The NHS today struggles to maintain standards of care and deliver a comprehensive service to all [1]. For nearly a decade, the NHS has experienced a significant slowdown in funding growth while conversely, service demand (and cost of service provision) has snowballed [1].
Clinical radiology, predominately a service specialty, is an integral part of the majority of medical pathways with a vital role in the initial investigation and management of severely ill patients [2]. Patient-centered, high-quality care relies on rapid access and interpretation of imaging examinations [3]. “Prompt and appropriate imaging and intervention improves patient outcomes and avoids unnecessary procedures.” [3].
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Royal College of Radiology [3] states ‘demand for imaging is unrelenting and set to increase’, with a year-on-year increase in sophisticated cross-sectional imaging; 54% increase in CT, and 48% increase in MRI within the past five years alone. Radiology departments are struggling to cope with workload; only 2% of UK trusts/health boards were able to meet reporting requirements within their contracted hours [3]. Departmental bosses anonymously commented that increased demand meant “working increasingly fast and becoming unsafe’ and “unable to provide a safe and reliable radiology service.” [3].
The workload increase is multi-factorial; increased patient expectations, and co-morbidities, and the GMC recognized 33% of doctors making unnecessary referrals to reduce their workloads [4].
Outside traditional working hours, radiology services rely on smaller teams to deal with urgent cases, and the full complement of general, specialist, and support staff is not available [2]. Consequently, weekend imaging is to be triaged by urgency based on the need for clinical decisions related to immediate care and clinical management ([2].
The current employer is a university teaching trust over three sites providing general and specialist acute hospital services including pediatrics and hyper-acute stroke unit as well as a designated major trauma center, for a catchment of 600,000 patients. Imaging service demand within this trust is increasing, 2017 - 2018 recorded a 10% rise, above the current UK trend, the recent Trust board report identified ‘imaging as a challenging area’ [5].
Weekend acute radiology demand has seen an exponential increase in both quantity and complexity, above the general service. Trauma scanning, a time-pressure investigation that generates 1000s of images and requires a dedicated hour of uninterrupted interpretation, rose from a weekend average of 5 trauma scans in 2015 to 18 scans in 2019 (Graph one).
The quantity and complexity of weekend imaging have increased, and the weekend workforce has remained static. The radiology workforce covering the weekend consists of 3 radiographers, one healthcare assistant, one consultant radiologist, and a single radiology registrar. The remit of the radiology registrar is multi-factorial;
- Provide an acute ultrasound service
- Clinical interface for referring clinicians
- Primary read for trauma scans
- Interpretation of the hyper-acute strokes
The radiology registrar (SpR) is supported by a consultant radiologist who undertakes most of the non-neurological interpretation.
Weekend working pressures as experienced by the radiology registrars had become unsafe. National training surveys are a core part of the work GMC conducts to monitor and report on the quality of education and training in the UK; these surveys are viewed as a robust quality assurance tool and trends to inform policy developments (GMC 2018). From 2015 - 2018 radiology trainees at this trust highlighted the weekend workload as unsustainable. GMC perceived this now as a recurrent training issue.
This paper explores the potential for improvement in patient safety in radiology weekend services within a regional trauma center through a grass-roots radiology registrar (SpR) solution.
Literature Review
The literature review was completed using the commenced with the MDM110 module reading list, Brighton University database, Scope, Athens, and Pubmed. Search terms, incorporating Boolean operators were identified in the research question ‘How to improve radiology weekend working conditions?’ to provide a PEO framework.
Hand-searched publications from NICE, BMA, BMJ, Department of Heath, The King’s Fund, The Nuffield Trust, and The Health Foundation dating back to January 2007 as well as the Royal College of Radiologists back to 2008. I accessed The NHS Leadership Academy for leadership models unique to the NHS.
Case Study
As alluded to in the introduction radiology workload has increased; however, there had been no concurrent staffing increase. Graph one provides insight into the weekend trauma scanning trend.
The proposed change was a rota modification to increase the radiology registrar weekend cover.
Sussex Radiology Registrar (SpR) training scheme is a relatively new UK scheme, and as such the program is growing in registrar numbers with increases in funding. August 2018 the number of available on-call radiology registrars would rise to 19 (previously 14). Figure one below is a simple diagram depicting the current service delivery and the proposed rota change to provide combined cover.
Change and Management
Change in healthcare is vital in a healthcare institution that seeks to deliver quality and patient-centered care to its clientele [6]. NHS appears to be in a constant state of change; although there is not always a clear definition of what these changes may be, it is accepted to be some form of movement along a continuum [7]
Change management meta-theories as described by Chin and Benne (1984) (Cited by Nickols 1996), [8] provide an overall framework to guide change. Many NHS changes, as epitomized by the unilateral variation of the 2016 Junior doctor contract, may be perceived as a ‘Power-coercive’ approach to change management where successful change is an exercise in authority and sanction imposition. This prescriptive top-down directive approach avoids duplication of efforts through central coordination with clear accountabilities, providing a standardized process within large organizations [9]. However, the top-heavy approach of the department of health assumed that people are compliant and will do as they are told to do, without an option of an opinion [8]. This leverage can come at the expense of trust and undermines commitment [9].
The Radiology registrar cohort is not an influential powerful cohort and consequently, change was induced through an alternative, bottom-up approach, an empirical-rational strategy. A bottom-up approach is less directive, where it encourages and empowers people to achieve change locally with locally-tailored solutions [10]. Importantly a bottom-up approach allows for local ownership of the change process, aiding to overcome barriers of inadequate engagement [10]. The empirical-rational strategy considers people to be rationally self-interested and therefore will adopt change when the proposal is logically justified and the change will bring the individual benefit [11]. The following assumption of that the SpR body and those involved in managing imaging services are rational beings once reasoned with, and the right information supplied, could be persuaded to engage [8]. Benefits of the proposed change particularly relevant to, and likely to stimulate engagement from, the registrar body included; the potential to improve patient safety, especially topical in light of the rising weekend workload, and the registrar’s own educational experience. The change proposed had very little in the way of a risk and was attractive enough to outweigh any downsides involved [8].
Change is not without resistance [12], and as alluded to previously, change may involve risk and potential disadvantages resulting in disengagement. Force field analysis, as described by Lewin in 1951, is the culmination of forces that either facilitate or resist change; where success results when the forces facilitating change exceed those resisting change [12]. Force field analysis was applied to the case study in figure 2, providing a visual summary of the various factors supporting and opposing the two registrars' weekend on-call rota. The analysis delivered an insight into the group behaviors and barrier identification before initiating change and was used as an assistive planning tool.
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