Published: 14/10/2004, Volume II4, No. 5927 Page 28 29
A trust has successfully combated the national shortage of radiologists and cut waits with a sonographer-led ultrasound service. Ann Dix reports
Radiologist Dr Roger Moshy is a rare breed: a consultant prepared to do himself out of a job in the interests of patient care.
At Peterborough and Stamford Hospitals foundation trust, where Dr Moshy is clinical lead for ultrasound, sonographers now perform most of the ultrasound scans previously carried out by radiologists. They manage their own caseloads, working to clinical protocols, and are responsible for running the service, which means clinical governance, organising staff rotas and commissioning equipment.
The main impetus for change was a national shortage of radiologists, explains Dr Moshy. At one stage, the number of radiologists in the department fell by half.
'Until recently we had only four whole-time equivalents and survived only through the assistance of locums.'
This, combined with increasing demand for ultrasound scans, was resulting in long waiting times.
Since the introduction of a sonographer-led service, the department has reduced waiting times from 20-24 weeks to four to six weeks for most procedures.
The move to expand sonographers' roles started six years ago. 'It was a gradual thing that suddenly accelerated when the shortage of radiologists became acute, ' he says. 'In the past, sonographers were mainly confined to scanning pregnancies. Now they undertake all types of scans. The gynaecology and venography service is virtually entirely in the hands of the sonographers. The only thing they do not do is interventional procedures.
'The advantages of a sonographer-led service are that we have more sessions covered and this has increased the throughput of patients within the department.We undertake 25,000 to 26,000 ultrasound scans per year; about 95 per cent of this is done by sonographers.'
This frees radiologists to specialise in more complex cases that require a second opinion or intervention. But as Dr Moshy concedes, deskilling of radiologists is inevitable and this can lead to resistance in the profession. 'I can understand how it can be threatening, ' he says. 'The first concern is that you trained all these years and someone is doing your work. The second, which is more serious, is that there comes a point where if you are not doing the work, you lose the skills.'
Dr Moshy has experienced this first hand: he has hardly done any skeletal reporting over the past four years and believes he is getting to the point where he would need to retrain to do this type of work again.
'As a radiologist, you become much more specialist.
Some people regard that as a good thing and some as a bad thing, but That is the nature of the beast. That is why, for us, there is no going back.'
He admits this can be worrying for radiologists like him who work for a district general hospital and are expected to have a wide range of skills. 'But, in the end, what we should be looking at is what's best for care.'
The department has 13 sonographers totalling 10 whole-time equivalents, each specialising in different areas to ensure the team offers the full range of services.
Training is done with Hertfordshire University, and sonographers undergo continuing professional development. All are deemed enhanced practitioners and paid accordingly.
Superintendent sonographer and administrative lead for ultrasound Karen Wilson says many sonographers welcome the chance to train in new areas. 'Because we offer such a wide scope of ultrasound procedures, people can choose the areas they are interested in.'
As sonographers do most reporting, they have to follow written protocols and guidelines that are reviewed every six months. They can report on abnormalities and suggest further investigations, but they have the option of seeking a second opinion when they need it. This is usually done in team meetings, held twice a week with Dr Moshy to discuss difficult cases.
Sonographer Teresa Sims joined the department three years ago. 'We discuss ideas as a group rather than management simply telling us what to do, ' she says. 'It feels like you really are practising rather than being just a technician.'
Sonographers are also responsible for clinical governance. This includes an extensive quality assurance programme which takes three days a month to complete and provides a check on all the trust's ultrasound machines. Several audits are carried out each year, including patient and GP/consultant feedback about the service provided and peer review of sonographers' scanning abilities.
The reliance on sonographers, also in short supply, has resulted in measures to improve retention and recruitment. Up to one in five sonographers retire from the profession because of physical incapacity from musculoskeletal disorders brought on by scanning. A raft of measures have been introduced to minimise the risk of injury, the most successful being flexi-time.
'The introduction of flexi-time has meant we have not had any sonographer post empty in at least the last six years, ' says Dr Moshy. 'When we have created a new post we have not had to advertise as we often get sonographers writing asking if we have any vacancies.'
Ms Wilson says flexi-time is made easier because in a sonographer-led service, 'you do not have to rely on the radiologist being there'. The result has been a win-win situation: 'Using flexitime has enabled us to increase our throughput. Flexibility for us has translated into flexibility for the patient as appointments can be offered outside normal working hours'.
Chris Feather joined the department as a sonographer last November. 'I was attracted by two things, ' she says.
'The flexible hours and the opportunity to do a wider spectrum of work.'Although she doesn't have children, she has other commitments, including training as a counsellor and MRI work for a private health provider.
'By working longer hours I can reduce my days of working, ' she says.
In her previous job she worked for a department that was 'fairly sonographer-led'.
'But here There is much more of a team approach, ' she says.
'Sonographers do the whole spectrum of work and can choose what to specialise in.You do not get the radiologists keeping all the interesting stuff for themselves.'
Dr Moshy believes the model could be extended to other radiology services across the country.He adds that further developments are in the pipeline. 'Contrast studies of the liver are now being undertaken by sonographers supervised by a radiologist. Eventually, the sonographers may take over the whole of this aspect.'
And although he does not think there is room for sonographers in his trust to do interventional procedures at the moment, he does not rule it out for the future. 'There are radiologists who are beginning to do interventional procedures such as breast biopsies. If It is successful it could be something That is coming.'
Because of a national shortage of radiologists, sonographers in one trust are performing 95 per cent of ultrasound scans.
Using a team approach and flexible working, waiting lists have gone down from 20-24 weeks to four to six weeks for most procedures.
The model could be applied to other radiology departments.
To contribute articles to HSJ's clinical management section, please e-mail ann. dix@emap. com