Evidence submitted by the Royal College
of Radiologists (WP 70)
The Royal College of Radiologists (RCR) has
approximately 7,000 members and Fellows worldwide representing
the disciplines of Clinical Oncology and Clinical Radiology. Of
these, 4,900 are resident in the UK. All members and Fellows of
the College are registered medical or dental practitioners. The
role of the College is to advance the science and practice of
radiology and oncology, further public education and promote study
and research through setting professional standards of practice
Clinical Radiologists are trained to interpret
images from a wide range of different radiological techniques
and, more importantly, they provide a clinical opinion based on
such interpretation to assist in patient management. Clinical
Radiologists also undertake interventional techniques to diagnose
and treat disease under image guidance. In the light of technological
advance interventional radiology is becoming increasingly important
in patient management in a range of conditions including vascular
disease, heart disease and cancer.
Clinical Oncologists are clinical doctors who
specialise in the treatment of cancer. They are trained to prescribe
radiotherapy, chemotherapy and other systemic treatments. Most
Clinical Oncologists today subspecialise in specific tumour types.
The College's two specialties are in the spotlight
with respect to the demands made on the medical workforce. Government
priorities to develop and deliver effective cancer services in
the UK focused on multi-disciplinary teams has significantly impacted
on the workforce demands made on Clinical Oncologists. More recently,
the focus on diagnostics as being the "bottleneck" in
the patient pathway and the need to invest in diagnostics and
particularly in clinical imaging has brought Clinical Radiology
to the forefront.
The College aims to assist the Departments of
Health in the UK in workforce planning by offering statistical
evidence and analysis whenever possible. It is necessary to gather
this data regularly given the changing demographics around the
medical workforce with up to 70% of medical students now being
female. That gender balance within the workforce clearly has a
major effect on the total working lifetime commitment of the workforce
but furthermore, the new and appropriate emphasis on work/life
balance leads to all medical graduates of both sexes potentially
seeking to work less intensively or for shorter overall periods
than has been the case hitherto.
Plurality of provision of healthcare services
in the UK will also bring new complexities to the already complex
process of assessing future workforce needs. The College would
hope that artificial boundaries placed in the way of freedom of
movement between sectors—such as additionality—will
soon be entirely relaxed enabling doctors and other healthcare
staff to deliver services seamlessly between providers to the
benefit of the patient.
In this evidence, the College has addressed
issues raised in the Terms of Reference which are relevant to
both our specialties. However, there are particular dynamics that
apply only to Clinical Oncology or Clinical Radiology which should
be taken account of by the Committee in assessing the workforce
needs and planning for the future. Therefore specific aspects
relating either to Clinical Oncology or Clinical Radiology are
considered under each specialty separately.
CLINICAL RADIOLOGY
There are chronic workforce shortages of radiologists
worldwide. Furthermore, the UK radiology workforce per head of
population is traditionally one of the lowest in Europe. In response
to this, the Royal College of Radiologists in collaboration with
the Department of Health (England) has delivered the Integrated
Training Initiative with the primary aim of significantly increasing
the number of radiologists in training. The Radiology Integrated
Training Initiative(R-ITI) is a novel approach to training using
an electronic based programme which is being evaluated in special
designed Radiology Academies. Three Radiology Academies opened
in 2005 to deliver this innovative approach to training and the
initiative will increase the number of radiologists significantly
over the next five years. In 2005, an extra 40 trainees entered
radiology and in 2006 a similar number of additional trainees
are to be appointed. Even before the opening of the Academies
in 2005, there has been recognition of the need to train more
radiologists and this year nearly 200 trainees will be completing
their training and will gain a CCT, thereby gaining access to
the Specialist Register. However, even this welcome investment
has to date not eliminated the overall shortage of radiologists
in post.
Shortages of radiologists vary considerably
throughout the UK. There are particular shortages in Scotland
and the North of England whereas in the South of England the shortages
are much less apparent. The need to attract trainees to posts
in shortage area needs to be addressed. These factors must be
taken into account together with further workforce pressures,
namely:
— Increase in multi-disciplinary team
meetings in which the radiologist is key.
— Increase in use of more advanced
technology in emergency evaluation and treatment of patients (ie
providing 24 hour cover).
— Decrease in clinical experience of
clinicians with resultant increased reliance on imaging and imaging
reports from radiologists.
— Increase in feasibility and complexity
of interventional procedures.
— The need to provide rapid turn around
of imaging reports to determine management decisions in acute
medicine.
— Recent focus on waiting times imaging
services to meet Department of Health (England) targets, including
18 weeks.
Despite these pressures, expansion involving
new consultant posts is hindered by financial constraints in acute
Trusts and although there are still consultant post vacancies
in the UK, some have been filled by graduates from the newly extended
EU. UK CCST/CCT holders are finding there has been a significant
decrease in the number of available posts over the past 12 months.
A survey of vacant funded posts in the UK carried out by the RCR
in January 2006 identified that the number of CCST holders would
almost balance the number of advertised posts this year, but the
number of posts required clearly exceeds this.
In considering future demand and the effects of
recent policies, how should the effects of the following be taken
into account?
Recent policy announcements will have
an important impact on the delivery of radiology services. An
increase in out of hospital care and plurality of provision has
major implications for imaging. The Royal College of Radiologists
is working with the Royal College of General Practitioners to
provide guidelines for access to imaging in primary care to inform
and to facilitate attainment of the 18 week target and has also
worked tirelessly with the Department of Health to improve imaging
services provided by the Independent sector. However the lack
of integration of services provided in the NHS and by independent
providers is a barrier to the delivery of best practice. A uniform,
high quality service can only be provided for individual patients
if the pathway of care is seamless and conducted to the highest
standards laid down by the College and other professional bodies.
Technological advances in imaging continue
to revolutionise the way in which medicine is practised. The number
of images obtained today in a single examination far exceeds those
obtained even a decade ago. Three-dimensional images are available
in seconds after acquisition and clinicians now rely more heavily
on imaging for treatment decisions than ever before.
The ageing population will impact on
imaging as more elderly patients are treated for cancer, stroke
and other conditions which require imaging for management (see
Clinical Oncology evidence). By 2010 there will be an increase
in over 65 year olds of over 20% and an increase in over 85 year
olds of over 50% compared with 2004.
The increasing use of private providers of
services has had a major impact on imaging as this initiative
has clearly reduced waiting times dramatically. However, problems
persist because the services are not sufficiently integrated into
NHS Departments of Radiology and the additionality clause precludes
appropriate links between Independent sector radiologists reporting
overseas and NHS radiologists in the associated NHS department.
How will the ability to meet demands be affected
by the following?
Financial constraints will clearly lead to Trusts
being unable to advertise posts which are required to deliver
the service.
The European Working Time Directive will have
an adverse effect both on service delivery of radiology and on
training.
Increasing International competition for staff
at present is not a concern as the major flow is to the UK rather
than away from the UK. However, if opportunities for a well-balanced
career diminish, we may well witness reversal of this trend. Early
retirement is not perceived as a major issue in radiology but
occurs in some areas due to undeliverable increasing demands for
services.
To what extent can and should the demand be met,
for both clinical and managerial staff: by changing roles and
improving skills of other staff?
Over the past few years radiography staff have
increasingly taken on traditional radiologist roles but this is
under strict protocol arrangements working within the team in
radiology departments. Skill mix can be a valuable asset to disease
management and is welcomed, however these personnel take a significant
amount of consultant time to train and the work they are best
suited to perform is focused on a particular task and is therefore
necessarily limited.Questions have been raised about the cost-benefit
of extending skill mix and the College is looking into the feasibility
of a detailed study to evaluate this important aspect of modernising
healthcare further.
Better retention of staff in radiography is
likely to be a benefit of properly implemented skill mix but it
must be noted that only a minority of radiographers are likely
to want such high levels of clinical responsibility. Initiatives
to attract new radiography staff in England should be explored.
International recruitment of UK radiologists
is less likely than recruitment of overseas graduates to the UK.
In the latter scenario problems may be encountered when English
is not the radiologist's first language. Radiological reports
are in written form and nuances of language can be vital in defining
patient management with implications for patient safety. The international
recruitment potential is also limited by worldwide radiologist
shortages. Diagnostics (including imaging services) are moving
more towards primary care but this could exacerbate workforce
shortages despite having advantages for the patient. The efficient
model would be that Independent Sector Treatment Centres/primary
care imaging facilities are under the umbrella of Trust imaging
departments and serviced by staff rotating through all parts of
the service. This would ensure flexibility of staffing, could
make best use of teleradiology with images acquired peripherally
being transmitted to an available radiologist while maintaining
skills, good clinical governance and quality assurance of machines
and staff.
It would also improve the efficiency and quality
of primary care referral by improving communications between radiologists
and primary care doctors and other healthcare workers.
How should planning be undertaken?
As indicated in the Clinical Oncology section,
overall planning of the workforce should be centralised but should
take into account regional and local differences and there should
be local flexibility to meet the needs of local patients.
CLINICAL ONCOLOGY
In considering future demand and the effects of
recent policies, how should the effects of the following be taken
into account?
Recent policies will have an important
impact on clinical oncology workforce planning if chemotherapy
and radiotherapy services are devolved to local independent sector
providers who are completely new to the market. Strong management
as well as clinical links between the cancer centre and the devolved
service will be required to ensure patient safety and a seamless
service. If such services are provided by the independent sector
it will be vital to have input into multidisciplinary teams, irrespective
of the provider. This will require co-ordination of services by
clinicians/managers and an additionality clause in a contract
would be unsuitable for both clinicians and radiographers.
Technological advances in radiotherapy
are leading to more complex treatments which are more accurate
due to the ability to define treatment target volumes more precisely,
thus avoiding irradiation of unnecessary normal tissue. The impact
is likely to result in reduced morbidity and even mortality but
will require a highly skilled workforce to deliver such sophisticated
treatments.
An ageing population is already placing
increasing demands on clinical oncology because cancer is predominately
a disease of the elderly. Currently cancer incidence is increasing
in Europe by 2% per annum.
Over 50% of patients should undergo radiotherapy
during the initial management of their disease but a lower percentage
do because of inadequate provision. Thus there is a need to examine
health trends such as population growth, the age spectrum and
consequent cancer incidents. This work has been done in Scotland
to the period to 2015 in its Cancer Scenario document and recommended
for development in England by the National Audit Office. The College
is pleased to see that this work is now in hand as it will be
important in predicting workload and thus future staffing needs.
The Scottish document correctly identifies that
a very substantial increase in radiotherapy provision will be
required to cope with demand; however only 20% of this is accounted
for by predicted increases in cancer incidence. There is a current
shortfall of 60% in current provision. A similar gap was identified
in a pan-European review of radiotherapy services which indicated
that in 2003, the UK only had 50% of the required radiotherapy
capacity. The Department of Health's National Radiotherapy Advisory
Group (England) the College has two places which has commissioned
planning work to address these issues. It is clear that a major
expansion of the radiotherapy workforce is urgently needed, together
with capital investment.
How will the ability to meet demands be affected
by the following?
Financial constraints will clearly have
a major detrimental effect on meeting demands for radiotherapy.
Major capital investment is needed even to meet current demands
and the analysis above indicates how large the gap is. A recent
re-audit of waiting times by the Royal College of Radiologists
has shown that, although there has been reduction in waiting times
since 2003, they still remain longer that they were in 1997 with
53% of patients waiting longer than the recommended one month
for potentially curative treatment.
The continual developments of new systemic cancer
therapies which are more complex and time consuming to administer
are placing pressure on treatment capacity. Waiting lists for
curative chemotherapy and systemic treatments are now starting
to develop: the major obstacle is the availability of trained
staff and the funds to employ them. Clinic, day case and inpatient
capacity are also starting to become overstretched.
While the European Working Time Directive,
international competition and early retirement will all need
to be addressed in prediction of workforce needs in clinical oncology,
we do not think there are special circumstances in clinical oncology
which need to be considered separately.
To what extent can and should the demand be met,
for both clinical and managerial staff by changing roles etc?
The College believes that the key to effective
workforce planning is in the best use of skilled staff. There
is a need in radiotherapy to increase radiographer training places
and this points to the need to develop, perhaps, three skills
laboratories to train therapy radiographers out of the spotlight
of clinical pressures. An innovative solution is required to address
the substantial shortfall and might assist in addressing the current
30% dropout rate of trainee radiographers. Such approaches have
been successful in histopathology and radiology There is scope
for consultant radiographers to facilitate the service by taking
an active role in the treatment planning process that is emerging
as a potential bottleneck in the patient pathway. There is also
a need to retain staff once trained through developing appropriate
career pathways.
The College is hoping that the Integrated Training
Initiative (see Clinical Radiology Section) which is a ground
breaking way of delivering significant elements of training through
e-learning for radiology training will be made available for training
in Clinical Oncology and for therapy radiographers in the not-too-distant
future. Such an initiative will require major investment but in
the longer term would provide a highly skilled workforce of uniform
high standard.
How should planning be undertaken?
In clinical oncology, workforce planning should
be carried out with the engagement of clinicians, radiographers
and managers to provide a comprehensive plan. An overall framework
should be developed centrally which can be adapted for local use
to meet local service and patient needs. There is a need to continue
to examine cancer trends due to changing population demography,
and indications for treatment and to profile the consequent cancer
treatment consequences.
No one has successfully completed an equivalent
analysis for chemotherapy and biological therapies where all indicators
show that enormous growth is expected in this area of oncologists'
work over the next decade.
Professor Janet Husband
President, the Royal College of Radiologists
22 March 2006
REFERENCES:
1 Clinical Radiology: A Workforce in Crisis
Royal College of Radiologists, RCR BFCR(02)1, 2002.
2 Extended Working in Clinical Radiology
Royal College of Radiologists, BFCR(02)5, 2002.
3 Cancer incidence and Mortality in Europe,
2004, Boyle P and Ferlay J, in Annals of Oncology 2005 16:481-488.
4 Standards for issuing an imaging report,
RCR 2006.
5 Delaney G, Jacob S, Featherstone C, Barton
M The role of radiotherapy in Cancer Treatment. Cancer 2005;
104: 1129-37.
6 Radiotherapy Activity Planning 2011-15
Scottish Executive Health Department 2005.
7 Bentzen et al, Towards evidence-based guidelines
for radiotherapy infrastructure and staffing needs in Europe:
the ESTRO-QUARTS project. Radiother Oncol, 2005; 75:355-365.
8 Summers E, Williams M V The re-audit of
Radiotherapy Waiting Times Audit, 2005.
9 Equipment, Workload and Staffing for Radiotherapy
in the UK 1997-2002. Royal College of Radiologists BFCO(03)3.
London 2003.
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