Scottish Government

CHAPTER SEVEN

WORKFORCE

198. It is estimated that the capacity of radiotherapy services in Scotland will need to increase by 51% in order to meet future demands. Regardless of whether this additional capacity is met with 38 linacs working shorter hours or fewer linacs working longer hours, new ways of working and an increased workforce will be essential (Table 7).

KEY STAFF GROUPS

199. The key professional groups essential to the delivery of core radiotherapy services are clinical oncologists, radiotherapy physicists (including dosimetrists and engineers) and therapeutic radiographers (including advanced practitioners and assistants). Details of the roles and contributions of these key professional groups are found in appendix L.

200. Administrative and nursing staff, medical oncologists, pharmacists, physiotherapists, and dieticians are but a few of the other professional groups that make up the multidisciplinary cancer team. The impact on these professional groups and to other services e.g. haematology, pathology, radiology, surgery, of any change to the radiotherapy service as well as the increased patient numbers should be considered.

GENERAL ISSUES

201. In general the NHS is facing a workforce shortage and without careful planning this is likely to continue given that fewer people are of working age and that there is a 20% reduction in the pool of school leavers (Scottish Executive 2004).

202. The national Scottish Health Workforce Plan (Scottish Executive 2004a) identified the following strategies to address pressures:

• Offer flexible working patterns
• Re-distribution of workload
• Staff development
• Widening entry gate to education
• Use of telemedicine and automation
• Integrated workforce planning

203. Issues relating to the recruitment, training and retention of oncology staff are a recognised national concern. Currently there is an international shortage of radiation physicists and radiographers (Rostom 2000).

204. The reasons for staff shortages are complex and wide-ranging and whilst this problem can not be resolved overnight, an urgent review of staffing levels and a national approach to workforce planning needs to be embraced to ensure safe and modern delivery of radiation therapy both in the present and future health service (Abraham et al. 1999; Rostom 2000; RCR 1998).

205. As at 2004, there were 40.2 WTE consultant clinical oncologists in post in Scotland and 3 WTE vacant posts. This represents a 7% vacancy rate for 2004 although this represents a fall from 12% in 2003.

206. As with most workforces, the population profile is ageing. Twenty three percent of the current workforce will retire over the next 10 years.

Radiotherapy Physicists

207. Using current recommendations from IPEM (Institute of Physics and Engineering in Medicine) an establishment of 58.5 WTE radiotherapy physicists is required for Scotland. The current establishment is 42.5 WTE, a shortfall of 16 WTE posts. Also 8 WTE posts were vacant as at December 2004 and therefore only 34.5 WTE were in post, less than 60% of the recommended level.

208. Shortfalls also exist in the establishment of dosimetrists and engineers putting additional pressure on existing staff, particularly during this very busy period of rapid equipment expansion and replacement.

209. It is estimated that about 17% of the current workforce (radiotherapy physicists, dosimetrists and engineers) will retire over the next 10 years.

Therapeutic Radiographers

210. As at 2003, the therapeutic radiography establishment for Scotland was 162.64 WTE (not including academic posts) and 32.35 of these posts were vacant.

211. Eighteen percent of the current workforce is due to retire within the next 10 years. In addition, 50% of people in Higher Education lecturing posts are due to retire. This should not be overlooked as these posts will be filled from the current clinical workforce.

212. The leaving rate from therapeutic radiography is estimated to be about 8% per annum.

ESTIMATED FUTURE RADIOTHERAPY WORKFORCE REQUIRED

213. As indicated, it is projected that the capacity of radiotherapy services in Scotland will need to increase by 51% in order to meet future demand. Regardless of how this additional capacity is achieved, a concentrated and considerable investment in the workforce is required.

214. Estimating both the numbers and skills required of the radiotherapy workforce 2011-2015 is not straightforward and although some crude workforce models exist to support planning, in the main, they do not consider the commitment to training, research, role extension, skill mix, new working practices and increased demand resulting from more complex treatments and technologies.

Clinical Oncologists

215. There is currently a debate over how many new patients a clinical oncologists should see in a year. The Royal College of Radiologists current recommendation is 315 new patients per annum ( RCR 1998a) although this is being reviewed. If about 15,000 new patients are expected per annum, 2011-2015, a minimum of 47.6 WTE clinical oncologists to see this population - 10% increase on current establishment. If however, the Royal College recommends a patient workload of 250 new patients per annum, 60 WTE clinical oncologists may be required for Scotland - nearly a 60% increase in establishment.

Radiotherapy Physicist

216. By 2007/08 there will be 25 modern linacs for Scotland. Based on IPEM workforce recommendations, with modification by current Heads of Department, this will require 58 WTE radiotherapy physicists, 38.5 WTE dosimetrists and 34.2 WTE engineers.

217. To support service redesign it is estimated that 71.5 WTE radiotherapy physicists, 48.8 WTE dosimetrists and 42.3 WTE engineers will be required. This will require non-standard working hours for engineers and dosimetrists to allow routine servicing to be carried out during non-clinical hours.

218. Assuming the projected required capacity (354,000 fractions) holds true, 3/4 additional linacs will be required to enhance the core service change. It is estimated that this will require 80.1 WTE radiotherapy physicists, 54.6 WTE dosimetrists and 47.3 WTE engineers. This represents an 88% increase from current establishment in radiotherapy physicists but a 132% increase from current actual establishment.

Therapeutic Radiographers

219. Under Agenda for Change, the contracted working week for radiographers will be increased from 35 to 37.5 hours. Assuming that current College of Radiographer staffing models are applied (Society of Radiographers 1999) it is estimated that 217.6 WTE radiographers will be required to support the core clinical service change. This will increase to about 243.2 WTE if 3 additional linacs over and above the planned 25 are commissioned. This represents a 50% increase on the current establishment but considers only core staff requirements, that is to say staff for linacs and not for the many other roles which therapeutic radiographers undertake in a clinical oncology service.

220. Changing work practices and the development of new roles such a radiotherapy assistants may reduce the required radiographer establishment for routine linac/simulator staffing. For example, a model of 3 radiographers and one assistant per machine would require (based on proposed service redesign and 28 linacs) a radiography establishment of 182.4 WTE and about 61 WTE assistants.

221. It is recommended that further work be undertaken to test the existing workforce models and to ascertain if they still hold true for a modern service. Further consideration to alternative staffing models should also be given.

WORKFORCE SUPPLY

Clinical Oncologists

222. In 2004, there were 24 Specialist Registrars (SpR) in post in Scotland. The retention rate for SpRs according to recent figures is about 20% highlighting the need to do more to keep those training in Scotland.

223. Further work is required to consider if the current SpR training opportunities and retention of trainees in Scotland will adequately meet future needs.

Radiotherapy Physicists

224. Four medical physics training posts are available in Scotland each year. Training to become a fully qualified medical physicists takes 4 years post graduation and the sub-specialisation of medical physics which the trainee decides to embark upon is one of free choice. The demand for medical physics trainees within the NHS is great and as new opportunities arise e.g. PET, the competition to make radiotherapy an attractive career destination becomes fiercer.

225. Recently, there was some success in securing linked posts following the first two year training, this has enhanced the training experience and increased the employment opportunities for trained physicists within NHS Scotland. While it goes a short way to improving general retention of medical physics trainees to Scotland it does not address the wider training, recruitment and retention issues relating directly to radiotherapy physics and the potential impact of future service redesign/expansion.

226. It is recommended that the medical physics training posts for Scotland be increased from 4 to 6. Funding for two additional trainees per annum will require about £75,000 rising to £300,000 per annum once 2 additional trainees are in each of the four years of training. Further discussion about ring-fencing the additional training posts for radiotherapy physics is required.

227. This is still unlikely to satisfy the demand for trained radiotherapy physicists and further modelling and exploration of ways to increase the workforce need to be looked at.

228. The case of dosimetrists and engineers is similar and currently these posts are filled by graduates with relevant degrees. Recruitment of graduates with engineering degrees to the NHS is increasingly difficult as the demands from industry and other private and public sectors is considerable.

Therapeutic Radiographers

229. In Scotland, two higher education establishments provide academic training for therapeutic radiographer (4 years BSc Hon Degree). Clinical aspects of training are supported by all five cancer centres. The undergraduate student intake has been increased in recent years to help address the national shortage of trained staff. In total, 26 undergraduate places are available per annum in Scotland and attrition from this training, despite improvement, remains high and is currently about 20%.

230. As a one off agreement the Scottish Executive HDMB provided funding for a pilot fast-track postgraduate therapeutic radiography course hosted by Queen Margaret University College, Edinburgh. This two year pilot has recruited two cohorts of 15 students with the first 15 due to graduate November 2005. Preliminary evaluation of this course suggests success with minimal attrition. Due to current funding agreements regarding postgraduate education in Scotland, this course can not be continued by the SEHD. It appears unlikely at this stage that the course will be sustained unless the Higher Education Establishment successfully negotiate continued funding through normal Higher Education funding mechanisms. Even then, recruitment to the course may prove difficult given the considerable financial burden that would be placed on the student, which is likely to add to existing financial debts from first degrees. This is an issue faced by many institutions in Scotland wishing to offer postgraduate training opportunities.

231. Assistant therapeutic radiographers are recently recognised posts and a national training programme for Health Care Assistants has been credited and is due to commence in 2005. A therapeutic radiography training element has been approved and should enable opportunity for training as a therapeutic assistant practitioner in a number of further educations colleges. There are currently two fully trained assistant practitioners in post at the Aberdeen Cancer Centre and they demonstrate the benefit that can be gained from changing workforce dynamics and enhancing the skill pool through new posts.

Table 7: Current, Actual and Estimated WTE for Scottish Radiotherapy Service based on current Workforce Models

BALANCING THE WORKFORCE SUPPLY AND DEMAND

232. Complex modern radiotherapy is increasingly reliant on the expertise of clinical oncologists, therapeutic radiographers, radiotherapy physicists, dosimetrists and engineers to prescribe, plan and deliver quality treatment and patient care, maintain equipment to relevant standards, and develop and implement new techniques and technologies.

233. The is resulting in changing roles and new demands on existing staff. The role of a radiotherapy physicist for example, is changing considerably and advances in technology are resulting in more time consuming and work intensive planning procedures.

234. The proposed service model and subsequent service change indicated for the Scottish radiotherapy service over the next 10-15 years to achieve required capacity, is likely to need substantial increases in the workforce as demonstrated but, as importantly and possibly more challenging are the required changes to working practices, professional capacity, skill mix and role development.

235. In terms of therapeutic radiography, some of this work is already underway and the Radiography Role Development Project ( NES) funded by Scottish Executive Cancer and Workforce Department monies has demonstrated huge scope for developing the radiographer role at both ends of the professional spectrum to enhance the service and improve recruitment and retention to the profession. Initiatives that support clinical leadership in promoting service change and which help transform clinical practice, ways of working and improved skill mix are strongly indicated ( SOR 2003).

236. It is recommended that:

• Assistant therapy radiographer posts are promoted and supported.
• Advanced practitioner or consultant therapy radiographer posts are promoted and supported.

237. This would require funding and estimate costs are as follows:

• Total expected cost of assistant practitioner is c£18,000 per annum. This should cover training costs and on-costs. If a minimum of one assistant per linac is achieved initially, 25 assistant practitioners would be about £450,000 per annum.
• Consultant posts are estimated to cost £53,400 per annum including training and on-costs. The number of consultant therapeutic radiographer posts that are necessary and warranted will require further discussion with the service. Assuming one for every cancer centre would require 5 for Scotland at a cost of £267,000 per annum. This may not be justified by service needs and fewer consultant posts may be negotiated e.g. 3.

238. Within all professional groups, innovative change in skills mix is required to allow different professions to work in ways that will facilitate modern treatment pathways and make best use of specialist skills. Professional boundaries should be more permeable since fixed boundaries inhibit seamless care and best use of available skills and resource.

239. Increasing the core pool of skilled and trained staff to support proposed service changes is a major concern and while substantial increases in both funding and flexibility of funding will allow expanded and more versatile training opportunities, any expansion will be constrained by the number of clinical training placements and impacted by the recruitment issues faced by higher education establishments to education posts.

240. The crux of future cancer service is the workforce and is dependent on an inter-professional approach, where practitioners are valued for their flexibility as well as their specialist expertise. A culture change both within and between professional groups and service, to create an environment supportive of radical thinking and working, and which will allow mutual acknowledgement of the existence of valuable skills across the professional groups is crucial to a modern health service and will require support from the Scottish Executive and the NHS.

241. The right balance of skills will not occur without careful planning because of the conflicts between economic forces, political pressures and professional objectives (Martinez J & Martineau T 1998). A sustained and long-term workforce initiative is required and should be considered immediately to provide time to develop the workforce required by 2011-2015.

242. A partnership approach involving Unions, Colleges, Societies, Institutes and the service is strongly indicated since a number of changes and negotiations are required, including increased service hours, routine servicing at weekends, workforce structural change, and changed working practices. This is in addition to the need for increased staff numbers, increased training opportunities and improved recruitment and retention. Considerable HR support for new roles and role extension at both ends of the professional spectrum is required to improve skill mix and contribute to retention and professional development.