interventional radiology services in scotland a discussion

SCIN INTERVENTIONAL RADIOLOGY PAPER: - FOR FINAL VERSION PLEASE CONTACT [email protected]

Interventional Radiology

Services in Scotland

A Discussion Paper

Scottish Clinical

Imaging Network

(SCIN)

March 2016


Contents

Foreword ............................................................................................... 4

Key Recommendations ......................... Error! Bookmark not defined.

1. What is Interventional Radiology? .................................................... 6

2. Challenges facing the Interventional Radiology Service in Scotland 7 Emergency Access ............................................................................. 7 Elective Access .................................................................................. 9

3. A Networked Model ....................................................................... 10

4. Regional /National Interventional Radiology procedures ................ 11

5. Staffing and Training ....................................................................... 11

6. Conclusion ...................................................................................... 12

References .......................................................................................... 12

SCIN SLWG membership ................................................................... 12

Declaration of interest ......................................................................... 12


Document control Key personnel

Title: SCIN Interventional Radiology Discussion Document

Author: Dr Iain Roberston, Dr Ian Zealley, Dr Anne Marie Sinclair

Approver: SCIN IR Short Life Working Group

Owner(s): SCIN Steering Group

The Interventional Radiology short life working group met four times after which a first draft discussion document was produced. Alteration has been based on that feedback from the wider Interventional Radiology group and planned further consultation from the Diagnostic Steering Group Version history

Version Date of revision Summary of changes Changes marked

0.00 First draft presented by Dr Robertson No

0.01 Proposed changes by Dr Sinclair & Dr Zealley

Yes

0.02 23/2/15 Proposed changes by Dr Sinclair Dr Zealley

Yes


Yes


Yes

0.05 12/5/15 Final formatting changes prior to issue to group

No

Distribution

Name Organisation

Mrs Alexandra Speirs & Mr Liam Anderson NSS

SCIN Interventional Short Life Working Various

SCIN Steering Group Various


Foreword

This discussion document has been developed by a nationally representative group of General Interventional Radiologists with the support of the Scottish Clinical Imaging Network (SCIN). Neurointerventional radiology is out with the scope of this paper. There are significant challenges in providing a comprehensive elective and emergency IR services across Scotland as the services are currently configured. This is predominantly related to the challenges of delivering a 24 hour service serving each of the acute sites, on a background of difficulties in the recruitment and retention of trained staff. The current pattern of Interventional Radiology (IR) service delivery varies across Scotland, with most units working in relative isolation. Many hospitals have no robust on call interventional radiology service and no formal arrangements between health boards for the transfer of sick patients to access these services. This results in inequity of access to emergency services. This document is focused on opportunities to improve equity of access to this vital service and to improve patient outcomes by developing a shared services model across traditional health board boundaries. It also addresses improving the training model for IR within Scotland to support the sustainability of the workforce.

The recent publication of “A National Clinical

Strategy for Scotland” February 2016

emphasises the need to improve the use of

available healthcare resources and to improve

outcomes for patients. It states that

Planning and delivery with geographical and/or other boundaries will no longer deliver what is needed; planning and delivering services for and across populations, regardless of locality, is key.


1. Timely access to robust 24/7 interventional radiology cover, whether through on- site delivery or

formal network access to a linked centre, should be a priority for all acute hospitals in Scotland.

2. Regional planning of shared services for emergency and elective Interventional Radiology should be undertaken, to clarify what can be provided locally and to improve the use of available resources, sustainability of service and equity of access for patients.

3. The development of a number of regional IR networks, each of which may contain more than one site of delivery for IR services, across Scotland should be explored as the most sustainable model to support care.

4. These regional networks should assess the resources and manpower required to provide a

sustainable service and explore the integration of staff between neighbouring units.

5. Appropriate clinical pathways and transport facilities should be developed as part of the process to establish regional networks.

6. A process to identify Interventional Radiology procedures that should be delivered at regional

and national level, due to the complexity and/ or low procedural volume, is required.

7. Interventional Radiology training should be provided as a national scheme, working across traditional health board boundaries

8. Workforce predictions and numbers for Interventional Radiology trainees should be informed by

accurate local board numbers including anticipated retirals, future workforce demographics and demand.

Key Recommendations


1. What is Interventional Radiology?

1.1 Interventional Radiology procedures are minimally invasive, targeted treatments performed

under imaging guidance. These procedures are often at the forefront of the management of life threatening emergencies. A wide range of procedures are included extending from repair of ruptured arterial aneurysms to the treatment of cancer and it’s complications. Interventional radiology procedures often replace open surgical procedures as they are less invasive, reducing morbidity and mortality and allowing more rapid patient recovery and hospital discharge.

1.2 Interventional Radiologists are Clinical Radiologists who have

undergone additional specialist training in the practical elements of Interventional Radiology. Interventional Radiologists work as part of a team with specialist nurses and radiographers who are familiar with the equipment and devices required for Interventional Radiology.

1.3 Interventional Radiology encompasses a wide

range of procedures which range from frequent urgent procedures to rare complex interventions. The most frequently required out of hours interventional procedures are nephrostomy for sepsis and embolisation for haemorrhage control (2). These conditions may present to or within any acute hospital in Scotland and treatment need to be instigated promptly to improve patient outcomes.

1.4 The treatment of localised sepsis by percutaneous

abscess drainage is often undertaken by general radiologists though some centres will provide out of hours cover by interventional radiologists. Sepsis is a common emergency and again robust provision of services are essential, either on site or through robust network arrangements.

1.5 Safe Interventional Radiology procedures require a team which includes a

specialist Interventional Radiology nurse, an appropriately trained radiographer and a specialist Interventional Radiologist

1.6 Detailed standards for the provision of interventional radiology services are beyond the remit of

this document. The working group acknowledge and support the principles & standards outlined in the RCR/ BSIR document Provision of Interventional Radiology 2014 (1)

"Modern surgical practice relies on

Interventional Radiology to deliver

safe and effective care in both the

elective and the emergency setting.

In particular the ability to stop life-

threatening bleeding in post-

operative and severely injured

patients is of enormous benefit."

Mr Michael Lavelle-Jones, President, Royal College of Surgeons, Edinburgh


2. Challenges facing the Interventional Radiology Service in Scotland

(a) Emergency Access (b) Elective Access

Emergency Access

2.1 Timely access to 24/7 Interventional Radiology is challenging to deliver across Scotland but

should be a priority for all acute hospitals and is regarded as best practice in the management of a number of life threatening conditions .The concept behind interventional radiology is to diagnose and treat patients using the least invasive techniques currently available in order to minimize risk to the patient and improve health outcomes. These procedures have less risk, less pain and less recovery time compared to open surgery

2.2 Smaller hospitals in Scotland often have insufficient interventional radiologists and insufficient

nursing team members to develop sustainable out of hours cover and may not have formal networked access in another health board. These services are therefore not always available and at best an ad hoc service pertains. This places patients at risk of not receiving prompt or optimum treatment and it puts the staff, both referring clinicians and interventional radiologists, under undue pressure.

In some instances, rather than the patient receiving a minimally invasive procedure, other more invasive surgical procedures may be employed or there may be considerable delay in transferring the patient to another centre due to the use of unplanned ad hoc pathways. The continued use of current ad hoc local provision of services or agreements based on historic generic service level agreements places the patient at risk and can delay vital treatment. It is not appropriate for these services.

For the safety of patients, it is necessary that acute hospital trusts have formal and robust arrangements to ensure provision of emergency services 24 hours a day every day, of the year. The provision of interventional radiology is no exception and all patients regardless of geography and hospital size should have access to interventional techniques if required.

Royal College of Radiologists 2008 ( 1)


2.3 Table 1 below demonstrates the variation in provision of emergency interventional services

across the territorial health boards in Scotland Table 1

Drainage

Nephrostomy

Biliary Drainage

Vascular emergency

TEVAR

IVC Filter

Embolisation

Colorectal stent

A&A

Borders

D&G

Fife

FV

Grampian*

GG&C

Highland

Lanarkshire

Lothian

Orkney

Tayside

Shetland

Western Isles

*Mainly provided via locum consultant cover therefore an unstable situation

Full 24/7 service

Service via network with neighbouring board

Ad hoc service

No local service and no formal arrangements for networking

2.4 There are some historic networking arrangements which exist in two areas in Scotland; NHS

Tayside networks with NHS Fife and NHS Lothian with NHS Borders for interventional radiology services. The group felt that further improvement in this type of working was warranted in these areas and across Scotland as the current arrangements were not always robustly understood by the involved clinical staff leading to potential delays in transfer of patients.


2.5 While undoubtedly there is a shortage of trained Interventional Radiologists, a previous report Interventional Radiology Out of Hours: Standards for haemorrhage-control services in Scotland ( 2) documented that there is under utilisation of current IR staff with only 18 of 38 appropriately skilled Interventional Radiologists, who perform these procedures in hours, contributing to formal, prospectively planned out of hours services. This could be addressed through the implementation of regional Interventional radiology services.

2.6 An interventional radiology on call rota requires radiologists, radiographers and specialist

nurses. The coordination of these three staff groups on an on call rota is particularly challenging for the smaller health boards to achieve in isolation.

Elective Access

2.7 Elective Interventional Radiology services are challenged by increasing demand secondary to

the advantages of minimally invasive techniques. A recent RCR workforce paper (3) on interventional services states 21% growth in activity between 2010-2012. There has also been an increase in complexity of the procedures. This has led to progressively more consultant radiology sessions being dedicated to interventional services which have had some impact on diagnostic services as a result.

2.8 Modern medical practice requires that acute hospitals have access to a number of core elective

Interventional Radiology procedures. These include: 2.9 Hospitals which support vascular units require elective and emergency access to peripheral

vascular intervention 2.10 Hospitals which support renal units require elective and emergency access to fistula intervention

and complex venous access. 2.11 An on call rota with increasing out of hours activity leads to more compensatory rest which has

an impact on the ability to deliver the daytime elective service.

abscess drainage tunnelled line placement

venous access enteral access and stenting

IVC filter placement nephrostomy

biliary drainage

Approximately 2.9 million of the Scottish population are covered by a robust 24/7 Interventional radiology service and 2.4 million are not. In 2014, the four regions in Scotland which provide a 24/7 out of hours interventional radiology service performed endovascular haemorrhage control procedures at a rate of 4.4 per 100,000 population served.


3. A Networked Model

3.1 The development of shared services between neighbouring units with service delivery in a

network, supported by integration of staff from respective units, is thought to be the most sustainable model of care.

3.2 Networked services would need appropriate resource to deliver a new model of service; where

possible this should be by integration of existing teams but may require expansion or redistribution of resource.

3.3 It is important that any future shared service model support the integration of staff, into regional networks from neighbouring units, to aid service delivery. This approach will help develop more sustainable and resilient services by forming a larger more sustainable and flexible workforce .

3.4 Specific attention should be made to defining the scope of services, governance arrangements, clinical pathways and the transfer facilities to support these networks.

3.5 Possible models of service provision with their attendant risks and benefits, considered by the

group, are outlined in Table 2 Table 2

Option Number of Networks Benefits Barriers

1. 6 active sites as currently Maintain current IR sites as status quo

Use of locum agency staff required to maintain this situation

2. 5 networks I. Glasgow/FV /W Isles II. Lothian/D&G/Borders

III. Lanarkshire/A&A IV. Tayside/FV V. Grampian/Highland/O&S

Development of seven day services

Larger more sustainable centres

Efficiency savings

No ad hoc service

Equity of access

Transfer times

Coming off the diagnostic rota

Staff resistance

Recruitment

Retention

Journey times on call

?resident on call

3. 4 networks I. Glasgow/Lanarkshire/A&A/W

I II. Lothian/D&G/FV/Borders

III. Tayside/Fife IV. Grampian/Highland/O&S

4. 3 networks I. North II. West

III. East of Scotland

5. 2 networks I. Grampian/Glasgow II. Lothian/Glasgow


3.6 The SCIN working group considered the most sustainable model of service to be the delivery of IR services through regional networks across Scotland – option 3 or 4. The number and configuration of these networks were considered to be closely linked to future delivery of clinical services and therefore out with the remit of this group.

4. Regional /National Interventional Radiology procedures

4.1 There are a significant number of lower volume complex interventional radiological procedures

that are reliant on a small number of expert operators within Scotland and are supplied mainly by larger centres. At present within the current structure, despite being mainly delivered in tertiary centres, these services are often based on an ad hoc service, and would be better and more sustainably delivered by larger regional/ national services. These procedures include

4.2 A more systematic process of regional/ national planning for these procedures should be

undertaken in order to improve equity of access and enable better assessment of developmental procedures and audit of patient outcomes.

4.3 The process to support the assessment of the best type of service delivery for these procedures should be as open and as transparent as possible. Centres that currently provide these services should undertake robust data collection including outcomes to inform future practice.

5. Staffing and Training

5.1 There is a UK shortage of Interventional Radiologists with many sites struggling to recruit and

retain staff particularly smaller units. Anecdotal evidence indicates that the offer of substantial inducements is common practice in England and Wales in order to attract applications. Examples of these inducements include starting salaries at the top of the pay scale, golden handshakes of several tens of thousands of pounds, and flexibility in job-planning. This is a competitive recruitment environment and it should not be assumed it will be possible to recruit to vacant IR posts within Scotland without considering the use of similar schemes.

5.2 Interventional Radiology is a relatively young specialty and until recently has not had to account

for loss of staff secondary to retiral. This will change in the next decade as the first cohort of Interventional Radiologists retires.

5.3 6 out of 34 Interventional Radiologists in Scotland are due to retire in the next 4 years. (4) This

is on a background of at least 4 unfilled current posts. Replacing these staff members will be difficult in a market that is highly competitive.

5.4 It is essential that trainee numbers are calculated to take into account future workforce

projections that are based on accurate data. At present, there appears to be gap between Interventional Radiology departments and workforce planning for this specialty. Better data collection on national workforce demographics and on demand on the interventional service should be prioritised.

Fenestrated endovascular stent grafting

Ablation therapies for solid tumours

Transarterial chemoembolisation

Selective Internal Radioembolisation

Carotid intervention


5.5 There was a strongly supported view within the group that training in Interventional Radiology

would be better undertaken as a national process with trainees trained in centres across traditional health board boundaries to ensure the best possible training experience.

6. Conclusion

The delivery of sustainable interventional radiology services across Scotland is threatened by increasing demand, inadequate trainee numbers and geographical factors which mitigate against the delivery of 24/7 services for the whole of Scotland. The view of the Scottish Clinical Imaging Network is that the formation of regional networks with collaborative working across traditional health board boundaries will be necessary to deliver a safe and equitable IR service in the future. References

1. Standards for providing a 24-hour interventional radiology service- RCR 2008 2. Interventional Radiology Out of Hours Standards for haemorrhage-control services in Scotland.

Managed Diagnostic Clinical Imaging Network 2010. 3. Investing in the Interventional Radiology Workforce: The quality and efficiency case RCR 2014 4. RCR Scottish Census Document 2015

SCIN SLWG membership

Dr Iain Robertson NHS Greater Glasgow and Clyde (Chair) Dr Ian Zealley NHS Tayside (Vice-Chair) Dr Mark Ablett NHS Ayrshire & Arran Dr Neil Masson NHS Lothian Dr Anne Marie Sinclair NHS Greater Glasgow and Clyde Dr Shonagh Walker NHS Grampian Dr Lau Pui Fong NHS Lanarkshire Dr Reddi Yadavali NHS Grampian Dr Nik Arestis NHS Forth Valley Dr Petr Hrobar NHS Dumfries & Galloway Dr Michael Ashcroft NHS Highland Dr Susan Ingram NHS Lothian Dr Reddi Yadavali NHS Grampian Dr Michael Ashcroft NHS Highland Secretariat: Mr Liam Anderson Programme Support Officer, NNMS, NSS Mrs Alexandra Speirs Network Manager, NNMS, NSS Declaration of interest

Dr Iain Robertson is a Director of IR365 Ltd - which provides Interventional Radiology locums. Dr Reddi Yadavali is a Director of IR365 Ltd - which provides Interventional Radiology locums.

interventional radiology services in scotland a discussion

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