Written evidence submitted by The Society of Radiographers (WBR0065)
- The Society of Radiography (SoR) are the professional association and trade union for all those working in radiography and medical imaging, including both the Therapeutic and Diagnostic radiography professions, sonography and mammography and other developing areas of medical imaging. The S0R works in partnership with our charitable arm, the College of Radiography, which support regulation and professional standards and advises on training provision, content and all professional aspects of medical imaging, across all 4 UK nations and also internationally, being recognised as one of the global leaders in medical imaging.
- The SoR has over 30,000 members in the UK, with approx. 80% of qualified practitioners in active membership at all grades. We are supported by around 1500 volunteer Representatives and Professional Champions.
- We welcome the opportunity to contribute to this enquiry at this critical time for the NHS and the radiography and medical imaging professions specifically. This response gives a broad over-vue of our priorities and concerns. We are ourselves currently conducting internal research into some of the issues at the core of the consultation and have been contributing to ongoing studies with other stakeholders and partner organisations. As a consequence, we’d anticipate being in a position to offer further advice, support and evidence during the period when the Committee deliberates the submissions and would welcome further opportunities to provide this data and other evidence directly at a later point.
A Pre-Covid Crisis
- The Committee will already know about the long held cries of staff shortages in the NHS. These are often presented under a general banner of needing more ‘doctors and nurses’. However, this is too generalised and misleading. The reality is more complex and a strategic approach needs to start from this recognition.
- Each of the Allied Health Professions (AHPs) have distinct recruitment and retention challenges but radiography is a special and acute case. Radiography is a rapidly expanding area of practice, being at edge of technological advancement. In the region of 90% of patients, medical journeys will now involve accessing a radiographer – it is not unusual to be more likely to encounter a radiographer than a nurse. This is especially noticeable in cancer treatment and radiotherapy.
- Moreover, this advancement and increased demand is accelerating quicker than recruits can be identified and trained - forecast shortages for radiography and medical imaging dwarf most other areas of practice, including nursing. We are exploring this closely at present but early evidence suggests expanded recruitment will meet barely half the anticipated demand.
- This means, even before Covid19, there was a recruitment and retention crisis in radiography. The consequence for the frontline is outlines more below.
- Efforts are being made to expand the number of training places but these face real challenges in terms of delivery – practice educator numbers and the availability of enough machines to train on as well as meet patient demand need to increase in parallel and this is not necessarily happening. Equally, support and investment is needed to raise the profile of radiography to potential under-graduates, especially men who are in a significant minority of new entrants, a trend reflected across all AHPs. Our research indicates that gender specific recruitment campaigns could have an impact but this requires resource, time and flexibility from recruiters.
- In reality, whilst we are actively supporting efforts to increase graduate places, such is the demand in our areas, we also accept that this alone will not meet anticipated demand. We are encouraging the development of wider access routes and pathways, which we think would also help widen the diversity of the radiography workforce. This is an area where we believe more and better use of Assistant Practitioners and on-the-job training and development, not very dissimilar from the broadening of entry routes into teaching, could have a positive long-term impact. However, barriers exist to this presently that need to be fully addressed via partnership working and strategic investment – including addressing the frontline pressures on staff and especially managers to free up the space and time to support and develop more AP’s and trainees.
- Radiography is also, like other high tech sectors, already in an international market although it is questionable how well the UK is competing. Anecdotally, our experience reflects evidence previously provided by the Cavendish Coalition and others, regarding the number of EU born staff working in radiography having decreased since the Referendum at a time when any professional is precious to sustaining the system. We also have examples where Trusts and Boards have struggled to manage Home Office expectations and where Home Office guidance has been incorrect, leading to re-enforcement of the Hostile Environment image of working in the UK. We can provide confidential examples of cases on request to illustrate this point further.
- The new Visa system provides a critical opportunity to shift the balance more positively and we would appreciate opportunities to expand on how in partnership. In reality, Government must be strategic and honest in this regard. You cannot send contradictory messages - promoting hostility to immigration to appease a perceived electoral need in economically frustrated and disadvantaged communities will stop us successfully competing for professionals to move into those communities from abroad. You cannot have it both ways.
- These challenges and issues are reflected in the stories and experiences we have had reported to us during the Covid crisis, which we are ourselves still exploring further.
- One of the core challenges from a long-term shortage of staff in radiography has been extraordinary pressures on workloads and working patterns – especially in diagnostic radiography but also in some parts of radiotherapy. These are often complicated by difficulties with acquiring and maintaining the kit to meet demand and expectation.
- There are many interesting and innovative examples of practice where this challenge has been moderated – for example, some effective use of mobile imaging services and good use of community hospitals to accelerate diagnostic turnaround and these have anecdotally been amplified during the recent crisis. We would welcome the chance to detail these more thoroughly directly.
- However, such innovation was not enough to stem the sense of drowning in an unrelenting tide of extra demand before the crisis and now things feel worse. This must be seriously recognised.
- Crisis demand management has over recent years had three dominant resulting patterns, which have been exposed further and amplified by the Covid crisis:
a) Excessive demands on staff time and work-life balance - leading to increased retention difficulties with pre-Covid trends indicating higher turnover in early years (a challenge we are eager to explore and help tackle in training); both higher sickness and presenteeism; and burnout.
b) Excessive demands on first line managers, stuck in the middle trying to champion and maintain professional standards whilst being tested and measured against unsustainable targets – leading to huge difficulty recruiting and retaining middle managers, especially from a clinical radiography background, resulting in weak management practice and more burnout;
c) Evidence of abuse of the NHS pay and reward system which amplified both these problems. Agenda for Change facilitates local flexibility through mechanisms such as the Bank system. The aim of local Banks is to reduce the reliance on agency staff by facilitating additional, flexible working in-house. This is laudable. However, when poorly policed and exploited the Bank system is destructive. In radiography it can creates a two-tier workforce in departments – those who do all they can to maintain a credible and safe work life balance (disproportionately women with caring responsibilities) resisting efforts to spread workloads and shift patterns whilst another group can be employed via an abuse of the Bank system to work excessive and dangerous hours. We have recently uncovered examples of 70-hour weeks and members working more than 2 weeks without a day off. A Band 6 can commonly earn more taking into account standard “rostered” overtime or “Rostered Bank work” than an 8a manager who isn’t allowed to be paid overtime. In a recent SoR survey in a London Trust, the members working the excess hours were the least content and most likely to leave, showing all the signs of burnout - whilst those working standard hours were most resistant to changes in working patterns that could potentially reduce demand for overtime and waiting times for patients.
- We should perhaps at this point remind MPs that when a radiographer burnouts this can have a very literal and dangerous impact on patient safety. This is not something that seems to always resonate with senior NHS leaders when we seek to address these risks with them.
- This has created a vicious demand led cycle that needs to be strategically stopped and replaced with a more honest, sustainable and safer virtuous cycle – built up from a foundation of safe practice and high professional standards; appropriate management space and honesty from NHS leaders about what is possible. Only an honest approach will facilitate a more realistic, sustainable and safe culture and protect the quality and safety of provision for patients. The slowdown in some areas during Covid presents this opportunity for a system reboot but all current indications are that external, including political, pressures will overwhelm this opportunity.
- Demand for some services has stalled and created more space for professional reflection, thinking time and assessment of what is strategically needed in local areas. There has also been some excellent innovation. We would happily expand on the positives as well as the difficulties. The challenges include exposing middle management even more than normal to the pressures of being stuck in the middle – especially during the height of the PPE crisis.
- Most staff also report a level of emotional exhaustion. The start of the crisis was relentlessly pressured and the emotional tension has not eased regardless of patient demand in particular areas. Staff have been on high alert for months. Wearing PPE throughout a long shift and trying to maintain social distancing in environments where this is not easy and sometimes impossible without creating other risks, such as poor ventilation, is exhausting. Dealing with patients with understandably higher anxiety levels than normal is exhausting. Covering for even more absent colleagues than usual is exhausting.
- Government and senior leadership’s management has also demoralised staff, especially their critical middle managers – with advice to them changing from day to day; political spin not reflecting reality; and statements made before any planning had taken place undermining them further in front of their teams. This lack of faith in leadership will take a long time to recover from and makes efforts to promote partnership working with professional associations and unions, who staff still Trust, even more strategically important.
Present and Immediate Challenges and the NHS People Plan
- Whilst demand in some areas stalled this has built up a terrifying potential Tsunami when demand is fed back into a system that was barely meeting demand before. This fear is in danger of becoming overwhelming in some Trusts and early indications are that the aspirations in the NHS People Plan will be lucky to make the first fence let alone avoid falling at it. This may not be universal but any significant failings impact upon trust, confidence and the morale of staff across the whole service.
- The People Plan’s leading on flexibility and the need to prioritise staff support, welfare and retention are laudable aspirations but dangerous if they raise expectations that cannot be met. The SoR can readily share examples from the last few weeks where Trusts are:
a) consulting on changes to rosters that introduce longer working patterns citing a need to meet post-Covid demand;
b) rationing access to welfare support services because of excess staff demand exceeding supply in the welfare contracts;
c) moving to isolate and remove existing flexibilities rather than re-enforce them because of staff shortages amplified by the Covid;
d) And moving against those still needing to isolate or seeking to work flexibly after maternity leave for example.
- The feedback from many members, especially Managers, is that the People Plan is just setting them up to fail or a symbol of how out of touch senior leaders are with reality.
- The People Plan must deliver but it is very difficult to be optimistic. If it fails, it could be catastrophic. It lacks strategy, depth and relevant funding; being an abridged adaptation of the more jointly planned and developed strategic approach aborted by Covid. It may have been wiser to call it something else and/or delay it entirely until a fuller review of the lessons of Covid was possible. The original more comprehensive and strategic plan could then have been re-assessed, re-costed and strategically supported by HM Treasury.
For further information and to receive further input from the SoR please contact:
Director of Industrial Strategy & Member Relations