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Safe, Accurate and Effective: An Action Plan for Healthcare Science in NHSscotland

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CHAPTER 2: HEALTHCARE SCIENCE TOMORROW

THE EVOLUTION OF HEALTHCARE SCIENCE IS INFLUENCED BY SERVICE DELIVERY AND DEMANDS, THE STRATEGIC POSITION OF HEALTHCARE SCIENCE, TECHNOLOGICAL PROGRESS AND WORKFORCE SUSTAINABILITY.

The actions in this document are designed to address immediate and medium-term priorities and are set out against the following themes:

  • healthcare science visibility and engagement;
  • involvement, engagement with referrers to HCS services and communication;
  • the shift toward community-centred healthcare;
  • leadership capacity within healthcare science;
  • improvement, role development and diagnostic waits;
  • new technology: service impact and adoption strategies;
  • encouraging healthcare science networks;
  • education and training;
  • healthcare scientist associate practitioners and support workers;
  • healthcare scientists working in isolated situations;
  • continuing professional development; and
  • research, development and innovation.

SECTION 1 HEALTHCARE SCIENCE VISIBILITY AND ENGAGEMENT

HCS visibility and engagement is a key determinant of success for individual patients' clinical outcomes and for some NHSScotland strategic objectives.

HCS visibility must be woven into mainstream planning. At national level, the Scottish Forum for Healthcare Science ( SFHCS) has made an important contribution to unifying the HCS staff group and, for the first time, articulating its common response to policy. It is not the role of this action plan to recommend how the SFHCS should develop, but its continued contribution is recognised and acknowledged. In the meantime, opportunities to develop HCS visibility and engagement at local level should be grasped.

Healthcare Science Area Forums should be set up to offer NHS Boards a means of reflecting the diversity of healthcare science and to act as a collective point of reference. Area forums would not duplicate the role of existing professional advisory groups, but would instead enhance effective decision making; they would also assist in further unifying the HCS staff group towards a common purpose and create opportunities for mutual support.

The Tayside Area Scientific Committee was established in 2003 with the support of NHS Tayside. The committee consists of members elected by peers to serve a fixed term under a formal constitution with NHS Tayside support. The committee proactively addresses the development of the Local Health Plan and the NHS Board's strategic objectives by supplying a scientific perspective, either directly to the board or via the Area Clinical Forum.

In Lothian, the Healthcare Science Workforce Review Group, constituted to complete an important workforce report, 3 has begun to evolve into an HCS area forum. The Lothian group recently gained additional visibility following the assignment of a remit for healthcare science at board level to NHS Lothian's medical director.

A lead healthcare scientist was nominated by each NHS Board to support the development of this action plan. These leads have built a unique Scotland-wide network of healthcare scientists and have complied the workforce survey in the supplementary CD- ROM. Each lead scientist could now act as a catalyst for establishing HCS area forums and use the network to maximise their effectiveness.

The purpose, possibilities and opportunities presented by an HCS area forum are presented in Table 4; the list is not exhaustive.

Table 4. Purpose, possibilities and opportunities presented by an HCS Area Forum

Direct care-centred aspects associated with policy and strategy

Provide advice to NHS Boards on service development, impact and risk assessment of policy and service initiatives.

Provide NHS Boards with a scientific perspective on the development of the Local Delivery Plan and strategic objectives.

Share experience in demand management and approaches to process improvement.

Foster engagement between HCSs and workforce planners.

Develop cross-profession links for sustainable clinical teams and role development.

Promote multidisciplinary working.

Share experience and practice development to assure best patient care and clinical governance.

Improve and unify approaches to professional user engagement by healthcare scientists.

Promote HCS leadership in quality assurance of all diagnostic measurement.

Develop appropriate links with community health partnerships.

Indirect aspects

Act as a local horizon-scanning resource for healthcare scientists.

Link with national debate and the Scottish Forum for Healthcare Science.

Maintain a local network of experts to report on local HCS matters.

Identify opportunities for research in the context of local needs.

Support engagement with education providers.

Build an HCS profile at careers events.

There is a clear connection between healthcare science and some of the national HEAT targets. HCS area forums could therefore play an important part in helping NHS Boards formulate local delivery plans to meet these national policy objectives.

Recommendations
1.1 Each NHS Board should support the establishment of a local Healthcare Science Area Forum to improve service visibility and cohesion, ensure inclusion in board-level decision making that impacts on HCS demand, and to develop HCS services to meet the needs of patients and NHS referrers.
1.2 Each NHS Board should consider including special responsibility for HCS services in the remit of an existing Board member and explore connections between the Board member and the HCS Area Forum.

In addition, development of a public presence could support future HCS recruitment efforts, educate the public about services and open a channel through which members of the public could influence the development of the workforce.

SECTION 2 INVOLVEMENT, ENGAGEMENT WITH REFERRERS TO HCS SERVICES AND COMMUNICATION

Healthcare scientists cannot assume that referrers fully understand HCS services. Engagement with referrers is vital to ensuring that reasonable steps are taken to avoid unnecessary testing and investigations (and therefore extra work for the HCS service). Continuous involvement with referrers to healthcare science services represents good practice not only in relation to quality assurance, but also in developing a shared understanding of the patient's experience and signposting how HCS services should evolve in response to the new health agenda in Scotland.

"Enhanced feedback of requesting rates and brief educational reminder messages, alone and in combination, are effective strategies for reducing test requesting in primary care. Both strategies are feasible within most laboratory settings."

Essentially, engaging with referrers to HCS services is in the wider interest of service delivery but requires a proactive approach from healthcare scientists and clinical colleagues.

Examples of engagement with referrers to HCS services range from informal open events to update referrers on current and new HCS techniques to more formal feedback offered in response to test requests. Both present a two-way opportunity for HCS staff to learn, inform and raise much-needed visibility of healthcare science at the referrer interface.

Biochemistry at Aberdeen Royal Infirmary demonstrated an innovative new system that regularly gave feedback to GP practices about referral patterns. Educational "reminders" were attached to the results of nine core laboratory tests or a quarterly report of referral rates with enhanced educational information was offered. The programme yielded very strong evidence to support the reduction of inappropriate testing and demand on laboratories.

"Enhanced feedback of requesting rates and brief educational reminder messages, alone and in combination, are effective strategies for reducing test requesting in primary care. Both strategies are feasible within most laboratory settings". 4

Recommendation
2.1 NHS Boards should use their HCS Area Forum to encourage and support HCS services to engage with and educate their key referrers on appropriate use of HCS services.

SECTION 3 THE SHIFT TOWARD COMMUNITY-CENTRED HEALTHCARE

The shift towards community models of care provides a strong context through which healthcare scientists can change the way they work to improve services to patients. In addition, the focus on preventative and anticipatory care could open new opportunities for elements of this staff group. New local healthcare facilities (including reconfigured community hospitals 5) will act as hubs for walk-in care, as local diagnostic testing centres, as discharge units receiving patients from acute settings and as local community health projects.

Some elements of HCS services rely on established, large, central laboratories and clinical facilities. Genetics, immunology, embryology, complex physiological measurements and imaging services are examples of technology-intensive sciences that require centralised facilities. The economic implications and clinical effectiveness of providing community-based healthcare science services therefore require careful consideration.

Renal Technology (extract from HCS survey).
What are the pros and cons of running community-based or outreach services for your branch of healthcare science?

"Pros:Visiting patients and carers in the community enables patients to have the freedom of home therapy instead of travelling to the hospital three days a week for therapy. Satisfaction of providing support and advice to patients when problems occur during dialysis. Frees up dialysis slots in main hospital or satellite unit allowing further patients to be treated. Saves on nursing costs, ambulance transport costs, saves on capital costs of building new dialysis units.

"Cons:Additional travelling time for technologist going round these patients, therefore instead of a ratio of one technologist to around 50 patients in a hospital, it would drop to around one technologist to 20 patients in the community. Travelling costs for technologist, costs to adapt the patient's house for home therapy and the capital costs of purchasing the equipment, which will only be used by one patient three times a week, whereas one machine in the hospital could treat six patients a week."
Clinical technologist - renal unit, Central Belt.

There are, however, elements across the three HCS streams (life, physiological and physical sciences) that can undoubtedly build a community presence. Three primary issues will influence healthcare science community activity across all three streams:

  • What scientific services should be carried out in community settings?
  • Who should do it?
  • What benefit does it bring to patients?

Life sciences - analysis, testing and interpretation of clinical samples and products

Automation and portable technologies have made diverse biomedical tests available at the point of care, either within a hospital or GP practice. These tests involve measuring the properties of blood, urine or other samples, including those taken by swab, and can potentially be carried out anywhere. Table 5 offers an illustration of some life-science tests that can be done at the point of care ("point-of-care" tests ( POCT)).

Table 5. Some tests conducted at the point of care

Bilirubin

Blood gases

Cardiac markers

Chlamydia

Cholesterol

Coagulation ( INR)

Cotinine

Drugs of abuse

Electrolytes

Ethanol

Glucose

HbA1C

Microalbumin

Ovulation monitoring

Parathyroid monitoring

Pregnancy test

Therapeutic drugs

Thyroid hormones

Urinalysis

A full description of the individual tests is available at:http://www.labtestsonline.org.uk

International standard ISO 22870:2006 Point of Care Testing ( POCT) 6 specifies the involvement of healthcare science staff in the training of end users and in validation of equipment to assure the reliability of measurement. It applies to POCT in hospitals, clinics and primary care settings. The standard and its earlier versions underpin guidance from the Medicines and Healthcare Products Regulatory Agency ( MHRA) 7 which recommends healthcare scientists' involvement in POCT and extension to community, workplace and home settings.

Over-the-counter (and internet) availability of hand-held test devices has increased the scope for patient self testing and point-of-care testing. Patient/carer self testing is well established as part of self management of conditions like diabetes and in the safe administration of treatments such as anticoagulant therapy.

The success of community-based self testing is, however, highly dependent on users understanding the technology and purpose of the test. It is therefore important that healthcare professionals involved in distributing the technology to patients fully understand its operating procedures. Healthcare scientists can facilitate this understanding through the provision of appropriate training. Community biomedical and clinical scientists are well placed to identify the implications of extending point-of-care and patient self testing and offer the necessary training for healthcare professionals who are providing equipment, advice and guidance to patients and carers.

Patient safety and the community

A MHRA Safety Alert illustrates 8 the hazards of incorrect lancing devices (a needle holder) used for blood glucose monitoring in nursing and care homes. Confusion over the difference between single and multiple patient lancing devices raised the risk of transmission of hepatitis B.

Point-of-care testing quality assurance

Tayside's point-of-care testing ( POCT) group quality assures blood coagulation testing in GP practices. Practices use standardised test equipment and receive training from a biomedical scientist. The central laboratory at Ninewells Hospital acts as a reference laboratory to calibrate and assure the quality of the POCT measurements in the GP practices.

Recommendation
3.1 NHS Boards should use the facility of their HCS Area Forum to encourage robust systems of quality assurance for point-of-care testing in hospital and community settings, with guidance from biomedical and clinical scientists.

Physiological sciences - observation and objective measurement of human performance

Basic physiological parameters of, for instance, respiratory and cardiology function can be made using inexpensive portable monitoring devices. Table 6 lists some of the simpler cardio-respiratory tests that are undertaken routinely by non- HCS staff.

Table 6. Some basic cardio-respiratory tests

Respiration rate

Pulse rate

Blood oxygen saturation

FEV spirometry

Basic 3-lead ECG

Automated blood pressure

Exercise test combining O 2, respiration and heart rates.

The range and complexity of other physiological measurements have been summarised in a Department of Health guide. 9

"A major workload implication is going to be caused by demographics and the rise in diabetes. It means more infusion pumps used in the community, and so more demands on our services."
Equipment manager, Central Scotland

The objective of this action plan is to ensure that accurate and effective physiological measurement data are available to clinicians as a prelude to successful treatment interventions, regardless of who actually undertakes the measurement. The Scottish Intercollegiate Guidelines Network ( SIGN) guidance on cardiac care, for example, does not specify staff roles, but does highlight very clearly that precision is required in performing diagnostic physiological measurement and the competence dependency of such measures. 10

SIGN cites how corrupted 12-lead ECG measures can trigger further investigations by prompting unnecessary echocardiography requests (causing a capacity problem), administration of inappropriate medication and failure to detect vital physiological signs (both of which raise serious patient safety issues). As with the point-of-care test quality assurance activity of biomedical and clinical scientists in the life sciences, there is an opportunity for clinical physiologists to quality assure the safe, accurate and effective provision of physiological measurement.

Basic physiological testing can be carried out in the community, with clinical physiologists of all types being well placed to identify an inventory of tests and the limits of interpretation possible from them. Clinical physiologists constitute an expert resource for physiological measurement in the NHS but are few in number (perhaps less than 1% of the NHSScotland workforce) and consequently cannot possibly be present in all hospital and community settings.

Nurses, who constitute 42% of the NHS workforce, are most likely to be involved in performing these types of physiological measurements. Nursing and clinical physiology staff therefore need to explore collaborative working arrangements to ensure best-quality physiological measurement services for patients.

Clinical physiologists need to use their expertise in physiological measurement in partnership with other clinical and professional staff. They can underpin measurement quality to help avoid inaccuracies, false positives and subsequent inappropriate or unnecessary treatments.

Recommendation
3.2 NHS Boards should use the facility of their HCS Area Forum to encourage physiological measurement quality assurance in hospital and community settings, with support from clinical physiologists.

Physical sciences - using physics and engineering for patient imaging, measurement and treatments

End-user training on use of medical equipment is well established in Scotland and is an important function of existing equipment management services provided by clinical scientists and clinical technologists. Equipment management services in Scotland tend to be embedded within larger hospital-based medical physics services and are firmly in the domain of clinical scientists and technologists. As treatment and care migrates to community settings, so equipment will follow. Services related to equipment provision in its various guises are therefore likely to be the main focus of the physical sciences in the community.

"A major workload implication is going to be caused by demographics and the rise in diabetes. It means more infusion pumps used in the community, and so more demands on our services."
Equipment manager, Central Scotland

GPs, nursing staff and clinical scientists of electromedical equipment services ( EES) at Raigmore Hospital's Medical Physics and Bioengineering Department have defined a common range of GP practice-held medical equipment to improve safe, accurate and effective equipment management.

EES provides a mobile service for GP practices across Highland that conducts equipment function tests and calibrations on a range of standardised equipment, such as ECG units, spirometers, defibrillators, blood pressure monitors and suction units. Replacements are carried in its van and faulty devices are returned to EES to be repaired by clinical technologists.

Community health partnership general managers agreed to fund this service through modest top-slicing of the budget.

Immobile patients who use automated pressure-relieving mattresses may be at risk of injury should the device fail in service. Raigmore's Medical Physics and Bioengineering Department is attempting to reduce this risk by introducing planned preventative maintenance ( PPM) specifically for this type of equipment. Two assistant technologist staff members cater for nearly 700 users, including some in residential nursing homes. Expensive maintenance contracts and unplanned repairs on an ad-hoc basis are avoided.

The department has also introduced a van-based PPM and minor repairs service for NHS wheelchair users in rural settings. 11 Early evidence indicates a reduction in equipment failure that is reducing the need for emergency repairs and future pressure on out-of-hours services.

The Controls Assurance Standard highlights the rising sophistication of electro-technical devices held by joint NHS and local authority community equipment stores. 12 Attention to inspection and maintenance for these services, which are responsible for issuing thousands of items, has onerous implications in terms of staff time and potential external maintenance contractor costs. NHS clinical scientists can make an important clinical and economic contribution to advising on the effective and safe delivery of community equipment management and to aspects of the technology associated with the direct care of users.

Enablement technologies, including wheelchair services and assistive technology services, operate mainly in community settings, with HCS staff having direct patient contact. Demand for these services is expected to rise as the population ages, coupled with improvements in early medical care for young people with disabilities and management of patients with degenerative disorders. Clinical scientists in assistive technology have an opportunity to provide an impartial point of reference for community allied health professionals ( AHPs) who deliver the majority of these community-based services.

As part of an adult learning disability resettlement programme, NHS Tayside's Primary Care Division funded the training of a clinical scientist to develop expertise in smart house technologies and thereafter to lead the specification and implementation of this technology in a demonstration site. The role has fostered close links with the occupational therapy service in terms of advising about new technologies to assist with care and independent living, providing oversight of contractor installations and liaising with housing providers.

"The complexity of the technology makes this a specialist rather than a generalist area of work, as does its applications to complex/severe disability. On either/both counts there is a case for continued/growing CS [Clinical Scientist] involvement"
Clinical scientist, rehabilitation technology service, NHS Tayside

South East Scotland Mobility and Rehabilitation Technology Services ( SMART)13 has specialist pathways that link with community equipment providers for the design and manufacture of custom-made assistive devices for individual patients. Its Control Interfaces Service and Special Needs Design Service represent extensions of mainstream rehabilitation technology services that work collaboratively with AHPs and community equipment providers. 14

Opportunities therefore exist for healthcare scientists associated with all types of equipment-based disciplines to engage further with community healthcare services and to lead the evolution of HCS expertise.

Recommendation
3.3 NHS Boards should use their HCS Area Forum to encourage and support medical and enablement equipment-based services to explore how existing skills, approaches to quality management, risk and standardisation can be utilised to support the work of community healthcare services and community equipment users/providers.

SECTION 4 LEADERSHIP CAPACITY WITHIN HEALTHCARE SCIENCE

National policy and priorities in Scotland envisage new means of healthcare delivery. These can only be achieved by engaging with healthcare professionals and working in partnership with patients, communities and other sectors. Developing staff leadership capacity and skills will therefore be instrumental to achieving these changes.

Healthcare scientists have a critical role in driving service improvement, delivering better, safer care and enablement and enhancing health outcomes. Service leads should acknowledge and support the significant contribution that each individual practitioner and support worker can make to enhancing patient outcomes. This will involve encouraging and supporting healthcare scientists' expertise, their ability to innovate, and their ability to lead change.

Leadership development goals for healthcare scientists share much in common with those of other healthcare professions. Opportunities exist to encourage uptake by healthcare scientists of mainstream national leadership programmes, such as NHS Education for Scotland's "Frontline Leadership" initiative and many of the programmes operated by local training departments. Healthcare scientist leads should give careful consideration to this aspect of frontline practitioners' development; self awareness and interpersonal skills promoted through leadership development programmes are fundamental to healthcare science's visibility, presence and influence.

Recommendation
4.1 Healthcare scientist leads, heads of service and aspiring HCS leaders should be supported to develop leadership skills though local and national leadership development opportunities.

The development of higher-level strategic thinking skills is closely aligned with the desire to build a cadre of future healthcare science leaders. Proposals for higher specialist training across healthcare sciences will naturally reflect the research agenda, but equal weight should be given to the development of healthcare science leaders who are focused on translating policy into practice development, engaging strategically at top level and fostering innovation beyond professional boundaries.

Recommendation
4.2 The Chief Health Professions Officer will work in partnership with NES and other healthcare science stakeholders to explore how existing opportunities to develop NHS strategic leadership skills can include both senior healthcare scientists and those undertaking higher specialist training.

SECTION 5 IMPROVEMENT, ROLE DEVELOPMENT AND DIAGNOSTIC WAITS

Meeting the proposed 18-week patient pathway from GP referral to treatment as well as existing waiting times targets for cancer, audiology and genetics is a challenge for all healthcare professionals. For healthcare scientists, it also presents an exceptional opportunity to explore the added value their role brings by considering:

  • what is their role now?
  • what parts of it can be released?
  • what new roles need to be adopted?

Role development

This issue plays directly into the agenda to develop specialist and assistant practitioner roles in healthcare science, as described in the NHSScotland Career Framework. 2

Initiatives to develop healthcare science roles and improve services can only be realised in partnership with other healthcare professions. Patients receive services from a wide range of professionals, and the patient journey will not be improved by healthcare scientists repositioning themselves without consideration of the contributions and perspectives of other disciplines. Colleagues from the allied health professions, nursing and medicine have much to contribute in terms of redefining healthcare science roles and exert enormous influence on demand for HCS services.

Role development initiatives should also be taken forward within service redesign projects to ensure they make positive contributions to new services and complement existing and redesigned roles of healthcare professionals. Current HCS service activity does not necessarily correlate with its potential capacity, given the possibilities for role redesign. Within that context, extra resource to fund "more of the same" will not overcome role-limiting service configurations, nor will it provide important opportunities for healthcare scientists to develop their creativity.

The pathology laboratory service at Perth Royal Infirmary was relocated to Ninewells Hospital, Dundee in 2003/04 to create an area service. Extended opening to 18.00 required minimal staff cover and was achieved through a rota system. The streamlining of the laboratory led to an overall faster turnaround time for biopsy analysis of samples resected either in Perth or Dundee.

In March 2004, the Audiology Service at Glasgow Royal Infirmary ( GRI) had 1550 patients waiting over 100 weeks from referral to assessment. Typical waiting times from assessment to fitting for hearing aids stood at a further 52 weeks. Newly established self-referral rights and GP referral for digital hearing aids under the Audiology Modernisation Programme 15 had compounded the waits.

Clinical physiologist audiology staff responded by agreeing a role extension with ENT consultants to enable staff to conduct audiograms and proceed to prescription and fit within an agreed clinical protocol. Previously, accessing this service required patients to attend at least two visits (one to the consultant). A successful bid for temporary monies enabled three staff to work overtime (evenings and Saturdays). A receptionist worked alongside the clinical physiologists to fill additional clinical slots by direct telephone contact with patients (sometimes at short notice) to maximise service capacity.

The "did not attend" rate fell to below 5%, compared to over 10% previously, and the waiting list was cleared in less than three months. Referral to assessment for GRI patients is now conducted within nine weeks with fitting following within four weeks. A 13-week total patient journey (versus 152 weeks previously) has been achieved without locum support or permanent additional staff, and the service is in equilibrium with demand.

This remarkable success by NHS healthcare scientists in audiology must be seen in the context of a current national audiology standard 15 of 26 weeks from referral to fitting and the inclusion of audiology from January 2008 in the new 18-week target.

The GRI audiology department example provides a very positive model not only for other audiology departments (some of which are replicating the initiative), but also for other healthcare science services. It combines elements of role development and patient pathway redesign to minimise wasted time and resources and shows how enhancement of patient services can be achieved through sustainable incremental changes that may lead to major improvements.

The integrated Clinical Physiology Department at The Ayr Hospital faced a ten-week waiting list for echocardiography requests. Staff adopted flexible working practices that included extended opening from 08.00-18.00 four days a week, with time in lieu. Administrative staff maximised capacity by filling clinics at short notice.

An ultrasound assistant ( ATO) role was developed to apply basic electrodes, position the patient and provide assistance post measurement. While the helper prepared the next patient, the clinical physiologist was free to report the findings of the procedure. This modest redesign has cleared the echocardiography waiting list: there is now almost a zero wait for this urgent test.

"Workload demands/planning/reorganisation/delivery of service is of particular interest to me as I have had experience of slashing waiting lists from five months down to two weeks with separate initiatives, firstly at Stirling Royal Infirmary in 1996 and then Falkirk Royal Infirmary in 2004/05. These maximum waiting lists have been sustained since then, despite increased referrals, through constant adjustments to working practices including extension of opening hours at Stirling (when acute services were transferred from Falkirk in October 2005), with full-time staff working from 08.00 to 18.00 over four days per week."
Lead clinical physiologist, cardiology services manager, NHS Forth Valley.

In response to rising demand and follow-up episodes, clinical physiologists in audiology in NHS Forth Valley have introduced routine telephone reviews to patients receiving digital hearing aids. 16 Telephone reviews are undertaken by assistants using protocols defined by the clinical physiologist. Assistants' responsibilities and job satisfaction have been enhanced. In a pilot, 58% of patient telephone reviews did not require follow-up, allowing the clinical physiologists extra time to assess more complex patients.

Recommendation
5.1 NHS Boards should ensure that healthcare science services have access to local training opportunities to support service redesign and modernisation initiatives.

Diagnostic waits

Guidance on the implementation of the 18-week pathway for eight key tests was published in February 2007 as part of the Diagnostics Collaborative (Table 7). 17 Industry standard techniques in "lean-thinking", process redesign, "waste-spotting" and "rapid improvement" have been successfully utilised in health care. Healthcare scientists are well placed to assist in identifying these local improvement priorities across all services using the Collaborative's work as a model.

Table 7. eight key tests in the diagnostic collaborative

Gastroscopy (upper endoscopy)

Magnetic resonance imaging ( MRI)

Flexible sigmoidoscopy (lower endoscopy)

Computed tomography ( CT)

Colonoscopy

Barium enema fluoroscopy

Cystoscopy

Ultrasound (non obstetric only)

The extension of the 18-week maximum period from GP referral to treatment will shape services that involve Healthcare Science staff. Examples include the implementation of the national wheelchair service modernisation initiative 11 and the Scottish Government's new cancer strategy, due for publication in Spring 2008. Implementation of reviews of audiology services 15 and genetics services 18 also present clear opportunities to build on existing achievements.

The Scottish Patient Safety Alliance 19 links the NHS to the range of organisations which seek to secure and enhance the safety and quality of services provided to patients in NHSScotland. The National Patient Experience Programme "Better Together" seeks to make significant improvements to the overall experience of healthcare for patients and their families/carers. The overall approach of both programmes recognises and reflects the totality of the patient journey and recognises that care will take place in a range of settings, with primary and community-based care becoming increasingly prominent in terms of the delivery of complex packages of care. Healthcare scientists have an important contribution to make along with other healthcare colleagues in achieving this policy objective.

Recommendation
5.2 HCS Area Forums should identify local priorities for healthcare science service improvement exercises in the light of national programmes and targets.

Understanding of improvement techniques and the capacity for self help varies among healthcare scientists. Healthcare scientists will have opportunities to participate in these initiatives at both local and national level and should be encouraged to use these to the full.

Recommendation
5.3 The Chief Health Professions Officer should work in partnership with the Diagnostics Collaborative, NES and NHSQIS to explore opportunities for service improvement, sharing of learning and dissemination of good practice throughout NHSScotland.

SECTION 6 NEW TECHNOLOGY: SERVICE IMPACT AND ADOPTION STRATEGIES

Healthcare science services are influenced by rapid scientific and technological progress. New technologies make possible modes of service delivery unheard of a generation ago and may require evolution of roles and reconfiguration of services. But healthcare scientists, in partnership with other healthcare professions, must critically and dispassionately analyse new developments and be capable of assessing potential benefits (and pitfalls) for patients.

Detection and vaccination against variants of Human Papilloma Virus ( HPV) will shape future cervical cytology services, changing both the age and demand profile of vaccinated service users, including reduced demands for colposcopy (examination of the cervix). 20

The detection of brain natriuetic peptides ( BNP) (a hormone released from the ventricles in the heart) is a consistent indicator of chronic heart failure. 21 New laboratory tests and the future possibility of point-of-care tests for BNP should improve early detection, in tandem with clinical physiologists providing cardiac tests.

Individual genetic makeup affects a patient's responsiveness to medication: an early success in this field of pharmacogenetics includes screening the appropriateness of herceptin for certain types of breast cancers.

Scotland's NHS healthcare scientists represent an in-house expert resource that is well qualified to contribute to the debate about emerging technologies. Locally, the ability to spot key healthcare science innovations that are likely to influence healthcare will be an important part of the role of the proposed HCS area forums. More generally, healthcare science networks are helpful in building awareness of scientific and technological innovation within disciplines, but do not provide a national focus. Such a focus could be provided by the Scottish Forum for Healthcare Science working with partners within the Scottish Government on "horizon scanning" the potential of new technology for HCS services.

Recommendation
6.1 The Chief Health Professions Officer should open a dialogue with relevant stakeholders to explore the need for horizon scanning for new technology in healthcare science.

SECTION 7 ENCOURAGING HEALTHCARE SCIENCE NETWORKS

Broader healthcare science networks are vital to ensuring dissemination of good practice among individual healthcare scientists and services. Evidence has been found that the practice and roles of some HCS disciplines varies within and between NHS Boards; local and national approaches to networking would assist in producing more consistent service delivery. The overarching HCS area forums that have been recommended in this action plan would also support strategic visibility and assist with networking across the three HCS streams.

Barriers to local networking may stem from the physical location of a service. Many clinical physiology disciplines operate (by dint of historical "ownership") as small stand-alone units in larger medical departments. While co-location with other clinical physiology disciplines may not be feasible due to lack of facilities, there should be no reason why this key strand of healthcare science should not pursue local networking and clearly position itself through a clinical physiology grouping to explore common practice, flexibility and sustainability of service delivery.

Clinical physiologists recognising, interacting with and supporting each other will create substantial benefits for patients and professionals. They have a pivotal role to play in unifying their branch of healthcare science through networking, just as medical, nursing and AHP colleagues have done with theirs. For these reasons, specific action by clinical physiologists, within the overarching recommendation below, is suggested to improve the cohesion of physiological science, which is relatively weak in this regard compared to physical and life sciences.

"Since joining with other healthcare scientists and from some of the first action plan development meetings, I have enjoyed increased networking - both within individual professions on a more national basis and more importantly improved networking across the physiology groups. We've got common issues that can only benefit patient care.

"Cross-discipline links in physiology not only allow a greater awareness of national issues, but have also allowed our service to begin to develop contacts with other (non-cardiology) clinical physiologist colleagues, allowing improved communications and increased support."
Lead cardiac clinical physiologist - West of Scotland.

Physical sciences may be distributed and configured around specific clinical services such as oncology, radiology and rehabilitation, and consequently may overlook the benefits of closer links with a larger professional technical organisation. Various medical physics and clinical engineering disciplines have ad hoc networks that complement a professional body structure in Scotland, including renal technology (clinical technologists), bioengineering (clinical scientists) and a multidisciplinary Scottish Nuclear Medicine Group.

Opportunities to build and share common practice among disciplines are being missed across the physical sciences spectrum. Examples include:

  • clinical technologists involved in workshop-based services ranging from radiotherapy to rehabilitation;
  • equipment management, rehabilitation technology and maxillofacial prosthetics; and
  • all services that use computer-based image capture and processing tools, such as clinical measurement, biomechanics and clinical photography.

Healthcare scientists should endeavour to share and learn from colleagues in related physical sciences through the development of closer informal relations and joint education and development activity. The creation of a robust and mutually supportive network will improve visibility and aid the development of effective practice.

In the life sciences, the Scottish Pathology Network ( SPAN) ( www.pathologyscotland.org ), established in May 2006, fosters dialogue to improve services. In addition, the Institute for Biomedical Science ( IBMS) has an active branch in Scotland, biochemistry has a multidisciplinary network under the aegis of the Scottish Region of the Association of Clinical Biochemistry, and microbiology has a Scottish regional branch of the Association of Clinical Microbiologists.

Unidisciplinary networks such as these have a key role to play in the development of healthcare science services, but it is also important to create networks that promote professional links within and across HCS streams.

Recommendation
7.1 HCS area forums should develop local implementation plans to ensure effective cross-discipline working and service provision and sustainable services.

A professional network in any healthcare profession has, at its core, the purpose of disseminating good practice to ensure effective and safe patient interventions. Supporting this aspect of service improvement means that the practice development needs of healthcare scientists are no different from other NHS staff. The practice development unit within NHSQIS has developed a range of best practice statements, some of which are applicable to healthcare scientists. For example, the best practice statement relating to pressure ulcer prevention 22 is of interest to clinical scientists and technologists in rehabilitation and equipment management disciplines; likewise, the QIS best practice statement for radiotherapy skincare 23 can inform the practice of healthcare scientists in this field.

Recommendation
7.2 The Chief Health Professions Officer, in partnership with NHSQIS, should explore the potential for a HCS Practice Development work stream.

Peer networks are also about promoting continuing professional development as well as creating service improvements, and NHS Education for Scotland ( NES) has a role in supporting healthcare science networks through, for instance, developing healthcare science portals within the NHS e-Library modelled on those created for other disciplines and groups. Healthcare scientists could also be aligned with initiatives such as the development of an e-health managed knowledge network for nurses, midwives and AHPs.

Recommendation
7.3 NHS Education for Scotland should explore how healthcare scientists can be supported to make better use of e-library resources.

Nationally, opportunities to share generic good practice across healthcare science have been identified. In England, the Department of Health (via the Chief Scientific Officer) has sponsored an annual healthcare science event to showcase examples of good practice and celebrate service improvement. The Scottish Forum for Healthcare Science could take the lead role in planning a similar event in Scotland, either as an adjunct to its annual general meeting or as a separate periodic event.

The development of stronger links between healthcare science services, education via NES and best practice via NHSQIS could form part of an overall national strategy to support the establishment of a national healthcare science network. Figure 1 illustrates the possible relationships involving key stakeholders and reinforces the connection between local and national HCS visibility.

Figure 1. A national HCS network, involving the Scottish Forum for Healthcare Science

Figure 1. A national HCS network, involving the Scottish Forum for Healthcare Science

SECTION 8 EDUCATION AND TRAINING OF HEALTHCARE SCIENTISTS

Education and training of healthcare scientists presents NHSScotland with particular challenges. Education capacity and delivery approaches need to reflect the diversity of disciplines, relatively low numbers of staff and alternative (non- NHS) career options that many healthcare scientists have available to them. Shifting roles and the impacts of service redesign and new technology will also influence workforce demands and education needs.

Of the six types of healthcare science staff identified in this action plan (see Table 2), only one - the clinical scientist - has an established national training programme. Current arrangements support biomedical scientists to undertake degrees and an audiology degree exists, but there is currently no national training programme in Scotland for clinical physiologists or clinical technologists. Table 8 summarises the main training arrangements for healthcare science staff.

Table 8. Main training arrangements for HCS staff in Scotland

Key HCS staff

Disciplines

Training arrangement

Gaps

Clinical scientist

Life and physical science streams spanning: biochemistry, microbiology, molecular genetics, cytogenetics, medical physics and bioengineering.

Four-year grade 'A' postgraduate training to MSc aligned with Association of Clinical Scientist certification, NSD administered approximately 16 places per year. Proposed work-based higher research PhD sponsorship scheme approximately 10 places per year (awaiting approval). Some life scientists able to specialise up to MRCPath. a

Clinical scientist in audiology.

Biomedical scientist

Life science stream.

Co-terminous BSc (Hons) Biomedical Science degree.

None.

Clinical physiologist

Clinical physiology stream, audiology specialty.

Commissioned BSc Audiology, interim scheme.

Other clinical physiology disciplines.

Clinical technologist

Physical science stream.

None at present.

All disciplines in clinical technology.

Clinical/scientific assistants

Life sciences stream.

Cytoscreener training via NHS Lothian - NSD supported. Dundee College SVQ supported by NHS Tayside laboratories.

All others.

aMRCPath: Member of the Royal College of Pathologists; these staff have role equivalence to Medical Consultant Pathologists.

Commissioning individual education solutions for all 50 or so healthcare science disciplines is not economically feasible. Relatively low workforce numbers and turnover would challenge the sustainability and viability of courses. A greater coherence within each of the three strands of healthcare scientist training would be advantageous.

It will be important to scope out the existing and future training needs and development needs for this diverse group of professions across NHSScotland. Economic and effective education and training solutions which result in the preparation of flexible healthcare science staff may emerge from the identification of common training themes within HCS streams. As a minimum, the identification of common education and training solutions within each of the three HCS streams should be feasible. NES will be instrumental in supporting work in partnership with NHS Boards and HCS leads.

As an immediate priority in Scotland, two major gaps in the provision of healthcare science training are currently evident: training for clinical physiologists and for clinical technologists. An early examination of requirements for sustainable training of both is needed. There would also be merit in a re-examination of all healthcare science workforce needs, particularly at and below assistant practitioner level and specialist/consultant levels on the NHSScotland career framework.

Recommendation
8.1 The Chief Health Professions Officer and NES will explore the potential for a distinct work stream at NES focusing on the education and training needs of the healthcare science staff group, with early prioritisation of clinical physiology and clinical technology.

At present allocation of resources for education and training across the healthcare science professions is uneven, and significant gaps remain (Table 8). Some clinical physiology services have won ad-hoc local support for individual staff to attend work-based programmes, but such local solutions perpetuate the fragmentation and unplanned nature of this HCS workforce - with unwanted consequences for service delivery. For all strands of healthcare science, we have articulated that a national oversight of education and training is highly desirable - including consideration of alternative models of allocating existing resources.

Recommendation
8.2 The Chief Health Professions Officer, in partnership with NHS Boards and NHS Education for Scotland, should consider alternative models of utilising existing education and training resources for those aspects of healthcare science not nationally catered for, and explore pooling into a national programme.

Higher Specialist Training for Clinical Scientists is currently under review in Scotland. Options for the future may include a PhD level programme and the possibility of expanding this approach at an appropriate level for other healthcare scientists. Defining the service requirements for higher-level scientific expertise in parallel with any education programme will be key to these considerations.

A unified HCS work stream within NES would, for the first time, present the possibility of a joined-up approach not only to education and training within the healthcare science group in Scotland, but also to synergies with education and training needs of other health care professionals. Skills for Health has identified generic National Occupational Standards ( NOS) applicable to a variety of health care practitioners. 24 With over 500 HCS-specific NOS already defined, the NES Memorandum of Understanding with Skills for Health reinforces the message that healthcare science education and training must meet the needs of service.

Recommendation
8.3 NES will explore opportunities for joint and common learning approaches within the HCS staff group and with other health professions.

HCS education that leads to registered status (Health Professions Council or voluntary register) requires work-based practice. This may be incorporated into an education programme through block release or through an agreed training placement with an employer after graduation. Work-based education and training could be supported by blended learning approaches.

Recommendation
8.4 The Chief Health Professions Officer should initiate discussions involving NES, education providers and SFHCS regarding work-based, distance learning and other education models for healthcare science.

For NHSScotland's healthcare science workforce, training schemes for the three streams of healthcare science must develop professionals who can become registered with the HPC in due course. Many scientists, engineers and technologists employed by the NHS as healthcare scientists have already had core training focused on the holistic development of their scientific and technical understanding, followed by role-specific training delivered through advanced-practice certificates, courses and work-based learning mechanisms. This model has served NHSScotland well and can be reasonably expected to deliver the variety of staff needed to populate the NHSScotland Career Framework. 2

Existing training models have also:

  • allowed healthcare science staff to gain transferable qualifications recognised by a range of employers;
  • avoided the problems of graduate over-supply;
  • mitigated the risk of NHS exposure as the "sole employer" of healthcare scientists; and
  • encouraged work-based training ideas closely aligned with NHS needs.

Recommendation
8.5 The Chief Health Professions Officer and NES will maintain a regular dialogue with the Health Professions Council that includes ensuring training programmes for healthcare scientists in Scotland reflect the UK regulatory context.

A revision of healthcare science education and training is under consideration by the Department of Health in England. The Scottish Government is working closely with colleagues from England, Wales and Northern Ireland to explore where these developments have applicability in the Scottish context.

SECTION 9 HEALTHCARE SCIENTIST ASSISTANT PRACTITIONERS AND SUPPORT WORKERS

The future healthcare demands of the people of Scotland will require all NHSScotland staff to practice in a way that promotes maximum positive outcomes for patients. This may mean releasing healthcare scientist time and energy for specific interventions by devolving some core functions to assistant practitioners, support workers and others.

Assistant practitioners and support workers, in particular, can very effectively carry out a range of skilled tasks following appropriate preparation and under experienced supervision. They have an important role in relieving higher-level healthcare scientists of mechanistic tasks and consequently generating overall capacity for more-complex tasks to be undertaken (the contribution assistants make to service improvement and reduced waits has already been illustrated).

Healthcare scientists need to have the confidence to allow assistant practitioners and support workers to take on those tasks once competent to do so. This will call on healthcare scientists to further develop the effectiveness of their delegation and supervisory skills.

The role and training needs of assistant practitioners are, as yet, undefined in several branches of healthcare science. Not all staff participating in healthcare science services will be in roles that require higher-level qualifications (a degree). More limited roles may not require HPC registration, provided supervision from a higher-level regulated practitioner is available. The debate is really about the competence and skills that underpin patient services, rather than the creation of profession-specific boundaries.

Recommendation
9.1 NES should explore how work currently being undertaken on meeting the education and support needs of healthcare support workers can be linked to support and assistant practitioners in HCS in relation to the NHSScotland Career Framework.

SECTION 10 HEALTHCARE SCIENTISTS WORKING IN ISOLATED SITUATIONS

Healthcare scientists work in remote and rural settings where they are potentially isolated from colleagues. A similar situation can also exist in some on-call services at night (particularly in "hospital at night" settings) or while contributing to emergency care services. Each scenario presents specific workforce and education support needs.

Resolving the education and training needs of Scotland's healthcare scientists in settings distant from the main centres has regularly been recognised as a challenge. Rurality may demand that the practitioner becomes multi-skilled across a broad range of scientific activities but perhaps not to the depth of specialist practitioners in the main centres, whose focus can be much more specific. The generalist is not well represented in the existing NHSScotland career framework, 2 in which the emphasis is on advancement through specialisation.

The Remote and Rural General Hospital Workstream Project 25 is exploring the possibility of an "advanced generalist" in the laboratory and physiological sciences capable of administering a range of core diagnostic tests, perhaps supported by links to main centres through video-conferencing, telemedicine and broadband facilities. An unambiguous inventory of healthcare science services in remote and rural settings (similar to those developed by the Centre for Rural Health for nursing, general practice and some AHP disciplines in relation to services for older people 26) would prove very informative for core services planning in rural settings.

Recommendations
10.1 The Chief Health Professions Officer should initiate discussions involving NES, workforce planners, the SFHCS and other stakeholders to explore the scope and need for generalist healthcare scientist practitioners within each HCS stream to meet the needs of rural, night-time and emergency care services.

10.2 The Chief Health Professions Officer should initiate discussions with relevant stakeholders to identify a national consensus on the composition of core HCS services in remote and rural settings.

SECTION 11 CONTINUING PROFESSIONAL DEVELOPMENT

Attracting staff into healthcare science careers is the foundation of NHSScotland's workforce supply. Retaining these staff, particularly during the initial post-qualification phase, has been recognised in other healthcare professions as vital.

Attrition problems are not particularly evident for the healthcare science group, but registration should not mean the end of learning. Innovative NES-led education interventions would provide a clear signal to newly qualified healthcare scientists that science in NHSScotland is as dynamic as that found elsewhere. All practicable means must be pursued to encourage healthcare scientists to understand that learning is life-long and that the roles they assumed on appointment will be very different in 20 years' time.

The terms of statutory regulation of healthcare scientists with the Health Professions Council now oblige registrants to maintain their fitness to practice by undertaking recorded and evidenced continuing professional development ( CPD) activity. It is beyond the scope of this action plan to specify exactly how CPD should be pursued by individuals or groups; the HPC website ( www.hpc-uk.org ), however, offers sound guidance on this, and various healthcare science professional bodies provide CPD portfolio templates. Ultimately, it is most likely that CPD activity will be driven by the individual and may consist of a mix of self-study, professional events and involvement in formal education.

NHS Boards should appreciate that they have a duty to ensure that healthcare scientists have reasonable opportunities to take part in CPD activity. Equally, healthcare scientists must realise that CPD is a personal responsibility and take advantage of the many opportunities for development that arise as part of their day-to-day work. This has been recognised by other professions which support the principle of half a day per month of CPD time.

Recommendation
11.1 Healthcare science heads of department should, through engagement with stakeholders, work towards the establishment of designated CPD time for all staff, but particularly those registered with the Health Professions Council or aspirant professions on voluntary registers.

SECTION 12 RESEARCH, DEVELOPMENT AND INNOVATION

Research, development and innovation are intrinsic to the work of healthcare scientists. Many scientists have made significant contributions to the advancement of healthcare, but they could do much more with support and encouragement.

At present, there is no national strategy that gives direction to research by NHS healthcare scientists as a staff group, although the CSO supports research across the breadth of healthcare interests and operates a range of schemes to help foster appropriate health research skills.

Other NHS staff groups have recognised the clinical governance imperative of a sound research base in the delivery of patient care. Nursing and Midwifery 27, and AHP28 staff have both identified generic themes that underpin capacity of these professions to undertake research (these are summarised below in Table 9); these themes are patently applicable to healthcare scientists.

Table 9. genetic research themes

Theme

Meaning

Research tools, skills and capacity.

Individual ability to identify a research theme, hypothesise, design experimental protocols and analyse appropriately.

Support for research.

Identification of funding, partnerships and research alliances.

Dissemination.

Promoting the product of research into development programmes and ultimately clinical practice, both individually and by national frameworks for best-practice.

Clinical/academic career pathways.

New roles for NHS-based researchers.

Levels of research involvement have been identified under the Research Governance Framework. 29 (Table 10). These apply in principle to healthcare scientists. Not all will be active researchers, but most should expect and aspire to some level of participation - as collaborators, for example. The ability to query current practice and pose a question that could lead others towards a line of research should become the norm for HPC-registered staff, that is, those operating at least at Level 5 of the NHSScotland Career Framework.2

Table 10. Levels of research involvement 29

Research level

Meaning

Principal investigator/lead researcher

Holder of overall responsibility for the study. Experienced and research-trained, could be combined with other clinical duties, management and project lead roles.

Investigator

Experienced researcher with particular technical skills. Appears on grant/ethics submissions. Develops protocol, obtains resources, employs research workers and publishes.

Clinical collaborator

Experienced staff with clinical/managerial influence able to access service users/staff. Not necessarily concerned with the detail of research implementation.

Research worker

Employed to conduct study. May play a lead role in study design and data analysis, or may only collect data.

Supervisor

Research students must have academic supervisors and may have clinical supervisors. A sponsor of study and has responsibility for its proper conduct. Supervision of research teams by steering groups of service, academic and service-user steering groups.

Maximising the research potential of healthcare scientists goes beyond a simple survey of research interests. It requires the construction of a framework of interested parties willing to support an infrastructure that nurtures healthcare science research across all three HCS streams. Figure 2 illustrates the possible configuration of stakeholders around NHSScotland's healthcare scientists' research development and innovation activity.

Figure 2. A Framework of Support for NHSScotlandHCS Research, Development and Innovation

Figure 2. A Framework of Support for NHSScotland HCS Research, Development and Innovation

The recommendation on this aspect of healthcare science forms the basis of action to harness healthcare scientists' research and development potential. Developing an evidence base for practice aligned with service needs would involve:

  • identifying current research and development activity;
  • developing research awareness among healthcare scientists and promoting their influence on national priorities for research;
  • facilitating a culture that taps the economic potential of NHS research;
  • identifying funding streams available to healthcare science and extending the understanding of how healthcare science can contribute to health and healthcare needs; and
  • exploring the potential for academic and clinical career pathways in key areas of healthcare science.

Recommendation
12.1 The Chief Health Professions Officer will open a dialogue with relevant stakeholders to assess the current research and development activity undertaken by NHSScotland's healthcare scientists in the context of current and emerging priorities for NHSScotland and with a view to exploring healthcare science research, development and innovation.