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AchievingWorld-ClassCancerOutcomes:TheVisionforTherapeuticRadiography.

ForewordfromSheilaHassan,President

Thetherapeuticradiographyprofessionhasbeenevolvingeversincethecareerprogressionframeworkwasfirstdescribedin1999.RecentSocietyandCollegeofRadiographers(SCoR)surveysdemonstratethisevolutioncontinues,withourprofessionbeingjointlyresponsible(withourclinicaloncologyandmedicalphysicscolleagues)fortheprovisionofequitable,highquality,safeandpatient-centredradiotherapyservices.Thisisalongsideanincreasingnumberanddiversityofrolesbeingimplemented,especiallyatadvancedandconsultantlevelsofpracticewheretherapeuticradiographersareroutinelyresponsibleforthecareoftheirpatientsacrosstheentiremanagementpathway.Manytherapeuticradiographersarenowfulfillingtheroleofkeyworkerfortheirpatients,identifiedascriticalwithintherecentIndependentCancerTaskForceReport.

ThisguidancefromtheSocietyandCollegeofRadiographers(SCoR)isintendedtobeavisionforourprofessionastheserolescontinuetochangeanddevelopinthefutureinresponsetotechnical,operationalandpoliticalinfluences.Italsoaimstoassistradiotherapymanagersinmakinginformeddecisionsabouttheirlocalserviceneeds.Atanearlystageinitsdevelopmentitwasestablishedtherewasnoevidencebasefor‘onesizefitsall’approach,sothisdocumentoutlinestheinfluencesthatradiotherapyservicemanagersmustconsiderwhenidentifyingtheirlocaltherapeuticradiographyworkforceneeds.ItbuildsupontheSCoR’sPrinciplesofsafestaffingforradiographyleadersguidancepublishedin2015,andassistsmanagersinprovidingpatient-centredcare.

IwasprivilegedtobeamemberoftheSCoRRadiotherapyAdvisorySub-Groupwhoworkedhardtounderstandtheneedsofradiotherapyservicesandprovidethisrobustandusefulguidancerelevanttoradiotherapyservicemanagers.Thegroupcomprisedofarangeoftherapeuticradiographers,reflectingthefullrangeofprofessionalpracticeaswellasincludingapatientrepresentative.Aspecialthanksgoestoallthesub-groupmembersincludingSCoRProfessionalOfficers,SarahJamesandSpencerGoodman.

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Introduction

Therapeuticradiographersplayavitalandchangingroleinthedeliveryofradiotherapyservices.Theyareextensivelyinvolvedatallstagesofthepatient’sradiotherapyjourneyandtheonlyhealthcareprofessionalsqualifiedtoplananddeliverradiotherapy.Therapeuticradiographersarenotonlyresponsiblefortheplanninganddeliveryofaccurateradiotherapytreatmentsusingawiderangeofsophisticatedandtechnicalequipment,theyhaveuniqueexpertiseandskills1requiredtocareforpatientsbefore,duringandafterradiotherapy.Theyaresupportedbytheappropriateuseofhealthcareassistants,administrativeandclericalstafftoundertakeactivitiesnotrequiringtheexpertiseoftherapeuticradiographersandareheadedbyaRadiotherapyServicesManager(orsimilartitle),astateregisteredtherapeuticradiographerwhoisrecognisedastheprofessionalleadwithintheirorganisation.

Diagramdemonstratingthethreemodelsofradiographerledexpertpracticeinthecancercarepathway

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BackgroundMorethanhalftheworkforceinradiotherapyaretherapeuticradiographers.Since1997whentheSocietyandCollegeofRadiographers(SCoR)publishedTherapeuticRadiography:AVisionfortheFuture2,guidanceandadvicedocumentshavebeenpublished3,4,5,6,7,8,9whichhavedefinedthedirectionoftravelfortherapeuticradiographersandsupportedthemtoembracechangeinordertorespondandtodeliverpatient-centredcare.ThisdocumentsupersedesandreplacesexistingSCoRtherapeuticradiographyguidance.10,11,12Itoutlinesthepracticeoftherapeuticradiographyinprovidinghighqualitycaretopatientswhilecontinuingtodevelopthescopeofpracticeoftherapeuticradiography,safelyandeffectively13whenworkingasacriticalpartoftheradiotherapyteamandrespondingtothechallengesofachanginghealthcareproviderenvironment.14,15

ItbuildsontherecentlypublishedSCoR’s‘Principlesofsafestaffingforradiographyleaders’16guidance,informsthetherapeuticradiographyprofessionandsupportstheheadofradiotherapy(radiotherapyservicemanager)byoutliningtheprinciplestobeconsideredwithregardstothetherapeuticradiographyworkforce.Itencompassesthefuturevisionofaflexibleworkforceutilisingalltheirskillsatthehighestpossiblelevel.Therapeuticradiographersmayfulfiltheroleof‘keyworker’forindividualpatientsthroughouttheircarepathway,whilealsoutilisingtheiruniqueknowledgeandexpertisetoensureevidence-basedpracticeandthesafeimplementationofinnovationforspecificpatientgroupsandtechnicalspecialitieswithinradiotherapy.Ofcoreconsiderationaretherequirementsforthedeliveryofsafeandeffectivepatient-centredservices,setinthecurrentpoliticalcontext.15

Therapeuticradiographystaffingguidancehaspreviouslymodelledtheworkforcerequiredtostaffagenericradiotherapyservice,thusidentifyingthetherapeuticradiographyworkforceneededtostaffa“linearacceleratorhour”,thesocalledBenchmarkFigure.10In2010,theNationalCancerActionTeam(NCAT)developedasophisticatedWorkforceIntegratedPlanningTool(WIPT)17whichenabledservicemanagerstomapandidentifynon-medicalworkforcerequirementsforradiotherapyservices,allowingforvariablessuchasequipment,workload,demand,modelofservice.Theuptakeandongoinguseofthistoolwasnotwidespreadacrossradiotherapyservices,indicatingthelimitedusefulnessofthismathematicalapproachtoidentifyingradiotherapyworkforcerequirements.TheInternationalAtomicEnergyAgency(IAEA)hasinvestigatedanddocumentedanactivity-basedapproach18bymeasuringarangeofproceduresbutacknowledgesthatthisisanoneroustaskandlagsbehindemergingtechnologiesand,asaconsequence,islimitedinitsusefulness.TheseissuesalongwithcontinuallyevolvingservicedevelopmentsacrosstheUKindicatethatitisunrealistictoestablishareplacementbenchmarkfigurethatwouldbemeaningful,usefulandsafe;compoundedbytheincreasingdiversityofmodelsofradiotherapyserviceprovision.Thisguidancedoeshoweverprovideexampletherapeuticradiographyworkforcearrangementstoillustratetheoutlinerequirementsforaseriesofdifferingserviceprovidermodels.ThesehavebeenbasedupondatacollatedfromrecentUKSurveys.19,20,21,22

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ContextThecontextforoutliningthefutureofthetherapeuticradiographyprofessionisdrawnfromarangeofinfluencesasfollows:NationalandpoliticalinfluencesOngoingnationalworktoraiseradiotherapystandardssincethepublicationoftheNationalHealthService(NHS)CancerPlan,23thesubsequentformationoftheNationalRadiotherapyAdvisoryGroup24in2005,andthemorerecentlypublishedVisionforRadiotherapy2014–202414havebeeninfluentialinimprovingradiotherapyprovisioninbothqualityandaccessibility.ThisVisionpaperhighlightstheimportanceofskills-mixandnewrolesatadvancedandconsultantlevelsofpracticeinordertoenabledeliveryofinnovativeandadvancedradiotherapytopatients.TheseprincipleshavebeenendorsedbytheIndependentCancerTaskForceReport.25

TheIndependentCancerTaskForcewasestablishedin2015,withanactionplanaimingtoimprovetheoutcomesthattheNHSdeliversforpeoplewithcancer.Thestrategy25proposesthefollowingstrategicpriorities:increasingaccesstoradiotherapy;investmentinaradiotherapyequipmentreplacementprogramme;addressingcriticalworkforcedeficits;astrategicreviewoffutureworkforceneedsandaccesstoaclinicalnursespecialist(CNS)orotherkeyworkerforallpeoplewithcancer.Allofthesewillimpactthetherapeuticradiographyprofession,andthisguidancemaythereforeneedtoevolveinparallelastheactionsoftheCancerTaskForceImplementationGroupbecomeevident.AtthetimeofdevelopingthisguidancetherewerealreadyanumberofNHSinitiatives,recognisedasbeinginfluentialindrivingthesestrategiesforward.Theseinclude:

• NHSServicessevendaysaweek26• Partnershipworking(centralisationofspecialisedservices,wherenotallproviderswill

deliverallservices)27• Financialpaymentsrelatedtooutcomesratherthanactivity27• NationalCancerSurvivorshipInitiative.28

Theaboveareallunderpinnedbytheneedtoensureholisticpatient-centredcare,29thatisequitableandaccessibletoallusers.TheSCoRpolicyoutliningthetherapeuticradiographyprofession’scontributiontothesestrategiesisinherentwithintheapproachoftheprofessionimplementingthefollowingspecialistpractitionerrolesatbothconsultantandadvancedpractitionerlevel:SiteSpecificexpertpractitioner,technicalspecialistexpertpractitionerandcommunityliaisonexpertpractitioner.Theimplementationofsuchrolesassistswiththeintroductionoftreatmentinnovationsandtransformationalservicechangesacrosscancercarepathways,thuscontributingtothesafeprovisionandcontinuityofcareacrosstheentireradiotherapypatientmanagementpathway.

ServiceprovidermodelsDevelopmentsintechnology,thedrivetoimprovepatientaccessibilityandtheincreasingprovisionofradiotherapybyindependentsectorandprivateprovidersisresultinginarapidincreaseinthenumberofgeographicallocationsofradiotherapyservicesacrosstheUK,aswellasanincreaseinthevarietyofserviceprovidermodels:largecancercentres,satellitesfromexistingcentres,new

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centresbynewproviders,partnershipworkingbetweenproviders27andprovidersofspecialistmodalitiessuchasstereotacticradiotherapyandprotonbeamtherapy.

LeadershipThedevelopmentandimplementationofnewertechnologiesrequireseffectiveleadershipatalocalservicelevel,andwillnecessitatemulti-professionalguidancefromtheradiotherapyprofessionalbodiestoensureconsistencyofimplementationandequalityofaccessforpatients.Theheadoftheradiotherapyservicemustworkwiththeirmedicalandphysicscolleaguestoensurethedeliveryofahighqualityradiotherapyservice.OneofthestrategicmechanismstofacilitatethisistheleadershiproleoftheRadiotherapyBoard.Thiswassetupin2013todeveloptheworkofthenowdefunctNationalRadiotherapyImplementationGroup(NRIG).ItwasestablishedjointlybytheSCoR,IPEMandRCRtosupportthedeliveryanddevelopmentofradiotherapyservicesintheUKandhasrecentlypublishedanumberofguidelines.30,31,32

ChangesintherapeuticradiographyscopeofpracticeSCoRcontinuestoencouragethetherapeuticprofessionalworkforcetoseizeopportunitiesfordevelopingroleswithinadynamicallychanginghealthcareenvironment.15Inresponse,theprofessionhasdevelopedbotheducationallyandinpractice,resultingindiversifiedandexpandedrolesatadvancedandconsultantlevels,thuscontributingtoqualityimprovementstothebenefitofradiotherapyprovisionandserviceusers,allbuildinguponthelongestablishedfourtiersofthecareerprogressionframework.5,6

Theincreasingcomplexityofbothradiotherapyplanninganddelivery,suchastheuseofmultipleimagingmodalities(4DCT,PETCT,MRI,Ultrasound)willrequiretherapeuticradiographerstohavecomplexskillstosupporttheuseofexistingandnewertechnologiesastheyemerge.33,34,35Thisincludestheimplementationofnewermodalitiessuchasprotons,MRIlinacsandmolecularradiotherapy,andtheincreasinglycomplexdecisionmakingrequiredwhenimaginganddeliveringradiotherapy.Theincreasinguseofcombinedtreatmentmodalitiessuchasradiotherapy,chemotherapy,immunotherapyandbiologicaltherapieswillalsorequireeffectivemulti-disciplinaryworkingbetweenallinvolved;workingcollectivelytoprovidecontinuityofcareacrosstheentirecancermanagementpathway.Therapeuticradiographerswillplayapivotalroleincaringforpatientsbefore,andduring,radiotherapy,andintothesurvivorshipphaseoftheircarepathways.Studieshaveidentifiedthatthepaceofchangecontinues.19,20,36,37,Theroleoftheprofessionaltherapeuticradiographyworkforcecontinuestoexpanditsresponsibilitiesacrosstheentireradiotherapypathwayinthemajorityofradiotherapycentres:specificallytheseincludeadvancedandconsultantlevelpractitioner-ledplanningservicesandon-treatmentreview,supplementaryandindependentprescribing.38Manycentreshavebothtumoursitespecialistsandtechnicalspecialistroleswithintheirestablishmentandasmallernumberofcentreshavedevelopedcommunityspecialistradiographerroles.Theannualtherapeuticradiographyworkforcecensus21andregulartherapeuticradiographyscopeofpracticesurveys20,36,37demonstratethevastmajorityofradiotherapyserviceshaveradiographer-ledtreatmentplanningservicesandradiographer-ledon-treatmentreview.Alongsidethesetherehasalsobeenasteadygrowthinthenumberofspecialistradiographersappointed,particularlyintumoursitespecialistrolesatbothadvancedandconsultantlevelsofpractice.Therapeuticradiographersinthesespecialistpostsundertakevitalrolesinco-ordinatingandprovidingconsistentlyhighqualitycaretotheirpatientswhilebeingapointof

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contactandthepatients’keyworkerduringtheirradiotherapypathway,asspecifiedintheCancerTaskForceReport.25

Clinicalgovernance,auditandresearchAlltherapeuticradiographershaveadutyofcaretoensuretheydeliverthehighestpossiblestandardsofcaretoalltheirpatients.Toembraceserviceinnovationandtechnicaldevelopments,thetherapeuticradiographyworkforceneedstoundertakeserviceevaluation,auditandradiographer-ledresearchinlinewiththeSCoRVisionforResearch39todrivelocalqualityimprovementswhilealsoensuringpatients’treatmentandcarefollowsevidence-basedpracticethatisprovidedinatransparentandaccountablewaywithapatient-centredapproach.

ProfessionaleducationEducationunderpinsthetherapeuticradiographyprofession,wheretheeffectiveimplementationofskillsmixisakeycomponentwithinthecomprehensiveeducationandcareerframeworkforthetherapeuticradiographyworkforce.1Thisoutlinestheimportanceofindividualpractitioners’competency,whilealsoplacingsignificanceontheneedforeducationprovidersandservicemanagerstoprovideeducationalandsupportivemechanismsintheclinicalsetting,forbothpreandpost-registrationradiographers.Thisshouldincludeaccesstothetoolforuseineducationprogrammedevelopment,whilealsofacilitating,supportingandmonitoringtheachievementofbothprofessionalandpersonaldevelopmentgoalsoftherapeuticradiographyprofessionsacrosstheircareerpathway.

Theindicativecurriculum40forpractitionersreflectstherequirementforahighlyprofessionalisedworkforcewithaclearidentityandsetofvalues.These,togetherwiththeappropriateknowledgeandskills,ensurethatradiographersareabletooperateprofessionallyinuncertainenvironmentsandinadynamicallychangingworkplace.Thevaluesofintegrity,person-centred,personalresponsibility,respect,trustworthiness,collegialityandreflectivepracticeareembeddedtoensurethecurriculumpreparesnewlyregisteredradiographersenteringtheworkplaceasnoviceprofessionalstodevelopthelevelofprofessionalmaturityrequiredtoenablethemtoprogresstoadvancedandconsultantlevelpractitionerroles,includingthosewitharemitofleadershipandmanagement.Theroleoftherapeuticradiographersinpublichealtheducation.Whiletherearearound40,000peopleemployeddirectlytoworkinpublichealth,itisincreasinglyrecognisedthatthisworkforcealonecannottacklethenation’spublichealthproblem.41TherecentreportfromPublicHealthEngland42recognisestheroletherapeuticradiographersalreadyplayasoneofthetwelveAlliedHealthProfessionals,inchampioningthepublic’shealthandwellbeingthroughtheirdaytodaycontactwithpatients.

Healthconversationsormakingeverycontactcount(MECC)43encouragesallthoseworkingwithinthehealthcaresectortouseeveryopportunitytomakeasignificantcontributiontothenationalpreventionagendaasoutlinedintheNHSFive-YearForwardView.44ThePHEreportidentifiedexamplesofwheretherapeuticradiographersarealreadymakingadifferencetotheirpatient’shealththroughhavinghealth-relatedconversationswiththemwhilecaringforthemacrosstheirentirecancermanagementpathway.Therehavealsobeenanumberofcasestudiespublishedwheretherapeuticradiographershavebeeninvolvedindevelopinglocalstrategiesandimprovingpatientcare,leadingtoimprovementsinthehealthandwellbeingoftheirpatients.45,46Theregular

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contacttherapeuticradiographershavewithpatientsgivesthemtheopportunitytoprovidecontinuityofcareprior,duringandaftercompletionoftheircourseofradiotherapy.Duringthistimetheydeveloparelationship,soallowingthemtodiscussmoresensitiveissuessuchastheneedforemotionalandpsychologicalsupportandthebenefitsofadoptinghealthlifestylebehavioursastheyentertheir‘survivorship’phaseoftheircancerjourney,hopefullyleadingtoimprovedsurvivalandqualityoflife.47Thegrowingnumberofspecialisttherapeuticradiographersatadvancedandconsultantlevel18,19willprovideincreasingopportunitiesfortherapeuticradiographerstoplayaneverincreasingpartinimprovingthenation’sgeneralhealth.

Principlesoftherapeuticradiographerstaffing

ThePrinciplesofSafeStaffingforRadiographyLeaders16outlineskeyconsiderationswhenreviewingstaffingmodels,forbothclinicalimagingorradiotherapy/oncologyservices.

Thisguidanceoutlinesprinciplesofstaffingthatapplyspecificallytothetherapeuticradiographyworkforce,thusbuildinguponthegenericguidance.16Inordertoprovidehighquality,efficient,effectiveandsaferadiotherapyservicesitisnowrecognisedthattheradiotherapyworkforceprofilesdifferfromthosemodelledin2006.24Thisisowingtotheincreasinglysophisticatednatureofradiotherapyespeciallyatthetimeofradiotherapydelivery.However,itisacknowledgedthatworkforcerequirementswillcontinuetobedependentuponanumberofotherfactorssuchas:

§ serviceprovidermodelegsinglesite,multiplesiteservices§ commissioningarrangementsegregional,supra-regionalornationalserviceproviders§ culturetoenableimplementationofinnovationandtransformationalservicechanges§ skillsmixacrosscarepathways§ linkstoothercentresandtheextentofregional-wideprotocolstandardisation,

governancearrangementsandstaffcoverarrangements§ casemix§ geographicallocation§ radiotherapyequipment,egavailabilityofdosimetricplanning(onsiteorremote)§ modalityandtechnicalabilityofunits§ optimaluseofavailabletechnologies§ useofautomatedandcomputer-assistedtechnologieswhenappropriateandsafe§ ITinfrastructurewithinthecentreandlinkswithneighbouringcentres.

Therewillbeanexpectationthattherapeuticradiographystaffingprovisionwillenableservicestoprovideclinicalplacementsforpre-registrationtherapeuticradiographersandtheclinicaleducationofotherrelevantprofessionals.

Oncetheabovefactorshavebeenidentifiedwithintheclinicalsetting,therewillneedtobeprovisionfortheeffectiveleadershipandmanagementoftheradiotherapyserviceandtherequiredtherapeuticradiographyworkforcetoensurethefollowingcriteriaarefulfilled:

a) Patient-centredservice.Staffingrequirementstobebasedupontheneedtoprovideapatient-centred,holisticapproachacrosstheentireradiotherapypathwayofcareincludingtheprovisionofpatientinformationandpsychologicalsupport.Itwillbeneedtobestreamlinedcare,sensitiveandresponsivetopatients’needs,andnotbasedupon

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professionalrolesand/orhistoricalpractices.29.48Overallstaffingrequirementsmustbeidentifiedtoensureappropriatestaffingarrangementsatalltimes,sothatplannedabsences(professionaldevelopment,mandatorytraining,annual,maternityandpaternityleave)andunplannedabsences(sickness)donotcompromisethequalityandcontinuityoftreatmentandcareprovided.

b) Headofradiotherapyandprofessionalleadforthetherapeuticradiographyworkforceandnameddeputy/deputies.Thepostholderwillbearegisteredtherapeuticradiographerwhoworksinconjunctionwithallrelevantprofessionalcolleaguesinvolvedinprovidingcareacrossthepatientradiotherapymanagementpathway,whileadheringtoallrelevantmulti-disciplinaryguidancethusenablingamulti-professionalapproachtoworkforceplanningacrossthewidercancercarepathways.

c) Clinicalgovernance,qualitymanagementandaudit.Serviceprovisionwillneedtoconformwithallrequiredapplicablelegislationandnationalguidance.LocalproceduresanddocumentationmustbeinplacetoensurealllegalrequirementsaremetasoutlinedintherecentSCoRguidance,16examplesofwhicharethecurrentIonisingRadiation(MedicalExposure)Regulationsandamendments(IR(ME)R)49andtheIonisingRadiationsRegulations1999(IRR).50IR(ME)RisdesignedtoensurepatientsafetyandIRRtoensurepublicandstaffsafety.Non-statutoryguidanceexistsforbothRegulations.51,52ThenewEuropeanMedicalExposuresDirective(MED)waspublishedattheendof2013,53thebasisofwhichwillformnewUKradiationprotectionlegislationin2018.

d) Implementationofeffectiveandappropriateskillsmixacrossthemulti-disciplinaryradiotherapyworkforce.Thedevelopmentoftheradiotherapyworkforcetoenableeffectiveskillsmixisessentialsothattherapeuticradiographersplayavitalroleinthedeliveryofthemoreroutineelementsoftheradiotherapypathwaypreviouslydeliveredbyclinicaloncologists.ThiswasclearlyoutlinedbytheNationalRadiotherapyAdvisoryGroupReport24

andrecentlyreaffirmedbytheVisionforRadiotherapyReport:2014-2024.14Thisprincipleisfacilitatedbythefollowing:i) Implementationofthecareerprogressionframework(seebelow,pleasenotein

radiotherapy,theServiceDirectorisoftentitledtheRadiotherapyServiceManagerorHeadofRadiotherapy)tosuitlocalserviceneed,whileenablingandsupportinginnovation.TheEducationandCareerFrameworkfortheRadiographyWorkforce1

definestheeducationaloutcomesforeachlevelofpracticeandissufficientlybroadtoalloweducationandservicetorespondtoserviceneedwhenimplementinginnovation.CompletionofSCoRaccreditation54atconsultant,advancedandassistantlevelpracticealsoprovidesassurancetoemployersandpatientsofindividuals’competenceandcapabilitytofulfiltheirroles.

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Careerprogressionframework.

ii) Implementationofthethreemodelsofradiographer-ledexpertpracticeatbothadvancedandconsultantpractitionerroles:

• sitespecialistexpertpractitioners• technicalspecialistexpertpractitioners• communityliaisonexpertpractitioners.

ProgresswiththeimplementationoftheserolesacrossclinicalpracticeisevidentfromaseriesofSCoRsurveys.19,20,21

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Diagramdemonstratingthethreemodelsofradiographerledexpertpracticeinthecancercarepathway

iii) Effectivesuccessionplanningofkeypostswithinthetherapeuticradiographyworkforcetoensurecontinuityofserviceprovisionwhenpostholdersresign.

iv) Appropriateandeffectiveuseofsupportworkforceinradiotherapysuchas:• healthcareassistantsbeingemployedtosupportradiotherapyservicesby

providingbasicnursingtaskssuchasdressings,bloodtestsandpatientcare• administrativeandclericalstaffprovidingsupporttoalllevelsofpractitioner

throughoutthepathway.Thesestaffmaycoverarangeofactivitiessuchasappointmentscheduling,activemonitoringoftheserviceactivityandcancertracking.

e) Researchanddevelopment.Toprovidehigh-quality,evidence-basedandoutcome-

improvingradiotherapy,alltherapeuticradiographersmusthaveresearchanddevelopmentactivityscheduledwithintheirjobplan.Departmentalworkforceplanningshouldincludeprovisionfordedicatedresearchandacademicradiographerstoleadresearch,toengageininternational,nationalandlocalresearchpolicy,topublishfindingsandtotranslateresearchfindingsintoclinicalimplementation.AssetoutintheSCoRvisionforresearch39all

Head of Radiotherapy - Member of Strategic/Regional/Network Cancer Services Team

Hol

istic

Pro

cess

es

Patient follow-upinto survivorship

RadiotherapyPre-treatment Procedures (Imaging: CT, MRI, PET,

Ultrasound) – Online Imaging and Treatment Delivery

Radiotherapy Clinical Operational Management Team e.g. Service Area Specific Leads, Section Heads, Team Leaders etc

Expert Practitioner Consultant – Technical Specialist

Expert Practitioner Advanced – Technical Specialist eg. Pre-Treatment/

Treatment Delivery

Treatment & Planning Teams, Practitioners,

Preceptees, Assistants

Radiotherapy Patient Care Pathway - Radical or Palliative Treatment

Expert Practitioner – Site Specific (Consultant/Advanced Practice)

Expert Practitioner – Community Liaison Radiographer – links to GP’s, Specialist Nurses, MDTs

Tech

nica

l Pro

cess

es

GP ReferralDiagnosis& Staging

MDTRadiotherapy

Referral

RT TreatmentPrescription

Patient TreatmentReview &

Assessment1st Follow-up

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radiotherapycentresshouldstrivetohavealocalresearchstrategyandtheworkforcetodeliverthis.Thereisemergingevidencethatpatientstreatedwithinaresearch-activesettingdobetterthanthosewhodonot15andtherapeuticradiographershaveavitalroleinthedevelopment,implementationandqualityassuranceoflocal,nationalandinternationalclinicaltrials.

f) Datamanagement.IncreasinglytheprovisionofhighqualityaccuratedataisarequirementtocomplywithmandatednationaldatagatheringegRadiotherapyDataSet(RTDS)andlocallyforbusinessplanningandfinances.Theradiotherapyserviceisbestplacedtomanageandqualitycontrolthedataflowsfromthedepartment.Therapeuticradiographersareintegraltoensurethataccuratedataisinputtedatsourceietherecordandverifysystemsconnecttothetreatmentunits.Themanagementofthesedataitemsisoftenbestsupportedbyadedicatedtherapeuticradiographerwhohastheknowledgeandskillstoverifydataacrossthepatientpathway.

g) Professionaleducation.Professionalpracticewithpractitioneroutcomesandanindicative

curriculumisinplacetoensurepre-registrationradiographerscanachievetheHCPCStandardsofProficiency55andbewellpreparedfortheiron-goingcareerdevelopment.Thereisaclearfocusonprofessionaldevelopmentandcollaborativepracticetoensureprovisioninthelearningenvironmentforbothpreandpostregistrationprofessionals;thismustbereflectedintheclinicalsetting.Boththeemployerandemployeeareresponsibleforensuringanindividual’scompetencetopractice,enablingthemtobecompetenttopracticeacrosstheentirerangeofresponsibilitieswithintheircurrentrole.Thereshouldbetheappropriateprovisionofeducationalandsupportiverolestofacilitateeducationandsupervisionforallpracticingtherapeuticradiographers.

Theextentandmannerinwhich(a)to(g)havebeenimplementedinradiotherapycentresacrosstheUKisinconsistentatthetimeofwritingthisguidance.Itisimperativethattheseapproachesarefullyimplementedbyallserviceproviderstothebenefitofallpatientsinordertomeetchangingserviceneedandoptimisecare.Toassistradiotherapymanagersmakeinformeddecisionsabouttheirlocalserviceneeds,theinformationinAppendixAprovidesoutlinetherapeuticradiographyworkforceprofilesbaseduponthecurrentsituationforarangeofdifferingradiotherapyservicemodelsandsizes.

Itisrealisedthatthetherapeuticradiographyprofessioniscontinuallyevolvingandthereforefuturetherapeuticradiographyworkforceprofileswillchange.Inthelightofthis,itisexpectedthatAppendixAwillbereviewedinthefuture,toensureitremainsinlinewiththeprogressionoftherapeuticradiographyprofessionalpractice.

SummaryThetherapeuticradiographyworkforcecontinuestorisetothechallengeofprovidinghighqualityradiotherapyservicestopatientsinarapidlychangingworkingenvironment.ThisguidancebuildsontheprinciplesoutlinedintheSCoRdocument‘Principlesofsafestaffingforradiographyleaders’.16Itdefinestheroleofthetherapeuticradiographyworkforceandsupportsradiotherapymanagersin

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identifyingtheirworkforcerequirementsforthedeliveryofsafeandefficientpatient-centredradiotherapyservices.

AcknowledgementsAllcentresparticipatinginthesurveyconductedbytheSCoRRadiotherapyAdvisorySub-GroupduringMarch2016:

• BelfastHealthandSocialCareTrust• CambridgeUniversityHospitalsNHSFoundationTrust• ClatterbridgeCancerCentreNHSFoundationTrust,• EastandNorthHertfordshireNHSTrust• HampshireHospitalsNHSFoundationTrust• LancashireTeachingHospitalsNHSFoundationTrust• MaidstoneandTunbridgeWellsNHSTrust• NewcastleUponTyneHospitalsNHSFoundationTrust• NHSGreaterGlasgowandClyde• NorthMiddlesexUniversityHospitalNHSTrust• PeterboroughandStamfordHospitalsNHSTrust• TauntonandSomersetNHSFoundationTrust• TheChristieNHSFoundationTrust• UniversityHospitalsBirminghamNHSFoundationTrust• UniversityHospitalsBristolNHSFoundationTrust• UniversityHospitalSouthamptonNHSFoundationTrust• VelindreNHSTrust

References1.SocietyandCollegeofRadiographers(2013).EducationandCareerFrameworkfortheRadiographyWorkforce.London:SCoR2.SocietyandCollegeofRadiographers(1997).TherapeuticRadiography:AVisionfortheFuture.London:SCoR3.DepartmentofHealth(2000).MeetingtheChallenge:AStrategyfortheAlliedHealthProfessions.London:DH4.SocietyandCollegeofRadiographers(2000).AStrategyfortheEducationandProfessionalDevelopmentofTherapeuticRadiographers.London:SCoR5.DepartmentofHealth(2003).RadiographySkillsMix:Areportonthefour-tierservicedeliverymodel.London:DH6.SocietyandCollegeofRadiographers(2009).Implementingthecareerframeworkinradiotherapy–policyintopractice.London:SCoR7.SocietyandCollegeofRadiographers(2009).ConsultantRadiographers:SuccessionPlanning.London:SCoR8.SocietyandCollegeofRadiographers(2009).Theroleofthecommunityliaisonexpertradiographerpractitioner:guidanceforradiotherapyandimagingservicemanagersandcommissioners.London:SCoR9.SocietyandCollegeofRadiographers(2010).EducationandProfessionalDevelopmentStrategy:NewDirections.London:SCoR10.SocietyandCollegeofRadiographers(2005).RadiographicStaffing:ShortTermGuidance:2005BenchmarkforStandardCoreFunctionswithRadiotherapy.London:SCoR

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11.SocietyandCollegeofRadiographers(2006).PositioningTherapeuticRadiographerswithinCancerServices:DeliveringPatient-CentredCare.London:SCoR12.SocietyandCollegeofRadiographers(2009).RadiotherapyMovingForward:DeliveringnewradiographystaffingmodelsinresponsetotheCancerReformStrategy.London:SCoR13.SocietyandCollegeofRadiographers(2013).ScopeofPractice.London:SCoR14.CancerResearchUKandNHSEngland(2014).Visionforradiotherapy2014-2024.London:CRUK,NHSEngland15.IndependentCancerTaskforceDepartmentofHealth(2015).Achievingworld-classcanceroutcomes:AstrategyforEngland2015-2020.16.SocietyandCollegeofRadiographers(2015).Principlesofsafestaffingforradiographyleaders.London:SCoR17.NationalCancerActionTeam.WorkforceIntegratedPlanningToolkit(WIPT).[updated12May2013].http://webarchive.nationalarchives.gov.uk/20130513211237/http://www.ncat.nhs.uk/our-work/ensuring-better-treatment/radiotherapy?#tab-workforceintegratedplanningtoolwipt18.InternationalAtomicEnergyAgency(2015).StaffinginRadiotherapy:AnActivityBasedApproachIAEAHumanHealthReportsNo1319.SocietyandCollegeofRadiographers(2015).TheProstate/UrologySpecialistCancerWorkforce:ProvisionofSpecialistTherapeuticRadiographersintheTreatmentandCareofMenwithProstateCancer.London:SCoR20.SocietyandCollegeofRadiographers(2015).ScopeofPracticeSurvey.London:SCoR21.SocietyandCollegeofRadiographers(2015).RadiotherapyWorkforceCensus.London:SCoR22.SocietyandCollegeofRadiographers(2016).RadiotherapyAdvisoryGroup–SubgroupdatacollectionexerciseJan-March2016.London:SCoR.Unpublished23.DepartmentofHealth(2000).TheNHSCancerPlan.London:DH24.DepartmentofHealth(2008).Radiotherapy:developingaworldclassserviceforEngland.ReporttoMinistersfromNationalRadiotherapyAdvisoryGroup.London:DH25.TheIndependentCancerTaskforce.Achievingworld-classcanceroutcomes:astrategyforEngland2015-2020.2015.Availableat:https://www.cancerresearchuk.org/sites/default/files/achieving_world-class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf27.NHSEngland(2016).TheNationalCancerTransformationBoard. AchievingWorld-ClassCancerOutcomes:Takingthestrategyforward.Availableat:https://www.england.nhs.uk/wp-content/uploads/2016/05/cancer-strategy.pdf28.TheNationalCancerSurvivorshipInitiative.http://www.ncsi.org.uk/29.DepartmentofHealth.TheMid-StaffordshireReport:FrancisReport2013.London:DH30.SocietyandCollegeofRadiographers(2015).Managementofcancerpatientsreceivingradiotherapywithacardiacimplantedelectronicdevice:Aclinicalguideline.London:SCoR31.SocietyandCollegeofRadiographers(2015).IntensityModulatedRadiotherapy(IMRT)intheUK:Currentaccessandpredictionsoffutureaccessrates.London:SCoR32.SocietyandCollegeofRadiographers(2015).GuidanceonImprovingAccesstoRadiotherapy–Increasingworkinghours.London:SCoR33.MilesEAetalTheimpactofintroducingintensitymodulatedradiotherapyintoroutineclinicalpractice.RadiotherapyandOncology(2005)77(3):241-24634.NationalCancerActionTeam(2012).NationalRadiotherapyImplementationGroupReport:ImageGuidedRadiotherapy(IGRT)Guidanceforimplementationanduse.35.SocietyandCollegeofRadiographers(2015).IntensityModulatedRadiotherapy(IMRT)intheUK:Currentaccessandpredictionsoffutureaccessrates.London:SCoR36.SocietyandCollegeofRadiographers(2008).ScopeofPracticeSurvey.London:SCoR37.SocietyandCollegeofRadiographers(2012).ScopeofPracticeSurvey.London:SCoR

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38.NHSEngland.CommissiononMedicines2016.Availableat:https://app.box.com/s/jv487awvqzzsrdql0o34h9gg350ceyd4/1/3477158784/47424519277/139.SocietyandCollegeofRadiographers(2015).ResearchStrategy2016-21.London:SCoR40.HealthandCareProfessionsCouncil(2014).StandardsofeducationandtrainingLondon:HCPChttp://www.hpc-uk.org/assets/documents/10002C0EHPCStandardsofeducation(A5)(final).pdf41.NHSFutureForum(2012).TheNHS’sroleinthepublic’shealth:AreportfromtheNHSfutureForum.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216423/dh_132114.pdf42.PublicHealthEngland(2015).HealthyconversationsandtheAlliedHealthProfessionals.43.PublicHealthEngland(2016).MakingEveryContactCount.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/495087/MECC_Implementation_guide_FINAL.pdf44.NHSEngland(2015).DeliveringtheForwardView:NHSplanningguidance2016/17-2020/21.https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf45.HuttonD.Givingup.SynergyNews(June2015).http://synergynews.sor.org/node/399246.MannL.Acareplanandmanagementsurvey.(January2014).ImagingandTherapyPracticeOnline.http://itp.sor.org/january2014/role-of-the-therapeutic-radiographer47.MacmillanCancerSupport(2015)RoutesfromDiagnosis:Themostdetailedmapofcancersurvivorshipyet.London..http://www.macmillan.org.uk/documents/aboutus/research/researchandevaluationreports/routes-from-diagnosis-report.pdf48.SocietyandCollegeofRadiographers.(2015).ThejointresponseoftheSocietyofRadiographersandtheCollegeofRadiographerstotheFinalReportoftheIndependentInquiryintocareprovidedbyMidStaffordshireNHSFoundationTrust.London:SCoR.49.HerMajesty’sStationaryOffice(2000).TheIonisingRadiation(MedicalExposure)Regulations2000.StatutoryInstruments2000No1059London:HMSO,.50.HerMajesty’sStationaryOffice(1999).TheIonisingRadiationsRegulations(1999).StatutoryInstruments1999No3232London:HMSOwww.opsi.gov.uk/si/si1999/19993232.htm51.TheSociety&CollegeofRadiographers(2012).TheIonisingRadiationsRegulations1999(IRR’99):GuidanceBookletLondon:SCoR,http://www.sor.org/learning/document-library/ionising-radiations-regulations-1999-irr99-guidance-booklet-052.TheRoyalCollegeofRadiologists,SocietyandCollegeofRadiographers,InstituteofPhysicsandEngineeringinMedicine(2008).AGuidetoUnderstandingtheImplicationsoftheIonisingRadiation(MedicalExposure)RegulationsinRadiotherapy.London:TheRoyalCollegeofRadiologists53.CouncilDirective2013/59/EURATOM(2013).EuropeanCommission.http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2014:013:0001:0073:EN:PDF54.SocietyandCollegeofRadiographers.Consultant,advancedandassistantpracticelevelaccreditation.London:SCoR.Availableat:https://www.sor.org/career-progression/consultants/consultant-practitioner-accreditation;https://www.sor.org/career-progression/advanced-practitioners/advanced-practitioner-accreditation;https://www.sor.org/career-progression/assistant-practitioners/assistant-practitioner-accreditationhttps://www.sor.org/learning/education-accreditation/education-approval-and-accreditation55.HealthandCareProfessionsCouncil(2013).Standardsofproficiency–RadiographersLondon:HCPChttp://www.hcpc-uk.org/assets/documents/10000DBDStandards_of_Proficiency_Radiographers.pdf(Allwebsitesaccessed22/5/16)

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RadiotherapyAdvisorySubGroupmembership:

GeriBriggs–PatientSafetyManager,OxfordAcademicHealthScienceNetwork,previouslyQualityManager,RoyalBerkshireNHSFoundationTrust

KateBurton–ConsultantRadiographerinNeuro-Oncology,CambridgeUniversityHospitalsNHSFoundationTrust

AngelaFrancis-HeadofRadiotherapyService,Guy'sandStThomas'HospitalNHSFoundationTrust

SpencerGoodman–ProfessionalOfficer,SocietyandCollegeofRadiographers

SheilaHassan-PresidentSocietyandCollegeofRadiographersandSanctioningLeadRadiographer,Guy'sandStThomas'NHSFoundationTrust

SarahJames-ProfessionalOfficer,SocietyandCollegeofRadiographers

BarbaraJones–Patientrepresentative,SocietyandCollegeofRadiographers,PatientandPublicLiaisonGroup

JulieMassey–GeneralManagerforRadiationServices,ClatterbridgeCancerCentreNHSFoundationTrust

LibbyMills-PrincipalRadiographer,Radiotherapydepartment,TheChristieNHSFoundationTrust

KevinSullivan-RadiotherapyServicesManager,UniversityCollegeLondonHospitals

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AppendixAOutlinetherapeuticradiotherapyworkforceprofilesbasedonthesituationasofMarch2016,forarangeofdifferingradiotherapyservicemodelsandsizes.

Itisbeyondthescopeofthisguidancetobeprescriptiveaboutlocalworkforcerequirementsforanentireradiotherapyserviceasconfigurationswillbedependentuponavarietyoffactorsandwillneedtovarytomeetlocalcircumstances.

Thisinformationhasbeenprovidedtoassistradiotherapymanagersmakeinformeddecisionsabouttheirlocaltherapeuticradiographyworkforcestaffingrequirements.AllinformationprovidedinthisappendixisbasedupondatacollatedfromarecentSCoRsurvey22conductedbytheSCoRRadiotherapyAdvisorySub-Group(RASG).SeventeenradiotherapycentresweresurveyedduringMarch2016toprofiletheirmulti-disciplinaryradiotherapyworkforceestablishments,radiotherapyactivity(levelandspecialities),equipmentandworkinghours.

TheSCoRRadiotherapyAdvisorySub-Groupadvisesthattheinformationprovidedinthisappendixmustnotbetakeninisolation.ItshouldbeconsideredinthecontextofthePrinciplesofTherapeuticRadiographerStaffingcriteria(a)to(g)onpages5-8withinAchievingWorldClassOutcomes:TheVisionforTherapeuticRadiography.Itistheviewofthisexpertgroup(RASG)thatthefollowingoutlinesthecurrenttherapeuticradiographystaffingrequirementsforavarietyofmodelsandsizesofserviceprovider.

Managerialandsupervisoryradiographerposts

o Headofradiotherapy(RadiotherapyServiceManager)whoisanHCPCregisteredtherapeuticradiographerwithdeputy/deputieswhois/aretheidentifiedleadsintheeventofabsences.

o Serviceareaspecificleads(egpre-treatmentandtreatmentlead)foreachworkingareawithinthemaincentreandeachsatellite.

Registeredpractitioners:consultant,advancedandpractitionerlevelsTherapeuticradiographersplayapivotalroleincaringforpatientswithcanceracrosstheentireradiotherapypathway.Theyarecriticalinthedeliveryofpatientcentredcareand,assuch,theyarerequiredtocareforpatientspriortoandduringradiotherapydelivery,andintopatients’survivorshipphaseoftheirmanagementpathway.

Thecurrentdatahashighlightedtheneedfortherapeuticradiographerstooperatebothpre-treatmentimagingunitsandtreatmentunits,andundertakearangeofotherassociatedactivitiesallofwhicharecriticaltoensureasafe,efficientandeffectiveradiotherapyservice.Theseincludethefollowing:

• MDTmeetingattendanceanddecisionmaking• pre-treatmentpatientinformationandpatientconsent• roleoftherapeuticradiographeraskeyworker• supplementaryandindependentprescribing• dosimetryandmouldroomservices• professionaleducation• clinicalgovernance,qualitymanagementandaudit• datamanagement

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• clinicaltrials,researchanddevelopment• brachytherapy• molecularradiotherapy• radiographerledontreatmentclinicreviews,followupclinics,survivorshipclinicsand

communityliaison• radiographer-ledinformation,supportandcounsellingservices.

Thevariablenatureofthedataacquiredduringtherecentsurvey22supportstheprinciplethatmanyoftheseassociatedactivitiesarenotalwaysexclusivelyundertakenbytherapeuticradiographers,butareoftencarriedoutinconjunctionwithprofessionalcolleagues;clinicaloncologists,medicalphysicistsandnurses.Asaconsequence,ithasnotbeenpossibletoidentifydefinitivetherapeuticradiographerstaffingrequirementsforeachoftheseessentialassociatedactivities.Amulti-professionalapproachwillberequiredbytheservicemanagertodeterminetheoverallradiotherapystaffingrequirementsastheywillbeinfluencedbylocalservicerequirementsandarrangements.

Itwillbeforeachindividualradiotherapycentretoimplementthenumber,rangeandmixoftherapeuticradiographersrequiredatconsultant,advancedandpractitionerlevels,accordingtolocalcircumstancesbasedonanumberoffactorstoinclude:specialistpatientneeds,caseload,availabilityofSpecialistRegistrarsandsuccessionplanning.

ConsultantandadvancedpractitionersThenumberofconsultantandadvancedpractitionerswillbedependentonlocalcircumstances.Jobdescriptionsandjobplansincludetherequirementtofulfilthefourdomainsofpractice1inaccordancewithSCoRguidance.7Theyareonlyallocatedaspartof‘core’treatmentorplanningdeliveryteamforasmallproportionoftheirjobplan.

Thecurrentdatahighlightedthatradiotherapycentressupportthefollowing:

a) uptotwoconsultantpractitionersregardlessofmodelorsizeofradiotherapycentreb) thenumberofadvancedpractitionersvaryaccordingtoradiotherapycentremodelandsize,

asfollows:• multi-sitecentressupportbetween3-7WTEs• largecentres(8-10linacs)supportbetween0-5WTEs• mediumcentres(4-6linacs)supportbetween0-7.5WTEs• smallcentres(2-3linacs)supportbetween0–7WTEs.

DetailsabouttherangeandnumberofspecialistradiographerpostsinemploymentinradiotherapycentresacrosstheUKhavebeenpublishedbytheSocietyandCollegeofRadiographers.20,21Thesesurveysdemonstratethevarietyoftumoursitespecific,technicalspecialistpostsandcommunityliaisonspecialistpoststhathavebeenimplemented.ArecentcollaborativeprojectwithProstateCancerUK19hasalsodemonstratedthatsignificantgrowthinnumbersisexpectedinthenextthreeyears,forbothprostate/urologytumoursitespecialistradiographerandpalliativespecialistradiographerposts.

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PractitionersPractitionersunderpintheserviceandarethelargestproportionofthetherapeuticradiographyworkforce21responsibleforthedeliveryofdailycareforpatientsattendingradiotherapypre-treatmentimagingandtreatmentunits.

Localcapacityanddemandplanningwilldictatethehoursofservicerequiredtooperateeachavailableimagingandtreatmentunitwithintheradiotherapycentre.AlldataprovidedwithinthisappendixhasbeenacquiredfromtherecentSCoRsurvey22bybenchmarkingseventeenradiotherapycentres’workforcerequirementsforan8hourday,highlightingthatalltheseradiotherapycentressupportthefollowing:

• whenworkingtocapacity,alinearacceleratordeliveringradiotherapyacrossaneighthourdayrequiresaradiotherapyworkforceoffour,intheircapacityasentitledIR(ME)ROperators.Theskillsmixofthisworkforcewillbereflectiveoftherequiredelementsofthecareerprogressionframeworkwhichwillbedependentuponthecomplexityandrangeofimagingandtreatmentsbeingdelivered.Thisistoenabletheefficientuseoftechnicallysophisticatedequipmentwhilealsodeliveringpatientcentredcare.

• anuplifttothisstaffinglevelisrequiredforextendedhoursbeyondtheeighthourday.

• whenworkingtocapacity,animagingunitworkinganeighthourdayrequiresaradiotherapyworkforceoffour,intheircapacityasentitledIR(ME)ROperators.Theskillsmixofthisworkforcewillbereflectiveoftherequiredelementsofthecareerprogressionframeworkwhichwillbedependentuponthecomplexityandrangeofimagingbeingundertaken.Thisistoenabletheefficientuseoftechnicallysophisticatedequipmentwhilealsodeliveringpatientcentredcare.Insmallercentres,theimagingunitmaynotbeworkingtocapacityand/ormaynotbeworkinganeighthourday,inwhichcasethedatasuggestsareducedstaffinglevelisappropriate.

AssistantpractitionersAssistantPractitionersareasmallproportion21(3.8%)oftheworkforceandthecurrentdatahighlightsthat:

• multi-sitecentressupportbetween0.5–5WTEs• largecentressupportbetween1-2WTEs• mediumcentressupportbetween1.8-5WTEs• smallcentressupportbetween0-1.2WTEs.

Thedataalsohighlightsthatassistantpractitionersareincreasinglyworkinginpre-treatmentareassuchasimagingunitsandmouldroomratherthanontreatmentunits.OtherstaffingrequirementsThecurrentdatahashighlightedtheneedforarangeofsupportstaffsuchashealthcareassistants,administrativeandclericalstafftoundertakearangeoftaskssuchasappointmentscheduling,receptionistdutiesandbasicnursingandpatientinformationduties.Thevariablenatureofthedata

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acquiredduringthesurvey23indicatesthatitwillbeforeachindividualheadofradiotherapytoidentifyandemploytherequirednumberofsupportstafftofulfilthesetasksintheircentre.

sWholeTimeEquivalent

NBTheOperatordoesnothavetobearegisteredhealthcareprofessional.Thedefinitionof‘Operator’isstatedinIR(ME)Rasanypersonwhoisentitled,inaccordancewiththeemployer’sprocedures,tocarryoutpracticalaspectsofexposures.