1

Highland NHS Board

27 November 2018 Item 3.4

Final Report – NHS Highland Radiology Strategy Short Life Working Group Report by Dr Roderick Harvey, Board Medical Director and Dr Gaener Rodger, Non-Executive Director. The Board is asked to note the contents of the report of the Short Life Working Group and to endorse the recommendations. 1. Introduction

As outlined to the Board in September 2017, Radiology services in Highland are currently under unprecedented pressure predominately due to a shortage of radiologists compounded by increasing demands on the service. Several groups of clinicians have expressed concern regarding the potential implications of the situation in relation to quality and patient safety. This concern was shared by the Executive Team. Radiology provides a key diagnostic service to a broad range of clinical disciplines across both primary and secondary care as well as providing some direct therapeutic procedures through interventional radiology. It was acknowledged that the current configuration of radiology services in NHS Highland was unsustainable. The Board agreed that there was an urgent need to define a strategic plan for the delivery of a sustainable radiology service in Highland that would meet the needs of the local clinicians and the patients for whom they care. It was proposed that a short life radiology strategy group should be established, co-chaired by the Medical Director and a Non-Executive Director of the Board. The Radiology Strategy Short Life Working Group has been established and eight workshops have been held to date. The group comprises a range of stakeholder users of radiology services including clinicians from primary and secondary care, together with local staff involved in the provision of radiology and radiography, and relevant external experts. Patient input was sought via a Patient Experience Questionnaire designed by the SLWG. 2. Key areas of work

1. To specify and define the functional range of radiology services that are required to be provided within the NHS Highland Board area from a patient and clinical user perspective.

2

2. To specify the desired standard of service delivery in terms of access, image acquisition and reporting for each component of the required service.

3. To define the relevant key performance metrics. 4. To identify and define the key additional requirements that are essential

elements of an effective radiology service from the clinical user perspective 5. To develop a Patient Experience Questionnaire to capture the patient facing

requirements of the service from the user perspective and to seek feedback on areas of improvement in current service delivery.

6. Considering potential models of service delivery that could meet the defined requirements agreed by the SLWG whilst considering both the regional and national radiology programme plans.

7. To agree recommendations for a preferred model of service delivery taking into account the available work force, skill mix and the opportunities for regional and national working

Radiology Short Life Working Group October 2018

3

NHS Highland Radiology Short Life Working Group Report October 2018

1. Introduction & Background

Due to the growing pressures across the radiology and diagnostic services in Highland to meet demand, it is evident that radical alternative solutions are required to realise improvements within the organisation and business processes. Radiology services across NHS Highland are currently under unprecedented pressure due to a shortage of radiologists compounded by increasing demands on the service. Several groups of clinicians have expressed their written concern over the implication of the current situation in relation to quality and patient safety, and this concern is shared by the Executive Team. It was agreed that a short life radiology strategy group (SLWG) should be established, co-chaired by the medical director and a non-executive director of the Board following discussion on the 27th September 2017 at the NHS Highland Health Board meeting. The group was tasked with delivering a strategic plan for the delivery of a sustainable radiology service in Highland that meets the need of the local clinicians and the patients for whom they care. As a service specialty the group was asked to look at the service from the user perspective. It was agreed the membership of the group should comprise of a range of stakeholder users of radiology services including clinicians from primary and secondary care together with local staff involved in the provision of radiology and radiography services, patient representatives and relevant external experts. By bringing together a wide mix of individuals who each play a key role in the delivery and use of services the aim was to achieve inclusive discussions from all perspectives. Initially meeting on the 22nd November 2017, the SLWG have met on seven further occasions for workshop events on a monthly basis each targeted at reaching the objectives laid out in the terms of reference. The SLWG terms of reference (Appendix 1) outlines the objectives of the group and its membership. The work of the group was divided into two phases. In phase one the group was tasked with defining the type of services and standards of service delivery that are required from the user perspective, the associated relevant key performance metrics and the patient facing requirements of the service. Following on from this, in phase two, the group was tasked to consider and advise on models of service delivery that might meet those requirements, taking into account the available skill mix and the opportunities for regional and national working. The NHS Highland Health Board requested a final report from the SLWG to be brought to the Board meeting in November 2018. Throughout its discussions the SLWG has recognised the benefits of a locally delivered service in terms of patient access, responsiveness and the development of

4

clinical relationships and informal networks. However it has also recognised that local services are often intrinsically lacking in resilience and that there are substantial opportunities for utilising the ability to move electronic images and information rapidly and hence deliver some aspects of the service remotely. Indeed this is a model that is already well established within the Board area for the support of the Rural General Hospitals and Community Hospitals. Radiology services are provided for North Highland by a radiology department at Raigmore Hospital which is integrated with the department in Argyll and Bute where two radiologists are based at the Lorn & the Islands Hospital. Some referrals for more complex examinations in Argyll and Bute also go to NHS Greater Glasgow & Clyde through the NHSH SLA for acute/secondary services. Across radiology services within NHSH reporting capacity currently does not meet demand and the shortfall is met by commercial outsourcing both for elective work and urgent out of hours reporting of CT scans. A variety of radiology services are provided within the three NHSH Rural General Hospitals including plain film x-ray, cross sectional imaging (CT Scan) and ultrasound imaging. The Lorn & the Islands Hospital in Oban, and the Belford Hospital in Fort William, also offer some fluoroscopy imaging. All of these radiology services are routinely offered at Raigmore Hospital. Raigmore hosts the majority of the NHSH radiology team and in addition to the services available at the RGHs provides MRI cross sectional imaging and interventional radiology services including general diagnostic biopsies and specialist vascular and other interventional procedures. In total there are fifteen consultant radiology posts in North Highland and two in Argyll & Bute (currently provided by three individuals), but there are a number of vacancies. Of the fifteen posts in North Highland, as at the 30th October 2018, eight are substantively filled with a total of seven vacancies. Of the vacant posts four are without substantive backfill, one is filled by a long term NHS locum, one interventional post partially covered on a long term basis by a part time NHS locum and one by an overseas specialty doctor working towards specialist registration in the UK and consultant status. Two fixed term appointees are expected to take up post in early 2019. Even if the NHSH radiology service was at a full establishment of radiologists it is most unlikely that it could meet current demand without external augmentation as the number of posts is significantly below current Royal College of Radiologists workforce reccomendations The most recent UK and Scottish census data on radiologist staffing are available at; https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr185_cr_census_2017.pdf

5

https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr167_scotland_census.pdf At the meeting of the NHSH Board on 29th May 2018 the Board publically reiterated its commitment to continue to have a range of local radiology services delivered across the NHS Highland area, including Interventional Radiology, not only for the benefit of the population but also to ensure that local radiology staff can maintain the full breadth of their skill sets.

6

Fundamentals of Radiology Service The Radiology service can be divided into two sub-sections, Diagnostic and Interventional, both of which can include elements of image interpretation and the performance of real time patient contact procedures. (i) Image interpretation Image interpretation is dependent on three steps: Step 1: Image Acquisition - The ability to acquire images is dependent on the availability of specialised equipment, which is often not readily moveable and/or fixed in location. As X-Rays involve potentially harmful ionizing radiation the exposure of patients is tightly controlled under the Ionising Radiation Medical Exposure Regulations (IRMER). Image acquisition involves three key stages encompassing the requesting of an image, the justification of an image request and the acquisition of the image.

Step 2: Reporting - The reporting of an acquired image by a suitably qualified healthcare professional, with the correct level of expertise, is usually separated, both in time and place, from the image acquisition process. Currently most images are reported by a consultant radiologist, but some can also be reported by a trained reporting radiographer and in limited circumstances by the requestor alone. In all circumstances a written report of the image is required which constitutes the definitive result of the examination for medico-legal purposes

Step 3: Dialogue - There is often the need for the service users or referrer to have a discussion about the appropriate examination, the findings of the report and any relevant further imaging with the providers of the service. Importantly, radiologist input is a core component of formal multidisciplinary care team (MDT) meetings where patient care is planned and therapeutic decisions made.

(ii) Procedural

Procedural Radiology accounts for a significant proportion of diagnostic work, including ultrasound, fluoroscopy, and general intervention such as guided diagnostic biopsies. This requires in house expertise and cannot be separated in time or place from the acquisition process.

Specialist interventional radiology is overwhelmingly procedural. It is performed by consultant radiologists with specific subspecialty training and is used for diagnosis and treatment a wide array of conditions across most clinical specialities. These range from line placement (chemotherapy / nutrition / dialysis) through to direct cancer treatments and emergency life-saving major haemorrhage control. Elective work is integral to several surgical specialties especially urology and vascular where it accounts for about two thirds of vascular surgical procedures. Being minimally invasive the development of interventional radiology has reduced the need for open surgery and has become the preferred modality of care for many surgical emergencies.

7

Location of radiology services

The SLWG considered the needs for the future provision based on the following two principles:

1. Imaging modalities required to support the clinical activity expected at relevant sites, including a specification of available access times

2. The convenience of access and how far is it reasonable for a patient to travel.

8

2. Specify and define the functional range of radiology services that are required within the NHS Highland Board area from a patient and clinical user perspective

Table one represents the output of the group in defining the aspirational radiology services that would be needed to support current NHS Highland clinical services as described by service type.

*Within the Trauma network Raigmore is designated a trauma unit rather than a major trauma centre. However, Raigmore receives a large volume of trauma compared to other trauma units. **Under defined protocols only The agreed aspirational provision of services in the above table by service type would mean that NHS Highland would need to give further consideration to, and clarity around, the hospital services and the imaging capabilities supporting those services, which would be provided in Community Hospitals and Rural General

Service Type Modality Location Urgent Within

24 Hours Planned In Hours &/or

Out of hours

General Practice

Plain X Ray

Ultrasound

CT

Local hospital

RGH / DGH

RGH / DGH

No

No

No

Yes

Yes

Yes

In hours only

In hours only

In hours only**

Community Hospital (planned & unscheduled admissions)

Plain X Ray On site Yes Yes Available daily

Minor Injuries Unit

Plain X Ray On site Yes N/A During opening hours

Hospital Providing for Emergency Receiving & Minor Trauma

Plain X ray

CT

Ultrasound

On site Yes

Yes

Yes

Yes

Yes

Yes

24 hours

24 hours

Within 12 hours

Hospital Providing for Emergency Receiving & Major Trauma (Local Emergency Hospital)

Plain X ray

CT

Ultrasound

On site Yes

Yes

Yes

Yes

Yes

Yes

24 hours

24 hours

Within 12 hours

Hospital Providing for Emergency Receiving & Major Trauma (Trauma Unit*)

Plain X ray

CT

Ultrasound

Interventional radiology

MRI

Fluoroscopy

On site Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

24 hours

24 hours

24 hours

24 hours

Within 12 hours

24 hours

9

Hospitals. It should be noted that 24 hour access to interventional radiology is not available at Raigmore Hospital 3. Specify the standard of service delivery in terms of access, image

acquisition and reporting for each component of the required service.

The following table provides a breakdown of the aspirational time standards the SLWG agreed to be their target for booking, image acquisition and reporting across all modalities. The table breaks down Inpatient & Emergency, Outpatient and Primary care modalities and has been populated with what the group consider, from a reasonable patient perspective, would be the optimum times we should aim towards delivering as a service. N.B. The times are sequential from the completion of the previous step to the start of the next step and exclude patient travel times to the site of image acquisition

Modalities Inpatient & Emergency Dept. Outpatient Primary Care

Booking To start of Acquisition

Reporting Booking To start of Acquisition

Reporting Booking To start of Acquisition

Reporting

Plain Film Emergency 5 minutes 15 minutes 40

minutes 5 minutes

15 minutes 40 minutes

N/A N/A N/A

Urgent 5 minutes 1 hour 2 hours 5 minutes

30 minutes 2 hours N/A N/A N/A

Elective 5 minutes 4 hours 4 hours 5 minutes

30 minutes 2 hours 1 hour 1 week 24 hours

CT Emergency 5 minutes 20 minutes 1 hour 5

minutes 20 minutes 1 hour N/A N/A N/A

Urgent 5 minutes 3 hours 1 hour 1 day 1 week 4 hours N/A N/A N/A Elective 2 hours 8 hours 4 hours 1 day 2 weeks 8 hours 1 hour* 1 week* 24 hours* MRI Emergency 5 minutes 1 hour 31 hour 5

minutes 1 hour 1 hour N/A N/A N/A

Urgent 5 minutes 3 hours 1 hour 1 day 1 week 4 hours N/A N/A N/A Elective 2 hours 8 hours 4 hours 1 day 2 weeks 1 day N/A N/A N/A Ultrasound Emergency 5 minutes 20 minutes 5 minutes 5

minutes 20 minutes 5 minutes N/A N/A N/A

Urgent 5 minutes 3 hours 5 minutes 1 day 1 week 5 minutes N/A N/A N/A Elective 2 hours 8 hours 5 minutes 1 day 2 weeks 5 minutes N/A N/A N/A General Interventional Emergency 5 minutes 5 minutes 1 hour 5

minutes 1 hour 1 hour N/A N/A N/A

Urgent 5 minutes 3 hour 1 hour 5 minutes

1 week 4 hours N/A N/A N/A

Elective 2 hours 8 hours 1 hour 5 minutes

2 weeks 8 hours N/A N/A N/A

Specialist Interventional

Emergency 5 mins 20 mins 5 minutes N/A N/A N/A N/A N/A N/A Urgent 5 minutes 3 hours 5 minutes 1 day 1 week 4 hours N/A N/A N/A Elective 2 hours 8 hours 4 hours 1 day 2 weeks 8 hours N/A N/A N/A

*Primary Care referrals for CT Scans as per agreed protocols only.

10

4. Define the relevant key performance metrics.

Key performance indicators have been identified based on the scoping of service requirements timescales agreed by the SLWG. Below is the standard format of the KPIs to be adopted for each specific modality and admission type.

These KPIs are in addition to the standard performance metrics that have been set by the Scottish Government.

KPI [Example] Modality/Priority/Location: Reporting Frequency Weekly by week of request Requesting to Acquisition Measure The % of films acquired within the audit standard time from request 99th percentile for interval from request to acquisition % of requested examinations for which an image has been acquired Acquisition to Reporting Measure The % of films reported within audit standard time for acquisition the 99th percentile for interval from acquisition to reporting % of examinations for which an image has been reported Requesting to Reporting Measure the % of films reported within audit standard time from request 99th Percentile for interval from request to reporting % of requested examinations for which an image has been reported

5. Essential requirements for a Radiology Service in Highland that can meet

the performance targets

i. Staffing – Radiologists, Radiographers, Radiology Nurses, Support and Secretarial Staff

ii. Hardware – modern machinery with fixed replacement programme iii. Digital Support – dedicated departmental eHealth personnel 6. Additional Requirements

The SLWG has identified 4 key additional requirements that are essential elements for a service that is resilient and which can perform to the required standards. I. Electronic Processing All processes from requesting a radiology image, booking the appointment, justification, acquisition of an image and the reporting of the results should be

11

electronic. This will facilitate rapid processing through instantaneous transmission of information and will require standard work to be developed with resultant improvements in patient flow, patient experience and patient safety. Most importantly electronic processing will facilitate the opportunity for remote working such that processes can be delivered by staff working either locally within NHS Highland facilities or at remote sites in other Boards or through third party providers. This is a key contributor to enhancing resilience. The SLWG were of the opinion that simple interim electronic solutions for requesting and possibly justifying examinations could be adopted with a short lead time to obtain immediate benefit pending the implementation of a fully functioning integrated order-comms system. II. Trusted Professional Relationships During discussions within the SLWG it was clear that the communication and consultation between service users/referrers and radiology staff is hugely valued and may be required both before and after the acquisition of an image. There remains a view that face to face communication is particularly valuable and this is common practice within Raigmore Hospital. However this is resource heavy in terms of travel time within a large hospital setting, highly constrained in terms of availability given the requirement for co-location and does not provide an equitable service for users across the whole board area. The SLWG agreed that other methods of communication using technologies such as video conferencing, email and telephone could be effective provided that good trusting professional relationships had been established between those seeking and providing advice. Knowledge of and confidence in an individual providing advice was seen to be more important than physical co-location. The group recognised that the provision of remote radiological advice, including that of the function of the current “duty radiologist” could be effective provided that the access times and responsiveness were equivalent and that consistent professional relationships with the remote provider had been established. III. Input into MDT meetings Radiology staff are core to MDT meetings that require imaging to be reviewed. This is ongoing and key to delivering good quality care to patients. IV. Automated notifications Within primary care, electronic systems are routinely used for alerting referrers to the availability of reports from radiology services. These are not available at present within secondary care settings as, in addition to paper reports, electronic reports are simply available for passive viewing within the SCI-Store repository. Adoption of an alert system in secondary care would ensure a timely clinical response to imaging results. It is unlikely that this can be achieved without the implementation of a fully functioning order-comms system.

7. Identify the patient facing requirements of the service from the user perspective

12

From the outset the delivery of a sustainable radiology service in Highland that meets the need of the local clinicians and the patients for whom they care has been paramount. Therefore, the group has endeavoured to ensure that the service user perspective, whether from a referring clinician or a patient’s point of view, is at the forefront of the considerations and discussions of the SLWG.

In order that the patients themselves inform the group a patient questionnaire was developed (Appendix 2) to survey patients experiences of radiology services and to seek feedback on areas of improvement in the current service. The questionnaire was circulated across a variety of NHS Highland sites including Raigmore Hospital, the Rural General Hospitals and a community hospital. Questionnaire responses were sought and collated from patients attending for plain X-Ray, CT, MRI and Ultrasound services. An example data report can be found in Appendix 3.

328 patients responded to the questionnaire and had visited either the Belford Hospital in Fort William, the Lorn & the Islands Hospital in Oban, Raigmore Hospital in Inverness, the Lawson Memorial Hospital in Golspie or the Caithness General Hospital in Wick.

The majority of respondents attending radiology services for a CT scan or an MRI scan were attending their appointment on that day as part of a consultant outpatient appointment. In contrast, the majority of respondents attending an ultrasound scan were attending their appointment on that day for that investigation only and not as part of a consultant outpatient appointment. Similar numbers of respondents attended radiology services for an x-ray as part of a consultant outpatient appointment as attended for that investigation only.

Across radiology services a higher number of respondents were attending for an x-ray or an ultrasound scan due to a new medical reason. While marginally higher numbers of respondents were attending for a CT scan or MRI scan as part of a planned follow up appointment for an existing medical reason.

The majority of respondents strongly agreed or agreed with the following statements about their experience of radiology services in NHSH: 1. I understood what was going to happen to me 2. I was given an opportunity to ask questions 3. I was given enough time 4. I was treated with compassion and understanding

Waiting times for receiving an appointment across radiology services ranged from patients that were seen either immediately or within a few days to those that had to wait for a number of months. Overall the majority of patients indicated that they were satisfied with their waiting time for a CT scan, Ultrasound scan and x-ray investigation. 50% of patients attending for an MRI scan indicated that they were satisfied with their waiting time.

When asked if they would like to be informed of the result of the investigation, the majority of respondents replied that, yes, they would. Their expectation would be that they would have their results within approximately 2 weeks (anticipated wait ranged from the same day to 8 weeks).

13

Overall the majority of respondents were satisfied with the number of miles they had to travel to attend their appointment. Regardless of which hospital patients attended there were a minority that had return journeys of between 100-250 miles. In addition, a number of patients attending the Lorn and the Islands Hospital had ferry journeys. Some respondents found the distances unacceptable whilst others took them to be part of the everyday life of living in a rural and/or remote location. The average return journey across all of the respondents was approximately 53 miles and ranged from 0 to 250 miles. For these journeys the majority of patients told us that they used their own car.

Respondents told us about a variety of things they thought went well on the day of their appointment. This feedback covered a variety of themes including general comments, treatment by staff, how quickly they were seen and the outcome of the investigation. Staff across radiology services were highly praised for their friendliness, professionalism, compassion and support.

Respondents were also asked to tell us about what they felt could have gone better or perhaps be done differently to improve the service. Specific comments relating to attending radiology services included recognition that we had a shortage of radiologists; navigation around the hospital; being told more information beforehand; shorter waiting times for appointments; the need for more scanning technology and the need to have a wider range of services across our NHS Highland Hospital sites.

14

8. Potential new models of service delivery

The SLWG was asked to identify and consider potential new models of service delivery that could meet the defined requirements agreed by the SLWG in section 3, 4 and 5 of this report. These new models were discussed in the context of both the regional and national radiology programme team plans. The group confined discussion to general radiology services and excluded specialist interventional radiology for the following reasons.;

• Potential solutions for the provision of interventional radiology were likely to be very different from those for more general radiology services given the need for direct patient contact

• Interim arrangements for the provision of interventional radiology were being addressed separately

• Longer term solutions are likely to require a regional approach which is discussed later in this report.

Based on the discussions in phase one of the SLWG’s workshops, the group identified areas of the service that could be delivered differently and that were important to the realisation of the ambitious aspirational model for radiology services in NHS Highland.

Discussions took place around the following topics in the context of service providers (radiologists) not necessarily being co-located with requestors.

1. How can we ensure rapid and effective requesting? 2. How can we ensure discussions with Radiologists take place before finalising

requests where necessary? 3. How to ensure rapid reporting 4. How to ensure discussions with reporting radiologists can take place

1. How can we ensure rapid and effective requesting?

Requesting of image acquisition must be electronic because of the timescales that have been set within the standards of service delivery and the potential separation of requestor and justifier. It would simply not be possible to move paper at the required speed. From the referrer’s point of view, it must take no longer to fill out and send than the current paper based system. It would also be desirable if an electronic system gave direct feedback as to how each request was being processed, particularly for emergency and urgent requests.

During discussions in Phase 1 the group agreed to trial requesting of radiological imaging for in-patients using Formstream as an interim electronic solution. This would allow rapid electronic requesting and should happen at the earliest opportunity to gain benefit and traction.

In the longer term NHS Highland should plan to process electronic requests through a formal Order Comms system, the expectation being that this would be provided

15

through the TrakCare system. It is important to note however that currently patients attending hospital Emergency Departments are not included in TrakCare.

Currently the RGH’s and Raigmore have separate booking systems for radiology. The group identified the need for a single Highland wide system for the requesting and booking of radiological imaging. This will eliminate silo working, facilitate equity of access and help maximise the use of available resources.

The group recognised the limitations of the current RIS (Radiology Information System) and the difficulty posed by the use of separate systems in North Highland and Argyll and Bute.

Consideration should be given to replacing the current RIS system to ensure a unified system across Highland or to use the integration technology being procured and implemented as part of the Scottish Radiology Transformation Programme (SRTP) to interface with the existing RIS systems and to directly provide some of the RIS functions.

2. How can we ensure discussions with Radiologists take place before finalising requests where necessary?

There was strong agreement that the role of duty radiologist as a point of contact for discussion and urgent requesting of radiology examinations is a vital part of the service from a user perspective. Members of the group clearly valued the opportunity for a face to face service. Views were expressed that any attempt to deliver this remotely would inevitably be a downgrade.

Remote provision of access to radiology advice was also discussed in the group discussion session; there was concern that this would probably be provision at a grade down from the current consultant level if it were provided from a larger Board with a teaching hospital set up.

The group concluded that the principle of remote duty radiologist advice was sound, but that if it were implemented there would from the referrer’s perspective need to be absolute clarity as to who to contact at any given time with a reliable single point of contact. This could be a service for the whole of Highland including Argyll and Bute, thereby providing equity of access.

The group recognised that remote access and local provision were not mutually exclusive and that a mixed model of provision could be effective provided that communication channels were organised such that direct on site contact was not required.

The group agreed that a discussion prior to an image request was not always required and that the default position should be that it would not happen, provided the requesting process was optimised. It was agreed that it must be possible for a discussion regarding a radiological imaging request to be initiated by either the requesting clinician or the Radiologist receiving the request.

16

There also needs to be appropriate communication back to the requester. This may be something we want to build into the requesting form. It was suggested that having a better electronic form, with a number of mandatory fields could be a good way forward. Clinical decision support software being piloted by the SRTP may eventually become available to assist requestors.

The group recognised that a duty radiologist may not always have the appropriate expertise to provide advice on all subspecialty areas of radiology. A process needs to available whereby local clinicians and radiologists can have those conversations with subspecialty specialists regardless of where they are based in order to ensure equity of access for the patient population. This would fit with a regional or national approach to service delivery.

3. How to ensure rapid reporting

The group recognised that rapid reporting can only happen if there is a balance between capacity and demand. It is clear that lessons can be learnt from the outsourcing companies in terms of how they work and achieve rapid reporting.

The following approaches to balancing demand and capacity were considered.

• Ensuring appropriate image requesting and acquisition with the aim of maximising value and reducing harm from over investigation.

• Use where appropriate of reporting radiographers

• Maximising efforts on local recruitment with the aim of maximising the proportion of images that can be reported locally

• Engaging in cross boundary insourcing or outsourcing to commercial companiesMaking provision for effective home working for current radiologist staff to provide additional internal capacity

• As an NHS board if we approached image reporting using lessons learned from outsourcing companies, what would this mean in terms of the quality of work stations we might provide, the ability and flexibility of the service to facilitate staff to work from home.

4. How to ensure discussions with reporting radiologists can take place

The group discussed the current process whereby urgent findings may be communicated verbally through a conversation between the referrer and the Radiologist, usually by phone or face to face depending on the location of the staff involved. This process is mainly used for in-patient and emergency or OOHs reporting regardless of whether the reporting is outsourced or in-house.

It was agreed that communication through written reports only would normally be acceptable provided that a secure system was in place to ensure that a report had been read by the clinician responsible for the patient. This will require a means of notifying the clinician of the availability of the report and a means for the clinician to acknowledge receipt.

17

Whilst the latter could be achieved in a manner akin to that used within SCI-Store for laboratory results the ability to provide a proactive electronic alert as to the presence of a report within secondary care is not likely to be possible without the implementation of a full order comms system.

The group agreed that if a conversation with a reporting Radiologist does need to take place then there needs to be a process in place to allow this to happen regardless of whether the conversation is with someone that is in house, in Raigmore, in Highland or outside of NHS Highland.

18

9. Conclusions

Whilst working towards defining a preferred model of service delivery the SLWG took into account the aspirations for the NHS Highland service, the available work force, skill mix and the opportunities for regional and national working whilst identifying present or future challenges to its implementation. From all of the information discussed during the SLWG workshop sessions a number of key issues were identified and conclusions can be drawn as follows, which have helped shape the recommendations from the SLWG:

(i) Electronic requesting & booking

The group agreed that the request for a radiology image acquisition should not be paper or messenger dependent. Further work should be done on the development of an electronic system. The use of FormStream has been discussed as a short term solution with a view to moving towards the use of an Order Comms system in the longer term. This would encourage working in flow vs batching and should be a more effective and efficient use of time.

The requesting of a radiology image should not be dependent on face to face discussions but the group acknowledged that conversations should still be had if required.

The adoption of Clinical Decision Support software could help clinicians decide whether making a request is in the best interests of the patient. This software is being piloted through the SRTP and in the meantime use of the RCR i-refer guidelines by referring clinicians, should actively be encouraged. These are available free throughout NHS Scotland at https://www.irefer.org.uk/..

Booking for radiology examinations across NHS Highland including in the RGHs should be a uniform integrated process with no unwarranted variation. The development of a centralised, lean process should lead to significant improvements for patients. In addition, those patients waiting for radiology examinations need to be booked in line with NHS Highland Patient Access Standards Policy. The long term aim for the service would be to provide patient focused electronic self-booking.

The group concluded that it was important to preserve the ability for a discussion to occur if required between the responsible clinician (often the referrer) and the reporting clinician (usually radiologist).Those having these discussions should not need to be co-located. The preferred option would be to have the staff in-house to allow clinical discussions to take place within the NHS Highland Team. However, there is recognition that there are possibilities for remote regional or national working.

(ii) Off Site Reporting

The group concluded that it was difficult to give views on off-site reporting as there is uncertainty around how much capacity will be available as part of the SRTP cross boundary reporting initiative, and therefore how much capacity needs to be bought from commercial organisations. Share Plus will allow the

19

current Radiology Information System (RIS) that Boards use to be accessed nationally so that any users can report on any images form any Board. For Highland, this software will allow radiologist in North Highland to report images from Argyll and Bute reinforcing an integrated team approach. Currently, we have one radiology department in highland split across Highland and Argyll & Bute with different RIS’s. We should move at the earliest opportunity to exploit this national software to allow our department to move to function as a single department on several sites. This would maximise use of our available capacity including reporting radiographers.

The group agreed that we need a more strategic approach to the utilisation of off-site reporting and that this should be a shared management and clinical approach taking into account skills sets, capacity, MDTs etc.

(iii) Multi-disciplinary Teams (MDT)

The group agreed that contribution to MDTs is an essential part of a radiology service. Taking part in a MDT meeting could be done face to face or virtually. The primary purpose of an MDT is to have a multi disciplinary discussion about the management of a patient taking into account all of the findings.

There is a College of Radiologists requirement to align subspeciality radiology reporting to participation in relevant MDTs. Job planning and work allocation within a relatively small group of radiologists needs to be actively managed to help achieve this standard

(iv) Duty Radiologist

The group agreed that the Duty Radiologist function was essential to providing advice and facilitating imaging requests on urgent or emergency radiology cases. Currently this function is provided for North NHS Highland and Argyll and Bute separately in hours but through a shared on call rota out of hours. This can be locally or remotely provided although the preferred option for a sustainable NHS Highland service is to continue provision locally where possible.

The ability to speak directly to a radiologist is valued by referrers, as well as personal knowledge of the individual as that is an important factor in confidence building.

There is the potential for regional working with access through a single point of contact.

(v) Reporting

The reporting of radiology images has been frequently discussed during the life of this SLWG. Some of this is currently done off site via a private company but about 50% is still reported locally by the NHS Highland Radiology Team. The group agreed that it was important to get the balance right here as our Radiologists and Radiographers need to retain their reporting skills and expertise. The group explored whether home working might be an option for reporting and it was seen as one that potentially may make jobs more attractive. There was

20

agreement that we could learn from the private sector models and that there would have to be an in-house agreement as to how outputs were measured and recompensed.

There was agreement that NHS Highland is in a strong position to use the regional and national strategic work to its advantage and that we would want to align with the SRTP (Scottish Radiology Transformation Programme) new reporting solution Share Plus as soon as possible.

Whilst the benefits of SRTP are clear in terms of providing a route to resilience and capacity, the group was also concerned that its implementation could pose a threat to the integrity and critical mass of the locally based radiology service. There is a definite need for a locally based service, augmented by external and remote support. The ready ability for radiologists to work remotely, and particularly within large departments in the central belt area of Scotland, may further compromise the ability of NHS Highland to attract applicants for locally based posts and hence exacerbate the current problem. This emphasises the importance of ensuring that posts made available locally are constructed to be as professionally attractive as possible, and indeed ideally should constructed to have the potential to contribute expertise to other areas via SRTP

The group agreed that the audit trail for radiology reporting should be strengthened, although this was likely to require the implementation of order comms.

In the longer term the development of better artificial intelligence systems that would reduce human input to image interpretation might lead to further opportunities for different method of reporting.

(vi) Workforce

The SLWG recognised that even at full establishment the current department would be unlikely to be able to meet demand in terms of reporting capacity. There was extensive discussion as to potential optimal staffing levels in terms of radiologist numbers. It was suggested that an aspirational figure would be to match the UK average of 7.5 WTE diagnostic radiologists/100,000 population or alternatively the Royal College of Radiologists workforce standard.

It was recognised however that at present the figures are academic as recruitment difficulties would make achieving such figures very difficult even if financial resources were made available.

The group did recognise the importance of ensuring good job satisfaction and maintaining the morale of those working locally within the department.

There was agreement that it is critical that we look into strategically developing extended professional roles for image acquisition and reporting. It would be useful to develop a skills matrix looking at what roles could be extended and how they would be trained and supported. This could include extending the roles of Radiographers, Physicians Associates, AHP other clinicians. Further discussions

21

around the potential for reporting by wider staff groups would need to take place with NES and the professional registration bodies.

Within NHS Highland it would also be crucial to look at how we better use our current capacity within radiology and move towards an integrated team approach.

(vii) Interventional Radiology

Although the focus of the workshops has substantially been on non-interventional radiology the group recognises that there are significant issues with the current Interventional Radiology service. The ability to deliver sustainable interventional radiology services is completely different to the other more general radiology services that the NHS Highland Radiology Team provide. In addition, the sustainability of the current interventional radiology service has become particularly fragile due to the retirement of one post holder and the recent resignation of another. An urgent remodelling of the service is needed as core clinical services within NHS Highland would be at risk without the continued provision on-site interventional radiology.

The group noted that there has never been a formal out of hours emergency interventional radiology service in Highland, although an ad hoc one has often been available on the basis of good will. Arrangements have been established with NHS Grampian and NHS Tayside to access interventional radiology services in emergency situations going forward, although it is acknowledged that the logistics of patient transfer remains a challenge.

22

10. Recommendations Recommendation 1: NHS Highland should move to electronic requesting of radiology examinations and implement an interim solution that emulates current business processes with immediate effect.

Recommendation 2: Implement an order comms system for reliable electronic requesting and clinical acknowledgement of reports. Depending on the solution this may require re-provision of the RIS system.

Recommendation 3: Encourage the use of RCR i-refer guidelines by referring clinicians and when available adopt the use of Clinical Decision software, to help clinicians decide whether making a request is in the best interests of the patient.

Recommendation 4: Develop a detailed workforce plan for a Highland wide radiology service to meet the requirement for a core locally delivered self-sustaining service, supplemented as required by external support. This must take account of the current age profile and be benchmarked against staffing levels elsewhere in Scotland.

Recommendation 5: A skills matrix should be developed to better understand the potential for extended advanced roles within the radiology service.

Recommendation 6: Work with NES/ professional bodies to broaden the potential for reporting by wider staff groups beyond radiologists and radiographers e.g. AHP’s such as physiotherapists.

Recommendation 7: Use a team job planning approach to optimise the use of the current capacity within NHS Highland Radiology Team.

Recommendation 8: Explore the potential for home working for reporting purposes and develop an agreed process to manage output and remuneration.

Recommendation 9: Radiology reporting should be distributed and shared across a whole board wide team of both radiologists and reporting radiographers. This will require enhancement to the function of the current RIS and PACS systems and should make full use of the new software applications and opportunities provided by the Scottish Radiology Transformation Programme (SRTP).

Recommendation 10: Develop a strategic approach for selection of examinations for off-site reporting involving both managers and clinicians to ensure the maintenance of quality.

Recommendation11: An effective duty radiologist function serving the whole of the Board area should be developed which can be delivered through use of appropriate communication tools by either staff based within the board area or by individuals working remotely. This should exploit the infrastructure being developed by the STRP.

Recommendation 12: NHS Highland should commission an urgent external review as to the practical options for future local Interventional Radiology provision including biopsies and drainage procedures.

23

Recommendation 13: Develop KPIs in a standard format to be adopted for each specific modality and admission type to allow measurement of progress towards the aspirational time standards specified in this report.

24

Appendix 1

NHS Highland Radiology Strategy Short Life Working Group Terms of Reference

The group will:

• Specify and define the functional range of radiology services that are required within the NHS Highland Board area from a patient and clinical user perspective

• Specify the standard of service delivery in terms of access, image acquisition and reporting for each component of the required service.

• Define the relevant key performance metrics.

• Identify the patient facing requirements of the service from the user perspective.

• Consider potential models of service delivery that could meet the defined requirements

• Advise on a preferred model of service delivery taking into account the available work force, skill mix and the opportunities for regional and national working

• Identify any current barriers to the implementation of the preferred model

• Prepare a report on the conclusions and recommendations of the group for the Board

Phases: Phase 1: During this phase the group will consider the individual components of the service stratified by requestor location, imaging modality, urgency and define minimum standards for requesting, image acquisition and reporting.

Phase 2: Develop models for delivery of the service specified in Phase 1 taking account of the opportunities for regional and national working. Identify preferred model and current barriers to implementation.

Reporting arrangements A report on the conclusions and recommendations of the group should be brought back to the Board in March 2018 and a progress report submitted to the Board in November 2017

25

Membership Rod Harvey – Board Medical Director (co-chair)

Gaener Rodger – Non-Executive Director (co-chair)

Karen McNicoll - Divisional General Manager

Kirsty Corsar - Radiographer

Stewart MacPherson- Associate Medical Director

Nicola MacInnes - Consultant Emergency Medicine

Duncan Scott - Consultant Physician

Michael Lim -Consultant Surgeon

Anthony Thorpe - Consultant Radiologist

Mark J Nichols - Argyll and Bute Lead Radiographer

Ken McDonald - Associate Medical Director, Raigmore Hospital

Samantha Butler - Radiology Service Manager

Jill Bannister - Specialist Appointment Booker

Barbara Flont - Consultant Radiologist

Jason Walker - Consultant Radiologist

James Cannon - National Transformation Programme Director - Scottish Radiology

Transformation Programme (SRTP)

Hamish McRitchie - Medical Director - Scottish Radiology Transformation Programme

(SRTP)

Deborah Jones - Director of Strategic Commissioning, Planning and Performance

Claire Wood - Associate AHP Director

Jerry Dishman - Systems Specialist (Radiology)

Katherine Jones – Associate Medical Director

David Gillman – General Practitioner

Moira Graham - General Practitioner

Sian Jones - SE Highland CHP Cancer & Palliative Care Clinical Lead

Colin McDougall – General Practitioner

Paul McMullan - General Practitioner

Stephen Thomas - Consultant

Jacqui Thorpe - Radiographer

Sara Ramsey - Consultant Urologist

Carol Duncan - Business & Administration Manager

Iain Ross - Head of eHealth

Marc Turner - PACS/RIS Clinical Facilitator

26

Meeting frequency Every 6 weeks until March 2018 Administrative support The work of the group will be facilitated and supported by a 0.5 wte project manager

27

Appendix 2 – Patient Questionnaire

Dear Patient/Carer We would like you to ask you about your experience while visiting the Radiology Department today. Your feedback is important and will help us to understand how the service is working for patients and how it can be improved. We do not ask for your name and you will not be identified in the results. Please answer each of the following questions by ticking the box which best matches your experience of the Radiology Service, adding comments if you wish. If you are not the patient, please respond on their behalf. 1. What was your reason for attending the Radiology Department today?

For this investigation only I had this investigation as part of an Consultant outpatient appointment Other Don’t know 2. Was your Radiology investigation today for a….

New medical reason Planned follow-up 3. Thinking about your experience today, please indicate your agreement with the following statements

Strongly agree

Agree Neutral Disagree Strongly disagree

I understood what was going to happen to me

I was given an opportunity to ask questions

I was given enough time I was treated with compassion and understanding

4. How long did you wait for the appointment. Please state in day(s)/week(s)?

Number of day(s)/week(s)

5. How do you feel about the length of time you had to wait to get your appointment?

Satisfied Neither satisfied nor dissatisfied Dissatisfied Please provide a comment to explain

28

6. Would you like to be informed of the result of the investigation? Yes No Not sure How long do you think it would be reasonable to wait to get the results from your investigation today? Please state in day(s)/week(s) 7. How far are you travelling today to attend this appointment?

Number of miles, roundtrip. Please estimate if unknown

How do you feel about the distance to attend your appointment? 8. How did you travel to your appointment today?

Own car Public transport Lift with friend or relative Patient transport Other 9. Please use the box below to tell us what you feel went well today

10. Please use the box below to tell us what you feel could have gone better or perhaps be done differently to improve the service?

Thank you for taking the time to provide your feedback.

29

Appendix 3 – Patient Experience Questionnaire reports (Example) Raigmore Ultrasound – Patient Experience Questionnaire (N=38)

For this investigatio

n only 58%

Part of an Consultant outpatient

appointment 39%

Other 3%

Q1 - What was your reason for attending the Radiology Department today?

New medical reason

68%

Planned follow-up

29%

Unknown 3%

Q2 - Was your Radiology investigation today for a….

0%10%20%30%40%50%60%70%80%90%

100%

I understood whatwas going to

happen to me

I was given anopportunity toask questions

I was givenenough time

I was treated withcompassion andunderstanding

Q3 - Thinking about your experience today, please indicate your agreement with the following statements

No answer given

Strongly Disagree

Agree

Strongly Agree

30

Q4 - How long did you wait for the appointment. Please state in day(s)/week(s)? 28 out of 38 respondents gave an answer in days, weeks or months. This ranged from 3 days to 6 months. The 2 longest waits of 6mths and 28 weeks were investigations that were not for a new medical reason. Please provide a comment to explain: ‘The pain I had been experiencing had already gone so I wasn’t too concerned’ ‘Was expecting to have to wait a lot longer’ ‘Very satisfied. Had to make a Monday appointment due to work’ ‘On time’ ‘Preplanned after initial appointment’ ‘Very satisfied’ ‘Not a major issue just uncomfortable’

Yes 92%

No 3%

Not sure 5%

Q6 - Would you like to be informed of the result of the investigation?

Satisfied 84%

Neither satisfied nor dissatisfied

13%

Unknown 3%

Q5 - How do you feel about the length of time you had to wait to get your appointment?

31

How long do you think it would be reasonable to wait to get the results from your investigation today? Please state in day(s)/week(s) 12 responses were given. 3 respondents thought it reasonable to wait for 1 week. 5 respondents thought it reasonable to wait for 2 weeks, 1 respondent thought it reasonable to wait for 1-2 weeks and 1 respondents thought it reasonable to wait for 3 days. 2 respondents gave unclear answers. Q7 - How far are you travelling today to attend this appointment? Respondents estimated the distance in number of miles, round trip. The minimum distance traveled was stated as 0.5 miles and the maximum distance traveled was stated as 200 miles. The average distance travelled was 40 miles and the median distance travelled was 30 miles. How do you feel about the distance to attend your appointment? Comments from respondents travelling under 50 miles return journey: ‘No problem’ ‘OK’ ‘No problems’ ‘Not a problem’ ‘OK’ ‘Normal my choice to live in a rural area’ ‘No problems’ ‘OK’ ‘Not a problem’ ‘Nearest hospital’ ‘Reasonable’ ‘Normal’ ‘Distance fine/ Parking poor (park and ride would be great)’ ‘Fine’ ‘Fine’ ‘OK’ Comments from respondents travelling under 100 miles return journey: ‘Happy. Part of living in the Highlands’ ‘Understandable for main hospital’ ‘Fine’ ‘Fine. Closest hospital with this facility.’ ‘OK. I reside in Invergordon’ Comments from respondents travelling under 150 miles return journey: N/A Comments from respondents travelling under 200 miles return journey: ‘Normal’

32

Q9 - Please use the box below to tell us what you feel went well today Respondents comments were grouped into 3 themes - General comments; Treatment by staff; Comments on Outcome of investigation.

General Comments OK It was fine Everything went very well Everything Everything No issues All my appointment went very well Everything Everything OK Everything Everything Everything n/a All good Treatment by staff Very nice ladies. Just brill Everything from start to finish, even though I was

late for my appointment. Treated with utter respect. Everyone should get an A+

The entire appointment went really well, couldn’t have asked for better treatment

Friendly reassuring staff. On time :)

The staff were very nice and made me feel at ease Everyone was friendly and professional Lovely staff. Very much felt at ease Staff very pleasant My experience was relaxed and informative All of it. Nurses were fabulous! Staff were very professional

Outcome of investigation I felt I was treated very well & don’t feel concerned about any outcome

Getting explanation to treatment as was been done

Finding an answer to the problem

66% 8%

18%

5% 3%

Q8 - How did you travel to your appointment today?

Own carPublic transportLift with friend or relativePatient transportOtherUnknown

33

Q10 - Please use the box below to tell us what you feel could have gone better or perhaps be done differently to improve the service Respondents comments were grouped into 2 themes – Parking; General comments. Parking Car parking is a real issue General comments Nothing I have no complaints This appointment was as good as it can be! All very well It was all fine Nothing n/a All went well & efficiently It was perfect! Nothing Nothing None n/a All was fine Nothing, keep everything the same, staff

included! Nothing Nothing Excellent service Nothing A full set of the data reports is available on request and can be downloaded: Short Life Working Group Patient questionnaire data.pdf

34

Appendix 4 Radiology Glossary: General Computed tomography scan (Also called a CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

Diagnostic radiology - the use of various radiology techniques, mostly noninvasive, to diagnose an array of medical conditions. Diagnostic radiology includes the use of x-rays, CT scans, MRI scans, and ultrasound.

Elective - Requests from outpatients and primary care Emergency - Immediate response required to preserve life or function e.g haemorrhage control, stroke thrombolysis Fluoroscopy - a study of moving body structures, similar to an x-ray "movie." A continuous x-ray beam is passed through the body part being examined, and is transmitted to a TV-like monitor so that the body part and its motion can be seen in detail.

Interventional radiology - a area of specialty within the field of radiology which uses various radiology techniques (such as x-ray, CT scans, MRI scans, and ultrasounds) to place wires, tubes, or other instruments inside a patient to diagnose or treat an array of conditions.

Intravascular ultrasound - the use of ultrasound inside a blood vessel to better visualize the interior of the vessel in order to detect problems inside the blood vessel.

Magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

Plain film – see X ray

Radiographers - are healthcare professionals who specialise in the imaging of human anatomy for the diagnosis and treatment of pathology.

Radiography - is an imaging technique using X-rays to view the internal structure of an object.

Radiologist - a physician specialising in the medical field of radiology.

Radiology - is the science that uses medical imaging to diagnose and sometimes also treat diseases within the body.

Ultrasound - a diagnostic technique which uses high-frequency sound waves to create an image of the internal organs.

35

Urgent - To support unscheduled care where rapid diagnostic information or therapeutic intervention is required to provide safe patient management e.g.Time critical cancer pathways

X-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.