Research and analysis

Pilot evaluation report: assistant practitioners working in clinics with remote radiographic supervision

Published 21 September 2020

The NHS Breast Screening Programme (NHS BSP) currently invites 2.9 million women per year (April 2018 to March 2019) of which around 2.2 million attend for screening. Service delivery requires a highly skilled and specialised workforce.

Challenges facing the breast screening programme

The NHS BSP has a shortfall in mammographic staff to provide the service, and demand on service provision is increasing year on year. Since the inception of the NHS BSP in 1988, the needs of the service have changed considerably. Further development of the workforce needs to be considered to meet the continuing and increasing demands.

The backbone of the breast screening programme is the mammography workforce. Public Health England (PHE) conducted a national workforce audit of 80 screening services in 2016, with a response rate of 66%. Vacancy rates for radiographers were identified as 15% at that time. The audit found that the workforce is ageing, with around half of all radiographic practitioners aged 50-plus and likely to retire in the next 10 years. In addition, two-thirds of services reported vacancies for radiographic practitioners at that time. This situation was confirmed by another survey in 2017 which obtained a 100% response rate.

There is now an opportunity to use advances in communication technology to help us maximise the skill set of the current workforce and to help address capacity issues. This would be supported by clear mammography protocols to mitigate risks.

Current service models

Since its introduction in 1988, the NHS BSP has developed a mixture of staff roles in response to service requirements, including:

• introduction of 2-view mammography at all screens (2003)
• extending the upper screening age limit from 64 to 70 years (2004)
• the age extension trial (2010)

These changes required training of non-medical staff to undertake activities formerly performed by medical staff who could no longer manage the increased workload.

The information below outlines the current 4-tier radiographic workforce structure within the NHS BSP.

Educational level 4/5

Associate Practitioner (level 4)

Scope of practice: routine mammography (supervised role).

Previously undertaken by: assistant practitioners and practitioners.

Assistant Practitioner (AP) (level 4/5)

Scope of practice: routine mammography now, but working to extend this scope of practice with Society and College of Radiographers (SCoR) to include advanced imaging views in assessment, quality assurance (QA) and quality control (QC) roles (can include remote supervision).

Previously undertaken by: assistant practitioners and practitioners for routine mammography, practitioners for extended role.

Educational level 7

Radiographic Practitioner (RP) (state registered radiographers)

Scope of practice: Routine and complex mammography working independently. Quality control/assurance roles. Radiation protection roles. Service delivery support. Supervision of APs and other support staff. Line management. Research and development. Training and development roles.

Previously undertaken by: practitioners or advance practitioners.

Educational level 7 plus education for advanced scope

Advanced (autonomous) Practitioner

Scope of practice: Image interpretation. Tissue sampling biopsies. Ultrasound. Breast clinical examination. Pre-operative tumour localisation. Team leadership/management roles. Part of multidisciplinary team (MDT) delivering their role as part of the care pathway. Previously undertaken by: Service managers (team leadership and management). Consultant radiologists or breast physicians (clinical skills).

Educational level 7/8

Consultant Practitioner

Scope of practice: All of the above, plus research and audit, education, lead clinics and take responsibility for own case load and patient management across the care pathway.
Previously undertaken by: Consultant radiologists or breast physicians

To encourage recruitment the NHS BSP has established apprenticeships for the associate practitioner and assistant practitioner roles. This is also under consideration for the registered advanced practitioner role.

Pilot planning

Rationale

The pilot was set up to test a potential solution to the workforce capacity issues in the NHS BSP. It was to assess whether there was scope for allowing experienced assistant practitioners (APs) to work remotely on mobile vans or remote static sites, with indirect supervision from registered radiographic practitioners (RPs).

The NHS BSP follows the Department of Health and Social Care’s (DHSC) Guidance on Ionising Radiation (Medical Exposure) and the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2017. IR(ME)R 2017 entitles both RPs and APs to work as ‘operators’ (including taking mammographic x-rays and routine performance testing of equipment) within a scope of practice defined by their employer’s written procedures. RPs (as registered professionals) are also entitled to ‘justify’ exposures.

Current NHS guidance on assistant practitioner responsibilities and the SCOR assistant practitioner scope of practice guidance requires an RP (as a registered radiographer) to supervise an APs clinical practice and review the resulting images. This requirement was introduced when the NHS BSP used analogue imaging, meaning an RP needed to be on site to supervise and support an AP as necessary.

Many screening centres use mobile units or remote static sites in community settings. The current requirement for an AP to be supervised means the staff role mix on such sites is restricted. An RP also has to be present, which reduces staff available in the rest of the local service.

Assistant practitioners are often very experienced. Many have worked in radiography or breast screening for over 10 years. They are trained to undertake routine mammograms, and their performance is equivalent to registered mammographic practitioners. Images produced by APs and RPs are measured using the same national standards. The proportion of APs in the workforce is currently limited by the need for RPs needing to be physically present to supervise them. Currently around one fifth of the mammographic workforce as APs.

Now that the screening programme is fully digital, there is an opportunity to revisit the current model of supervision. This could maximise workforce potential while still ensuring the programme operates effectively and safely. Mobile phone technology now allows communication opportunities that did not exist when the programme was established. Digital imaging also provides the potential for APs to work on mobile vans or remote static sites with remote RP supervision. Technology can provide a safe mechanism to support supervision. Images can be accessed and monitored in real time to ensure that those taken by APs meet the national standard. This monitoring would only be required on rare occasions where the AP considers that a repeat image may be needed.

Pilot aims

The pilot was to assess the feasibility of experienced APs working on mobile or remote static sites with indirect radiographic supervision. We considered this a potential solution to staffing shortages which could be considered by stakeholders for adoption into the NHS BSP. Adoption could accomplish a:

• reduced risk of screening slippage (delayed screening appointments so people are not screened at the usual 3-yearly interval)
• reduction in delayed diagnoses, which would improve the efficacy of the programme

Our expectation was that additional autonomy in their role (although still supervised) may well encourage APs to stay in the service and develop their skills and level of competencies and responsibilities further. This would promote career development, as well as free up RPs to concentrate on other responsibilities and their own career development.

The Interim NHS People Plan launched in 2019 also supports this role development, describing it as a means of ‘developing a richer and more varied skill mix to enable staff to perform at the top of their licence’.

If the pilot was a success, PHE would seek to allow this clinic model to be voluntarily adopted by suitable breast screening services if they wished. We would develop a national implementation guide detailing work instructions to ensure the clinics were run safely with appropriate governance.

Consultation and implementation

Key stakeholder consultation

Before pilot implementation, we consulted the SCoR to gain their understanding, input and approval. This is the professional body and trade union that defines the scope of practice for radiographic roles, including mammography within the NHS BSP. They considered the pilot was safe and workable and agreed of some of the key criteria.

We also consulted the Care Quality Commission (CQC) in relation to IR(ME)R regulations and any limitations this may cause for APs working without a radiographer on site. The CQC considered the pilot suitable. They confirmed that APs could not agree to screen a client who attended for screening but had not been invited by the NHS BSP, as this is an IR(ME)R 2017 practitioner role which cannot be performed by a non-registered member of the workforce. However, this authorisation can be sought from an IR(ME)R practitioner by an AP if needed. This is a rare occurrence.

There are restrictions in practice for APs screening a woman whose previous screen was unable to be read due to a technical issue (‘technical repeats’). This was clarified with the CQC. Although not completely disallowed, APs could only perform technical repeats during the pilot if specific documented procedures had been signed off by a practitioner (radiographer). This advice contributed to defining the types of screening APs were able to perform within the pilot. It also identified the need to establish local work instructions for APs assessing the need for and performing repeats if the pilot went ahead. If the expanded role for APs is adopted, this will need to be reflected in Employers Procedures under IR(ME)R 2017.

Expressions of interest for the pilot

We sent out a call for expressions of interest (EOI) to English breast screening services in July 2019 via a national email message from the NHS BSP team. This included details of the:

• purpose of the pilot
• current challenges in the mammographic workforce
• support that would be offered to pilot sites
• criteria services would need to meet to take part in the pilot

We asked services to submit an EOI confirming that they met the specified criteria, providing details of their screening service, and giving a written statement highlighting the reasons the service would be a good pilot site.

Criteria to become a pilot site

We considered that 4 services running the pilot over a period of 4 months would be adequate to assess the efficacy of the change in practice. To make sure that potential pilot services were in an optimal position to take part, we asked them to confirm that they could:

• run the pilot for a period of 4 months
• provide telephone support to an AP from an available radiographer (mobile text/mobile or landline call/email)
• demonstrate good IT connectivity so that images could be seen within minutes back at the static site by a radiographer (if required)
• provide APs that meet the technical recall/repeat standards of <3% (acceptable) over the last 4 quarters
• provide 2 mobile vans to pilot APs working with remote supervision for the duration of the pilot (not necessarily every day)
• provide APs that have been qualified for at least 2 years (full-time or equivalent if working part-time)
• demonstrate enthusiasm by service personnel for piloting this new national initiative
• gain approval by the trust to indemnify the practice
• gain approval by the local commissioning team

Pilot sites

Following submission of the EOIs, 4 services were identified as suitable to participate in the pilot. These were Manchester, Coventry, Bolton and Leicester.

On confirmation of their acceptance, the services completed a pilot confirmation form to provide assurance that they had the appropriate facilities, governance and staffing in place to successfully start the pilot (see the pilot sign off form). This was signed off by the service’s medical physics expert, director of screening and commissioner or screening and immunisation lead.

Pre-pilot workshop

We held a workshop in October 2019 for the participating pilot sites, run jointly by PHE and the SCoR. The workshop provided additional background information, more detail about how the pilot would run, and the opportunity for questions and concerns to be raised by the services.

As service configurations differ, we asked the pilot sites to consider how they would implement the pilot and incorporate new local working practices and policies. We encouraged each staff group (radiographic practitioners, lead radiographers/managers and assistant practitioners) to voice their opinions in open and honest conversation. We also conducted an anonymous survey at the start and end of the workshop to gain an understanding of attendees’ experiences as an AP or RP, and how they felt about their roles and responsibilities prior to commencing the pilot.

Feedback from the workshop fed into the pilot pack which included:

• information to explain to women why screening had to be done in another clinic if they had breast implants or implanted medical devices
• audit sheets (feedback forms) for completion by APs and RPs to document why women could not be screened or where contact needed to be made with a supervising radiographer
• a series of frequently asked questions to support staff during the pilot

Running the pilot

The pilot ran for 4 months from 1 November 2019 to 28 February 2020. For each clinic held, the responsible APs and RPs completed separate feedback forms. The APs completed a form detailing queries they needed to raise or advice sought from RPs. The RPs completed a form to verify the comments from the APs and to confirm the advice they had provided. The AP feedback form also collected information about any advice or other sources of support they sought without the need for RP involvement, such as discussions with other APs.

Support was available from the PHE breast screening team during the pilot. They were the first point of contact for any concerns or issues experienced by the pilot sites. PHE collated all feedback forms and other data from the pilot.

Post-pilot survey

We sent participating APs and RPs a post-pilot survey 2 weeks after the pilot finished. This was to gain feedback on their experience of the pilot, the appropriateness of the level of support provided, any suggestions for improvement and their opinion on whether they considered this model appropriate for implementation within the NHS BSP.

Results

The table below shows the screening activity at each site during the pilot.

Activity	Service A	Service B	Service C	Service D	Total
Total women attended	1,232	354	1,689	1,129	4,404
Total women not screened	11	1	26	9	47*
Total APs participating	4	2	6	4	16
Total clinics run	27	9	38	29	103

*an additional 8 women were not screened due to ineligibility

During the pilot, services ran a total of 103 clinics, screening 4,349 women. Sixteen assistant practitioners took part in the pilot, with numbers varying from 2 to 6 by service.

Not screened

Of the women screened at pilot clinics, only 47 out of 4,349 (1%) could not be screened by APs due to the staff not having the authorisation to perform the required screening technique or ability to suitably screen the woman. A small number of technical recall (TR) appointments could not proceed due to local guidelines (some services allowed APs to complete TR appointments, others did not). There was one case where the AP could not get the correct position for a suitable image, and another where the woman was in a wheelchair and had mobility issues so rebooking was the best option for her.

The table below shows the breakdown of reasons why a screen could not be completed by an AP (according to local protocols).

Reason not screened	Number
Breast implants	24
Implanted medical device	18
Technical recall (required repeat examination)	4
Wheelchair use/mobility issue	1
Total	47

Re-attendance for women not screened in the pilot

Women who could not be screened in the pilot clinics needed to be seen in another clinic on the same day or re-booked for another appointment. Only 2 women did not attend this rescheduled appointment. This means 91% successfully re-attended. Some (5%) are not yet accounted for at the time of writing as their appointments are scheduled in the future. Although some women were disappointed at needing to be rebooked, the sites did not receive any formal complaints.

Frequency and duration of supervision/support requested by APs

APs made infrequent contact with their supervising radiographer for advice. This was evidenced in the daily clinic feedback provided by both APs and RPs. Comments often referred to there being no issues or that it had been a ‘good day’. Some APs positively referred to ‘good teamwork’ at the clinic.

APs recorded any requests for support they made during the pilot. The reasons for these contacts were:

• administrative queries relating to the pilot (34%)
• seeking advice from an RP (20%)
• administrative queries not relating to the pilot (16%)
• quality control issues due to local policy (16%)
• queries on previous mammography dates (10%)
• seeking advice from another AP (4%)

APs made 144 contacts for support in total – however, 23 (16%) of these were of an administrative nature. We believe an RP would also have raised the same queries under routine circumstances (such as booking new women onto the clinic list or IT issues). An additional 49 (34%) queries were of an administrative nature due specifically to the pilot (such as re-booking women who attended with breast implants or medical devices who should have been booked into a standard clinic). Thirty of these administrative queries were made directly to the screening office, but some were fielded by the supporting RP. A breakdown of the queries is available in the report on AP support requested.

For the first 2 weeks of the 13-week pilot, there were slightly more contacts made, while APs adjusted to working on their own and became familiar with what they could do autonomously.

The longest waiting time for advice from an RP was 10 minutes. The longest wait for a woman being screened was 15 minutes, with an average of 3 minutes to resolve any queries prior to screening. No complaints were received from any of the women attending the pilot clinics regarding an additional wait time or the outcome of their appointment.

Technical recall/repeat rates

We conducted analysis to compare the technical recall and repeat rates for each service for the 4-month period before the pilot (July to October 2019) with the 4 months during the pilot (November 2019 to February 2020). This did not show any increase in technical recall and repeat rates during the pilot period.

Participant feedback from the pilot

We asked pilot members (APs and RPs) to identify the length of time they had worked in breast screening. The information from those who responded showed that:

• staff were aged between 30 and 59
• all radiographers were working full time at more than 30 hours per week
• APs were working from 15 to over 30 hours per week
• APs tended to have more years’ experience than radiographers
• most pilot members had more that 5 years’ experience, up to 20 years

We also asked pilot members to provide feedback on how they felt about the pilot (using a post-pilot survey). The majority of participants stated they felt ‘calm’ in dealing with any problems that arose during the pilot. RPs did, however, report a slightly higher level of feeling ‘tense’. This may be due to their supervisory role, and the fact that some were also supporting other clinics at the same time.

The majority of participants reported that they had received enough support for the pilot, both from PHE and from their screening colleagues.

Comments from RPs on the pilot included the following responses:

It highlighted that APs are a valuable resource to imaging. They are experts in their field and competent of lone working when performing mammography, and addressing clinical and departmental issues in relation to the work. The APs proficiently handled patient and equipment queries, often only required to feed back information.

We had very few problems overall and very few phone calls from the APs other than those that possibly the radiographers would have rung about.

Our APs have done a great job and have helped out tremendously with rotas, I think we’ll miss it when it stops next month.

Comments from APs on the pilot include the following responses:

I have learnt not to be afraid to ask for help from a practitioner like myself. We are, after all, one team.

We showed we could organise ourselves with minimum supervision… could work out problems (including minor equipment issues) … communicate with the ladies with positive feedback from them, we could work well as a team, we rose to the challenge and stayed positive.

We organised ourselves, communicated well, and maintained a smooth-running list. We problem-solved between ourselves but contacted our mentor when needed, who was always there for us.

I think it enabled the rest of the team to get on with their roles. It offered more flexibility in the unit, therefore I feel it maximised the potential of the screening service.

I have gained confidence in the knowledge that I can do my job to a high standard and positive patient feedback supported this of both of us.

The ability to have more flexibility when developing rotas for mobile vans or remote static sites was a driver to services wanting this AP clinic model to continue. This was particularly due to the impact of recruitment issues for radiographer roles. The comment below came from a service manager.

We are struggling to recruit and retain radiographers whereas, in direct comparison, we have a lot of interest in the band 4 AP opportunity. In order for the screening programme to survive I recognise that the only way to increase capacity is to embrace AP working.

The participants were all generally supportive of the pilot, deeming it a success. However, there was a recognition that a longer duration would have allowed the process to be tested out at different locations and sites to identify any differences. There was hope from the services that this model of working would continue in the future.

Considerations for implementation

Some considerations for implementation within the NHS BSP were highlighted, as below.

Staffing

There was a recognition that there needed to be enough qualified APs with sufficient experience to run these types of clinics effectively. This way of working should not be mandatory for all APs, and should be regarded as a development opportunity. There also needed to be sufficient support by a pool of radiographic practitioners.

Limitations of autonomy

The need for some sites to seek approval for all repeats, QC checks and being able to complete technical recalls was frustrating for some APs. Not being able to screen women with breast implants or medical devices was seen as limiting the effectiveness of the clinics, requiring additional administration. Some APs expressed a desire to be trained to perform additional images and tasks.

Recognition for new ways of working

Out of 11 APs who responded, 5 commented that if this way of working was implemented, consideration should be given regarding appropriate remuneration. Several were receptive to undertaking further training to enhance their scope of practice (for example, to include taking special views to screen women with breast implants and implanted medical devices).

Discussion

All sites successfully completed the pilot and wanted this to continue as a standard way of working post pilot. Participants mainly reported that the pilot ran as expected, with some radiographers surprised at how little support they needed to provide to APs.

There was some variation in the numbers of queries raised by APs, but this was mainly due to the variation in the cohort being screened. The average delay to a screening appointment while APs sought radiographic advice was 3 minutes. This did not unduly delay screening, compromise efficiency or affect subsequent screening uptake (over 90% re-attended for screening).

The screening invitation letter requests women to inform the service if they have breast implants, have received a screen in the last 6 months or have a disability or mobility issue. However, such women often attend without prior contact. In the pilot, women in these categories required rebooking upon attendance. This did not impact on the uptake rate, however, with only 2 women not re-attending.

Only 1% of all women who attended the AP clinics could not be screened. Of those cases, 89% were due to having breast implants or an implanted medical device. To further improve the efficacy of AP screening clinics, we believe consideration should be given to extending the APs’ scope of practice. If APs were authorised and trained to screen these cases, almost all the women in the pilot would have been screened at their initial invitation. If APs received accredited training to undertake Eklund and other specialised views, they could undertake a full range of mammography and operate autonomously with remote supervision on an occasional basis, when required. This would benefit programme management as special considerations would not need to be made for AP clinics. This would also allow for career progression, thereby boosting staff morale and helping with staff retention. It would also potentially reduce demands on RPs.

Some sites had local policies which instructed APs to seek approval from RPs under circumstances not mandated by national policy. For example, to approve over-age self-referrers for screening, to review QC results or to approve ‘attended not screened’ paperwork. The level of advice or approval required for APs to complete these tasks could be re-assessed to allow APs to have more authority and autonomy.

Previous IR(ME)R guidance required APs to confirm with a radiographer if a repeat is required. Not all services were aware that the guidance is now updated to allow APs to undertake repeats autonomously. APs can decide on repeats if this is reflected in local policy and they are appropriately trained to do so. Allowing APs to work more autonomously where supervision is not mandated could improve this way of working and reduce the frequency of RP contact required.

The success of the pilot was due to the level of experience of the participants taking part, and to the APs feeling supported when they did need advice. APs in the pilot were required to have at least 2 years’ breast screening experience and to meet the TR standard. Consideration is needed to determine what the appropriate level of experience should be, going forward. The pre-pilot workshop enabled development of a suite of materials which assessed the efficacy of this way of working. It also enabled PHE to develop an implementation guide which could aid services who want to safely and effectively adopt this practice in the future.

The response from APs was that not all staff would want the extra responsibility of this expanded role, including some staff with longstanding screening experience. We would need to consider both service configuration and staff choice if this way of working is to be implemented within a service.

Having APs available to run clinics would build in greater flexibility for clinic planning, allowing RPs the opportunity to focus their practice in other areas requiring their radiographic expertise. It would allow interested RPs more scope to progress their skills within advanced practice. As breast screening services already get a lot of interest in AP posts, increasing the number of APs and scheduling some experienced AP clinics would help to increase workforce capacity (especially as it has been difficult to recruit radiographers nationally).

The pilot required services to have reliable IT connectivity so that images could be transferred and remotely checked by radiographers, when necessary. This requirement will impact on which clinics could operate using the AP-only model. Only 20% of services in the NHS BSP currently have this facility. During the pilot, only 7 images needed to be transferred for an opinion from an RP (0.2% of all women screened). Consideration should be given to supervision by phone, as an opinion on screening images was so rarely required.

Conclusion

PHE recommends that assistant practitioners working in clinics with remote radiographic supervision should be considered as a recognised way of working in the NHS BSP. This will help improve the current capacity issues in the programme.

The pilot demonstrated that experienced APs have the skills and desire to increase their level of responsibility and manage mobile breast screening clinics with a minimum of remote radiographic supervision.

This method of managing clinics could be an option for services to consider where there are appropriately trained and willing APs and the necessary IT connectivity to the clinic site. The AP role is attractive, training is short in comparison to RP training and there is no shortage of demand. The demand for AP role posts is supported by the new associate apprenticeship route into mammography.

The potential for APs to expand their scope of practice further, to include undertaking their own repeat images and imaging breast implants and implanted medical devices, would improve service efficiency. It would be a developmental opportunity for APs who wish to advance their career within the NHS BSP. This could improve levels of staff satisfaction and help with staff retention. If APs successfully complete training (level 5) this could be an acceptable and effective way to support services which are facing increasing challenges to screening provision. The increased scope of an enhanced AP role would need to be agreed by the SCoR.

Expanding the AP scope of practice would, in addition, allow more RPs to best utilise their more comprehensive knowledge and skill sets within screening assessment and symptomatic practice. It would also allow them to further up-skill into advanced practice and beyond.