CLINICAL MANAGEMENT

Published: 28/07/2005, Volume II5, No. 5966 Page 30 31 32

Four years ago, Addenbrooke's trust in Cambridge was struggling with serious staff shortages in radiotherapy - but a New Ways of Working pilot turned everything around for patients and staff, as Ann Dix reports

The shortage of specialist staff is a major obstacle to driving down cancer waiting times. The government has increased training places for radiographers, radiologists and oncologists, but it will be years before the benefits are felt.

Meanwhile, the NHS has to find new ways of working to meet tough cancer targets and improve the quality of care.

Four years ago, Addenbrooke's trust in Cambridge was experiencing an acute shortage of radiographers. Vacancy rates in radiotherapy were as high as 27 per cent, with 13 out of 40 posts unfilled. The department's graduate intake had dried up - a major blow to a teaching hospital. It was struggling with poor retention rates and spending on agency staff was high. An injection of government cash meant there was new equipment but nobody to staff it. Meanwhile, radiotherapy waiting times for patients diagnosed with cancer were close to 10 weeks and rising.

Then the chance arose for it to be a pilot for a Department of Health New Ways of Working programme aimed at tackling the problem. 'We grabbed the opportunity with both hands, ' says professional development co-ordinator Jane Head.

The programme was designed to explore new and redesigned roles in therapy radiography. It was based on a four-tier career structure devised by the College of Radiographers - from the new role of unregistered assistant practitioner to stateregistered practitioner, advanced practitioner and consultant radiographer.

Designed in response to the acute shortage of radiographers, the idea was to bring new staff into the clinical workforce while improving career opportunities for registered radiographers.

Promoted as a multidisciplinary model that shapes clinical teams around service needs rather than professional boundaries, it had already been piloted in breast cancer screening with early signs of success. In 2001 it was extended to radiotherapy in nine pilot sites.

By January this year, Addenbrooke's (now Cambridge University Hospitals foundation trust) was among the most advanced of these pilots, having put all four tiers of the therapy radiography model in place. Today the department is almost fully staffed, with only three vacancies for senior posts in an expanded workforce of 60 radiographers. Staffing has increased by 50 per cent since the programme began.

The rewards have been immense: the trust has seen waiting times for radiotherapy halve to less than five weeks and has been able to improve the quality of care by assigning the patient to an advanced practitioner, who supports them through all stages of the care pathway. In addition, the career opportunities offered by the new structure have raised morale and contributed to a full intake of eight graduate radiographers this year. Graduates also benefit from a clinical and professional development programme developed by the pilot to support the progression from graduate to practitioner.

Associate director of operations for oncology Karen Taylor describes it as a 'huge turnaround'.

'Staff are motivated by the new career structure, morale is higher, working times are reduced hugely and We have been able to open two new linacs [linear accelerators], recruit staff and sustain it, ' she says.

But as Ms Head explains, it has been a tough challenge. Not least because it demanded a lot from staff at a time when the department was already under intense pressure.

A condition of the pilot was to implement the model as a whole and an education package to support it. Occupational standards were being developed by Skills for Health for all levels.

Addenbrooke's had a head start with the advanced practitioner role because it was already developing specialist radiographers. But, says head of radiotherapy Katharine Walker, the need to expand the clinical workforce meant 'it was the new role of assistant practitioner that really sparked our interest'.

Each pilot received£75,000 from the DoH over three years. 'We were very lucky in that the trust also made vacancy money available [from the radiography posts], which didn't happen on some of the other pilot sites, ' says Ms Walker.

Having been instrumental in drawing up the tender, Ms Head was made project lead. The first priority was to recruit advanced practitioners to 'get more bodies on the treatment floor', she says.

'We wanted a competent support worker, hands on in the treatment room, and that is how we developed the role.' They advertised externally to spread the net wide. 'We knew we wanted people who were numerate and liked patient contact, but we also wanted people who liked the technical side.' They also wanted to offer a salary that would attract people of the right calibre, she says. This meant that instead of using the suggested Whitley council salary grade of radiography helper, the trust created its own grade, which sat between what was then the health grade and the graduate grade.

The response was good. An open morning attracted 60 people, resulting in 30 applicants for four posts. Ms Walker says the idea was to attract a broad range of candidates. At the same time, 'there had to be an element of courage'.

'They knew very much that they were coming in as guinea pigs.' There was also the task of developing workplace education and training. This was made easier by Addenbrooke's having its own learning centre, which was an accredited NVQ provider. An existing NVQ3 in care was adapted for the role. This subsequently led to a collaboration with Anglia Polytechnic University to develop a distance learning foundation degree for assistant practitioners, including those wishing to train as radiographers.

The department now has five trained and two trainee assistant practitioners who help in the pre-treatment and treatment areas, including assisting radiographers in treatment delivery.

'A trained assistant practitioner can do anything they are competent to do that the radiographer wants them to do without direct supervision, ' says Ms Head. 'If you wandered into one of our treatment units, you would have difficulty knowing which one was which'. But, she says, 'the clinical decision-making skills stay with the radiographer'.

Some assistant practitioners have gone on to train as radiographers, but Ms Head stresses that it is not about getting in radiographers 'through the back door'. 'If one or two of them want to do that, That is fine, but That is not why we are recruiting them. We actually want and value assistant practitioners for what they are because they are a very flexible workforce.' But she admits it has not all been plain sailing.

'For staff already stressed in their workplace, the idea of having a learner in a pilot - a nonregistered, non-radiographer practitioner - within the confines of the treatment room itself was a bit of a leap for them, ' she says.

Radiographers also felt they were losing support. 'Another radiographer gives you that support for making a decision, whereas they wouldn't necessarily have that with an assistant practitioner.' The trust responded by giving staff information, reassurance and support, says Ms Head. It helped that before the pilot a College of Radiographers representative had been invited to talk to staff about new career structure. This served as 'a sort of drip-feed introduction before it hit the ground running', says Ms Head.

'We informed staff all the way along about what we were doing and bit by bit they did feel positively... To say we consulted them is possibly a little strong, because with all the pressures that were going on they might have said no.

'Accountability was the big issue we had to talk staff through. Radiographers had to undertake practical training of the assistants, but we promised them that if at any time this became a training burden, I would step in and they would be supported.' In the event they didn't need her help. 'We made sure that the assistant trainees were well prepared before they went on to the treatment unit, ' says Ms Head.

'They had the training required to work with the radiographers, which could be built on, and the radiographers knew exactly what tasks and competencies they had undertaken and what that individual was capable of doing in their area.' At the same time, radiographers could come and check with her, and get reassurance.

Ms Walker believes the radiographers are now confident of the new system. 'Because the assistant practitioners have stayed and become very integrated into the department, that core group of radiographers have accepted them. They would miss that role now if you took it away.' There were similar challenges with the advanced practitioner role. A framework of skills, education, training and criteria against which this level could be assessed was developed within the pilot. The DoH then visited each of the pilots to identify radiographers working at this level.

Addenbrooke's had already laid the groundwork by developing specialist radiographers. But as waiting times rose, staff pressure to get these people back on the treatment floor intensified, says Ms Walker.

'We fought against that because, one, they would leave, which would help nobody and two, the department wasn't going to benefit in the long term.' Some of the clinical oncologists also felt threatened. 'There was a feeling of: 'Are these people going to take my job?'' But by the time the pilot ended last year, the battle had been won. 'These people had progressed beyond belief in these roles, were accepted by their medical consultant colleagues as integral to the multidisciplinary team and now are very supportive to the treatment floor and to patients, ' says Ms Walker.

The advanced practitioners develop expert clinical practice in a specific field, freeing up oncologists and medical physicists to work on other areas. It takes two to four years before they become proficient enough to work autonomously within that scope of practice. They also provide continuity of care, supporting patients through the whole care pathway, including follow-up care.

The department has now appointed two advanced practitioners; one in neuro-oncology and one in technical development. It also has three novice advanced practitioners in head and neck, urology and pre-treatment planning. In addition, they have appointed their first consultant radiographer in gynaecological oncology (see box).

The development of these specialist roles has been service-led, with a clearly defined career progression between the two. 'We have made our definition of advanced practice quite tight and it is something you need to go through before you get to consultant status, ' says Ms Head. 'This is a career progression, not a fudge.' A particular feature of the consultant role is that they work across professional boundaries, adds Ms Walker. And while advanced practitioners tend to be trust-based, the consultant's role is to look across the whole cancer network, developing multidisciplinary team-working across primary and secondary care.

One of the benefits of these specialist roles is that it frees up the oncologists to do the more complex work. The shortage of clinical oncologists, and the trend towards part-time work or joint appointments across the cancer network, could drive this further, she says.

'In a couple of years' time there is nothing to say that radiographers couldn't take on more complex work. But the doctor will always take the clinical decision on how the patient is treated and have ultimate responsibility.' At the same time, she says, not all radiographers will want to advance their careers in this way. It is important that 'if they do not want to we do not value them any the less'.

One problem with the pilot is that 'it sometimes looked as if we were ignoring the staff who are actually doing the job'. The focus of the pilot was to develop the top and bottom of the career ladder. 'But it couldn't have happened without the hard work of the floor radiographers, who have kept the whole thing ticking over. They are the unsung heroes.'

Find out more

A strategy for the education and professional development of therapeutic radiographers. College of Radiographers 2000.

www. csp. org. uk/download/lis/ csp_lrc_docalert_mar05. pdf

Radiography skills mix: a report on the four-tier service del ivery model. DoH 2003

www. dh. gov. uk/policyAndGuidance

To contribute articles to HSJ's clinical management section, e-mail ann. dix@emap. com

FOR BETTER OR WORSE?

WHAT THE PROGRAMME HAS MEANT FOR STAFF

Brenda Adams Assistant practitioner Brenda Adams worked at Addenbrooke's, coding medical records, before becoming an assistant practitioner.

One of the attractions of the job was the opportunity to work with patients, she says.

'Often patients develop a close bond with us because we spend a lot of time talking to them.' She finds working on the machines and computer systems 'very enjoyable', although she has no ambitions to train as a radiographer.

'We are treated like a basic radiographer but without the clinical decision-making.'

Kate Burton Advanced practitioner, neuro-oncology If radiographer Kate Burton hadn't had the opportunity to specialise, she might have moved on by now.

She has spent six years specialising in neurooncology, and recently became one of Addenbrookes' first fully trained assistant practitioners in therapy radiography. She has now been with the trust for 13 years, and feels more accepted by her colleagues. 'At first there was some animosity from radiographers on the treatment unit, ' she says, but the role is helping to 'break down professional boundaries'.

Jo Treeby Novice advanced practitioner in urology Before she started training as an assistant practitioner, Jo Treeby was a superintendent overseeing treatment machines.

'My job has changed to more hands-on treatment of the patient rather than simply switching the machine on and off, ' she says.

'It is about smoothing the patient's journey and offering ongoing support through all stages of their care from the point of diagnosis. Often patients get peak side-effects when they are no longer coming in daily. Now they've got that contact point.'

Lisa Punt Macmillan consultant therapy radiographer, gynaecological oncology Funding from Macmillan Cancer Relief has allowed Addenbrooke's to appoint its first consultant in therapy radiography.

Lisa Punt started specialising in gynaecological cancer eight years ago and is just completing a Master's in science. Much of her immediate work will involve establishing links across the cancer network and developing care pathways, as well as networking nationally.

She hopes surgeons might soon be able to refer some patients to her directly soon.

Dr Sarah Jefferies Clinical oncologist, head and neck and neurooncology Having experienced the benefits of working with an advanced practitioner radiographer, Dr Sarah Jefferies 'can't imagine life without them'.

'It would certainly detract from patient care. They are an established member of the multi-disciplinary team, as essential as oncologists and specialist nurses.

'Having a highly trained professional who is there continuously, gets to know the patient very well and is technically able takes a huge workload off me.'

Key points

Addenbrooke's trust in Cambridge had an acute staff shortage in radiotherapy four years ago.

The trust enthusiastically signed up to a DoH New Ways of Working programme for developing radiographers.

New roles helped to bring the radiography department to the near-full level of staff ing it has today.