Where now for the four-tier structure in clinical imaging?

It is now almost 20 years since the first outcomes from pilot sites implementing a four-tier structure were published¹. These presented a clear vision to support new ways of working with advancement of practitioners to recognised advanced and consultant roles, and the introduction of assistant practitioners educated and trained to a specific scope of practice.

Despite the very clear ambition and commitment from the Department of Health at the time, implementing this structure across the entire system has been challenging, with many opportunities still unrealised. We hope in this article to discuss the opportunities we now believe exist to support the radical approach recommended in the early 2000s to be more effectively implemented across imaging services, helping to support improved outcomes for patients and offering rewarding careers for all staff.

The healthcare landscape has changed over the past two decades. First, the publication of multi-professional frameworks in each of the nations^2-4 is driving change, each recognising the value that could be realised through developing the existing skills of the workforce through post-registration education and training, both in supporting improved patient outcomes and transforming care pathways while also helping to retain skilled professionals through rewarding careers. The publication of the government’s long-term plan in 2019⁵ recognised that health systems needed to change and adapt to better respond to service innovation and society changes. Reducing health inequalities, improving the efficiency and outcomes for people were key drivers. We could no longer continue working in traditional ways, often in professional silos, and a more integrated approach with visionary leadership and team working was being suggested.

A specific focus on the workforce discussed new entry routes to the professions, apprenticeships and better use of all workforce skills, alongside recommendations for increases in workforce numbers while ensuring individuals were valued and their contributions recognised. More recently, the Richards report⁶ has proposed more radical service delivery patterns, underpinned by greater collaboration across organisations and with the independent sector. These are designed to improve outcomes for patients but, again, lay out the importance of brave workforce planning and ambitious targets for training. Alongside this, the government’s apprenticeship strategy for healthcare has been rolled out in England⁷, with standards being developed to support all levels of practice, from support worker through to registered practitioner and advanced practitioner level.

So, what does the future hold: is the four-tier framework still relevant and what policy levers can drive the aspirations presented in this once innovative approach? Importantly, do the perceived advantages of this framework reap benefits in terms of patient care and career progression in the current and future healthcare landscape?

The 20^th century saw the radiography career structure mapped out around the different tiers alongside expansion of the radiology workforce, but local developments were often fragmented and based on service pressures and workforce gaps. Team working became more formalised, and sometimes fluid, to best deliver care to patients and recognise the contribution and value of each person and profession. Individual drive for progression led to new posts, with consultant radiographers most noticeably emerging in breast imaging. Successful development of new assistant practitioner roles enabled this model to effectively grow, with clearly defined education and training supporting a limited scope of practice to be undertaken safely, effectively and at scale. This released registered practitioner capacity to access postgraduate education and training to deliver new roles at higher levels of practice. These roles have shown significant benefit where implemented but funding challenges have remained, and workforce shortages often resulted in professionals not being able to fully utilise their skills in a planned way for the benefit of the service.

Externally, imaging was seen as the leading light for the skills mix and effective use of all levels of the workforce – to such a point that the multi-professional models now being implemented across the healthcare systems in each of the nations all now reflect this initial approach. A focus on transformational, system-wide change should deliver improved outcomes for patients, making best use of the workforce capability, ensuring safety through support for “formally recognised” development at each progression point.

The focus across the nations is, once again, on workforce transformation through better use of the skills and capabilities of the multi-professional workforce. Ambition and capability have no geographic boundaries but opportunities for individuals to fulfil their potential have not been consistent and a key driver currently is to ensure equity of access for patients to services and care. The strategic approach to implementation of advancing-level roles now being led by government bodies is enabling change, based on system-wide approaches. This is positive, with advancing practice being seen as a lever to drive and deliver care differently in teams. Advanced practitioners will be integral members of multi-professional clinical teams, with systems being developed to assure public safety through nationally accredited postgraduate programmes.

With this it will be important to remove the barriers that have inhibited developments to ensure all roles are optimised, with practitioners enabled to work at the level to which they are trained and educated. Each country has an advanced practice/advancing practice framework^2-4 that is consistent in its expectations. Opportunities for those who are aspirant advanced practitioners, who may be working at an enhanced-practice level, will be supported to take the next step in education and responsibility, with research and service improvement skills importantly embedded and used in their area of expert clinical practice. Change and role transformation remains essential to better support and deliver improved outcomes for patients, streamlining pathways and reconfiguring how we work, and breaking down traditional boundaries remains a priority.

The renewed emphasis on team working is essential and close collaborations between all the workforce groups involved in specific pathways of care are being challenged. Care can be delivered differently, more efficiently and more holistically around the priorities of patients, and new models of service delivery are seeing further innovation in multi-professional teams and individual roles.

Post-registration education and training remains a priority and it is positive that the master’s-level education and training standards for musculoskeletal reporting will have been published by the College of Radiographers (CoR) and The Royal College of Radiologists (RCR) working with Health Education England (HEE). The collaboration between the two colleges is stronger than ever and there is a commitment to deliver these standards to ensure patient outcomes are maintained, regardless of the profession involved in their care. Future work is being planned for other areas. Jointly agreed standards will underpin postgraduate education and training and assurance to support standards of practice at advancing levels.

The revised Quality Standard for Imaging (QSI)⁸ was published by the CoR and RCR in 2021, having set national quality criteria for imaging services since it was first launched by the two bodies in 2009. We believe that this provides a clear framework to support service improvement and the opportunity to consider the workforce skills mix and configurations across imaging pathways, with the goal of striving to really adapt and improve outcomes for patients.

The review of the CoR individual accreditation scheme, together with programme approval at postgraduate level, will help align radiography to the national goals in implementing safe and effective advancing practice, building clinical and professional leadership through consultant roles and senior manager developments.

The CoR education and career framework (ECF) underpins and aligns with professional ambitions and wider policy goals across the UK. The refresh in 2022 will restate the expectations and opportunities in radiography careers. The ECF will embrace practice from the wider support workforce through to all levels, from support workforce through to advancing levels of practice and leadership, including academic and research roles.

So, what will support the vision of 2003 being fully implemented consistently within teams across imaging services? The model’s success is based on all levels being in place to best support service and patient requirements across pathways, recognising the specific skills required to provide each element of a patient’s care, while also clearly providing progression between the tiers through approved education against national standards.

Imaging support worker
First, the recognition of the need to formalise entry into the imaging workforce is now appreciated. A support worker framework for imaging and the wider allied health professions (AHPs) has been published⁹ and there is a national goal to work towards development of a level 3 apprenticeship standard. Achieving this standard should allow successful individuals to meet the entry criteria for pre-registration courses for diagnostic or therapeutic radiography, depending on their work area.

Imaging assistant practitioner
The goal must be to support development of the assistant role across all areas of imaging. To enable the release of radiographer capacity, brave steps must be taken to ensure this tier can be introduced to all modalities. This also raises the potential for a level 5 radiography assistant practitioner apprenticeship standard specifically for imaging. Successful completion of a level 5 qualification should give access to an accelerated programme of study for pre-registration diagnostic radiography apprenticeship programmes at degree level, leading to eligibility to register as a diagnostic radiographer. This provides diagnostic radiography-specific pipelines for the registered workforce alongside the traditional degree route.

Enhanced practice
Recognising the value and investment of skills development to innovate and support service delivery, a new level of practice is being defined as the “enhanced level”, which applies to the multi-professional workforce. A framework is being defined and an apprenticeship standard has been established⁷. At the enhanced level, apprenticeships support development in specific clinical areas and this is the step towards advanced practice for those intending to continue this career trajectory.

Advanced and consultant practice
The multi-professional advanced practice apprenticeship at MSc has been approved. This will support and deliver impactful change to pathways of care for patients through a rigorous standard embracing the four core capabilities of advanced practice. This will mean change in the education sector to deliver programmes to meet these standards (often alongside existing provision) and recognition of the importance of wide capabilities in the workforce. For too long, advanced practitioners have not always had access to the education and training to support the scope of these levels of practice, with focus often solely restricted to the delivery of the expert area of clinical practice or specialism. But alongside this, credentialling through accreditation of levels of practice will be essential to ensure transferability and consistency in practice. Further credentials are also likely, focused on areas of greatest impact where existing standards do not exist, or where there is a very broad opportunity for multiple professions to impact service delivery.

However, appropriate job planning is important¹⁰ to ensure that, as posts are developed, there is the appropriate time to fulfil all facets of the roles, especially at advanced and consultant levels. The leadership, education and research components must be recognised and supported alongside the expert clinical practice. But, equally, all professionals must have the time and opportunity in their job plan to maintain and develop their skills.

The four-tier structure has not gone away. Indeed, the principles as set out in the 2003 report still apply but should be considered more of a career progression model, with improved access to all levels of practice and progression between supporting the natural life course of professionals. However, the opportunities are much broader and not solely focused on clinical roles. We must build on this. Imaging is integral to almost all clinical pathways – the challenge is, again, to revolutionise delivery to provide best care for all patients, while empowering professionals to have the opportunity for development in a way that recognises their contribution, system wide.

Developments over the next few years will not be limited to the four tiers. Broader career opportunities will underpin and maintain the evidence base in the profession and service delivery, for example, clinical research roles and clinical-academic posts. Leadership through the next phase of change is critical. With imaging in the government spotlight, it is key that innovation is once again needed and that engagement locally, regionally and nationally is also required. The future is not yet set and, although there is a broad direction of travel in place, we can yet set out our roadmap. It is clear that this is not a journey that clinical imaging departments will take alone but collaboration with others, including educators, will ensure that the next two decades will deliver the aspirations of the early 21^st century and, ultimately, the care that patients deserve.

Professor Beverly Snaith is Clinical Professor of Radiography in the Faculty of Health Studies at the University of Bradford.

Charlotte Beardmore is Executive Director of Professional Policy at the Society and College of Radiographers.

References

1. Department of Health. Radiography Skills Mix: a Report on the Four-Tier Service Delivery Model. 2003.

2. Health Education England. Multi-Professional Framework for Advanced Clinical Practice In England. 2017. Available at https://www.hee.nhs.uk/sites/default/files/documents/multi-professionalframeworkforadvancedclinicalpracticeinengland.pdf

3. NHS Wales. Modernising Allied Health Professions' Careers in Wales: A Post Registration Framework. 2020. Available at https://gov.wales/sites/default/files/publications/2020-02/modernising-allied-health-professions-careers-in-wales.pdf

4. NHS Education for Scotland. Advanced Practice Toolkit. 2012. Available at www.advancedpractice.scot.nhs.uk/

5. NHS England. The NHS Long Term Plan. 2019. Available at www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf

6. Richards M. Diagnostics: Recovery and Renewal. NHS England. 2020. Available at www.england.nhs.uk/wp-content/uploads/2020/10/BM2025Pu-item-5-diagnostics-recovery-and-renewal.pdf

7. Skills for Health. Apprenticeship Standards. Available at https://www.skillsforhealth.org.uk/info-hub/category/apprenticeships/ Accessed 6 February 2022.

8. United Kingdom Accreditation Service. Quality Standards for Imaging (QSI) Accreditation. Available at www.ukas.com/accreditation/standards/quality-standard-imaging/ Accessed 6 February 2022.

9. Health Education England. Support Worker. Allied Health Professions’ Support Worker Competency, Education, and Career Development Framework. Available at www.hee.nhs.uk/sites/default/files/documents/AHP_Framework%20Final_0.pdf

10. NHS England and NHS Improvement. Allied Health Professionals Job Planning: A Best Practice Guide. 2019. Available at www.england.nhs.uk/ahp/allied-health-professionals-job-planning-a-best-practice-guide/