GOOD MANAGEMENT - SKILL-MIX

Traditional ways of NHS working are being broken down. There is more staff flexibility and diversification of work patterns.

Non-medically qualified medical staff will be increasingly empowered to take on clinical roles, including admission, treatment and discharge of patients.

When requesting diagnostic investigations - involving ionising radiation, ultrasound or magnetic resonance imaging - there are questions about the role of nonmedically qualified practitioners in the multidisciplinary team. For example, will they request examinations to an agreed protocol for the work-up and assessment of patients for transplant or malignancy?

Before ordering any request for an investigation involving ionising radiation, non-medically qualified practitioners have to comply with the ionising radiation medical exposure regulations (IRMER), designed to protect patients from unnecessary radiation during examination or treatment.

The regulations state, for example, that a referring practitioner for a chest x-ray is a medical practitioner, dental practitioner or other health professional entitled by the employer's procedures to refer individuals for medical exposure.

It is the duty of the employer to ensure that procedures are in place to comply with IRMER, which is generally delegated to a named person in the radiology department or to a medical exposures committee of radiologists, radiographers, medical physicists and managers.

Under the regulations, all medical and dental practitioners in a hospital or primary care trust are entitled to act as a referrer. Non-medically qualified staff who want to refer must be approved and identified to the medical exposures committee.

Approval is given if they are familiar with local protocols for the examinations they will request and are aware of the risks. The supervising medical practitioner must take responsibility for ensuring the exact role the non-medically qualified practitioner will have.

But before non-medical practitioners are approved to order x-ray investigations, the radiology department should make an assessment on the future impact this will have on workload. Lack of confidence and experience, for example, may see non-medical practitioners requesting more investigations, although local audit of accident and emergency nurse practitioners has shown they request fewer x-rays than junior doctors.

It is still too early to judge the impact nurse practitioners and other non-medical staff will have on the workload of a radiology department.

There is no national information on how many practitioners have been approved to order investigations. With radiographers and radiologists in short supply, the impact on workload and reporting times is unknown, but it needs to be nationally audited and assessed.