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Breaking the Mould: Roles, Responsibilities and Skills Mix in Departments of Clinical Oncology

Ref No: BFCO(02)6

Board of Faculty of Clinical Oncology

The Royal College of Radiologists

38 Portland Place

London W1B 1JQ

Telephone 020 7636 4432

Fax 020 7323 3100

The Royal College of Nursing

20 Cavendish Square

London W1G 0RN

Telephone 020 7409 3333

Fax 020 7647 3425

The Society and The College of Radiographers

207 Providence Square

Mill Street

London SE1 2EW

Telephone 020 7740 7200

Fax 020 7740 7204

Institute of Physics and Engineering in Medicine

Fairmont House

Tadcaster Road

York YO24 1ES

Telephone 01904 610821

Fax 01904 612279

Citation details:

Board of the Faculty of Clinical Oncology

The Royal College of Radiologists, The Society and The College of Radiographers, The Royal College of Nursing, the Institute of Physics and Engineering in Medicine (2002)

Breaking the mould: roles, responsibilities and skills mix in departments of clinical oncology

Royal College of Radiologists, London.

Email: enquiries@rcr.ac.uk

On publication this document will be made available on the College’s web site: http://www.rcr.ac.uk

ISBN 1 872599 83 4

RCR Ref No BFCO(02)6

© The Royal College of Radiologists, November 2002

This Publication is copyright under the Berne Convention and the International Copyright Convention.

All rights reserved.

This booklet was prepared and published on behalf of the Royal College of Radiologists (RCR). Whilst every attempt has been made to provide accurate and useful information, neither the RCR, the members and Fellows of the RCR nor other persons contributing to the formation of the booklet make any warranty, express or implied, with regard to accuracy, omissions and usefulness of the information contained herein. Furthermore, the same parties do not assume any liability with respect to the use, or subsequent damages resulting from the use of the information contained in the booklet.

Contents

Foreword

Executive Summary

1 Introduction

2 The Team, its Objective and its Members

2.1 The clinical oncology team

2.2 Team objectives

2.3 Team members

2.4 Protocols and guidelines

3 Tasks and Responsibilities

4 Delegation and Referral

4.1 Delegation

4.2 Referral

5 Skills Mix

5.1 Background

5.2 Extended role of clinical technologists, medical physicists, nurses and therapeutic radiographers

5.3 Financial implications of skills mix

5.4 Prescribing of drugs

5.5 Clinical consultations in departments of clinical oncology

5.6 Evidence base for skills mix

5.7 Clinical records

6 Principles of Skills Mix

7 Successful Skills Mix

7.1 Characteristics of high quality inter-professional collaboration and teamwork

7.2 Planning of skills mix

8 Standards of Care

8.1 Patient information

8.2 Consistency of information to patients

8.3 Informed consent

8.4 Confidentiality

8.5 Psycho-social support of patients

8.6 Quality of service

9 Education and Training

10 Communicating with Patients

11 Interface with Primary Care

12 Radiotherapy Planning, Delivery and Verification

12.1 Responsibilities

12.2 Treatment planning team

12.3 Treatment localisation

12.4 Target volume definition

12.5 Plan production

12.6 Authorisation of plan and treatment prescription

12.7 Verification of treatment

12.8 Delivery of radiotherapy treatment

12.9 Dosimetry and quality control

12.10 Maintenance of equipment

12.11 Development of new techniques and equipment

13 Brachytherapy

14 Radionuclide Therapy

14.1 Multi-professional team

14.2 Legislation

14.3 Specific areas of treatment

15 Radiotherapy Patient Review Clinics

Appendix 1: Definition of terms

Appendix 2: Advice from the GMC on good medical practice

References

Foreword

This document has been developed on behalf of this College, the Royal College of Nursing, the Society and The College of Radiographers and the Institute of Physics and Engineering in Medicine. I would like to thank all members of the working party: Dr Ian Kunkler, Chairman; Ms Marjorie Day, RCN; Ms Catherine Hall, IPEM; Ms Janet Shephard, SCoR; Ms Noreen Sinclair, SCoR; Mr Bryan Stubbs, IPEM. This document builds on the first edition (1999)1 and incorporates a revision of Interprofessional Roles and Responsibilities in a Clinical Oncology Service (1999)2. It seemed logical to amalgamate these two documents as they shared much common ground. New elements in the current edition are: radiotherapy planning, delivery and verification; dosimetry and quality control; maintenance of equipment; brachytherapy; radionuclide therapy; and the interface between departments of clinical oncology and primary care.

I would like to acknowledge Dr Roger Buchanan, immediate past Dean of the Faculty of Clinical Oncology, Dr Jane Maher and Dr Ian Driver for their valuable contributions to the working party and Jackie Henshaw, Faculty Board Secretary for Clinical Oncology for her assistance in preparing successive drafts.

Professor Ann Barrett

Dean

Faculty of Clinical Oncology

Executive Summary

Summary of Recommendations

  • Each department of clinical oncology must:
  • Clearly define the roles and responsibilities of members of its team.
  • Review the application of skills mix to improve the quality of patient care.
  • Develop new roles crossing traditional professional boundaries and widen opportunities for professional development.
  • Develop multi-professional radiotherapy treatment planning teams.
  • Extend the role of staff to improve communications with patients.
  • Encourage the development of competency-based multi-professional training to develop core skills shared across a range of health care professionals.
  • Identify the necessary resources to implement and audit skills mix.
  • Develop written agreed protocols on skills mix.
  • Ensure patients are fully informed about the roles of staff involved in their care.
  • Constantly monitor the development and maintenance of skills.
  • Develop new roles that cross existing boundaries, including the provision of care (e.g. between primary and tertiary care).
  • Encourage extension of roles in radiotherapy planning, delivery, “on treatment” review and follow-up.

1 Introduction

1.1 In this document we aim to enhance patient care by (i) defining aspects of working relationships between professionals who provide a clinical oncology service to patients and (ii) describing the application of skills mix. With the increasing development of multidisciplinary working and competency-based occupational standards there are opportunities to make better use of skills within the clinical oncology team for the benefit of patients.

1.2 Traditional roles and responsibilities need to change if the potential gains of skills mix are to be realised. Reflecting the interdependence between skills mix and professional roles and responsibilities we have brought together revisions of guidance in these areas1-3 in a single document. In early chapters we deal with roles and responsibilities and in subsequent chapters with the principles and application of skills mix.

1.3 Substantial changes in skills have already occurred in many departments of clinical oncology. However, to deliver the ambitious targets of reducing cancer mortality within the resources available, the pace of change in skills mix needs to be accelerated. We hope that this document will stimulate departments of clinical oncology to undertake a fundamental review of skills mix and/or extend its application into new areas.

1.4 In all considerations the welfare of the patient is paramount. The introduction of skills mix initiatives should not diminish the quality of service to the patient or compromise patient safety.

1.5 Where the practice of a professional member of the clinical oncology team extends beyond that established by custom and practice, written protocols defining new roles and responsibilities are essential.

1.6 Skills mix, by definition, looks only at the skill factor in the work force.4 It is based on a critical assessment of service needs, both now and in the future, in order to ensure an optimum distribution of particular skills amongst the workforce, so that a cost-effective service can be provided. It may result in changes in the roles that individual health care professionals play in the delivery of patient care.

1.7 Within departments of clinical oncology we have a rich resource of skills and experience. However traditional inter-professional boundaries often limit optimal use of these skills for the benefit of patients. If these constraints are set aside and competency becomes the main criterion for undertaking particular tasks, the clinical oncology service could be radically redesigned. For example the demands and complexities of conformal radiotherapy and intensity modulated radiotherapy provide opportunities for harnessing the skills of the clinical oncology team in new ways.

1.8 In order to ensure progress and improve patient services the following questions need to be addressed in all departments.

  • Could the clinical technologist, medical physicist or therapeutic radiographer, if trained in the interpretation of cancer imaging, become involved in clinical target volume definition?
  • If variations in the definition of target volume are a major factor in influencing local control, should the radiologist become a member of the radiotherapy planning team?
  • If therapeutic radiographers and nurses have the daily experience of observing skin reactions, are they not best placed to run “on treatment” review clinics?
  • If equipped with the necessary examination skills, could they examine the irradiated site?

1.9 Oncologists have taken a more strategic role in the management of patients by chemotherapy and nurses play an increasing role in its delivery. A similar principle might apply to radiotherapy with clinical technologists, medical physicists and therapeutic radiographers extending their roles in the delivery of radiotherapy.

  • Could therapeutic radiographers undertake independently the planning of all types and schedules of external beam palliative radiotherapy?
  • Could specialist nurses look after patients both in primary care and hospital settings, managing a caseload jointly with the clinical oncologist?
  • Could they or experienced medical secretaries undertake most of the direct liaison with patients and their general practitioners keeping them up to date with the results of investigations and progress through radiotherapy?
  • Do we need to restructure the training of members of the clinical oncology teams and develop multi-professional training in the cancer sciences?
  • Could helper roles be developed as an initial step in the career ladder providing an alternative pathway of entry?
  • Could these roles be developed and integrated with a clear pathway for career development?

1.10 Clearly there are some limits to the changes in roles that can be made and we allude to these where appropriate. However this document seeks to redraw some of the boundaries. Innovative models of workforce planning (Jane Maher, personal communication) will be needed to facilitate skills mix. We hope that departments of clinical oncology will be bold in rethinking the delivery of the clinical oncology service for the benefit of patients.

1.11 This document concentrates on the radiotherapy process but follows the patient’s cancer journey from (i) primary care, (ii) through the first consultation, (iii) to advice on treatment, treatment planning and delivery, (vi) through “on treatment” review, (v) to post-treatment surveillance. Appendix 1 provides a definition of the terms used in this document and Appendix 2 lists relevant statements from General Medical Council (GMC) guidance.

1.12 This document will be reviewed by the RCR Faculty of Clinical Oncology in 2005.

2 The Team, its Objective and its Members

2.1 The clinical oncology team

The purpose of a clinical oncology service is to provide high quality treatment for patients referred to it. The delivery of this service requires the expertise of individuals drawn from various professional and other groups. The team requires a proper mix of skills and knowledge; it also requires the maintenance of such expertise by each individual member of the team, because an individual must undertake a task only when competent to do so. The individual responsibilities of team members are interdependent and collectively enable delivery of the clinical oncology service.

In order for this model of service to be achieved there is a need to change traditional divisions of function between staff. The pyramidal structure, with the consultant at its apex, should be adjusted to a more broadly based multi-disciplinary team in which each member of the team would contribute to the management of care. In this new model, medical practitioners would continue to have the principle role in the assessment of new patients and advising on their management. They would also retain responsibility for the care of the patient. Non-medical members of the team would play an increasingly important role in the delivery of radiotherapy, monitoring treatment reactions and assessing the outcome of treatment.

2.2 Team objectives

There are medical, clinical and management objectives.

2.2.1 Medical and clinical objectives will be determined by the medical problem presented by the patient. The medical and/or clinical roles of each team member are regulated by the relevant statutory bodies and are defined by the team in the light of guidance from their professional organisations. These roles should be agreed with the employer(s). Individual team members each bear responsibility for their own activities, whether medical or otherwise, and this responsibility cannot be transferred from one individual to another.

2.2.2 Management objectives are directed towards delivering an efficient and effective service. Local management arrangements will vary. Where aspects of management require the skills of particular individuals within the team, such persons may, by agreement, assume responsibility for their delivery.

2.3 Team members

Clinical oncology services are provided by a multi-disciplinary team consisting of individuals with differing competencies and levels of training.

2.3.1 Medical practitioners will possess a medical degree and will be registered with the GMC. Clinical oncologists will have undergone a formal programme of specialist postgraduate medical education and will be entered on the Specialist Medical Register. Other medical specialists, such as medical oncologists and radiologists, may be involved in the provision of a clinical oncology service and will also be appropriately trained.

2.3.2 Other clinical staff involved in the provision of a clinical oncology service will be non-medical health care professionals, these include clinical technologists, medical physicists, nurses, pharmacists and therapeutic radiographers. They will normally be members of a profession regulated by a statutory body and will have received training to graduate or postgraduate level. They will be competent to perform various clinical tasks, and will thus be in a position to contribute to the care of patients attending a clinical oncology service.

2.3.3 Non-clinical staff within a clinical oncology service include secretarial and administrative staff, receptionists, porters, and voluntary workers. They will have been trained to perform various non-clinical tasks.

2.4 Protocols and guidelines

Departmental protocols and guidelines, drawn up by medical and other clinical practitioners consulting together, are necessary for tasks to be performed in such a way as to achieve team objectives. The employing authority must approve these.

3 Tasks and Responsibilities

3.1 A medical task is a task requiring the knowledge and skills of a registered medical practitioner. It may be delegated or referred to another medical practitioner.

3.2 Medical responsibility may be borne only by a medical practitioner and transferred, by referral, only to another medical practitioner.

3.3 A clinical task is a task requiring the knowledge and skills of a registered medical practitioner or other clinical practitioner. It may be delegated or referred to either another registered medical practitioner or to another clinical practitioner.

3.4 Clinical responsibility may be transferred by a process of referral to either a registered medical practitioner or to another clinical practitioner.

3.5 A non-clinical task is any task not requiring the knowledge and skills of a registered medical practitioner or of a clinical practitioner. It may be undertaken by any suitably competent health care worker.

3.6 Tasks undertaken by professionals in a multi-disciplinary team are limited by statute, by the requirements of the appropriate statutory regulatory bodies and by the terms of employment which define lines of accountability.5-7 They are informed by guidance from the relevant professional organisations. Within these limits the team collectively apportions tasks as appropriate to the service. In practice there will be tasks that could equally well be carried out by medical or non-medical members of the team.

3.7 The patient should always be informed of the name and status of the person performing a task which forms part of the clinical oncology service.

3.8 Skills mix may result in changed roles for individual employees. It is the duty of the employer to ensure that the individual is appropriately qualified and competent to undertake that role. Appropriate education and training, resources and support should be provided. Where changes in skills mix have been agreed with employers, the employer is liable for acts of commission or omission. Where these changes have not been explicitly agreed with the employer, the employee rather than the employer is liable.

3.9 Of necessity some tasks will demand specific skills, knowledge and training and must be performed by specific staff groups.

3.10 The requirement of the Manual of Cancer Services Standards8 that all staff working in a radiotherapy department shall be accountable to the clinical director of the radiotherapy service is recognised.

3.11 The responsibility for scientific standards and scientific management should be vested in a clinical scientist appointed as the Head of Radiotherapy Physics.7,9

3.12 Any review of roles or structures of accountability must reflect statutory requirements and recognise that each staff group involved in the radiotherapy service brings their own particular expertise to the specialty.

4 Delegation and Referral10

4.1 Delegation

By the current GMC definition:

Delegation involves asking a nurse, doctor, medical student or other health care worker to provide treatment or care on your behalf. When you delegate care or treatment you must be sure that the person to whom you delegate is competent to carry out the procedure or provide the therapy involved. You must always pass on enough information about the patient and the treatment needed. You will still be responsible for the overall management of the patient.

Delegation requires that:

  • the person to whom the task is delegated is competent;
  • the process is defined in a protocol agreed by the delegator, the person to whom the task is being delegated and the relevant employer(s);
  • the process and outcome are monitored, and that this process is then modified should this be found necessary;
  • the person to whom the task is delegated assumes responsibility for it, except that the medical responsibility for the patient remains with the delegating medical professional.

4.2 Referral

4.2.1 By the current GMC definition:

Referral involves transferring some or all of the responsibility for the patient’s care, usually temporarily and for a particular purpose, such as additional investigation, care or treatment, which falls outside your competence. Usually you will refer patients to another registered medical practitioner. If this is not the case, you must be satisfied that such health care workers are accountable to a statutory regulatory body, and that a registered medical practitioner, usually a general practitioner, retains overall responsibility for the management of the patient.

4.2.2 Referral requires that:

  • the person to whom the task is referred is competent to undertake the task;
  • the process is defined in a protocol agreed by the referrer, the person to whom the task is referred and the relevant employer(s);
  • the process of referral and its outcomes are monitored, and that this process is then modified should this be found necessary;
  • the person who accepts a referral assumes responsibility for his or her action consequent upon the referral;
  • the medical responsibility remains with the referring medical practitioner or the medical practitioner in overall charge of the patient, unless the responsibility is assumed by a medical member of the team to whom the patient is referred.

5 Skills Mix

5.1 Background

National developments in cancer services that encourage skills mix

5.1.1 Major organisational changes are in progress to improve the quality of cancer services for patients in the UK. The Calman–Hine policy framework for commissioning cancer services in England and Wales11 and its equivalents in both Scotland12 and Northern Ireland13 have emphasised the value of multi-disciplinary teams for delivering improved outcomes to patients. It is suggested that this could be achieved through an integrated approach resulting in cohesive and patient focused care. Clinical networks are the new structures within which cancer services will be delivered. Such an integrated approach to the delivery of care was also seen as key to achieving improvements in the quality of cancer care within the resources available.

5.1.2 The recommendations of the Calman–Hine report11 concerning the delivery of care by non-medical specialist staff identifies the need for specialist education in this area and the availability of staff functioning at different levels of expertise. This will lead to a more comprehensive service for patients with cancer ensuring access to a structured team incorporating: (i) registered nurses and specialist cancer nurses; (ii) medical physicists and clinical technologists; (iii) therapeutic radiographers.

5.1.3 The NHS White Paper The New NHS: Modern Dependable14 endorsed the Calman–Hine collaborative team model as the framework of choice for delivering cost-effective, high-quality health care in the future.

5.1.4 Clinical governance, a concept referred to in the Government’s White Paper,14 provides the framework within which the quality of care can be maintained and improved. It will lead to improved clarity around the criteria that underpin professional competence and standards of best practice. This will require more openness about the skills and knowledge of professionals and increasing their responsibility and accountability for meeting standards necessary to deliver cancer services.

5.1.5 The development of occupational standards will formalise the competencies necessary to carry out particular tasks, within the cancer framework, currently undertaken by clinical oncologists, clinical technologists, medical physicists, nurses and therapeutic radiographers.15

5.1.6 The NHS Cancer Plan for England: a Plan for Investment16 identifies inflexible demarcation between different professional groups in oncology preventing the most effective use being made of the skills and potential of the workforce. Major shortages of cancer professionals including clinical oncologists, medical physicists and therapeutic radiographers were highlighted. In addition to proposing investment in expanding training and recruitment of these professional groups, the report explicitly endorses the use of skills mix to empower staff, increase autonomy and job satisfaction.

5.1.7 The NHS Cancer Plan16 acknowledges that “people with cancer spend much more of their time living in their own homes than in a hospice”. Health care professionals working within the primary care setting will therefore be the first and usually the last point of call on the patient’s cancer journey.

5.1.8 A report, the Nursing Contribution to Cancer Care17 emphasises the importance of nurses to the delivery of care to patients through improvements in workforce planning, organisation of services, career pathways, training and continuing professional development.

5.1.9 The Society and The College of Radiographers in their document, A Strategy for the Education and Professional Development of Therapeutic Radiographers18 has proposed a new tiered structure. This should enable more experienced radiographers to extend their roles. A series of national pilot sites supported by central NHS funding has been established for the application of skills mix in therapeutic radiography.

5.1.10 A report on the future delivery of services by health care scientists, Making the Change: a Strategy for the Professions in Healthcare Science19 which is relevant to medical physicists and clinical technologists, emphasises the importance of team-working across professional and organisational boundaries and flexible working to make best use of the range of skills and knowledge of members of staff.

5.1.11 The National Cancer Plan for Scotland: Action for Change20 aims to offer patients greater flexibility in how they access their care by optimising the use of skills of the whole health care team.

5.1.12 A combination of clinical, epidemiological, professional, governmental and educational factors are driving the need for skills mix in clinical oncology. These include:

  • the opportunity to improve patient care;
  • the target of the National Cancer Plan16 to shorten the time between referral of a patient by a general practitioner to treatment to 2 months;
  • an ageing population21 and consequent increased workload;
  • the need to minimise delays and reduce gaps in radiotherapy treatments;22
  • increased expectation of quality of care among patients;
  • changes in health care legislation;
  • the need for information to be shared between health care professionals for effective, efficient and safe patient care;
  • changes in the roles of medical staff, for example taking on new roles in hospital management (in addition there has been a reduced service required of junior doctors due to a reduction in hours of work23 and an increased commitment to postgraduate education and training);24
  • acknowledgement of the high levels of skills vested in non-medical health care professionals (e.g. clinical technologists, medical physicists, nurses, therapeutic radiographers);
  • reform of initial and continuing health care education programmes to include more inter-professional learning will facilitate and support skills mix;25
  • increased freedom allowed to Trusts to develop skills mix in the interests of patient care.

5.1.13 Given the changes outlined, it is becoming increasingly important that departments of clinical oncology clearly identify the key skills required to deliver current and future services.

5.2 Extended role of clinical technologists, medical physicists, nurses and therapeutic radiographers

Nationally, the development of clinical technologists, medical physicists, nurses and therapeutic radiographers with specialist competencies, has been driven by local service demands. However individual specialist posts do not address the underlying problem of inflexibility caused by utilisation of the workforce in accordance with strict professional boundaries. Effective multidisciplinary team working requires that the skills of all members are maximised and utilised for the benefit of the patient.

5.3 Financial implications of skills mix

The main aim of any review of skills mix should be improved cost-effective patient care rather than reduced costs, as changes in skills mix may not result in financial savings. For example the substitution of highly experienced nurses for junior doctors to undertake certain tasks may prove more expensive.26

5.4 Prescribing of drugs

The extension of prescribing and dispensing drugs according to locally agreed written protocols to non-medically qualified members of the clinical oncology team should facilitate the application of skills mix.27,28

5.5 Clinical consultations in departments of clinical oncology

It is essential that members of the multidisciplinary team provide consistent information about the principles, delivery and side-effects of radiotherapy.

5.6 Evidence base for skills mix

It is recognised that the evidence base for skills mix is weak in many areas. However this does not preclude the development of skills mix where the appropriate competencies have been demonstrated to undertake particular tasks.

5.7 Clinical records

5.7.1 The importance of maintaining high quality multi-professional clinical records in any change in skills mix is emphasised.

5.7.2 The use of electronic medical records should be encouraged to facilitate access at all times to relevant clinical information to all members of the team.

6 Principles of Skills Mix

6.1 A number of principles should govern the implementation of skills mix. The following principles also draw on and incorporate the operational standards on “skill sharing” issued by the Royal College of Physicians of London and the Royal College of Nursing29,30 and the report of the Scottish Royal Colleges on “skills mix”.31

6.2 Skills mix should be patient-focused in that its primary purpose should be to maintain and continue to improve standards of patient care.

6.3 Changes in skills mix should be compatible with the professional and statutory responsibilities of individual health care professionals within the multidisciplinary team.

6.4 Skills mix should focus on the competencies, skills and knowledge of the individual professional rather than their job grade.

6.5 Appropriate initial and continuing education and training programmes, which incorporate both practice and theory, should underpin all roles. These should relate to work-based competencies and should be accredited both professionally and academically in accordance with professional body policies.

6.6 The development of protocols is vital. Skills mix widens the range of health care professionals who can take responsibility for the care of the patient. There must be agreed written protocols that define the role and responsibilities of health care professionals. These should be comprehensive documents, which give a framework for practice, including the sharing of patient information, and should include agreed mechanisms for the regular review and audit of practice. The relevant authority within the Trust must approve all protocols before any change in skills mix occurs.

6.7 Responsibilities for clinical procedures or decisions must be clear to patients and staff.

7 Successful Skills Mix

7.1 Characteristics of high quality inter-professional collaboration and teamwork

Collaboration needs to include attainable shared vision, clear stated objectives with mutual support, effective participation, task orientation, and an appropriate information and management structure with adequate support for innovation.

7.2 Planning of skills mix

In planning changes in skills mix it is important to achieve:

  • clear lines of responsibility;
  • effective training;
  • inter-professional co-operation;
  • co-ordination of care;
  • co-ordinated expert advice and/or supervision;
  • multi-skilling to avoid duplication of roles;
  • defined resources to implement and audit skills mix.

8 Standards of Care

8.1 Patient information

When skills mix is changed it is important that the role of each of the members of the team is clearly explained to the patient at the first consultation with the doctor. This is to ensure that there is no disparity between the patient’s expectation of care and its actual delivery.

8.2 Consistency of information to patients

The agreed plan of care needs to be disseminated effectively within the multi-disciplinary team. There should be well-defined policies/protocols for handling common problems (e.g. on skin care during radiotherapy).

8.3 Informed consent

Consent should be obtained for all clinical procedures. Patients are entitled to receive sufficient information in a way that they can understand about the proposed treatments, the possible alternatives and any substantial risks so that they can make an informed judgement. Consent should be obtained by an appropriately qualified member of the team in accordance with agreed procedures that are specified within the protocol and within the GMC guidance.32

8.4 Confidentiality

All members of the clinical oncology team must treat personal information about patients as confidential in accordance with the codes of practice of their professional bodies.5,6,33

8.5 Psycho-social support of patients

Changes in skills mix should aim to maintain and improve the psychosocial support available for patients and their carers. Patients may require specialist support of a clinical psychologist or psychiatrist from outside the cancer centre or cancer unit if not locally available. There should be close consultation between these specialities and account taken of their specialist skills during any changes in skills mix.

8.6 Quality of service

Standards of care should be regularly audited against nationally recognised and locally agreed clinical standards. The skills required to achieve these standards should be recognised as part of any formal quality improvement programme and should be supported by appropriate continuing professional development. Appropriate resources are required to support this.

9 Education and Training

9.1 All health care professionals caring for patients with cancer must be appropriately qualified and competent to undertake the tasks that they perform.

9.2 The development of skills mix should not compromise the acquisition and retention of the core skills of the individual professional.

9.3 Specialist registrars have always received part of their training from clinical technologists, medical physicists, nurses and therapeutic radiographers. This should continue. Consideration should be given during the implementation of changes in skills mix to the likely effect that this would have on training. The changes should be seen as beneficial to specialist registrars rather than to reduce their training and experience.

9.4 The changes in skills mix proposed should not be influenced to any extent by the current shortage of consultant clinical oncologists for England and Wales to be addressed by 2008/2009.16 The proposed changes in skills mix should again be seen as beneficial to the consultant’s continuing professional development and not lead to any significant reduction in skill and experience.

9.5 These changes should increase the involvement of the doctor in the radiotherapy planning and treatment team rather than distance the doctor from some of the key decisions.

9.6 Successful skills mix is dependent upon a shared commitment to the maintenance and extension of competence in the individual through appropriate continuing professional development. There is a case for education and training to be shared between professionals but it is recognised that the value of some aspects of multidisciplinary education and training have to be established.

9.7 The skills and competence necessary to carry out particular roles should be continually monitored in accordance with advice from professional bodies and in line with their procedures.

9.8 Certain roles, for example intravenous cannulation by therapeutic radiographers and nurses, require skills training with theoretical underpinning, followed by assessment of competency before they can be practised. Some Trusts and local employing authorities may licence individuals to undertake such roles in-house. However the setting of clinical standards is a function of the professional body. Therefore professional bodies are able to offer national accreditation as opposed to in-house, non-transferable accreditation of individual Trusts.

9.9 Training in curative/palliative cancer care to a universally accepted minimum level should be encouraged in both community and hospital settings.

10 Communicating with Patients

10.1 It is of considerable importance to patients and their general practitioners to receive timely and accurate information about the clinical management of the patient while under the care of a department of clinical oncology. Particular anxieties are caused to patients awaiting the results of investigations.

10.2 In close consultation with medical staff, consideration should be given to extending the roles of cancer professionals including nurses, radiographers and medical secretaries in communicating with patients, informing them of the results of hospital investigations, co-ordinating appointments for staging and treatment and assessing the need for medical review.

10.3 The types of information that may be communicated to patients by non-medical staff should be agreed by the clinical oncology team and defined in written protocols.

10.4 Medical secretaries play a key role in supporting the work of senior and junior medical staff and are the first point of contact for patients within departments of clinical oncology. Suitably experienced secretaries could extend their role in notifying patients of the results of some investigations and co-ordinating administrative aspects of multidisciplinary clinics, staging investigations and treatment appointments.

10.5 Formal training in communications skills should be considered an essential part of the training of staff undertaking an extended role in communicating with patients or health care professionals.

11 Interface with Primary Care

11.1 The appointment of lead cancer clinicians within primary care organisations should enable links with departments of clinical oncology and primary care to be developed and provide support for patients in both community and hospital sectors. These posts should provide better continuity of care for patients.

11.2 While most anti-cancer treatment is predominantly hospital based, primary care staff may have to deal with the toxicities of treatment and symptom control. Managing these side-effects in the community would be advantageous. For example, general practitioners and community nurses wishing to play a greater role in dealing with toxicity of treatment and symptom control could share appointments between primary care and departments of clinical oncology. Such staff might play a role in outpatient consultations for new patients, participation in multidisciplinary meetings, monitoring of treatment reactions and post-treatment surveillance.

11.3 Similarly there is scope for nurses or therapeutic radiographers, from within departments of clinical oncology, to extend their role into the community.

11.4 There needs to be commitment from managers in primary care and departments of clinical oncology to provide relevant training, work placements and support for staff wishing to extend their roles from primary into secondary care and vice versa.

12 Radiotherapy Planning, Delivery and Verification

12.1 Responsibilities

12.1.1 These recommendations do not intend that any particular staff group carry out any particular task in preference to any other staff group, so long as:

  • the requirements of the Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R)34 and associated guidance35 with respect to the definition of referrers, practitioners, operators and medical physics experts are observed;
  • those involved in the different aspects of pre-treatment planning have the training and competencies to undertake these tasks;
  • those involved in the definition of target volume and organs at risk work under the overall responsibility of the consultant clinical oncologist and those involved in preparing treatment plans would work under the overall responsibility of a medical physics expert (radiotherapy).9

12.1.2 It is anticipated that professionals from the following groups, and occasionally trainees, might interact with the patient at some stage during this part of the pre-treatment process: clinical oncology, clinical technology, diagnostic imaging, medical physics and therapeutic radiography.

12.2 Treatment planning team

12.2.1 It is in this area of the patient’s management pathway that the patient is likely to meet the greatest variety of professional groups, consequently communication channels are extremely important and continuity of patient care should have the highest priority. If skills mix is to be applied most effectively to these areas, it is recommended that a multi-professional treatment planning team be established. The judicious use of the appropriately skilled personnel within the team will promote inter-professional working, maximise resources and focus the exercise on the patient rather than individual processes.

12.2.2 The role of the dosimetrist within the treatment planning team, irrespective of professional qualification, should be encouraged.

12.3 Treatment localisation

12.3.1 Immobilisation of the patient is paramount and when this requires a specific beam directional device, an insight is needed into the proposed treatment plan for the individual patient. Appropriate competencies will be required of professionals working in a mould room environment, including an adequate understanding of the principles and processes of radiotherapy, patient care, communication skills, technical ability, innovation, and manual dexterity.

12.3.2 Localisation of the tumour volume and organs at risk will require a knowledge of a wide variety of imaging modalities, including computed tomography, magnetic resonance imaging, ultrasound, radionuclide imaging and positron emission tomography.

12.3.3 An appropriately trained member of staff should administer radiographic contrast, if required, according to agreed protocols.

12.4 Target volume definition

12.4.1 The definition of the gross tumour volume, clinical target volume, planning target volume and organs at risk remain the responsibility of the clinical oncologist.36

12.4.2 While the responsibility for the definition of target volumes and organs at risk rests with the clinical oncologist, the process of outlining may be carried out by other suitably trained members of the treatment planning team, in accordance with recommended written protocols and within the context of current legislation, regulations and policies. Specific examples of such existing practice are the production of planning target volumes for prostate and outlining organs at risk such as the spinal cord or lens of the eye.

12.4.3 Staff will be required to show evidence of: (i) a high level of academic knowledge regarding anatomy, tumour behaviour patterns and radiobiology; (ii) clinical competencies associated with recognition of both normal anatomy, normal variants and pathology, radiological anatomy; and in interpretation of orthogonal and cross-sectional imaging.

12.4.4 Acquisition of patient outline and subsequent accurate identification of target volume and organs at risk are essential elements in pre-treatment preparation and must be accomplished by suitably trained and competent staff. These processes must be defined by protocols.

12.4.5 Currently the process of localisation is limited by adherence to traditional roles. The application of skills mix to this process will have benefits in terms of greater efficiency, promotion of inter-professional working and improvement in the quality of patient care.

12.5 Plan production

12.5.1 A medical physics expert has responsibility for determining the range of clinical applicability of the treatment planning system algorithms and for authorising use of the treatment planning system for clinical practice.

12.5.2 Treatment plan production and checking should be effected by suitably qualified staff, under the scientific supervision of a medical physics expert (radiotherapy) in any respect which might involve the physics content of the plans.9

12.6 Authorisation of plan and treatment prescription

12.6.1 The consultant clinical oncologist, (or deputy) must, prior to the first fraction of a radical treatment, authorise the treatment plan.

12.6.2 Localisation and prescription of palliative radiotherapy, whether a single fraction or a fractionated course, may be carried out by a clinical oncologist or a therapeutic radiographer, working to agreed protocols.

12.7 Verification of treatment

12.7.1 Verification of treatment field placement may be undertaken on the treatment unit, or in the simulator, by an appropriately trained and competent member of staff.

12.7.2 Locally agreed protocols should specify this important step in the radiotherapy process and should state the frequency of portal imaging and the arrangements for comparing these images with the “gold standard” (simulator or digitally reconstructed radiographs).

12.7.3 The role of in vivo dosimetry should be identified in the local verification protocols.

12.8 Delivery of radiotherapy treatment

12.8.1 Therapeutic radiographers are responsible for the operation and management of the external beam treatment machines and the training and supervision of trainees and assistant practitioners working within the team.

12.8.2 Any changes to equipment or treatment technique, which may affect the dose delivered to the patient, must be authorised by a medical physics expert (radiotherapy) and clinical oncologist as appropriate.

12.8.3 A medical physics expert (radiotherapy) has responsibility for developing and authorising for clinical use the data set and documentation including the system of charts used for calculating monitor unit settings and treatment times for the treatments of individual patients.

12.9 Dosimetry and quality control

12.9.1 The dosimetric and geometric accuracy of radiotherapy equipment is of paramount importance in determining treatment outcomes. Medical physics experts (radiotherapy) are responsible for providing the framework of radiation dosimetry (including the interpretation of national dosimetry codes of practice and the application of these to local radiotherapy equipment), treatment planning algorithms and treatment machine quality control that enable the team of clinical technologists, oncologists, therapeutic radiographers, medical physicists to practise safe, state-of-the-art radiotherapy. However, adequately trained clinical technologists or therapeutic radiographers may perform routine checks of dosimetric and geometric accuracy according to local protocols established by a medical physics expert (radiotherapy).

12.9.2 A comprehensive guide to the physics aspects of quality control in radiotherapy has been published by IPEM.37

12.10 Maintenance of equipment

12.10.1 Effective planned preventative maintenance and repair arrangements must be established to ensure that radiotherapy equipment is safe and suitable for clinical use. Maintenance and repair may be carried out by manufacturers or an in-house service repair team or a combination of both working in partnership. The Medical Devices Agency has published guidance on equipment management in Medical Devices and Equipment Management for Hospital and Community-based Organisations (DB9801)38 and Medical Devices and Equipment Management: Repair and Maintenance Provision (DB2000(02)).39 In all cases, the medical physics expert (radiotherapy) is responsible for ensuring that adequate quality control checks are carried out following any planned preventative maintenance or repair work, prior to the equipment being handed back for clinical use.

12.10.2 A medical physics expert (radiotherapy) has responsibility for those areas which have an effect on the delivery of radiation treatment to patients, although measurements may be carried out by clinical technologists, medical physicists or therapeutic radiographers who are designated as operators under IR(ME)R.34 Any operator in the team may make an interim decision to withdraw equipment from clinical use. The decision to hand over a piece of radiotherapy equipment for clinical use after a repair which might affect the safety or accuracy of the equipment must be made by a medical physicist. Ultimate responsibility for these arrangements lies with the medical physics expert (radiotherapy).

12.11 Development of new techniques and equipment

The provision of a state-of-the-art radiotherapy service requires the ongoing development and introduction of new techniques and equipment. Such developments require the advice of the clinical oncologists, clinical technologists, medical physicists and therapeutic radiographers involved in the provision of the service.

13 Brachytherapy

13.1 The quality of brachytherapy is dependent on the skills of the operator which require a high standard of dexterity. The RCR in its publication The Role and Development of Brachytherapy Services in the UK40 recommends “the recognition of designated staff for specific brachytherapy-related roles”. It also recommends the appointment of a Clinical Director or Lead Clinical Oncologist for Brachytherapy to co-ordinate services.

13.2 Brachytherapy involves a multi-professional team including clinical oncologists, clinical technologists, diagnostic radiographers, medical physicists, nurses, radiologists and therapeutic radiographers.

13.3 This team needs to cover the range of tasks necessary to treat a patient with brachytherapy. These include compliance with legislation, source ordering and preparation, patient preparation, nursing care, target localisation/definition, treatment planning, applicator/source positioning, imaging, dose calculation, source/applicator removal and cleaning, radiation protection, quality assurance and source stock management.

13.4 There are also several patient related tasks in addition to source insertion such as giving information, counselling and follow-up that need to be considered in drawing up appropriate protocols.

13.5 The application of skills mix in this area should be considered, agreed and documented by the multiprofessional team taking note of appropriate legislation e.g. the Ionising Radiation Regulations 1999 (IRR99)41 and IR(ME)R.34 In particular the clinician responsible for justifying the administration of brachytherapy must possess a site-specific Administration of Radioactive Substances Advisory Committee (ARSAC) certificate.42

13.6 It would be expected that only a clinical oncologist would undertake any invasive procedure but procedures such as vaginal applicator insertion could be undertaken by other staff groups after appropriate training and assessment of competency.

13.7 Other interstitial implants such as prostate and iridium wire implants as well as manual gynaecological insertions will be performed by a doctor.

13.8 Treatment plan production and checking should be done by suitably trained staff, under the scientific supervision of a medical physics expert (radiotherapy) in any respect which might involve the physics content of the plans.

13.9 The operation of remote afterloading equipment and initiating treatment should be done by staff trained to operate the equipment and who understand the treatment plan for that patient. This will include clinical technologists and therapeutic radiographers. For low and medium dose-rate afterloading equipment other staff, usually ward nurses, after appropriate training and assessment of competency, may interrupt and restart treatments to check on or deliver care to the patient.

14 Radionuclide Therapy

14.1 Multi-professional team

Radionuclide therapy is normally carried out by a large multi-professional team made up of radiopharmacists, medical physics experts (radiotherapy), radiographers, clinical technologists, nurses and clinicians with expertise in radionuclide therapy involving radiopharmaceuticals (see legislation below). Such clinicians would usually be from the following specialties: clinical oncology, endocrinology, haematology and rheumatology. Many of the tasks involved in the administration of the appropriate treatment can be carried out by more than one staff group provided that the role of each particular staff group within the team has been considered, agreed and documented. Of necessity some of the tasks will demand specific skills (see below).

14.2 Legislation

The Medicines (Administration of Radioactive Substances) Regulations,43 IRR9940 and IRMER,34 in particular, define areas of responsibility but these do allow delegation of specific duties under written protocols. The clinician responsible for justifying the administration of the radionuclide therapy (the practitioner-IR(ME)R)34 will possess a site-specific ARSAC43 certificate for the treatment to be administered. The employer is responsible for the provision of written procedures supported by a suitable quality assurance programme while staff acting as operators have responsibility for the practical aspects that they undertake. Expert physics advice should be available35 during radionuclide therapy procedures. The employer will also appoint a radiation protection advisor who will advise on IRR9940 and the Radioactive Substances Act.44

14.3 Specific areas of treatment

14.3.1 Pre-treatment planning

Whilst many treatments are given as a standard activity, a pre-therapy, dosimetric study may be required in order to calculate the activity required to deliver a specific dose to the target organ or in some cases limit the radiation dose to other sensitive tissues. In these cases a series of quantitative diagnostic investigations may be carried out to determine tissue uptake and residence time in the target organ. Image acquisition and processing skills along with an in-depth knowledge of radionuclide dosimetry protocols are essential for this work, which is usually carried out by a small team comprising clinical technologists or radiographers and medical physicists.

14.3.2 Radiopharmaceutical preparation

The identification of the appropriate radiopharmaceutical should be carried out by a member of staff with a practical knowledge of its use. Preparation of the radiopharmaceutical, including measurement of activity, requires dexterity, an understanding of radiological protection issues and competence in pharmaceutical handling—often in sterile conditions.

14.3.3 Treatment delivery

Various routes can be used to deliver radionuclide therapy (oral, intravenous, intra-articular, intra-cavitary) and different levels of skill will be required accordingly. In all cases the safety of both the patient and the members of staff is paramount. Those involved in the preparation and administration of the radiopharmaceutical will do so as operators under IR(ME)R34 and should have full documented training in the practical aspects that they undertake.

14.3.4 Radiation protection issues

Radiation protection issues: the ARSAC licence holder should ensure that sufficient information regarding patient circumstances has been gathered so that a risk assessment can be completed. The employer’s written procedures should include a requirement that the implications of the treatment are explained to the patient. Any professional involved in such communication with the patient must have a thorough knowledge of current legislation, radionuclide and pharmaceutical properties and basic radiation protection principles. The radiation protection adviser is responsible for scrutinising and countersigning all ARSAC applications from doctors. In general, radiation protection issues should be tackled prospectively and proactively especially when other staff groups (e.g. junior doctors, nurses, hospice workers, carers) are likely to be involved. This should include procedures that define areas of responsibility and lines of communication both between the different staff groups and with the patient.

15 Radiotherapy Patient Review Clinics

15.1 Traditionally a doctor has reviewed patients in most departments on a weekly basis during a course of radical or palliative radiotherapy. Under a system of appropriate delegation, for some common radical and palliative radiotherapy schedules, suitably trained nurses or therapeutic radiographers could undertake some or all of “on-treatment” review. It would be the responsibility of the therapeutic radiographer or cancer nurse to report unduly acute radiation reactions to the doctor.

15.2 Nurses and therapeutic radiographers gain substantial experience in monitoring treatment reactions and are therefore well suited to monitor the severity of treatment reactions.

15.3 Written protocols defining which patient groups are suitable for radiographer- or nurse-led “on-treatment” reviews must be in place.

15.4 Clear written information should be available to patients explaining the role of “on-treatment” review clinics and of the staff undertaking them.

15.5 Appropriately trained nurses and therapeutic radiographers could contribute considerably in the follow-up of patients who have undergone radiotherapy, complementing the skills of the consultant clinical oncologist.

15.6 For certain groups of patients, follow-up specifically requires the skills of a doctor.

15.7 Training in history taking and, where appropriate, clinical examination (for example of the breast/chest wall and peripheral lymphatics) should be provided to ensure the necessary clinical competencies to assess patients at “on-treatment” radiotherapy review or follow-up visits.

15.8 Nurses and therapeutic radiographers may request laboratory and radiological investigations (e.g. blood tests and x-rays) according to agreed protocols and regulations.

15.9 Criteria for referral to a doctor should be locally agreed and accord with professional codes of conduct.

15.10 Account must be taken of the expectations of patients for reasonable levels of medical involvement in follow-up.

15.11 Patients may also request to see a doctor if they so wish.

RCR:

Approved by the Board of the Faculty of Clinical Oncology: 28 June 2002

Approved by Council: 26 July 2002

SCOR:

Approved by the Council of the Society and The College of Radiographers: 3 July 2002

IPEM:

Ratified by the Institute at the Council: 10 July 2002

RCN:

Approved by the Royal College of Nursing Cancer Nursing Society: 3 October 2002

BFCO(02)6

Appendix 1

Definition of terms

A clinical technologist working in radiotherapy normally holds a degree, HNC or equivalent qualification in science or engineering, and appropriate practical training, normally obtained through a designated programme of in-service training, and is involved in the application and development of the principles and techniques of medical physics and clinical engineering to the diagnosis, treatment and prevention of human disease.7,45

The term doctor describes a person medically qualified and registered with the General Medical Council.

The dosimetrist is a new and evolving role in radiotherapy. This term is being used to describe staff undertaking all aspects of treatment planning, including patient immobilisation and the preparation of patient-related accessories. Dosimetrists may also undertake radiotherapy equipment dosimetry and quality control, and patient in vivo dosimetry. This role may be undertaken by staff trained as clinical technologists, clinical scientists or radiographers, but the dosimetrist must be professionally accountable to a medical physics expert (radiotherapy) for the dosimetric aspects of the work.46

A medical physicist (state registered clinical scientist) working in radiotherapy physics is a qualified physicist with an honours degree in a physical science or equivalent and extensive postgraduate experience in the application of physical science to radiotherapy, with the skills and fundamental scientific understanding to provide leadership, advice and innovation in the planning and delivery of radiotherapy treatment.46

A medical physics expert in radiotherapy is a state registered clinical scientist with MIPEM or equivalent and at least 6 years of appropriate experience in radiotherapy physics.

The term nurse describes a person appropriately qualified and registered with the Nursing and Midwifery Council.

The term radiographer describes a person appropriately qualified and registered with The Society and College of Radiographers.

The term other health care worker describes any other person employed to provide health care. Some will be appropriately qualified and registered with a statutory regulatory body.

The adjective medical refers to the activities of a medical doctor.

The adjective clinical refers to the activities of a medical doctor, nurse, radiographer, medical physicist, clinical technologist or other health care workers.

Appendix 2

Advice from the GMC on good medical practice

  • The GMC have prepared a revised edition of Good Medical Practice10 from which the following are extracted:
  • All patients are entitled to good standards of practice of care from their doctors. Essential elements of this are professional competence, good relationships with patients and colleagues and observance of professional ethical obligations (paragraph 1).
  • Good clinical care must include referring that patient to another practitioner, when indicated (paragraph 2).
  • In providing care you must make efficient use of the resources available to you (paragraph 3).
  • Health care is increasingly provided by multi-disciplinary teams. Working in a team does not change your personal accountability for your professional conduct and the care you provide. When working in a team, you must:
  • respect the skills and contributions of your colleagues;
  • maintain professional relationships with patients;
  • communicate effectively with colleagues within and outside the team;
  • make sure that your patients and colleagues understand your professional status and specialty, your role and responsibilities in the team and who is responsible for each aspect of the patient’s care;
  • participate in regular reviews and audit of the standards and performance of the team, taking steps to remedy any deficiencies;
  • be willing to deal openly and supportively with problems in the performance, conduct or health of team members.
  • Delegation involves asking a nurse, doctor, medical student or other health care worker to provide treatment or care on your behalf. When you delegate care or treatment you must be sure that the person to whom you delegate is competent to carry out the procedure or provide the therapy involved. You must always pass on enough information about the patient and the treatment needed. You will still be responsible for the overall management of the patient (paragraph 46).
  • Referral involves transferring some or all of the responsibility for the patient’s care, usually temporarily and for a particular purpose, such as additional investigation, care or treatment, which falls outside your competence. Usually you will refer patients to another registered medical practitioner. If this is not the case, you must be satisfied that such health care workers are accountable to a statutory regulatory body and that a registered medical practitioner, usually a general medical practitioner, retains overall responsibility for the management of the patient (paragraph 47).

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