RESOLUCION ADMINISTRATIVA DE LA PRESIDENCIA DEL PODER JUDICIAL Nº 212- 212-2007-P-PJ

Early evidence of the need for role development was identified in the discussion paper; Staffing and Standards in Departments of Clinical Oncology and Clinical Radiology (RCR, 1993) and the; Calman Hine policy framework commissioning report (DoH, 1995) actively encouraged the development of skills mix amongst doctors, nurses, radiographers and other healthcare professionals, again acknowledging the benefits for cancer services. In addition, the SCoR document: Skills Mix in Clinical Oncology (SCoR, 1999), which provided an overview of skills

Consultant Practitioner Advanced Practitioner Accredited Practitioner Provisionally Accredited Practitioner

Practitioner Assistant Licensed X-Ray operator

mix working in both cancer nursing and therapeutic radiography and emphasised its value in relation to improving services. Given this policy direction, a working party was established by the Royal College of Radiologists to oversee the potential integration of skills mix working within clinical oncology departments, which later resulted in developing the document: Skills Mix in Clinical Oncology (SCoR, 1999). The document highlighted the issues to consider if departments were considering this process and how to best effectively use each member of the team.

In therapeutic radiography the earliest evidence of role extension began with “on treatment review,” whereby a suitably trained therapeutic radiographer reviewed some or all patients (from a selected group) during their course of treatment, a role traditionally undertaken by the clinical oncologist or medical staff. Colyer (2000) acknowledged that the role developed as a result of radiographers own personal drive to take advantage of an opportunity. These developments allowed the medical staff to hand over responsibility to the radiographer, thus releasing medical staff for other duties and tasks. The research by Colyer (2000) overall highlighted one such example on a scale of role development in therapeutic radiography.

The drive for role development then continued. In 2000, the Labour government’s attention was now focused on implementing health reform in the UK and launched “Agenda for Change” to the NHS plan. Agenda for Change highlighted a need for a change of pay and career structures, identified new ways of working to best deliver the range and quality of services required to meet the needs of the patients and defined the core skills and knowledge for staff through the Knowledge and Skills Framework (KSF). Sycamore (2008) acknowledged that the consequence of Agenda for Change saw the development of multidisciplinary teams to better manage patient care and provide an efficient and effective service. To support the change, a national skills mix project was initiated, to introduce and pilot a four tiered service delivery model (DoH, 2003). Clear roles and responsibilities were described demonstrating a level of escalation and expertise appropriate to each role (see Box 1.1). In response to this initiative, the Society and College of Radiographers recognised the benefits of such a model for patients and clients and how it would provide the opportunities for radiography services to create new roles, firmly placing radiographers as experts in their sphere of practice. Subsequently a working party was formed comprising the

Royal College of Radiologists and the Society and College of Radiographers to develop a four-tier service delivery model.

Consultant Practitioner (State registered):

A consultant practitioner provides clinical leadership within a specialism, bringing strategic direction, innovation and influence through practice, research and education

Advanced Practitioner (State registered):

An advanced practitioner, autonomous in clinical practice, defines the scope of practice of others and continuously develops clinical practice within a defined field

Practitioner (State registered):

A practitioner autonomously performs a wide-ranging and complex clinical role; is accountable for his or her own actions and for the actions of those they direct

Assistant Practitioner:

An assistant practitioner performs protocol limited clinical tasks under the direction and supervision of a State registered practitioner

Box 1.1 The four-tier service delivery model (DoH, 2003)

In practice, implementation of the model has created a shift in working practice with assistant practitioners undertaking simpler tasks, enabling practitioners and advanced practitioners to focus on more complex tasks fulfilling the requirements of role progression as stated by the DoH in its 2003 report:

“The model is designed to encourage clinical staff to delegate certain activities to others as they increasingly develop their own skill-set and in turn undertake clinical activities more typically done by other professions and disciplines” (DoH, 2003:12).

The implementation of the four tier model has been pivotal in radically changing the career structure of the therapeutic radiographer included within their scope of practice and service innovation. Since the implementation of the four-tier model, the Society and College of Radiographers has published a significant amount of guidance for service development and career progression further embedding the structure within clinical practice. In 2004 the Society and College of Radiographers, reflecting this shift in practice, moved away from the concept of “four-tier service delivery model”, and incorporated the model into the “Career Progression Framework” (SCoR, 2004). It was recognised by Sycamore (2008) that the Career

Progression Framework was strengthened and underpinned by the NHS Knowledge and Skills Framework (NHS KSF, 2004) which highlighted the knowledge and skills needed to provide quality services and is integral in a therapeutic radiographers career development. The framework offered a thorough structure on which to base review and development for staff; therapeutic radiographers are encouraged and supported to progress in their careers through annual identification of development needs and opportunities.

To reinforce the concept of career progression the Society and College of Radiographers published a position paper setting out various ways in which therapeutic radiographers could play a part in the delivery of patient centred care across the patient pathway. The document: Positioning Therapeutic Radiographers within Cancer Services: Delivering Patient Centred Care (SCoR, 2006) illustrates three expert practitioner roles at advanced and consultant levels of practice: the site specialist, the technical specialist and the community liaison practitioner co- ordinating care across multiple agencies of care.

The paper also acknowledged the current work that therapeutic radiographers were involved in providing support for patient centred cancer services Radiotherapy Moving Forward: Delivering new radiography staffing models in response to the Cancer Reform Strategy (SCoR, 2009) subsequently provided overall guidance on supporting the development of new staffing models. Skill mix was seen as vital to support efficient and effective service delivery. Figure1.2 depicts the differing roles and levels of radiotherapy practice.

Figure 1.2 Staffing models in the cancer reform strategy (SCoR, 2009:5)

In relation to cancer services the National Radiotherapy Advisory Group (NRAG) was tasked in guiding departments to consider skills mix to improve patient and service outcomes. A comprehensive report published by NRAG emphasised the issues of staffing levels, technical advances and targets to reduce waiting times. One crucial area it acknowledged was the need for departments to capitalise on and make sure of the skills their staff currently possess to improve patient care. The NRAG report (DoH, 2007) reported that nearly 20% of the work in radiotherapy required the involvement of the clinical oncologist, whilst the remaining 80% potentially could be accomplished by an advanced or consultant practitioner.

In 2012, the Society and College of Radiographers conducted a national survey entitled “Scope of Radiographic Practice Survey” to assess the prevalence of role development in clinical departments in both diagnostic and therapy radiography services (SCoR, 2012). Analysis of survey responses from 143 diagnostic imaging and 43 radiotherapy service managers concluded that radiographers had an increasingly prominent role in the inter-professional healthcare team by progressing and developing their roles. A substantial number of diagnostic departments had radiographer led examinations in modalities such as Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) and additionally radiographers were carrying out a variety of interventional procedures. Other role developments

identified in the survey were an increased number of the research radiographers2 in post (SCoR, 2012). Equally, in therapeutic radiography services, there too had been an increase in role development with radiographers leading in pre-treatment imaging (e.g. examinations in modalities such as Computed Tomography (CT)), and radiographer led treatment planning (e.g. tumour volume delineation). The report re- iterated the vital importance of radiographers evolving their roles and embracing innovative ways of providing services with a new career structure with more opportunities for staff (SCoR, 2012).

The report: Vision for Radiotherapy 2014-2024 (CRUK, 2014) recognised that therapeutic radiographers play a key role within the radiotherapy pathway. A conclusion also reinforced by the Society and College of Radiographers. Currently, the development of the radiotherapy workforce to enable effective skills mix is high on the agenda for the Society and College of Radiographers as acknowledged within the document entitled: Achieving World Class Cancer Outcomes: The Vision for Therapeutic Radiography (SCoR, 2016). As such, the 2016 Vision of Radiotherapy provides an updated career progression framework which shows the progression through to consultant practice (see Figure 1.3) implemented by the SCoR to be aligned with the original staffing models as indicated in the 2009 Cancer Reform Strategy.

Within a changing therapeutic radiography workforce, the aim is for role development to continue to expand across the entire radiotherapy pathway with roles such as the consultant practitioner created with the aim to provide benefit to service provisions and service users.

2 _{Responsible for leading clinical trials /research} 15

Figure 1.3 Radiography Career Progression Framework, (SCoR, 2016:9) 1.5 Rationale for the research

Changes in therapeutic radiography have promoted the development of a consultant practitioner role in clinical practice. Clinical duties that were once performed by the clinical oncologist are now being shared in some trusts by CTRs who are experts in their scope of practice (SCoR, 2009). The first consultant radiographer post in therapeutic radiography was established in 2003 specialising in gynaecological malignancies. However, the literature surrounding the concept of consultant practice and the introduction of the CTR role is somewhat scarce; with Nightingale and Hogg (2003) highlighting that within radiography there was a shortfall of documentary evidence recognising consultant practitioner roles. However, the authors do point out that some literature does exist on role extension but rather more so in the discipline of diagnostic radiography than in therapeutic radiography. Since 2003 there has been little growth in the literature and this only reinforces the need to conduct this research and fill this knowledge gap. This is also reinforced by Forsyth & Maehle, (2010) reporting no formal national evaluation of the role has been undertaken.

The drive for this research stemmed from both a personal and professional interest. From a personal stance, issues surrounding role development in therapeutic

radiography (such as consultant practice) is appealing and the idea of pushing current boundaries through staff role development is equally fascinating. From a professional stance, during my time working in a clinical setting I embraced role development through my own role as an Advanced Practitioner in Education and Development. Also my experience of therapeutic radiography and nurse consultant roles in various NHS trusts, have made me aware of role development expansion across all healthcare services and specifically in radiography. Moreover, as therapeutic radiographers have always been at the forefront in delivering cancer care, developing personally and professionally to meet the ever evolving changes within the profession, there is a need to examine this topic and in particular the role of the CTR.

Having set the context and introduced some of the considerations that shaped the research, I will now address some of the wider issues relating to the perceived impact of consultant practice. This provides the theoretical underpinnings of the research and will set the scene for the methodological considerations later.