Guidance

Breast screening: assistant practitioners working with remote radiographic supervision

Updated 2 March 2021

Between November 2019 and February 2020, a pilot involving 2 assistant practitioners (APs) working together on mobile facilities with remote radiographic supervision, was successfully undertaken. The pilot report gives further details.

This guidance describes the implementation process for services wishing to adopt this way of working. Prior to the pilot, 1 radiographer supervising 1 AP on mobile facilities was the standard practice for mammographers working in the NHS Breast Screening Programme (NHS BSP). The term assistant practitioner used in this document includes both associate practitioners and assistant practitioners working in the NHS BSP.

The pilot was undertaken in response to the ongoing workforce shortage in breast screening services with the full support of the Society and College of Radiographers (SCoR), Health Education England (HEE) and Public Health England (PHE).

This initiative gives service providers and commissioners the opportunity to consider implementing a new staffing model. Managing the change will need enthusiasm and commitment from the whole team to be successful. This model of delivery will be appropriate for some services where the design of the workforce allows it to be considered.

Health and safety

The Guidance for breast screening mammographers and Ergonomics in screening mammography remain the main documents for mammographic practice in services. Employers must also make sure that health and safety is considered and managed using rigorous risk assessments.

Any change in working practice must be covered by employer-level governance processes and meet legislative requirements. Mammographers should comply with employer procedures and ensure they are up to date with all mandatory or other training identified in the risk assessment before making any changes to working practices.

Implementing APs working on mobile facilities with remote radiographic supervision

Services must be able to evidence that they fulfil the following requirements before they implement the new way of working.

Identifying the level of training and experience of APs

Ensure that:

• APs are adequately trained via a recognised and approved training route (apprenticeship, NVQ, Foundation degree, BTEC) or equivalent
• both APs working with remote supervision on the mobile facility have at least 2 years post qualification experience or pro-rata equivalent for part-time staff
• APs are confident, competent and willing to work remotely and must agree to work without direct radiographic supervision – it is the employer’s responsibility to make sure the job description of the APs identified for this role reflects this change in practice
• trained mammographers (APs) meet the acceptable technical recall or repeat standard of <3% over the last 4 quarters

IR(ME)R requirements for APs working on mobile units with remote supervision

Under the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2017, referrers and IR(ME)R practitioners must be registered healthcare professionals. APs are non-registered members of the workforce trained to perform radiographic exposures within a defined scope of practice. It is important to note that the term ‘practitioner’ in the context of APs is different from the practitioner role defined by IR(ME)R.

An AP may only perform the practical aspects of an exposure involving ionising radiation when they have:

• completed adequate training
• been deemed competent
• been entitled as an IR(ME)R operator

When APs are acting as entitled IR(ME)R operators they are legally and professionally responsible for their actions.

Under IR(ME)R, there must be a referral for each exposure. APs cannot perform this task as they are not registered healthcare professionals. Justification is also required for each exposure and this may only be performed by an IR(ME)R practitioner (registered healthcare practitioner). A practitioner may create written authorisation guidance locally which, if met, allows an operator to authorise the exposure. In these instances, the IR(ME)R practitioner is responsible for the justification of any exposure that is authorised by an operator following the authorisation guidelines. The IR(ME)R practitioner may include instructions within the authorisation guidelines specifying when technical repeats are justified. The AP cannot perform technical repeats autonomously without such prior justification.

Technical recalls may be authorised and undertaken by an AP. The justification for repeating the exposure has already been taken if interpretation of the image has resulted in a decision to recall. This process should be reflected in local written authorisation guidance.

If the AP wishes to query the justification for an exposure, there should be a robust and documented system in place for them to be able to contact a trained, competent and entitled registered healthcare professional (radiographer or radiologist) who can justify the exposure as required.

Governance requirements

All services must demonstrate compliance with IR(ME)R 2017 in line with NHS BSP guidance. In addition (prior to pilot):

• approval and support by the screening commissioner is needed
• there should be an initial pilot which is reviewed by the commissioner before full implementation
• the local screening quality assurance service should be informed – this should be facilitated by discussions at the local programme board meeting
• the service’s medical physics expert should be consulted for IR(ME)R 2017 compliance and support for updating employer procedures
• all staff involved should be consulted and supported through the change
• assistant practitioners on mobile facilities working with remote radiographic supervision must be indemnified through the employer’s clinical governance processes:
  • to support the change to remote radiographic supervision
  • to allow repeat examinations to be undertaken (following an IR(ME)R practitioner’s written authorisation protocol)
  • to allow the job description to be updated
• once this way of working is implemented in a service, additional APs adopting this practice will also need to undertake a probationary period to audit this way of working for 3 months

Practical requirements

Effective connectivity between mobile facilities or remote static sites and the screening service base is essential for this way of working. The service should:

• cover connectivity in any risk assessment
• ensure immediate direct telephone contact (mobile or landline) is available at all times with radiographers (services need to consider service continuity if communications fail)
• consider robust IT connectivity to allow images to be seen within minutes at the host site by a radiographer (this is desirable but not essential – the disadvantage of not being able to view images immediately is that a woman may need to be recalled if additional images are required as a technical recall)

Good availability of radiographic supervision is essential. Check that:

• the lead radiographer and an identified pool of reserve or additional radiographers can be available to provide supervision to APs when they are working remotely
• radiographers are aware they are providing remote supervision and are confident and competent to do so
• training courses designed to support mentorship (either provided internally or as study days at national breast training centres) are made available to radiographers wishing to attend them

The skill mix of the service will need to change over time for this model to succeed. To maximise flexibility and allow cross-cover for sickness and annual leave, the service needs enough APs and radiographers to provide a robust and high-quality service. Services should consider their capacity to train, develop and support APs as the model evolves. New rotas will need to be discussed and agreed with staff.

Initial pilot period

This involves:

• a pilot period of at least 3 months before implementation
• each AP agreeing to work in this way participating fully during the pilot phase
• AP clinics being scheduled at least once per week on mobile facilities with remote radiographic supervision (this is to maintain competency and confidence in this change of practice)

Audit and quality assurance during the pilot

The screening service should audit the performance of APs working with remote radiographic supervision closely for a period of 3 months. This is to make sure that the repeat or technical recall rates are within national standards.

The APs should record every instance where they seek guidance from the supervising radiographer on an audit record held on the mobile facility. An example of an audit record is available which can be adapted to suit local circumstances. This should be completed daily for the period of the audit. The lead radiographer at the service should review outcomes weekly during the 3-month pilot period. This will identify any areas of concern or trends to offer clinical or professional guidance to APs at the earliest opportunity.

Following the 3-month pilot period, the outcomes of the audit should be presented to the screening commissioners and the Screening Quality Assurance Service (SQAS) at a programme board meeting. A decision can then be made whether to adopt the change in working practice permanently.

Women who can be screened by APs on mobile facilities

APs who are suitably and adequately trained and assessed as competent may screen in their scope of practice women who:

• are invited for routine screening or as a self or GP referral appointment
• are attending as a technical recall
• are being screened using tomosynthesis as part of a research trial

The AP scope of practice currently excludes screening women with breast implants, and/or with implanted medical devices such as a pacemaker or Hickman line. The invitation letter requests women with implants or a medical device to make contact with the screening office. The administration team will need to make sure that women are not booked into AP-only clinics. If a woman is inappropriately booked onto one of these clinics, the service should:

• inform the women that a specialist clinic is required for her appointment
• provide her with information containing contact details (see the example information provided)
• if possible, contact the service to book a new appointment or ask the woman to make a new appointment at her convenience

Reasons for APs seeking radiographic advice

Support from a supervising radiographer may be needed in the following scenarios.

Consent

APs who are trained via an accredited or approved academic programme and are competency assessed may take consent to mammography as one of the responsibilities delegated to them by registered radiographers. However, this is limited to women who are co-operative and able to communicate their consent. If consent is in doubt, the AP must consult the supervising registered radiographer.

Partial mammography

If the whole breast has not been imaged due to the client’s body habitus or mobility, the APs on the mobile facility should review the images to make sure that further imaging would not improve visualisation of breast tissue. In this event, they should discuss with a radiographer to confirm a partial mammogram result. For further guidance, see Guidelines for breast screening mammographers.

Physical disability

Every effort should be made to image women with a physical disability and to produce images of diagnostic quality. However, this may not always be possible for women who have limited mobility in their upper bodies or who are unable to support their upper bodies unaided. This may be considered as a partial mammogram (see above).

Other circumstances

APs must request guidance and support at any time if they feel the input of a radiographer would be helpful. This could include queries about repeats, technical concerns, communication issues, site or mobile van issues.

Normal processes for escalation and management of equipment breakdown, quality assurance, staff sickness or other issues should apply. The responsibility of the AP in these circumstances has not changed.

Post-implementation good practice

Following the decision to adopt new working practices post pilot, it is important to initially maintain audit processes. This is to monitor and evidence the continuing success of and compliance with this way of working. This is achieved through:

• ongoing audit of individual technical repeat or recall rates to achieve national standards
• ongoing audit of the frequency of contact made with radiographers (high levels of contact may indicate an individual AP’s lack of confidence – the lead radiographer should address any issues arising from the audit and support should be made as appropriate – it is not necessary to continue auditing the frequency of contact unless concern is identified)
• ongoing support through appraisal and personal development plans for supervisors and APs