Dr Nicola H Strickland

Transcription

1 WHY WE NEED IN-SOURCED REPORTING BETWEEN PUBLIC (NHS) HOSPITALS IN THE UK, AND THE REASONS WHY IT HAS (SO FAR!) FAILED TO HAPPEN Dr Nicola H Strickland Imperial College Healthcare NHS Trust Consultant (Staff) Radiologist

2 Current and future concerns Topics covered: workforce workload out of hours working (OOH) teleradiology out-sourcing NHS in-sourcing reasons for failure of regional in-sourcing

3 Workforce and workload Lack of radiologists in UK genuine (census data) absolute deficit (221 of 3383 unfilled: 6.5%) regional deficit ++ Increase in workload complexity of imaging studies technology (CTC, PET-CT) numbers of images per study

4 The Problems: DGH (district general hospital) on call has become intolerable lifestyle miserable: rota 1:6, up all night dangerous working practice: no day in lieu cannot support 24/7 working too few radiologists in the UK uneven geographical distribution all OOH medical and surgical decisions now require imaging issue cannot be solved by training more radiologists needs DOH (Department of Health) agreement requires >5years training capacity

5 Proposed Solution using UK as example All hospitals in the UK: are linked by the IEP (image exchange portal) all have IG (information governance) agreements in place to allow transmission of imaging studies, and their reports, between these hospitals use NHS net as a secure and tested means of imaging study transfer

6 Proposed solution IEP was set up by DoH (Department of Health) need regional archives for temporary storage of: imaging studies for urgent OOH reporting their associated relevant previous imaging studies retrieved by duty radiologists OOH issued reports integrated back into RIS/PACS/EPR of hospital where patient located (and imaging study generated) within 30 mins of sending imaging study

7 Proposed solution regions will be defined by: extant geographical referral patterns MDTM (multidisciplinary team meeting) clusters the on-call rota for reporting radiologists will be organized on opt-in basis as currently for GP (general practitioner) on call no compulsion to join if Trust already happy to pay for private teleradiology, and no on call

8 Possible cost saving Private teleradiology out-sourcing: 100/scan 50 for IT, 24/7 maintenance, and admin 30 profit to company 20 to radiologist (or less!) NHS regional in-sourcing: 85/scan 50 for IT, 24/7 maintenance, and admin 5 profit to administrative body 30 to radiologist

9 Some details 1. other uses of OOH in-sourcing: clearing backlogs of unreported imaging studies specialist second opinion dispassionate double reporting audit 2. high OOH workload will require > 2 radiologists simultaneously on duty overlapping shifts

10 UK reporting backlogs 100s of 1000s of studies (mainly plain Xray) workforce + workload pressures other monitored targets all traceable on RIS/PACS a time bomb.. Northern Ireland investigation 2011/12 several lung cancers missed on CXR delays (>9 months) in treatment one family now suing

11 Advantages of in-sourcing 1. uses regional reporting radiologists: already known to local clinicians (or will become so) trust in their reports attend/can join MDTMs = learning via feedback easily contactable familiar with local practices/protocols FRCR-holding living in the UK (bound by GMC revalidation) fluent English speakers (other native language) 2. maintains full daytime complement of local radiologists in departments: no threat of replacement

12 Threat of private teleradiology Private teleradiology firms no holidays/pensions/sick leave no study leave no teaching no job security...etc.

13 LIFESTYLE Free range chicken, on its own farm, in the open air Remote battery hen isolated, confined?and ignored

14 Advantages of in-sourcing 3. improves radiologists lifestyle onerous on call rota disappears change from 1 in 5-6 days to 1 in 2-3 months adequate planned rest: the day off after on call Trusts can plan to cancel NHS list (so infrequent) safe practice: patients benefit stress, sick leave, burnout 4. Trusts could pay less per scan 5. radiologists motivated by fee per item

15 Reasons for failure of regional in-sourcing 1. Needs buy-in from several different trusts time and effort to explain the idea to radiologists, imaging department managers,... medical director, chief executive sell the advantages, be persuasive concept of long-term solution, not immediate fire fighting why bother? who cares? idealist concept

16 Reasons for failure of regional in-sourcing 2. Financial practicality of the scheme everything in the NHS is now cost-driven need detailed, specific business cases no proof of concept = a risk nuts and bolts of how it would work in practice re payment of radiologists currently paid for # PAs (professional activity) should work x PAs for region, y PAs for trust any fundamental change = effort resisted++

17 Reasons for failure of regional in-sourcing 2. Who will monitor the scheme and do the administration? no funding up front doctors have no time or inclination to do it Sectra (who own IEP) have refused if done by a private company, how does this differ from private teleradiology outsourcing? it doesn t! need electronic monitoring of who reports what, when administration of payments owed and made

18 Reasons for failure of regional in-sourcing 3. Should payment be on a fee-per-item basis? pros and cons: cherry-picking easy, quick cases quality of reports... No change how do you measure quality of reports? audits? Double reporting? what do you do about poor reports? incentive to ring clinicians etc if no fee-per-item, no incentive to work hard?

19 Reasons for failure of regional in-sourcing 4. who is responsible for the IT? setting up the IT infrastructure working out how it is to be done: cost coping with non-hl7 RIS : very labour-intensive IEP does not come with a viewer need old studies... how? speed? XSDi not universal! need immediate 24/7 help: central reporting house vs. home reporting central reporting easier to maintain equipment better camaraderie and ad hoc 2 nd opinion unpopular because of travel

20 Reasons for failure of regional in-sourcing 5. It is all just too much! too much effort too much time not worth it for the personal gain lifestyle easier to get in a private teleradiology company and not care about the consequences

21 Advantages of regional in-sourcing and diagnostic networks Above all: uses extant proven technology IEP and NHSnet in the UK; similar potential abroad high quality service, without threat to local radiologists locally in-sourced improves DGH radiologists lifestyle and raises morale better for patients broadens expertise available at MDTMs better for patients