 9 per cent, has created a more productive department.
Frequently, staff can resist passing on full responsibility to others if they believe they might not be up to the job. If training and supervision are not planned carefully, this can lead to duplication of effort where more senior staff excessively double check work.
Research with a strong statistical foundation was used to evaluate extended roles; leadership was another key element. One project was established to create an innovative radiographer led, high quality service for a new specialist CT scan, for which the demand was predicted to grow at an unprecedented rate.
The programme director and the lead consultant in a specialist area provided the vision, established quality standards and undertook capacity modelling. Physical scanner capacity needed to be maximised, while training in new techniques needed to be of the highest quality standards to avoid harm to patients.
A programme lead (a senior radiographer and clinical manager), was appointed and had an operational role for designing the service, the training strategy and workforce roles, while being responsible for maintaining standards using quality audits.
‘There has been a need for investment in training and in individuals in order for the gains to be realised’
Radiographer role extension in other areas has provided opportunities for cost improvement, while improving recruitment and retention. With the support of the Hertfordshire University, a consultant radiographer post was established to support radiographers who have undergone training and development to provide plain film reporting within a radiologist led environment. A further post at this level is being introduced in breast screening.
Other areas of role extension include training general radiographers in the emergency department to perform standardised head scans for stroke patients outside of normal working hours, allowing for a cost saving in specialist on-call rotas.
The creation of a new grade of staff in the department (assistant practitioner) to take x-rays, while supervised by fully trained radiographers, completes the gamut of approaches to using training and development within an established workforce to deliver service change and improvement.
There has been a need for investment in training and in individuals in order for the gains to be realised. The trust’s approach to the team’s ideas has been one of belief in long-termism.
The national shortage of sonographers can lead to delays in providing services and the use of expensive agency staff. This was avoided by implementing an in-house training scheme using vacancy money.
Improved technology can increase productivity − although at a cost. One option that is being explored is to invest in a more sophisticated picture archiving and communication system, and radiology information software that halves the reporting time of follow up scans.
‘There is an opportunity to redeploy staff in new roles such as clinical care coordinator’
The upgrade results in previous images being pre-fetched and the radiologist being presented with an index lesion to assess growth. Scans of a patient that have been taken at different times are lined up alongside each other and automatically measured to monitor change.
Junior doctors find themselves increasingly challenged to acquire the requisite skills and knowledge as, since the implementation of the European Working Time Directive, they spend less time being supervised by consultants. Consultants find they are changing the decisions of specialist registrars, both in radiology and in other specialties, too often. This has been addressed by a consultant led service, which provides higher quality and shorter patient pathways.
Three specialist registrars work directly with a consultant. Although this introduces additional costs, with a more supernumerary role for the trainee radiologist, it is supported by productivity gains elsewhere with improvements in both quality and productivity across the whole patient pathway.
There are other opportunities for junior doctors to extend their scope of operation − for instance, they can be trained to run evening ultrasound and catheter laboratory sessions.
The roles of healthcare assistant and that of administrative staff have been combined. This increases flexibility and provides staff with a more varied and interesting role.
The secretarial role is being reviewed, given a greater use of voice recognition. There is an opportunity to redeploy staff in new roles such as clinical care coordinator. Here they can contribute to reducing length of stay by chasing up delays in patient care.
Another new role will be to sample audit the 1,000 patients a month who have scans performed through a private sector contract.
‘While the whole approach is fully aligned with the QIPP programme, the work predates it by several years’
“Did not attend” rates have already been reduced to 3 per cent as patients are telephoned to arrange appointments that are most convenient to them. These should be reduced further when phone text reminders are introduced. Routine requests for scans have much shorter waits, which benefits patients and simplifies workflow, as a separate fast track queue is not needed.
Other elements in the overall approach are to future-proof change through succession planning and business continuity. A “deity”, who is a senior clinician programme lead, supports this. They use assessment tools, identify risk, chart the success of pilots and ensure a well managed programme rollout.
Training and staff development are based on an examination of skillsets through individual appraisal and underpin each programme. Adverts for new staff look explicitly for individuals with a strong sense of teamwork, who are flexible and able to adapt to changes in the working environment.
While the whole approach is fully aligned with the quality, innovation, productivity and prevention programme, the work predates it by several years. It is based on a conviction that continual self-assessment, reflection and audit are keys to success. They provide a powerful basis to implement extensive change without the need for external support.
Hopefully, this approach will become much more commonplace when more junior doctors complete the “Darzi” fellowship in clinical leadership to help transform healthcare through service redesign.
Dr Michele Marshall is clinical director for radiology and consultant radiologist at North West London Hospitals Trust, George Blair is managing consultant at Shared Solutions Consulting