GOOD MANAGEMENT - One trust's radiology services were in crisis until a review looked at everything from training to systems, writes Stuart Shepherd

At the start of 2003 the outlook for South Tees Hospitals trust's general radiology services was bleak. Efforts to cut waiting lists - it was taking 30 weeks for patients to get a general magnetic resonance imaging scan - were hampered by chronic difficulties in recruiting consultant radiologists and an overspend that would climb to£300,000 by June of that year.

Some measures to tackle these problems had already been taken. In October 2002, radiography assistants started foundation degrees to develop into assistant practitioners and take on supervised tasks such as routine x-rays. The radiology department at James Cook University Hospital, Middlesbrough, had also successfully bid for a second MRI scanner, in place from April 2003.

It was at this time that Ingrid Walker took up post at South Tees as divisional radiology manager. Soon afterwards, in June 2003, the department got the support of expert network the Cancer Care Alliance to run a four-month study looking at capacity demand.

'The study findings helped us understand the scale of the challenge ahead, ' says Ms Walker. 'It was clear that to respond to the inevitable increase in demand on our services, and at the same time reduce waiting lists, we needed more than just investment and a few new posts.' A service review explored changes in terms of who did what. Global and specific approaches to change management were implemented in tandem. All staff contributing to the patient pathway through radiology had to be committed to the task.

'You can't leave anybody out, ' says Ms Walker. 'The best system is rendered meaningless if the porter can't get the patient from A to B.

And schemes in other trusts have failed because they didn't receive the full support of the consultant radiologists.' South Tees encountered no such problems.

As well as assistant level, the radiographer role development programme expanded to incorporate consultant and advanced practitioners, in line with the national radiography services skillsmix project. Two consultant radiographers now lead their own clinics - one for breast imaging, one for gastro-intestinal examinations such as barium enemas. Advanced practitioners report on their own procedures (x-rays, computerised tomography scans) and have responsibility for interventions, including biopsies.

And as senior radiographers take on more and more specialised procedures, the assistant practitioner's ability to perform routine examinations has become essential to the day-to-day functioning of the service.

Systems also came under review.

Clerical and clinical support in and outside the x-ray suite has seen appointment times cut from 30 to 15 minutes. CT scan sessions run more smoothly now that patients have contrast medium injected by a venepuncturist in the waiting room.

'Because our regular clinics are more effective, ' says Ms Walker, 'practitioners can provide CT scan sessions in the evening and on Saturday. We also have a 24-hour, hospital-based on-call CT service.

Few UK hospitals have this facility.' Consultant radiologists and their patients also benefit. Senior clinicians now have time to participate in multidisciplinary cancer care meetings and give their expert views on treatment options.

South Tees has also made significant investments in technology. Installing a digital picture archiving and communication system in April 2004 has done away with x-ray film and developing. Images can be downloaded throughout the trust without any wait. Voice recognition software complements the system;

clinicians simply dictate their reports into a computer.

Lists have been cut dramatically as a consequence of these combined initiatives. 'In April 2003, waiting times for a general MRI scan, CT scan and fluoroscopy [barium enemas etc] stood at 30, eight and 35 weeks respectively. Now a wait for an MRI is four weeks, while CT and fluoroscopy waits are three weeks, ' says Ms Walker.

While National Institute for Health and Clinical Excellence guidelines and new cancer targets have contributed to the anticipated increases in demand, paradoxically waiting-time reductions have added to examination numbers.

'Patients are keener to stay on shorter lists, ' says Ms Walker. MRI procedures have increased by 73 per cent over two years, with CT scans up 35 per cent.

The redesign has also delivered a number of efficiency savings. Far from being in deficit, the department now underspends by£400,000.

'Staff retention is the main focus in a team with no radiography vacancies, ' explains Ms Walker. 'We are still short of radiologists, but now our future development needs are informed by capacity forecasts and a good HR strategy.' .