The radiology crisis in Scotland: sustainable solutions are needed now

Thursday 9 February 2017

RCR logoBackground

The radiology workforce crisis in Scotland is well recognised and documented and is currently worsening. On average, approximately 8% of Scottish radiologist posts are unfilled.1 Scotland has only eight radiologists per 100,000 population,1 while the European average is twelve radiologists per 100,000 people.2 Furthermore, 19% (nearly a fifth) of the current radiology consultant workforce will retire in the next five years.1 Shortages in radiography are even worse nationally across the UK.3

Over £5.25 million is currently being spent (2015) on outsourcing radiology services.1 However, despite this, waiting times for an imaging report are increasing and there remain nearly a quarter of a million unreported imaging studies across the UK waiting longer than 30 days for a report.4

Workable solutions

The policy of The Royal College of Radiologists (RCR) and its Scottish Standing Committee (SSC) to address this crisis comprises short-term and long-term measures. Both need to be acted upon together and without delay, as neither will solve the problem alone.

In the short term, there needs to be a sustained and vigorous programme by the Scottish Government to recruit more international medical graduates to fill vacant Scottish consultant radiologist posts. Engagement with this process has been limited and slow and there are issues around General Medical Council requirements, visas and NHS human resources (HR) engagement.

The RCR is aware that there are specialist recruitment agencies that can target parts of the world where there are radiologists ready and willing to come to work in all parts of the UK on fixed short-term contracts (generally for one year), not on a locum basis. Such agencies can assist and support those doctors negotiating the hurdles and requirements for entry to this country, as well as support them when they arrive. This includes working with Health Board HR departments.

It is essential that any overseas doctors quickly become acclimatised to the professional radiological working environment in the NHS and to the local culture. To that end, the RCR has produced videos and resources, freely available on its website, to assist both those coming to the UK, and the radiology departments which will be welcoming them. The RCR is also launching a “Jobs Corner” on its website, by linking to a radiologist-focused recruitment website Radjobs (https://radjobs.co.uk) which offers recruiters a targeted and effective means of finding people they need.

In the medium to long term a very significant increase in radiology trainee numbers is required to fill the shortfall and to take into account the rate of radiology consultant retirements. This requires 20–25 additional trainees every year for the next five years to meet current demands, and those demands that will also arise from the Cancer Strategy,5,6 patient expectation, new developments including interventional oncology, the Scottish trauma centres and the likely increased radiology involvement in the treatment of acute stroke (mechanical thrombectomy).

The requisite training capacity exists in Scotland, and should be supported by the implementation of the short-term strategy outlined above; that is, recruitment to vacant consultant posts with international medical graduates. Increasing the number of district general hospitals taking radiology trainees, and increasing the number of trainees overall, requires Government input and support.

Improved connectivity

Shared Services Scotland, now in conjunction with the Scottish Clinical Imaging Network (SCIN), and with central approval, are proposing to network radiology services across Scotland, to enable reporting from any site to be completed from anywhere.7 While this is entirely in keeping with the RCR’s policy, Who shares wins: efficient, collaborative radiology solutions for vendor-neutral networked teleradiology platforms, there are a number of important issues, one of which is the robustness and quality of NHS Information Technology (IT) systems.8,9 The other is that no account has been taken of the fact that over 90% of hospitals in Scotland cannot currently fulfil their radiological workload on a daily basis.1 Therefore, even with networked connectivity, it is unlikely that this would offer a workforce significant solution to reporting backlogs.  Any extra reporting undertaken via the networked system will be part of insourced paid additional work by volunteering Scottish radiologists, and therefore will be variable in amount and not necessarily sustainable.

Radiographer and other non-doctor reporting of medical images

The idea of expanding radiographer (and other non-doctor) reporting has recently gained momentum from within the SCIN and Shared Services groups. The reason for this is unclear, given the severe radiographer staffing shortages (13% mean vacancy rate across the UK),3 and extant difficulties in maintaining a 24-hour radiographer service, which is vital to the imaging process.

Imaging reports must be diagnostic and actionable to be of any value. It is the medical training of a clinical radiologist, which enables him/her to give a diagnostic interpretive opinion and advice to the referring clinician. Reports produced by those without medical training are inevitably observational and descriptive, without any depth of medical interpretation in the context of the individual patient concerned: such reports are therefore of little, or no, added value to the referring doctor in imaging studies of any complexity (such as chest x-rays or CT or MR scans). A radiologist medical opinion can influence whether the patient is discharged, followed up, or requires more tests. To provide such actionable opinions requires an understanding of the patient process and medical conditions derived from a minimum of five years’ specialist training after medical qualification. Observational reports lack these features, limiting or even inhibiting action that can be taken for the benefit of the patient. In modern healthcare, almost no medical diagnosis or major surgery can occur without some form of preceding imaging. The value of a radiologist’s report is assuming even greater importance with the complex diagnostic imaging studies now available. Imaging (both diagnostic and interventional) is essential to major trauma, to the whole cancer pathway and to multi-disciplinary team discussion. More than ever a radiologist’s report is central to patient decision-making, care and treatment. 

A recent survey10 of the views of radiologists in Scotland showed an overwhelming lack of support for radiographer reporting of cross-sectional imaging studies, with 85% of consultants and 98% of trainees against it. Given the issues of retention of both consultants and trainees, and the importance of sustainable team building and provision of radiology registrar training, their views should be recognised.

Radiographers can play an essential and growing role in the imaging team, acquiring advanced skills (for which there should be an incremental increased pay incentive) including vetting imaging study requests, post-processing complex imaging studies and paediatric image acquisition. The RCR is keen to promote and encourage excellence in radiography and such radiological team working is in the clear interests of patients.

Conclusion

The RCR is firmly of the view that the solution to the radiology crisis in Scotland does not lie in measures such as expanding radiographer and other non-doctor reporting of medical images. There needs to be a sustained programme of both short-term international recruitment and longer term increases in clinical radiologist training numbers. Both measures need to be started together and without delay.

References

1. The Royal College of Radiologists. The clinical radiology workforce in Scotland: 2015 census report. London: The Royal College of Radiologists, 2016.
2. http://ec.europa.eu/eurostat/web/products-datasets/-/hlth_rs_spec (last accessed 6/2/17)
3. Society of Radiographers. Diagnostic Radiography UK Workforce Report 2016. London: SOR, 2016. http://www.sor.org/learning/document-library/diagnostic-radiography-uk-workforce-report-2016 (last accessed 6/2/17)
4. The Royal College of Radiologists. Unreported X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) examinations: results of the February 2016 snapshot survey of English NHS acute trusts. London: The Royal College of Radiologists, 2016.
5. Cancer Research UK. Achieving world-class cancer outcomes. A strategy for England 2015-2020. Report of the Independent Cancer Taskforce. London: CRUK, 2015.
6. The Royal College of Radiologists. Beating cancer: ambition and action - How the Scottish government should implement the new Scottish Cancer strategy. London: The Royal College of Radiologists, 2016.
7. NHSScotland Shared Services. Radiology Programme. National Radiology Model Strategic Document. NHSScotland 2016.
8. The Royal College of Radiologists. Radiology in the UK: a case for a new service model. London: The Royal College of Radiologists, 2014.
9. The Royal College of Radiologists. Who shares wins: efficient, collaborative radiology solutions. London: The Royal College of Radiologists, 2016. www.rcr.ac.uk/who-shares-wins (last accessed 6/2/17)
10. The Royal College of Radiologists. Radiographer reporting of cross-sectional imaging: results of a survey of NHS consultant and trainee radiologists in Scotland – February 2016. London: The Royal College of Radiologists, 2016. https://www.rcr.ac.uk/sites/default/files/radiographer_reportctmri.pdf (last accessed 6/2/17)

Related reading

  • Federation of Surgical Specialty Associations. Appointment to Heads of School, Health Education England, August 2016. https://fssa2015.files.wordpress.com/2015/03/positionstatement_aug2016.pdf (last accessed 6/2/17)
  • The Royal College of Radiologists. Position statement on the recording of identity of healthcare professionals who report imaging investigations. London: The Royal College of Radiologists, 2015.
  • The Royal College of Radiologists. Standards for the Reporting and Interpretation of Imaging Investigations. London: The Royal College of Radiologists, 2006.
  • Boland GW, Enzmann DR, Duszak R Jr. Actionable Reporting. J Am Coll Radiol 2014; 11(9): 844–845.
  • The Royal College of Radiologists. Unreported X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) studies: results of the September 2016 survey of Scottish NHS health boards. London: The Royal College of Radiologists, 2016.
  • The Royal College of Radiologists. Scottish Standing Committee response to NHS Scotland Shared Services National Radiology Model Strategic Document. October 2016.
  • The Royal College of Radiologists. Radiographer reporting of plain films in Scotland. May 2015.

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