Supporting the
support workers

The rising demand for diagnostic imaging services, exacerbated by the Covid-19 pandemic, and the concurrent and long-standing need to ensure sufficient staffing capacity are well documented¹.

While the radiography profession was at the forefront of developing assistant practitioner roles in the NHS two decades ago², until recently there has been relatively little attention paid to the contribution that support workers (those employed in Agenda for Change pay Bands 2, 3 or 4) can make in enhancing imaging capacity and patient flow. This is changing. In 2021, Health Education England (HEE), partly in response to Professor Sir Mike Richards’ 2020 independent review of diagnostic services (which recommended an increase of more than 5,000 support workers to be employed in imaging services) commissioned the Society and College of Radiographers to work with King’s College London to assess how support worker capacity and capability could be maximised. This article reviews the outcomes of the first phase of this work, called Supporting Success.

Comprehensive data on the size and composition of the current radiography support workforce is not available. Snaith and colleagues³, though, estimate that there are around 570 assistant practitioners in post. The most recent College of Radiographers’ workforce census⁴ suggests, on average, that diagnostic radiography establishments employ 5.4% of their workforce at Band 3 and Band 4 – although it is very likely that this proportion will vary considerably by service¹. The census also suggests that 7.4% of Band 3 posts and 16.5% of Band 4 posts are vacant and that the support workforce is ageing, with 23.7% of Band 3s and 16.3% of Band 4s aged 55 or older. Turnover rates (4% on average) among support staff are a third lower than for Band 5s (11%) and almost half that of Band 6s (7.7%).

The support workforce, however, can face several issues in terms of its development, principally the inconsistently defined scope of practice, poor access to occupationally relevant education, and a lack of career development opportunities, including into pre-registration degrees, which nearly half of assistant practitioners would like to enter^{3, 5}. This means “…few trusts benefit from the full opportunities [of support workers] to increase capacity”⁵. Such issues are not unique to radiography support staff as the Cavendish review revealed⁶. The aim of the Supporting Success project was to reach a consensus on how these issues can be overcome. Phase 1 of the project ran from January to June 2021.

Critical to Supporting Success was the establishment of a profession-led Expert Group, which comprised service managers, clinicians, support workers, educationalists (including representatives from further education) and representatives from arm’s-length bodies, such as Public Health England. The group, chaired by Sue Johnson (from the Society and College of Radiographers) and supported by Penny Owens (subject matter expert) and Professor Richard Griffin (King’s College London), met virtually to consider the following questions, which were judged to be central to addressing the effective recruitment, management, deployment and development of the support workforce:

1. What roles and responsibilities should an appropriately qualified support worker at Agenda for Change Bands 2, 3 and 4 perform?

2. What qualifications and experience should support workers possess to be initially employed at Bands 2, 3 and 4 and what education should they acquire once employed so that they can work safely at the top of their scope of practice?

3. How can support worker education and development be improved?

4. How can we ensure safe and effective delegation of tasks to support workers?

5. What needs to happen to ensure that all services are able to fully utilise support worker capacity and capability, including enabling their career progression?

6. What is the right operating model to deliver effective workforce planning?

7. How can the future support workforce be secured?

The focus of the project’s phase 1 work became reaching an agreement on the roles and responsibilities that support workers should typically perform. Getting role boundaries right, it was recognised, lay at the heart of the answer to many of the above questions. For example, effective education depends on a clear scope of practice, which itself supports delegation and task allocation and, therefore, optimal deployment and career progression.

Whereas the original radiography four-tier model² started with the assistant practitioner role, the structure developed by the Expert Group encompassed the total support worker career framework, starting at entry level (normally Band 2), then educational level 3 (typically Band 3) and finally assistant practitioners (plus the mammography associate).

The Supporting Success career structure sets out the tasks that a support worker at each level would typically be expected to perform, following training and under appropriate supervision⁷. It also sets out educational and experience requirements (there are currently no set entry requirements for NHS support roles) and suggests titles, which again can vary. The structure, summarised below, seeks to provide clarity on what tasks support workers can – and cannot – perform and to create a progression pathway for those who wish to develop their careers. There is scope, in particular, to enhance the contribution of Band 2 and 3 roles to improve patient flow.

The structure begins with a clinical support worker (CSW) role, which enables patient care through undertaking important clerical, administrative and housekeeping tasks. These might include managing patient documentation, providing refreshments for people after an intervention, managing stock and acting as a chaperone. Staff at this level would be expected to have a level 2 qualification either on recruitment (such as GCSEs) or soon after employment (for example, via an apprenticeship).

The next level in the career structure is the senior clinical support worker (SCSW), who, in addition to the responsibilities of the CSW, provides clinical support and patient care before, during and after examinations. Examples of responsibilities include routine testing of ultrasound equipment, managing data, assisting patients on and off the imaging table and demonstrating tasks, within their scope of practice, to students and trainees. SCSWs would be expected to have level 3 qualifications, such as A levels, technical levels and apprenticeships, on or after recruitment.

The final level in the career structure is the assistant practitioner role, which supports clinical service delivery by performing non-complex protocol-driven clinical diagnostic imaging examinations under the supervision of a registered radiographer. Responsibilities include planning and prioritising their own workload within their scope of practice and the department’s operational policy, performing physiological measurements, reporting and recording results appropriately and performing protocol-driven diagnostic imaging examinations within their own scope of practice on co-operative patients using:

• Static and mobile fluoroscopic equipment.
• X-ray equipment.
• MRI scanner.
• CT scanner.
• Dexa machine.
• Nuclear medicine equipment.

The structure also includes the mammography associate role (typically graded at Band 4), whose scope of practice is defined by the 12-month appropriate level 4 apprenticeship standard⁸.

The Expert Group agreed a consensus statement that sets out its vision for the contribution of support staff in diagnostic radiography services. The statement includes the following:

“Our vision for the diagnostic radiography support workforce is one where all staff feel valued, integrated into teams, are able to work fully to their potential; have access to lifelong learning, including relevant formal qualifications, and feel they have a valued career, not just a job. We want support staff to be able to progress their careers if they wish and are able to (including into pre-registration) but, equally, that they are able to develop within their support roles and have a rewarding career if they do not wish to progress any further. Support workers are an integral part of the radiography workforce, across all modalities. Now is the time to invest in their education and development to maximise their contribution to care.”

As already noted, a high proportion of assistant practitioners would like to progress their careers into pre-registration degrees but many struggle to identify work-based pathways or nearby degree programmes. This means, among other things, that opportunities to “grow your own” radiographers are being missed at a time when the profession needs more qualified radiographers. This issue is not new or unique to radiography⁹ and has been recognised by HEE, which is seeking to address it nationally with partners including the Council of Deans of Health. The Supporting Success project is engaging with this important work.

One area the Expert Group wished to consider was apprenticeship provision at levels 2 and 3. However, during the first phase of the project, there was a national review of apprenticeship standards. The project was clear that there needs to be dedicated and occupationally relevant formal education available, particularly at level 3.

Securing the future diagnostic radiography support workforce is critical, particularly given its current age profile. The Expert Group identified the importance of services looking at new supply routes to address this, including the potential of recruiting college students and the new occupationally specific two-year technical level qualifications for 16- to 19-year-olds that include health and involve industry placements.

The issues that support workers face have evolved over a long period of time and will not be solved overnight, although it is hoped that Supporting Success and the wider HEE Allied Health Profession Support Worker Strategy and resources⁷ will help services, ideally working together, to take a big step forward in addressing them. Continuing support from HEE means that the project is moving to phase 2 (delivery). The next phase involves reviewing the effectiveness of the career structure developed by the Expert Group, as well as addressing education needs and producing guidance on supervision and delegation, taking account of new models of care.

It is hoped that the work of Supporting Success will assist diagnostic radiography services in reviewing their current deployment and education provision for support workers. Doing so will allow greater consistency of roles and ensure services maximise workforce capacity and capability safely to meet increasing demands on services. There should also be clear plans locally on how to recruit the future diagnostic radiography support workforce.

Richard Griffin is Professor of Healthcare Management at King’s Business School, King's College London.

The author would like to acknowledge the contribution of the Expert Group in supporting this project, particularly the leadership of Sue Johnson and expertise of Penny Owens.

References

1. Richards M. Diagnostics: Recovery and Renewal – Report of the Independent Review of Diagnostic Services for NHS England. 2020. Available at https://www.england.nhs.uk/publication/diagnostics-recovery-and-renewal-report-of-the-independent-review-of-diagnostic-services-for-nhs-england/

2. Department of Health. Radiography Skills Mix. A Report on the Four-Tier Service Delivery Model. 2003. Department of Health.

3. Snaith B, Harris MA and Palmer D. A UK survey exploring the assistant practitioner role across diagnostic imaging: current practice, relationships and challenges to progression. British Journal of Radiology 2018, 91 (1091). Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC6475955/

4. The College of Radiographers. Diagnostic Radiography Workforce UK Census 2020. Available at www.sor.org/learning-advice/professional-body-guidance-and-publications/documents-and-publications/reports-and-surveys/or-diagnostic-radiography-workforce-uk-census-2020

5. Halliday K, Maskell G, Beeley L and Quick E. Radiology GIRFT Programme National Speciality Report. 2020. Available at www.gettingitrightfirsttime.co.uk/radiology-report/

6. Cavendish C. An Independent Review into Healthcare Assistants and Support Workers in the NHS and Social Care Settings. 2013. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/236212/Cavendish_Review.pdf

7. Health Education England. AHP Support Worker Strategy. 2021. Available at www.hee.nhs.uk/our-work/allied-health-professions/enable-workforce/developing-role-ahp-support-workers

8. Institute for Apprenticeships. Details of the mammography associate apprenticeship. 2021. Available at www.instituteforapprenticeships.org/apprenticeship-standards/mammography-associate-v1-1

9. Turbin J, Fuller A and Wintrup J. Apprenticeship and progression in the healthcare sector: can labour market theory illuminate barriers and opportunities in contrasting occupations? Journal of Vocational Education & Training 2014.