Welsh Scientific Advisory Committee
16 October 2009
Advice on GP access to imaging investigations undertaken by radiology departments
Background
At a recent meeting with the Minister for Health and Social Services, the issue of variable
levels of GP access to diagnostic investigations undertaken by radiology departments across
Wales was raised, with a view that this could result in unnecessary referrals to secondary
care of patients who could be managed in primary care. Following this, the Medical Imaging
Sub-Committee (MISC) of the Welsh Scientific Advisory Committee and the GP National
Specialty Advisory Group of the Welsh Medical Committee (as the relevant parts of the
Welsh Assembly Government’s professional advisory committee structure) were requested to
collaborate to provide advice on the clinically appropriate level of access needed to support
modern primary care.
Advice
The importance of appropriate GP access to diagnostic tests such as imaging, to support the
increasing contribution of primary care is recognised by MISC and GPNSAG.
With the new Local Health Boards in Wales, there will be a common body for Primary and
Secondary care. MISC felt that access to imaging tests should be common within the LHB
area, following the principle that all patients should have equal access to imaging from
whatever referral source, preferably in line with local Care Pathways.
The principles that govern access arrangements to imaging should apply to any clinician in
that requests should be:
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justified in relation to their impact on clinical decision making;
consistent with RCR guidelines (see below);
be informed by dialogue and collaboration between requesting clinicians and radiology
departments
Formalised local Care Pathways are being developed locally for an increasing range of
conditions which specify the stage at which imaging procedures should be instigated and
who should request them. It is vital that imaging specialists are involved at an early stage in
Pathway development, to develop the principle that all patients should have equal access to
imaging from whatever referral source.
It will take time to fully establish these pathways. MISC and GPNSAG members support the
need - recognising current geographical access variations - to seek consensus between the
radiology and GP communities on an illustrative list of imaging investigations that GPs would
commonly require in all parts of Wales. This is attached at Annex 1.
It is recommended that GPs routinely consult the RCR guidelines “Making the best use of
Clinical Radiology” Edition 6 to confirm the recommended modality for the clinical indication.
The guidelines are available within the “guidelines” section of NHS Wales e-library for health
on HOWIS at: http://howis.wales.nhs.uk/sites3/docmetadata.cfm?orgid=520&id=94142.
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The list is not exhaustive; it should not limit more extensive access already available in some
parts of Wales; and that where care pathways have been agreed they should be followed by
all and supersede what is on the list.
It is noted that echocardiography is outside the scope of the list and should be available as
indicated in care pathways for cardiac services.
Both GPNSAG and MISC wish to emphasise the importance of active communication and
dialogue between GPs and their local radiology departments to promote an effective
evidence based approach to use of imaging investigations based on collaboration.
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Annex 1
ILLUSTRATIVE LIST OF CLINICAL INDICATIONS WHERE GPs COMMONLY REQUIRE IMAGING
(Not intended to restrict existing more extensive local access arrangements or to
override imaging arrangements set out in locally agreed care pathways)
Imaging Modality
(eg MRI,
ultrasound, plain
film)
Chest
Radiograph
Plain film
Plain film
Ultrasound
Ultrasound
Illustrative Examples of Clinical
Indications
(body part, symptoms)
Infection, early diagnosis of cancer,
pulmonary oedema, fibrosis
Joints;
evidence of arthritis –
management of OA in primary care
Bones:
Fractures, bony swellings,
metastases
KUB for Urinary outflow tract
obstruction, retention and prostatism
Scrotum: Lumps and swellings
Ultrasound
Pelvis: to confirm ovarian swellings,
position of I~UCDs, endometrial
thickness, fibroids
Ultrasound
Gallbladder: to look for stones
Ultrasound
Liver: To assess abnormal liver
function test, and suspected liver
pathology
Ultrasound
Assessment of palpable abdominal
swelling including possible aortic
aneurysm or abdominal mass
Peripheral
As per local Care Pathways: To
Venous Doppler exclude DVT
Ultrasound
Carotid Doppler As agreed in local TIA pathway
Ultrasound
Radionuclide
[After discussion with radiologist]
Bone scan
Looking for secondaries in possible
metastatic disease
MRI Knee
As per local Care Pathways: twisting
injuries and locking:?meniscal disease,
? ligament
MRI Spine
As per local Care Pathways:
patients with sciatica; to look for
prolapsed disc (nerve or cord
compression)
Barium swallow
Assessment of upper dysphagia.
Barium Enema
As per local Care Pathways: For
patients declining colonoscopy
CT Brain
As per local Care Pathways: Concern
re: SOL, work-up pre-referral to
memory clinic,
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