Dr. Erika R.E. Denton
Department of Radiology
Norfolk and Norwich
Mrs. Glynis Wivell
Radiology Academy Manager
Norfolk and Norwich
Ten years ago, the concept of skill mix in UK imaging departments was conceived to address the shortages of radiographers, radiologists and oncologists as well as the increasing pressures on services. Many imaging departments were dependent on temporary and part-time staff, with relatively high staff turnover and a large percentage of the imaging workforce were approaching retirement.
The development of new, more effective career pathways for radiographers with novel teams in imaging departments was a clear mechanism to address some of the challenges facing imaging. The then Prime Minister’s ‘Challenging Cancer’ summit agreed to develop a new model of service delivery within radiography. The government made a commitment to develop more staff, new grades of staff and to address these pressures for the benefit of patients.
Breast screening, therapy radiography and then diagnostic radiography (including ultrasound) were targeted for pilot projects. Breast screening was the first proposed skill mix project, as the NHS breast screening programme was committed to expansion both by age, from 50 - 64 to 50 – 70 years, and by adding a second view to all screening episodes rather than just the first screen. The aims for the skill mix project were to:
• Redesign the clinical team by skills and experience rather than profession;
• Introduce a tiered structure incorporating mechanisms for lifelong-learning and skills-escalation;
• Develop occupational standards for the clinical aspects of each service, and
• Review and implement learning processes to enable practitioners to develop new and valued roles within the multidisciplinary team.
These proposals led to anxiety from within the imaging community and all sought reassurance that the new roles would not dilute the standards or the scope of their professions. Reassurance that this was not the case became easier as milestones were achieved. A four-tier structure was proposed and is now successfully established in both breast screening and across radiography in general.
Non State Registered:
Assistant practitioner: Performs protocol-limited clinicaltasks under the direction and supervision of a state registered practitioner. This type of professional is regulated by the various Acts and Orders which ensure the public have access to, and are treated by, health professionals who are qualified and competent.
Practitioner: Autonomously performs a wide-ranging and complex clinical role and is accountable for own actions and for the actions of those they direct.
Advanced practitioner: Autonomous in clinical practice, defines the scope of practice of others and continuously develops clinical practice within a defined field.
Consultant practitioner: Provides clinical leadership within a specialty, bringing strategic direction, innovation, and influence through practice, research and education. Not as many opportunities as initially expected have developed for the consultant practitioner role. There are now 28 consultant radiographers across England predominantly involved in breast imaging but also oncology, neuro-imaging, GI imaging, ultrasound, emergency imaging and musculoskeletal imaging.
The breast imaging department at the Norfolk & Norwich University Hospital became one of four pilot sites for the ‘New Ways of Working’ project. Locally, we chose to develop the Assistant Practitioner and the Advanced Practitioner roles as there was no need for the department to train a consultant practitioner.
As managers of the unit, it was our job to lead the team through this period of controversial change. It is often said that management can be taught but that leadership is a skill that can be developed but must be inherent in the team leader. Managers who are good leaders are uncommon but we focused on both sets of skills to plan our work for the project. We set ourselves four key goals:
1. Get to Know the Team
We identified whom we could count on for support, and which team members were likely to cause problems and could negatively influence the others. The team had been together for almost ten years with new members joining but very few leaving. Standards were high and results good. The department had expanded in terms of size and equipment and a new prone breast biopsy table was in situ. The radiographers were keen to move into film reading, ultrasound and biopsies. The team was ideal for this kind of process.
2. Get to Know How to Manage the Team
Skill mix was viewed by most as an opportunity to develop their professional roles and most could see the benefit of the new Assistant Practitioner role. The cohort of staff that were most resistant were those who did not want to take on an Advanced Practice role and were to fill the second, pre-existing, Practitioner tier. We decided the best way to manage these members was to find them other responsibilities, with new or different roles to make them feel equally valued for their contribution.
3. Be Part of the Team
Never expect the team to do something you are not happy to do yourself. Communication became more important in an effort to make the team feel part of the decision-making process. The amount of work needed from the whole team to develop the Assistant Practitioner role in particular, cannot be overemphasised. Being part of a national pilot project put the whole department under a huge amount of national scrutiny. In many ways, this brought the team closer together.
4. Lead the Team to the Top
It was important to make the team feel special and valued. During the pilot, everyone took on additional work and responsibilities. The project unfolded rapidly and there were times we felt we were going backwards to move forwards. We successfully ‘created’ two excellent Assistant Practitioners capable of producing screening mammograms to a very high standard and two Advanced Practitioners with postgraduate qualifications in image interpretation and analysis, one of whom had a further qualification in breast ultrasound.
Project Undergoes Continued Growth
Completion of the pilot was only the beginning. Additional Assistant Practitioners have now joined the team. One of the original two has moved on and is now a Registered General Nurse and soon to train in midwifery. More radiographers have been trained to film read and their expertise has changed the relationship not only with the radiologists but also with the extended breast team. New team confidence has meant that members of the team have presented at national meetings, submitted posters and won several ‘best poster’ prizes.
This project taught us a lot as we have moved into new roles. The project in breast screening across three sites other than our own acted as the basis for role extension and the development of competency frameworks across imaging services. This ‘case study’ highlights aspects of management and leadership in a change management programme which can be transferred to many other scenarios. This is fundamental to the delivery of an effective imaging service with a motivated and progressive workforce that is able to function as an effective team.
• Radiography Skills Mix. A Report on the Four- Tier Service Delivery Model. (2003), Department of Health. London
• Role Development Revisited: The Research Evidence 2003 (2003), College of Radiographers, London.