Royal National Orthopaedic Hospital NHS Trust
Additional Imaging Staff
For Approval

This paper seeks Trust Board approval for the recruitment of a Consultant Radiologist.

The appointment is part of the overall Imaging staff plans detailed in this paper. Some of the proposals within this paper are also covered in the new Theatre Business Case.

The overlap in the 2 business cases will be addressed as part of the staff recruitment plans and the income and expenditure targets that will be set to reflect the agreed Trust Board investment.
1. Rational, Introduction and Strategic Context
1.1. In order to continue to deliver the increasing activity through the Imaging Department and in order to sustainably support both the inpatient and outpatient activity of the hospital, it has been necessary to assess the current level of staffing within the department. The proposed additional staffing will also assist in the delivery of the Trust’s future plans, including:

The new Bolsover Street development with a new Ultrasound service that will require supporting staff (Consultant Radiologist and Ultrasound helper);

Staff consultation over extended days/ times for Scanning Radiographer;

New Theatre Business Case requiring a Radiographer;

Imaging 18 week RTT Action plan/2 week turnaround times (all staff);

Increased activity within the Trust of at least 5% for 2009/10;

Clinical Governance Compliance of standards of reporting times within Radiology.
1.2. To deliver a timely Imaging service to achieve a 2 week diagnostic turnaround, the 18 week referral to treatment pathway, as well as ensure the department is staffed to deliver the current and future increases in activity as a result of the new theatre business case, the additional consultant appointments and the new Ultrasound service at Bolsover Street, it is necessary to increase many areas of the imaging staffing structure.
1.3. These can be summarised as:

Consultant Radiologist - to deliver and maintain a timely reporting service
(particularly the MR workload) as well as support the new Ultrasound service at
Bolsover Street.

Fellows in Radiology - to train and support service delivery for the RNOHT and maintain priority plain film reporting as well as undertaking interventional procedures;

Theatre Radiographer - to support the increase in theatre activity in theatre and in particular the proposed new theatre;
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
Scanning Radiographer - to support additional scanning activity as service extends to include Sundays;

Appointment Scheduler - to support scheduling of additional activity and provide reception cover for Sundays;

Ultrasound Helper - to support the new full time service at Bolsover Street and provide assistance to the Consultant Radiologist.
1.4. The costs of these additional posts along with an estimate of consumable expenditure to support the posts, can be summarised as:
Consultant Radiologist
Radiology Fellow
Band 7 Scanning Radiographer
Band 6 Theatre Radiographer
Band 3 Appointment Scheduler
Ultrasound Helper
Forecast additional consumable expenditure
£108k
£40k
£45k
£37k
£22k
£20k
£24k
Total £296k
1.5. Without the additional staffing, it would not be possible to increase the current capacity within the Imaging D epartment. For example, the Trust’s 18 week demand and capacity analysis has shown that the Imaging Department would be required to undertake significant additional lists to support delivery of the Trust’s forecast outpatient activity levels.
2. Current Service Profile
2.1. The current staffing level of the Imaging Department covers X-ray at Bolsover and
Stanmore, the DEXA service and the Scanning Unit at Stanmore. The service comprises of
6wte Consultants, 2wte Fellows and 27.92wte radiographers.
2.2. The table below sets out the current staffing profile:
Role All areas
Bolsover
X-ray
Stanmore
X-ray
DEXA
Stanmore
Scanning
Total
Consultants 6.0 6.0
Fellow 2.0 2.0
Total Medical
Radiographer band 2 1.0 1.8 2.0
8.0
4.8
Radiographer band 4
Radiographer band 6 2.2
2.0
10.0 2.0
2.0
14.2
Radiographer band 7 1.0 2.8 1.4 5.0
Radiographer band 8
Total Radiographer
A&C band 2
A&C band 3
A&C band 4
A&C band 6
0.8
1.0
1.0
3.0
1.8
0.8 1.0
2.5
1.0
100.0
10.1
3.6
34.7
3.0
3.5
2.8
1.0
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Total A&C 10.3
TOTAL 53.0
2.3. The capacity that this staffing level supports has increased year on year and is currently at over 99% capacity (attendance = 94% and booked DNA = 5%). The table below presents historical and forecast activity levels for all modalities, including Outpatients, Inpatients and Theatres:
Year CT MRI U/S NMR X-ray Fluoro DEXA Total
2006/07
2007/08
% Increase
2008/09
2,080 4,414 2,298 632 43,714 3,256 5,837 56,394
2,778 5,292 2,943 766 45,255 3,720 5,832 60,754
34% 20% 28% 21% 4% 14% 0%
3,589 7,020 3,724 910 49,568 4,181 5,884
8%
68,992
% Increase
2009/10 Forecast
% Forecast
2010/11 Plan
29% 33% 27% 19% 10% 12% 1% 14%
3,768 7,371 3,910 956 52,046 4,390 6,178 78,620
5% 5% 5% 5% 5% 5% 5% 14%
3,832 7,496 3,976 972 52,931 4,465 6,283 79,957
% Forecast
2011/12 Forecast
2% 2% 2% 2% 2% 2% 2%
3,897 7,624 4,044 989 53,831 4,541 6,390
2%
81,316
% Forecast 2% 2% 2% 2% 2% 2% 2% 2%
NB: Future activity has been calculated a ccording to the Trust’s strategy for activity increase; this is expected to be a minimum as it can be seen that historically the departmental activity has increased at a rate above the Trust’s overall activity increase.
3. Service Demand and Market Analysis
3.1. All orthopaedic patients will require Imaging at some stage during their clinical management.
3.2. The RNOHT has increased the Surgical Consultant compliment to not only achieve the current 18 week RTT pathway, but also the future increase in demand as a result of the full implementation of patient choice under ‘Choose and Book’. As a result, an increase in referrals to Imaging can be expected which along with the internal targets requiring
Imaging referrals to be performed within 2 weeks (including report) and Imaging treatments to be performed within 8 weeks of the request being made, presents a very challenging environment going forward.
3.3. From another perspective however, the increase in activity if resourced properly, should be seen as an opportunity.
3.4. For example, the introduction of unbundled tariffs for Outpatient Diagnostic Imaging and some interventional activity from April 2009, will allow the additional activity and subsequent income to support this business case and make a contribution to the Trus t’s overall financial position.
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3.5. The table below demonstrates this additional activity along with an indication of the potential income the service would generate as a result of the 18-week demand and capacity modelling:
Modality
CT
Number of additional lists
2
Number of patients seen on a list
10
Additional lists per annum (48 weeks)
480
Unbundled tariff cost
Forecast additional income
DEXA
Fluoro
MRI
NMR
U/sound
Total
1
4
3
1
5
16
12
4
22
5
6
576
192
1056
240
288
2832
£102
£86
£122
£48,960
£49,536
£23,424
£173 £182,688
£141
£55
£33,840
£15,840
£354,288
NB: The additional work identified in the above table would be undertaken by the posts presented in this paper.
3.6. Additional income is also forecast from providing more interventional radiography sessions. No data has been collected to fully support the business case and as a result has not been provided as part of the income analysis above. However, there is an expectation that income in the region of £150,000 could be expected.
3.7. To further support the activity and income assumptions above, at the end of the first quarter of 2009/10 where income levels were above plan by approximately 4%, the department delivered unbundled tariff income of £720k against a target £452k (see table below). Grossing this up for the whole year and assuming the same levels of activity continue, the service can expect to deliver income of approximately £2.9million against a target of £1.8million.
3.8. The table bellows outpatient activity and unbundled tariff income during 1 st quarter of the year and forecast for the remainder assuming the same historical levels.
CT MR U/S NM FLUORO DEXA Total
Activity
460 1222 584 121 217 415 3019
Diagnostic tariff revenue
Interventional tariff revenue
2009/10 Quarter
1 Total
2009/10
Forecast
£57k
£90k
£147k
£240k
£240k
£32k
£150k
£182k
£588k £960k £728k
£24k
£24k
£96k
£10k
£60k
£70k £58k
£280k £232k
£363k
£300k
£720k
£2.9m
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4. Case For Change and Options
4.1. The Imaging service has continued to grow in both demand and use of resources year on year. The service has now met a step change with regards to its ability to continue to develop in line with the needs of the rest of the Trust.
4.2. In order to be able to expand further and support the developments in other services, such as the additional theatre, extended working days in Outpatients and the increased flow of patients through the wards, it is necessary to review the staffing levels to support these changes.
4.3. This paper enables the known service developments in the Trust to be supported by the
Imaging Department and enables the department to develop as well as make a significant financial contribution back to the Trust.
4.4. Option 1 – Do Nothing
4.4.1. If additional staff are not approved it will not be possible

To establish the new ultrasound service at Bolsover Street;

Deliver a timely service in Imaging with the required turnaround targets for both diagnostic and treatment examinations;

Deliver a timely reporting service;

Accommodate the additional activity from the proposed growth for 2009/10 and the 2 years thereafter.
4.4.2. Inevitably access breaches will occur as a result of not meeting demand with the strong possibility of weak performance scorings. Furthermore, the continued goodwill of the
Consultants to perform additional reporting and interventional sessions is now reaching tipping point and cannot continue.
4.5. Option 2 - Appoint and fund all posts
4.5.1. Each post within the business case proposal will deliver a specific area of benefit across the Trust. This can be summarised as follows: a) Consultant Radiologist (£108k) – This appointment will enable the introduction of the new Ultrasound service and deliver a reduction in the reporting turnaround times. It will facilitate cover to create a seamless service. The Ultrasound service could not be provided without an additional Consultant Radiologist. Additionally, savings will be made against the current arrangements which require extra session payments of £500 per time to be made to the Trust’s Consultant Radiologists to clear the backlog of reporting within the service. b) Radiology Fellows
(£40k) – This will enable a training programme at the RNOHT for
Radiology with associated papers to further profile the Trust on an international basis. It will also enable extra reporting to be delivered and additional interventional lists in the
Ultrasound service. c) Band 7 Scanning Radiographer (£45k) - This post is required to cover the intended service extension to Sunday and to maintain the standards in the MR service as a joint
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lead. Part of the funding for this post will come from savings made as a result of the cessation of Sunday bank payments at £2.5k a month. d) Band 6 Theatre Radiographer (£37k) This post will become essential when the additional theatre is opened. e) Band 3 Appointment Scheduler (£22k) - This post is fundamental to a 7 day service in
Scanning and to facilitate cover for all appointments in Imaging. This will accommodate the additional referrals from the increase in Consultant numbers and be instrumental in recording and processing information to ensure unbundled tariff income is charged by the
Trust. f) Band 2 Ultrasound Helper (£20k) – The new service at Bolsover Street will be dependant on the introduction of this post.
4.6. Service benefits and risks to purchasers and patients:
Benefits:

The introduction of the new ultrasound service at Bolsover Street;

The ability to undertake a more timely reporting service;

Delivery of the interventional lists as a continuous service;

Extended capacity in Scanning/Sunday working;

Extended capacity in theatres/week-end working;

Maintain the full booking appointment service in Imaging.
Risks:

Ensuring sufficient equipment availability and utilisation of services to maximise demand;

Failure to meet NHS Plan 18 week RTT maximum target;

The profile of the RNOH would be adversely affected if specialist work were required to go elsewhere due to a lack of capacity.
5. Summary Financial Impact of Option 2
5.1.
Full year costs of £296k will be offset by additional minimum income of £354k, generating a profit of £58k. This is likely to increase by £150k, once the interventional radiography activity and income is confirmed.
5.2.
Staff cost savings will be made from stopping weekend bank payments of £30k per annum and additional session payments made to consultants. The latter is expected to save an additional £40k.
5.3. Therefore in total, the net full year contribution the business case will make to the
Trust’s surplus is forecast to be £278k.
5.4. For 2009/10, due to the timing of staff recruitment and allowing for a setup period for the new theatre and Bolsover Street, the expected contribution to the Trust’s surplus after meeting all costs is forecast to be approximately £50k. However, significant improvements in the quality of the service will have begun to embed themselves so that the benefits going forward will allow the income and activity targets to be delivered.
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6. Timetable and deliverability
Post
Consultant
Radiologist
Radiology
Fellow
Theatre
Radiographer
Scanning
Radiographer
Assistant
Practitioner
Imaging
Committee
July
09
Executive
Board
September
09
Vacancy
Panel
September
09
September
Recruitment
Process
September
09
September
Start date
09 09 09
October 09 October 09 December
09
September
09
TBC
(following vacancy)
September
09
September
09
October 09
TBC
October 09
September
09
December
09
September
December
09
TBC
December
09
December
09
Appointment
Scheduler
Ultrasound
Helper
7. Recommendation
7.1. The Trust Board is asked to approve the appointment of the Consultant Radiologist and increase in staff to ensure delivery of the additional activity the Trust has been and is forecast to deliver along with the new Ultrasound service, new Theatre and Consultant
Surgeon appointments.
Clinical Leader / Corporate Dept: Dr T Muthukumar
Clinical Director: Dr Mike Cooper
Lead Director: Mrs Sheila Puckett
Lead Manager / Author:
Funding Year: 09 – 10
Mrs Pauline Lodwick
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