Evidence submitted by the Royal College
of Radiologists (ISTC 51)
In offering this evidence, the Health Select
Committee is invited to note that the Royal College of Radiologists
has not to date had direct involvement with or experience of Independent
Sector Treatment Centres (ISTCs). However, the College has had
extensive experience of the rollout of, and dealing with the issues
arising from, the first wave of imaging procurement from the independent
sector which was for the provision of straightforward Magnetic
Resonance Imaging (MRI) Scanning Services. The College's experience
in this context offers insights and observations which are germane
to the ISTC enquiry.
The Committee may also wish to be aware of the
role of Radiologists within the framework of a clinical team.
As radiological techniques have advanced over recent years the
role of radiolgists has changed and developed so that they are
now pivotal to patient management, providing clinical advice and
consultation. Thus cases are referred to radiologists for a radiological
and clinical opinion rather than merely a radiological report.
There were several major problems identified
upon the introduction and rollout of the independent sector MRI
Fastrack service in 2004. However in many instances the service
has improved significantly in the interim period. The Royal College
of Radiologists rapidly engaged at a number of levels to identify
and attempt to resolve the problems and this work is referred
to below. Some issues still remain to be addressed and these are
alluded to in the responses we give to the Committee's specific
questions.
For Wave 2 of the outsourcing contracts, the
College has identified key concerns that need to be addressed:
— Relaxation of additionality with
respect to radiology and radiography by means of seconded work
in co-operation with NHS Trusts. This would resolve the important
issues related to clinical governance and allow integration of
the independent sector provision with NHS services thus providing
a seamless service for patients.
— Introduction of NHS clinical leadership
within the outsourced radiology services which would also address
clinical governance issues and avoid fragmentation of the service.
— Introduction of training into the
independent sector in radiology. Removal of additionality is essential
if the promised involvement of the independent sector in training
is to be realised.
— Financial support for administrative
work to provide integration between the independent sector and
NHS radiological services.
— Improved utilization of several Department
of Health NOF funded MR Units. Several of these recently installed
top-of-the-range machines are "mothballed" (UCH, Charing
Cross etc) or running at much reduced capacity (eg Yarmouth),
largely because of the Wave 1 Fastrack scheme.
The Royal College of Radiologists stand ready
to assist and work with the Department of Health on all these
issues.
The College undertook a number of initiatives
to try and address the Wave 1 issues collaboratively with the
Department of Health as follows:
(1) Engaging with the Department at the highest
levels and also with the newly appointed National Clinical Lead
for Diagnostic Imaging (Dr Erika Denton).
(2) Involvement in and support for the appointment
of an RCR/DH MRI Fastrack "Clinical Guardian"—Professor
Adrian Dixon—whose role is to oversee clinical governance
and whose work, which has been extensive and comprehensive, has
included vetting the CVs of all reporting radiologists under the
contract and also troubleshooting and problem resolution.
(3) Undertaking an audit in January 2005
comparing the service provided by the NHS with that provided by
Alliance Medical Limited (who won the contract for the first wave
provision). The audit showed there were delays in reports produced
by the independent sector, the technical quality of the MR examination
were similar, the language was better in most NHS reports and
clinical opinion was judged slightly better in most NHS reports.
Only one discrepancy in the independent sector was regarded as
a potentially serious error. The service has improved since that
2005 audit. Preliminary analysis of a new audit carried out at
the beginning of 2006 and due for publication in April shows considerable
improvement, with reporting times at least as good as those in
the NHS.
(4) The MRI Clinical Guardian was instrumental
in obtaining funding for administration and multi-disiplinary
team support and this must be incorporated into future contracts.
(5) Many bodies including the RCR have played
a key role in achieving some relaxation of additionality. Clinical
radiologists in the UK who are contracted to work for 40 hours
per week within the NHS can offer to do a further four hours per
week for their Trust. However, if the Trust does not wish to take
up that time, radiologists could do eight hours' work within the
independent sector. Further comment is made on this point in response
to the specific questions.
The College is also working on three further
inititatives:
— the introduction of a Radiology Service
Accreditation Scheme which would be multi-disiplinary involving
radiographers and physicists among others and would apply both
to NHS and independent sector services;
— re-engaging its leads in the regions
and establishing their links with the Strategic Health Authorities
to provide clinical radiological advice and leadership for Wave
2; and
— to provide its referral guidelines
for imaging services as an online resource for the NHS in the
UK and is also producing a framework for primary care access to
imaging services.
SPECIFIC QUESTIONS
AND ANSWERS
FROM THE
ROYAL COLLEGE
OF RADIOLOGISTS
What is the main function of ISTCs?
Answering this question in the context of experience
of independently procured MRI services—the role is to provide
extra capacity for diagnostic imaging which is a shortage speciality
with respect to radiologists and radiographers and in which investment
in eqipment over recent years has not met the increasing demands
for service. The new service provides competition and aims to
set new standards for access thereby raising overall quality of
service.
What role have ISTCs played in increasing capacity
and choice and stimulating innovation?
The major role in MRI services has been an increase
in capacity for a limited range of examinations/procedures. Were
the Government to review this progress it would be wise to consider
whether the planned next wave is entirely necessary in terms of
required capacity. The planned requirement of 50 per 1,000 head
of population per annum (ie 1 in 20) may be in excess of what
is really needed for good clinical practice. Whilst patients have
had a choice and have been able to access services faster, there
were and still maybe some delays between an MRI examination and
the subsequent outpatient appointment or operation.
What contribution have ISTCs made through reduction
of waiting times and waiting lists?
As a result of the outsourced MRI services,
waiting lists have been dramatically reduced—down to 13
weeks from 18 months to two years in some cases.
Are ISTCs providing value for money?
The expenditure on outsourced MRI services has
to be set against the incomplete usage of existing MRI capacity.
There were early problems which largely stemmed from the lack
of integration of the service.
A concern which persists is that the radiological
reports from European radiologists tend to be descriptive with
no definitive conclusion for management. Furthermore they frequently
recommend several additional investigations which may be unnecessary.
All this leads to inefficiency and waste of resources.
Radiologists at NHS Trusts frequently are required
to re-report scans from the outsourced centres because local clinicians
do not have confidence in radiologists they do not work with on
a day-to-day basis and from whom the reports are indecisive.
Does the operation of ISTCs have an adverse effect
on NHS services in their areas?
Yes—there has been fragmentation of services
to patients with re-reporting of images in some instances therefore
increasing workload. The input to multi-disciplinary team meetings
has been impaired and there has been no clinical leadership for
the outsourced service to integrate the service which is its biggest
flaw.
The whole concept of the service clearly did
not recognise and therefore undervalued the importance of the
clinical role of radiologists.
What arrangements are made for patient follow-up
and the management of complications?
For the MRI services, few arrangements were
made initially for follow-up and previous imaging was not available.
This caused clinical governance problems and potentially had an
adverse effect on patient management and implications for patient
safety. The work done by the Royal College of Radiologists however
has secured around £80,000 funding per cluster for funding
the administrative work to provide joined up services. This has
helped but persistence of the additionality clause will continue
to have an adverse effect on clinical governance arrangements
for patients.
What role have ISTCs played and should they play
in training medical staff?
The outsourced MRI service has had no role in
training to date. Training must in future involve the independent
sector otherwise radiology trainees will not learn simple procedures
and see "normal" reports. Furthermore in the future
radiologists will not be able to perform these examinations either
within the NHS or in the independent sector. Trainees could travel
to remote reporting sites such as in Edinburgh, Brussels, Barcelona,
and Cape Town. The group in Brussels has already offered to undertake
training of groups of radiologists from the UK, but funding and
the practical logistics of this would need to be addressed.
There has been some work done across Europe
with a small audit carried out by the European Radiology Training
Forum. This has shown that there is a significant adverse impact
on training in two centres in Europe where outsourcing is fully
operational. In these cases 21-50% of routine MRI scans and 50-70%
of Computed Tomography (CT) work has been outsourced. This audit
also revealed that there was concern about further impact when
Picture Archiving and Communication Systems (PACS) was widely
available. This would allow images to be accessed remotely and
moved around between services/centres much more easily thereby
obviating the need for studies to be reported where the trainees
were based.
Are the accreditation and appointment procedures
for ISTC medical staff appropriate?
Radiologists from mainland Europe are readily
accepted onto the UK Specialist Register which is the responsibility
of the General Medical Council. EU citizens do not have to undergo
a linguistic test (run by the PLAB at the present time, although
this is expected to be introduced imminently). However a linguistic
test does have to be part of the procedure for English speaking
doctors from other parts of the world. Some Eastern European countries
(such as Estonia) have limited MRI services but their radiologists
could be on the UK Specialist Register and in theory would be
eligible to work in the outsourced service. The safeguard is that
the MRI guardian vets all CVs. The Wave 1 procurement in MRI services
provided general radiologists whereas Wave 2 is seeking to employ
specialist radiologists which is an improvement. Furthermore,
waiving the additionality clause would help resolve the problem.
Are ISTCs providing care of the same or higher
standards as that provided by the NHS?
The independent providers' quality of work is
probably about the same as an NHS DGH. The error rate in the independent
sector is similar to that in the NHS. There are probably further
investigations generated as a result of a descriptive rather than
a clinical management reports. There has been considerably faster
access to some imaging procedures.
What implications does commercial confidentiality
have for access to information and public accountability with
regard to ISTCs?
We are not aware of any problems in this respect
as regards the outsourced MRI services.
What changes should the Govenment make to its
policy towards ISTCs in the light of experience to date?
From the perspective of radiological outsourced
imaging services, we would like to see:
— the relaxation of additionality for
the second wave procurement (see below).
— a network of official radiology guardians
to work with the new Strategic Health Authorities.
— exclusion of ultrasound from the
contract because ultrasound is an interactive examination and
cannot be reviewed remotely. It is therefore extremely difficult
to assure quality.
— secured and ongoing funding through
the assimilation of independent and NHS imaging services for supporting
multi-disciplinary team reviews.
— training and education to be part
of the service.
Additionality must be relaxed so that clinicians
will have a radiological report from someone that they work with
on a regular basis which offers a ready opportunity for discussion
about recommended treatment options for individual patients. This
would also ensure clinical governance, access to previous images
and would ensure that all radiologists working both in the NHS
and independent sector underwent annual appraisal.
Training and research must continue in order
to develop the service for the future and this will not be possible
in those services which are outsourced unless additionality is
relaxed.
The significant investment made by the Government
in increasing radiological training (up to 20% increase through
the three new Radiology Academies in England) must be recognised
and those encouraged into such training posts must have jobs available
when they complete their training.
Relaxing additionality would also develop opportunities
for the workforce in the light of new ways of working. For example,
the workforce of the future will be largely women, many of whom
will wish to work less than full time. Such radiologists would
be ideally suited to working partly in the NHS and partly in the
independent sector thereby retaining their clinical governance
links and continued professional development requirements through
the NHS departments. Such a plan would also benefit radiographers
who could work on a rotation scheme, thereby ensuring continued
professional development and supervision within the team.
Clinical leadership would help integrate a seamless
service. Relaxing the rules of additionality but maintaining NHS
Trust contracts would enable individual consultants to work (for
example one day per week) in the independent sector seconded by
their Trust. The Trust would receive funding from the private
sector provider for the radiologists' service and the Trust could
then employ further radiologists as required. This would also
be suitable for those working part-time and those who have recently
retired or who are between jobs. In this way the work would be
integrated through a single team. Such an approach would work
well in some areas of the UK but it is recognised that in some
areas this solution would be inappropriate as there are insufficient
radiologists. Nevertheless spare capacity in "popular"
parts of England such as the south-east could be used to meet
the shortfall in provision in other areas such as the Midlands.
In some areas overseas reporting would still be required at least
for the foreseeable future.
Finally the relaxing of additionality would
allow radiological input to and attendance at multi-disciplinary
team meetings and ensure that the reports in the UK were more
in line with current UK practice.
What criteria should be used in evaluating the
bids for the second wave of ISTCs?
— Robust Clinical Governance arrangements
must be in place.
— Training must be introduced.
— Ultrasound should be omitted from
the contract as it is difficult to assure quality in this highly
operator dependent technique.
— Administrative arrangements to provide
a seamless interface between the independent sector provider
and the NHS.
What factors have been and should be taken into
account when deciding the location of ISTCs?
As regards the outsourced MRI services, these
were initially provided on a geographically even basis and were
not directed to areas where radiology services were in short supply.
This should have been taken into account and should be in the
future. Administrative links must be made and maintained using
the additional funding mechanism which was latterly agreed for
Wave 1.
The effect on NHS Trusts complying with the
"payment by results" tariffs is made much more difficult
with the removal of simple and cheap investigations to the independent
sector ("cherry picking") leaving the more complex expensive
work in the NHS. Clinical Directors in the NHS need to be engaged
to keep interest in NHS work. Individual radiologists may prefer
to work in the private sector where the pressures of work and
the complexity of the work are much reduced.
The effects on radiographers must also be taken
into account. Radiographers are being "poached" from
the NHS because they are replacing those working in the private
sector who are transferring to the Wave 1 contract providers.
If independent sector procurement takes radiographers out of hospitals
this puts an increasing strain on existing service and the fragmented
nature of the service may not attract new staff into radiography.
Furthermore, radiographers could become isolated working in ISTCs
which could adversely affect their career development as well
as taking radiographers from some hard-pressed NHS Departments.
As with radiologists, radiographers may be attracted into the
simple work available in the independent sector thus depleting
NHS resources further.
How may ISTCs should there be?
The College believes that existing NHS capacity
must be used to the full and local requirements should be taken
into account for the future procurement of imaging services. The
shortage of radiologists and the shortage of radiographers which
is particularly acute in some areas should be taken into account
when services are planned for the future.
Professor Janet Husband OBE
President, The Royal College of Radiologists
14 March 2006
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