Bob Bury

Will Hunt simply add to teleradiology fears?

Will we never learn? Every time we get a new Secretary of State for Health, we think ‘perhaps this time’ – talk about the triumph of hope over experience.

So now we have Jeremy Hunt, who at least provides a rhyming opportunity for any cheery cockney docs who may be reading this. Turns out that his track record on the NHS is about as reassuring as his past performances in regulating media moguls. You’ll note that one of the services he is so keen to hive off to Richard Branson – who presumably has plenty of time on his hands since he lost his train set – is breast screening. Well, that’s a relief; wouldn’t want the private sector getting their hands on any important stuff, would we?

Of course, radiology as a specialty is particularly vulnerable to the current political obsession with selling the NHS off to ‘any qualified provider’. Imaging services can be neatly parcelled up for cherry-picking, and the digital revolution means that online radiology outfits are springing up in an entirely unregulated fashion around the world.

Opinions are ten-a-penny, and nowhere is that more true than in the field of teleradiology. Of course, that opinion on your patient’s CT scan will come from a radiologist you’ve never met, who practises in India or Milan and won’t, therefore, be available to discuss the result with you in the corridor or at the MDT meeting. And he or she may or may not possess a qualification that the GMC and Royal College of Radiologists would consider relevant to the task, and may or may not be visually impaired. Still it’s quick and cheap (and here I’m deliberately avoiding a distasteful comparison with low-class hookers), and can help cash-strapped trusts to make ends meet.

One person who has been very vocal on this subject is Richard Fitzgerald, a consultant radiologist from Wolverhampton. He has played a leading role for the RCR on various committees looking at the issue of teleradiology, and was also one of the refuseniks who pressured the college to take a more robust line on Lansley’s Health Bill. In a recent round-robin email urging action on Hunt’s support for the outsourcing of breast screening which went to college officers amongst others, he outlined his areas of concern:

– Difficulties in quality assurance and medical regulation, with associated risks for patients

– Deskilling of radiologists and radiographers in NHS departments

– Reduced funding for NHS hospital radiology departments with knock-on reduction in their ability to deliver other services e.g. MDT participation

– Negative impact on recruitment and retention in a branch of radiology which is already unpopular due to the litigation risk

– Adverse effect on morale as NHS staff see their department  being asset-stripped for corporate profit.

He is asking for the RCR to take a leading role in highlighting these risks to the public, in what is likely to be the first of many potential run-ins with HMG as they seek to fragment the NHS in the interests of plurality and (supposedly) efficiency. Breast screening would actually be a useful exemplar of the risks involved in the farming-out of services, given the high media profile of breast cancer. It is also an opportunity to link this most emotive of issues with the more general threat of unregulated teleradiology services – not an easy topic to get across to the public.

As one of the radiologists who became a thorn in the flesh of the RCR hierarchy earlier this year, Dr Fitzgerald shows great tenacity, and a very thick skin, in urging the college to take up arms against HMG’s insistence on privatisation. The result of the previous popular uprising was a significant shift in college policy on the Health Bill, albeit too late to have any effect. We shall have to wait and see if this latest attempt to rally the troops bears fruit.

To be fair to the RCR, it’s early days, and we wouldn’t have expected any public response yet, so hopefully Dr Fitzgerald will be pushing at an open door on this occasion. In the meantime, Jeremy looks set to take up a position in the DoH demonology alongside Fragrant Virginia, Alan the Red, Bruiser Reid et al (can’t think of a catchy, printable, epithet for Lansley – any offers?).

Unless, of course, he turns out to be a decent chap after all. I mean, it has to happen some day…doesn’t it?

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12 Responses to “Will Hunt simply add to teleradiology fears?”

  1. joshek says:

    well dear radiologists, you may consider this: for many years you have made sure that you’re not exactly loved by grilling poor houseplants when they were only doing their bosses bidding to get this and that image done. Or, by alienating A&E docs when they dared to need a CT out of hours. As for teleradiology: there is no shortage of radiologists in e.g. india who hold full qualifications from your very own college. The rcr, like all colleges, thrives on profitably exporting its “brand”. Whether i get the ooh ct report from an nhs consultant from home or an rcr qualified radiologist in india makes no difference at all: neither have seen the patient. Teleradiology WILL wipe out expensive nhs backroom reporting – only interventional radiologists have a future as nhs consultants and the name of the health secretary in post or even the party in government will make no difference whatsoever to this.

  2. Tom Goodfellow says:

    There was a very good talk given by Prof Giles Boland http://www.massgeneral.org/cancer/doctors/doctor.aspx?ID=16931
    at the RCR meting last week on the effects of the teleradiology explosion in the US over the last decade.

    He made the point that the US radiologists, paid very well on a cost-for-case basis, ensured that they reported all examinations during the day. Then at 6.00pm suddenly in-house reports were no longer essential and they all pushed off to their increasingly expensive houses. Consequently there came a huge expansion in outsourcing out of hours.

    Then, surprise surprise, one day their managers twigged that if radiologists were not essential at night perhaps they were no so essential during the day! The “added value” of in-house radiologists has quickly been eclipsed by the opportunity to reduce costs.

    So beware UK radiologists. Don’t sell your birthright for a mess of pottage!

    And Joshek if radiologists are grumpy at night it is possibly because it is the third call, effectively destroying a night’s sleep, yet they still have to come in the next morning to run the MDM! No clocking off at the end of the shift for them.

  3. Bob Bury says:

    Poor old joshek – you’ve obviously had some problems with radiologists over the years. Perhaps your rather unfortunate tone explains at least some of that.

    As for: Whether i get the ooh ct report from an nhs consultant from home or an rcr qualified radiologist in india makes no difference at all well, what can i say? You are clearly from the radiology-request-as-prescription school, a rapidly dwindling band, I’m pleased to say. You have presumably never made proper use of the radiology service, which is unfortunate for your patients.

    You have heard of MDTs?

  4. privatepracticeexpert says:

    Teleradiology is coming, there is no doubt about that. And all the fears Bob Bury highlights in his article I believe can be dealt with but one: The power of the face to face discussion regarding a difficult case. Yet even this, I believe, could be addressed in various ways.

    The problem is the nature of radiology itself: taking and interpreting images. (excluding interventional radiology of course). Firstly, it seldom requires a radiologist to take the pictures. Secondly, the images can easily be transmitted around the globe to a human expert to interpret them, 24 hours a day with a report back in minutes – not waiting days or at best hours for the registrars opinion to be run by the consultant which then sits on a dictaphone tape for days more until it arrives on the computer.

    But this is just the beginning of course. One thing computers are fabulous at is pattern recognition, and I predict that there will be a window of perhaps a few years whereby radiology reporting will be hived off around the world – then this too will disappear as computers will give opinions in seconds rather than minutes.

    Change is inevitable – but it also raises opportunities which can be hard to foresee. Perhaps instead of fighting what is clearly inevitable we should look at the hidden opportunities both for the profession and patient care.

  5. joshek says:

    bob, lets make this quick: the added value of a radiologist reporting the ooh ct from home over the rcr qualified radiologist reporting it from india is what exactly ??

  6. Bob Bury says:

    Well, Joshek, it depends. Sometimes no difference at all. The problem is, that you just don’t know, do you? Clinicians know their own radiologists, their strengths and weaknesses, they know how much confidence to place on a report and when to go and have a chat about the case. They will work with indivdual radiologists in MDTs and other clinical scenarios.

    Even with excellent teleradiology practices, that’s not possible, or at least, not easy. And you talkabout ‘rcr qualified’ radiologists as if they were an homogenous group. It’s possible to possess the FRCR but be inexperienced in some modalities or in some specific applications of those modalities (or, dare we say it, not very good at the job). This becomes rapidy apparent when you work with the radiogists on a day to day basis.

    And of course, the big problems won’t occur with the initial teleradiology practices, which will make a point of only employing highly qualified and experienced staff. Once the flood gates open, the bottom feeders will move in, and it will be very difficult to exert any kind of quality control.

    I accept that radiology is going to change, and that the current generation of radiologists will have to workin very different ways to mine. Huge changes have already occurred, and most of those have resulted in radiologists taking a more direct role in patient management rather than less, for example by spending much of the working week in MDTs. Teleradiology clearly pushes them in the opposite direction, and to some extent we’ll have to accept that. However, we’ll do no-one any favours by allowing it to spread uncontrollably at the cost of quality.

  7. joshek says:

    you make very good points bob – but these points only apply in a world that has largely vanished. allow me to use A&E as an example as i happen to know that field: the reality is that, especially ooh, it runs on locums – and this means your argument that clinicians knowing their radiologists just vanishes. not to mention the peak into the future by “privatepracticeexpert”, which i think is spot on: backroom (i.e. reporting) radiologists have no future.

  8. waffles says:

    The question is, Joshek, that if there’s really no difference between “backroom radiologists” and teleradiologists in India, then why would you be anxious or remotely concerned about switching from one set to the other? It’s not your money, after all. Also, your obviously bad attitude to radiologists in general, would still apply to the unfortunate teleradiologists, who at least would then have the escape options of disconnection, technical glitch or “faulty line”. This might not be good for your blood pressure, especially as you are clearly becoming older and crankier.
    The second issue is that if radiology can be conveniently “out-sourced”, there’s absolutely no reason in principle why any medical or surgical speciality of any stripe can’t receive the same treatment. With Skype as a prototype, just about anything is possible. You should really think of teleradiology as a sort of global pilot study for the rest of the medical profession.

  9. Bob Bury says:

    Joshek – I quite take your point, which confirms that you are being forced to rely on a sub-standard radiology service, and that’s a shame. You are right that we could reproduce that poor service more cheaply using teleradiology.

    I would much rather give you a good service now and show you what you (and your patients) have been missing.

  10. Malcolm Morrison says:

    In my experience, in most specialties, the consultant is pretty good at reading ‘images’; which begs the question that my radiology colleagues used to ask – if a junior clinician needed a consultant radiology opinion, why had they not asked for their clinical consultant’s opinion?

    I used to believe – and teach – that the most important item on a radiology report was the signature.! There is no substitute for personal conatct and discussion ;so clinicians and radiologists know who is ‘a good opinion’ on what.

    Of course, our beloved bean-counting accountants who now ‘run the show’ cannot appreciate the ‘value’ of this – because it cannot be ‘measured’; they only know the ‘cost’ of everything – and all too often get that wrong!

  11. Radman says:

    Joshek, we’re not all about to pack it in yet! A lot of the more straightforward reporting is now done by reporting radiographers in uk under supervision of consultant radiologists and is therefore lower cost, probably undercutting a lot of the teleradiology brigade. Local trusts that have outsourced OOH imaging have found costs skyrocketing as nothing is ever refused however unjustified as the companies earn from performing scans. Even at choose and book rates the income associated with a typical reporting session would greatly outweigh the cost of an NHS consultant PA.
    A large part of my time is spent advising colleagues on what imaging is needed to resolve a clinical problem and reviewing studies in the cold light of an MDT when the correct clinical information is available as opposed to the often ill considered and incomplete information presented to the original reporter. Its amazing how often a completely new diagnosis is identified and management changed.
    The idea of locum A&E doctors generating large volumes of poor quality requests farmed out to teleradiology outfits on another continent is simply a logistical and governance nightmare. Someone has to defend the interests of the patient against blanket use of inappropriate imaging as a substitute for clinical acumen and in the current NHS this is the role of the consultant radiologist.

  12. Bob Bury says:

    Radman – couldn’t have (but didn’t) put it better myself!

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