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Radiography 18 (2012) 153e159

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Radiography

journal homepage: www.elsevier .com/locate/radi

A survey on the progress with implementation of the radiography profession’scareer progression framework in UK radiotherapy centres

Sarah James*, Charlotte Beardmore, Claire DumbletonThe Society and College of Radiographers, 207 Providence Square, Mill Street, London SE1 2EW, UK

a r t i c l e i n f o

Article history:Received 21 December 2011Received in revised form12 March 2012Accepted 14 March 2012Available online 15 April 2012

Keywords:Career progression frameworkTherapeutic radiographersRadiotherapyRadiotherapy capacityWorkforce

* Corresponding author. Tel.: þ44 207 740 7238.E-mail address: sarahj@sor.org (S. James).

1078-8174/$ e see front matter � 2012 The College odoi:10.1016/j.radi.2012.03.002

a b s t r a c t

Aim: The purpose of the survey was to benchmark the progress with implementing the radiographyprofession’s career progression framework within radiotherapy centres across the United Kingdom (UK).Methods: A survey questionnaire was constructed using the Survey Monkey� tool to assess imple-mentation of the career progression framework of the Society and College of Radiographers. Onceconstructed, an on line link to the survey questionnaire was emailed to all radiotherapy centre managersin the UK (N ¼ 67) who were invited to provide one response per centre. The survey comprised twentynine questions which were grouped into nine sections.Key results: The workforce profile indicates that increases in assistant, advanced and consultant levelpractitioners are required to meet National Radiotherapy Advisory Group recommendations1 with onlya small number of centres having fully implemented the career progression framework. The overallvacancy level across the therapeutic radiography workforce was 4.6% at the time of the survey.Conclusions: and Recommendations: The survey has highlighted some progress with implementation ofthe career progression framework across the UK since its launch in 2000. However the current level ofimplementation demonstrated is disappointing considering it is a key recommendation within the NRAGReport 20071 with respect to England. It is recommended that all centres undertake a multi-professionalworkforce review to embed the career progression framework within their service in order to meet theworkforce challenge associated with the required anticipated large growth in radiotherapy capacity.

� 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction

The concept of the four tier career progression model was firstdescribed by Evans2 in 1999 and was outlined for therapeuticradiography in the 2003 College of Radiographers document,3 AStrategy for the Education and Professional Development of Ther-apeutic Radiographers’ and the subsequent Education and Profes-sional Development Strategy.4 The Department of Health fundeda national pilot project to develop the implementation of the fourtier career progression framework and the subsequent report5

identified the four aims of the four tier model as follows:

� to define multidisciplinary teams not by profession, but by theskills and competencies that best deliver the patient or client’sneeds;

� to promote new roles, extended roles and advanced practicethat will encourage lifelong learning;

f Radiographers. Published by Else

� to widen the routes of access to clinical careers and improverecruitment and retention of the health professions;

� in the public interest, to maintain practice standards anddevelop the inherent potential of all clinical practitioners.

Implementation of the four tier framework offers career devel-opment opportunities for radiographers, with new roles atadvanced and consultant levels of practice. The framework neces-sitates and offers the opportunity for the development of anassistant practitioner role working within defined areas of practiceto support the higher levels of practice and once competent assis-tant practitioners can work on a 1:1 basis with registered radiog-raphers as part of the team delivering radiotherapy. Theimplementation of this new role to support therapeutic radiogra-phers enables registered radiographers to use their higher levelskills more effectively for the benefit of patients and the service.

Since its inception, the implementation of the four tier careerframework has been seen as a key requisite to enable reform andmodernisation of the delivery of NHS health care services, in linewith a series of DH strategies; Meeting the Challenge: A Strategy forthe Allied Health Professions,6 The NHS Plan,7 NHS Cancer Plan,8

vier Ltd. All rights reserved.

Table 1Career progression framework questionnaire Categories.

Section Number ofquestions

Demographic details 2Therapeutic radiographer workforce

establishment7

Assistant practitioners 5Radiographers 1Advanced practitioners 3Consultant practitioners 2Service managers 2All therapeutic radiographers 4All assistant practitioners 3

S. James et al. / Radiography 18 (2012) 153e159154

the Cancer Reform Strategy9 and more recently ImprovingOutcomes: A Strategy for Cancer.10

Specifically for radiotherapy, the National Radiotherapy Advi-sory Group (NRAG), a multi-professional group which includedtherapeutic radiographers, was established in 2004 to adviseministers on the development and future delivery of world classradiotherapy services in England. The NRAG report1 in 2007 iden-tified a significant increase in future demand for radiotherapy andrecommended that NHS radiotherapy services deliver up to 54,000fractions per million population by 2016, which was a 91% increaseon the activity levels at the time. It also recommended that thera-peutic radiographers practicing at advanced and consultant levelshould be up skilled and supported by oncologists to take onresponsibility for planning and delivering more of the protocolgoverned standard treatments. NRAG recommendations stated thatthis could comprise up to 80% of patients requiring radiotherapy.This would release oncologists’ time and enable them to spenda higher proportion of their time with the more complex casesthereby utilising their higher level skills more effectively. The NRAGreport1 recommendation specified the full implementation of thecareer progression framework (four-tier radiography career struc-ture) in all radiotherapy departments as part of the solution toachieving the required increase in radiotherapy capacity inEngland. This recommendation was endorsed by both the CancerReform Strategy9 and the subsequent Improving Outcomes: Astrategy for Cancer10 and is supported by the multi-professionalguidance within the radiotherapy competencies on behalf of theNational Radiotherapy Advisory Group and Skills for Health:November 2007.11

In response to the NRAG Report,1 the National ImplementationGroup (NRIG) and working sub-groups (including the WorkforceSubgroup) were established in 2007 to oversee development andmonitor progress in England at a national level.12 The members ofthe NRIG continue to have oversight responsibilities for thedevelopment of radiotherapy services in line with the currentGovernment strategy: Improving Outcomes: A strategy forCancer.10 NRIG membership now includes observer representationfrom the other United Kingdom (UK) countries; Scotland, Walesand Northern Ireland to assist with supporting the development ofradiotherapy services in those respective countries and in order toencourage a coordinated approach to workforce development.13

In 2007 the Society and College of Radiographers (SCoR)commissioned a report14 to identify the existing scope of practicefor the radiography workforce across both imaging and radio-therapy in the UK. One of its key aims was to quantify the radi-ography workforce working in accordance with the careerprogression framework. It highlighted the existing variation inimplementation of the framework at that time for all levels in thetherapeutic radiography workforce; consultant radiographerswere employed in only 3 centres, advanced practitioners wereworking in 54% of centres and only 26 centres had assistantpractitioners.

The framework has now been in existence for over a decade andduring this time span the College of Radiographers (CoR) haspublished a number of supporting professional guidance doc-uments15e22 to aid radiotherapy service managers (RTSMs) andclinical staff with all aspects of its implementation. The most recentguidance “Implementing the career framework in radiotherapy e

policy into practice”22 provides a detailed case study of Adden-brookes Hospitals’ radiotherapy service experiences along withindicative job profiles as guidance to RTSMs across the UK. It alsooutlines the benefits that have been achieved by the implementa-tion of these roles,23 such as improved patient experience, reduc-tions in hospital admissions and improvements in practice throughthe implementation of new techniques.

Background to this survey

Since being established, and whilst facilitating a number ofworkshops and conferences, members of the NRIG WorkforceSubgroup acquired anecdotal evidence of the continuing widevariation of the implementation of the career progression frame-work in radiotherapy services across England, thus supporting thefindings of the 2008 University of Hertfordshire report.14 This isdespite NRAG report1 recommendations previously discussed andthe provision of supporting CoR professional guidance.

Whilst evidence about new roles is collected for each review ofthe profession’s scope of practice the SCoR recognized the impor-tance of collecting specific baseline data from every centre in theUK about progresswith implementation in radiotherapy centres. Asa consequence this survey was commissioned to provide evidenceto support the national and local drive for implementation of thecareer framework through NRIG.

Methodology

A quantitative methodology was adopted using a questionnairesurvey. A questionnaire was devised which consisted of 29 ques-tions in 9 sections (see Table 1) and included questions requiringyes/no responses, multiple choice responses and the submission ofnumerical data.

The questionnaire was tested prior to distribution by one RTSMfor understandability, accessibility and ease of use, and by the SCoRKnowledge Officer for Data Protection Act24 (1998) compliance.

All RTSMs in the United Kingdom (N ¼ 67) were emailed a linkto an on-line survey, using the Survey Monkey� tool and wererequested to submit one response per centre.

All respondents were requested to provide their centre’s nameand contact details to enable effective monitoring of responsesand assist with maximizing the response rate. It was agreed thatall data would be anonymised. In particular it was agreed that datawould be analysed across the UK in entirety, as centres in thedevolved countries may be identifiable due to the small number ofcentres per country. This was particularly the case in NorthernIreland.

The survey was distributed on 8th July 2010 with coveringinformation to encourage responses by the submission deadline of23rd July 2010. All RTSMs were requested to submit data for theirservice as at 1st July 2010. The importance of obtaining as higha response as possible necessitated extending the deadline to 6thAugust 2010. Follow up emails were sent to RTSMs to encourageresponses from the 23 outstanding centres. Direct targeting bya combination of telephone and emails enabled a final responserate of 94% (sixty three) by 7th January 2011.

S. James et al. / Radiography 18 (2012) 153e159 155

Results

Response rate

An excellent response rate of 94% (63 centres) was received. Allbut one of the RTSMs responsible for services provided on morethan one site provided a single response for their entire service. Theone exception was an NHS Trust which provides radiotherapyacross three sites and provided separate responses from each of thethree sites. One NHS radiotherapy department in England and oneindependent sector provider failed to provide data.

Multi-professional review of skills and competences requirementswithin the radiotherapy pathway

A multi professional review should be carried out according tothe methodology specified by NRAG11 and cover all relevant staffand professional groups who have direct patient contact.

Only twenty two (34.9%) centres confirmed that they hadundertaken such a review. One centre (1.6%) confirmed that sucha review is underway, leaving forty centres (63.5%) having notundertaken or not planning to undertake such a review.

Figure 2. 3 month WTE vacancies in the radiography workforce.

Number ofWhole Time Equivalent (WTE) staff within each agenda forchange banding in the radiography workforce establishment (UK)

Theworkforce profile from this survey shows that (see Fig.1) themajority of the UK therapeutic workforce working at bands 5, 6 & 7.

NOTE: those employed at band 5 and above are registeredradiographers.

Number of 3 month Whole Time Equivalent vacancies in theradiography establishment (UK)

The workforce profile in Fig. 2 confirms that the majority ofvacancies are in band 5.

The overall vacancy level at three months was 4.6%.

Figure 1. Number of WTEs in radiography workforce establishment.

Number of practitioners in the UK undertaking assistant practitioner,practitioner, advanced and consultant practitioner roles

A high number of practitioners is shown in Fig. 3 in relation tothe other tiers.

Job titles used in your centre that are aligned to the careerprogression framework and SCoR guidance

The career progression framework specified the key levels to be:assistant, practitioner, advanced and consultant practitioners. Thissurvey also investigated use of the role title ‘research radiographer’as per recent SCoR guidance.22

Results from this survey indicate that the numbers of centresusing the career progression framework and research radiographerjob titles are as in Fig. 4.

Current usage of each respective title varies; assistant practi-tioner being used by forty three (68.3%) centres, research radiog-rapher by thirty seven (58.7%) centres, advanced practitioner bythirty (47.6%) and consultant by eight (12.7%) centres.

Figure 3. Number of WTE individuals undertaking the following roles.

Figure 4. Are the career progression framework titles used within job titles in yourcenter for the following?

Figure 6. What percentage of your qualified assistant practitioners are accredited withthe SCoR?

S. James et al. / Radiography 18 (2012) 153e159156

Assistant practitioners

Assistant practitioners (AP) working 1:1 with radiographersupervision

Results in Fig. 5 indicate that thirty five (55.6%) centresconfirmed that assistant practitioners (APs) are working 1:1 witha registered supervising radiographer, four (6.3%) centresconfirmed that some APs within their centre work this way.However twenty four (38.1%) centres do not have APs working inthis capacity.

Allocation of assistant practitioners (APs) to all linear acceleratorsand pre treatment areas

Only three (4.8%) centres have APs allocated to all their linearaccelerators and five (7.9%) centres have APs allocated to all pre-treatment areas.

Workforce plans to increase the number of assistant practitioners(APs)

Thirty seven (58.7%) centres are planning to increase thenumber of APs working in their centres leaving twenty six (41.3%)centres with no such plans.

Percentage of assistant practitioners who are SCoR accreditedResults in Fig. 6 indicate only fourteen (22.2%) centres respon-

ded that between 76 and 100% of their assistant practitioners areaccredited by the SCoR. A further five (7.9%) centres confirmed that

Figure 5. Do the assistant practitioners work 1:1 with a supervising practitioner inyour center?

between 26 and 50% of their APs are SCoR accredited. Disap-pointingly, forty four (69.8%) centres confirmed that 0% of their APsare SCoR accredited.

Advanced practitioners

Roles of advanced practitionersFig. 7 shows the relative number of advanced practitioners in

post:

Workforce plans to increase number of advanced practitionersThirty nine (61.9%) centres confirmed they are planning to

increase the number of established advanced practitioner posts,with twenty four (38.1%) stating they have no such plans.

Numbers of advanced practitioners participating in the SCoR pilotaccreditation scheme

Results in Fig. 8 indicate only ten (15.9%) centres confirmed theyhave advanced practitioners participating in the SCoR pilotaccreditation scheme which was conducted between April 2010and January 2011.

Consultant practitioners

Roles of consultant practitioners in postResults in Fig. 9 indicate the relative numbers of consultant

practitioners in post.At the time of this survey there were seven centres with

consultant practitioners in post.

Figure 7. Roles of advanced practitioner in post.

Figure 8. Number of centers with advanced practitioners participating in the SCoRpilot accreditation scheme.

S. James et al. / Radiography 18 (2012) 153e159 157

Management review of clinical oncologist vacanciesCentres were asked whether they reviewed clinical/medical

oncologist vacancies as they occur with a view to appointing a non-medical consultant.

Only seven (11.1%) centres confirmed that they undertake sucha review, with the vast majority of centres (56, 88.9%) indicatingthat they don’t.

Radiotherapy service managers

Succession planning for future radiotherapy service managersFifty (79.4%) centres confirmed that succession planning is in

place.

Protected study time (PST) for Therapeutic Radiographers andAssistant Practitioners

Few centres have formal agreements in place. Only seven (11.1%)centres indicated that they have a formal agreement for theprovision of PST in place for therapeutic radiographers whereas ten(15.9%) centres indicated that they have a formal PST agreement inplace for assistant practitioners.

Provision of clinical supervisionThirty seven (58.7%) centres responded that they provide clin-

ical supervision for therapeutic radiographers, and twenty nine(46.0%) centres responded that they provide clinical supervision forassistant practitioners.

Figure 9. Roles of consultant practitioners in post.

Practice educator (PE)/clinical learning facilitators (CLF) in postSlightly fewer than half the centres (49.2%) centres confirmed

that they have PE/CLF posts.Note: role titles used in the survey are those in SCoR guidance.17

Limitations of the survey

There are certain limitations to the survey that need to be rec-ognised and which may have affected results.

As the questionnaire survey was emailed to the radiotherapyservicemanagers by an on-line link it is not possible to know if eachquestionwas fully understood in the manner intended as there wasno ‘face to face’ follow up. It is also unknown if all questions wereanswered honestly or if the survey was given the answer therespondent felt was correct.

The results from the question relating to the requirement fora multi-professional review of skills (which is an English directive),may be skewed due to the results from the devolved countries notbeing listed separately, as this would compromise anonymity. Thedevolved countries are not bound by the Cancer Peer ReviewMeasures25 pertaining to England and this may account in part forthe reported and discussed low compliance to this question.

Discussion

The high response rate (94%) eventually achieved providesa robust perspective on the implementation of the radiographyprofession’s career progression framework in relation to the ther-apeutic radiography workforce in the UK. Although the time scalefor the data collection was extended, the census date for the studyremained the 1st of July 2010 with a high number of responses (29)being received within the original time-frame. Hence, this studyprovides a reliablemeasure of the progress the profession hasmadewith the implementation of its career progression framework as faras radiotherapy is concerned. It should enable the SCoR to makeappropriate recommendations regarding future radiographyworkforce requirements for radiotherapy services.

Number of 3 month Whole Time Equivalent vacancies in theradiography establishment (UK)

The overall three month vacancy level indicates there werevacancies existing for the graduating practitioners during summer2010. It is possible that RTSMs had accrued vacancies at practitionerlevel to coincidewith the availability of the newgraduates thereforethis survey may indicate a slightly higher vacancy rate than if thesurvey had been undertaken in the autumn. However the NHSNational Cancer Analysis UK Radiotherapy National WorkforceCensus26 undertakenonSept 30th2010whichwaspublished inMay2011 indicated a UK vacancy rate at 5%, this was surprising as it wasassumed that the absorptionof thenew2010graduateswould resultin adecrease to thevacancy levels indicatedby this survey.Anumberof new centres and satellite services have opened during this periodincreasing radiotherapy capacity in the UK, these are both privatesector and NHS.27e30 In September 201031 NRIG was aware ofplanning for at least 25 newcentres in England alone in the next 5e7years. The continued level of expansion of radiotherapy services inthe future may be difficult to achieve whilst this significant vacancylevel continues as it will require a further increase in workforcenumbers and a range of skills to support new models of working.32

Multi-professional review of skills and competences requirementswithin the radiotherapy pathway

It was disappointing that so few centres had undertakena multi-professional review or undertaken a management review

S. James et al. / Radiography 18 (2012) 153e159158

of any arising oncologist vacancy. In England, the former isa requirement of the Cancer Peer Review Measures.25 The lowcompliance rate across England with this measure within theRadiotherapy Cancer Peer Review measures has also been high-lighted in the summarized outcomes of the Cancer Peer ReviewMeasures.33

Therapeutic radiography workforce profile

The profile of the therapeutic radiography workforce highlightsa low number of assistant practitioners in post, equating to 1.2 percentre across the UK. This indicates there is potential to increase thenumbers within this sector of the radiography workforce thusenabling therapeutic radiographer skills to be utilized more effec-tively. More encouragingly almost 60% of centres are planning toincrease this sector of the workforce. However with so few centresresponding positively to having assistant practitioners working 1:1with a supervising radiographer, a number of the twenty sixremaining centres with no such plans should also be consideringincreasing their assistant practitioner workforce. RadiotherapyService Managers have reported difficulties34 such as; funding,availability and accessibility of training courses, confusion andmisperception of the assistant practitioner scope of practice asbarriers to implementing the assistant practitioner role. Theexisting SCoR scope of practice guidance18 is explicit regarding thescope of practice and role(s) that assistant practitioners mayundertake. Alongside this the SCoR radiotherapy staffing guid-ance21 recommends that 10% of the radiographer staffing can beassistant practitioners, when considering staffing for the coreradiotherapy service. This low number of total assistant practi-tioners, in the UK, alongside the high number of practitioners atbands 5 and 6 implies that progression is not occurring as expected.The high number of practitioners at band 5 also suggests that themajority of these practitioners are not eligible for progression toband 6 after 18e24months employment in accordance with AnnexT of the Agenda for Change35 terms and conditions of employment.The number of advanced practitioners in post is encouraging,particularly the numbers of research practitioners and site specificadvanced practitioner posts. The largest numbers of advancedpractitioner roles are within the technical specialist role andprobably partly due to the need for services to implement newtechniques such as Intensity Modulated Radiotherapy (IMRT),Image Guided Radiotherapy (IGRT), and adaptive radiotherapy.10

NRIG34 acknowledge that the future demand on the advancedand consultant level practitioner will be high as the known serviceexpansion plans come to fruition, and full implementation of theframework is undertaken across all centres. The number ofconsultant practitioners in post is relatively low, this is disap-pointing as where these posts have been implemented a number ofbenefits have been realized23 such as improved patient experience,reduction in patient admissions and improvements in practicethrough the implementation of new techniques.

The level of succession planning for radiotherapy servicemanagers identified is encouraging. With the planned increases incapacity in England there is concern that there will be a significantgap in the therapeutic radiography workforce unless future leadersand managers with clinical experience are developed.

Provision of protected study time and clinical supervision

The low number of centres with formal agreements for pro-tected study time (PST) and provision of clinical supervision is ofconcern, the profession has seen considerable change in recentyears and support mechanisms for learners and clinical staff toprevent burn out will continue to be important in the future.

Hutton’s36 research into the factors influencing job satisfactionduring the transition from newly qualified to band 6 identified thateffective support mechanisms such as PST for practitioners are vitalto maintain job satisfaction whilst ensuring that practitioners aresupported.

The employment of clinical learning facilitators and practiceeducators by almost half of centres is encouraging. The benefits ofsuch roles were highlighted in the report by the SouthWest LondonSHA37 and the more recently published SCoR guidance.38 Postholders in these roles have been identified as critical as part ofeffective strategies to providing support in the clinical learningenvironments with the beneficial effects of reducing pre-registration attrition rates in line with the NRAG recommenda-tion.1 These post holders have also been identified as effectivemotivators in many centres with regard to the effective utilisationof Virtual Environment Radiotherapy Training (VERT) in clinicalradiotherapy centres.39 VERT was funded by the Department ofHealth in 2007 for both education providers and clinical centres inEngland as part of a national drive to reduce attrition levels intherapeutic radiography education programmes.

Conclusions

This comprehensive survey has highlighted some progress withimplementation of the career progression framework across the UKsince its launch in 2000, the DH Radiography Skills Mix Report in20035 and themore recent University of Hertfordshire report.14 Theresults indicate that many centres have yet to undertake a multi-professional skills mix review with only a small number ofcentres having implemented the framework in its entirety andhence it can be concluded that the radiography profession’s careerprogression framework is not fully embedded across the UK ther-apeutic radiography workforce. The continuing three monthvacancy level and the current mismatch of the therapeutic radi-ography workforce profile to that recommended by the NRAG1 areboth concerns with regard to being able tomeet the demands likelyto arise from the future expansion plans of radiotherapy servicesacross the UK.

Recommendations

The current political and financial climate40 will necessitate allclinical service providers (the radiotherapy service manager, leadphysicist and clinical director) to ensure efficiencies whilstproviding quality services. The efficient deployment of staff, themost effective use of their skills and ensuring appropriate skills mixacross the entire cancer pathway will be critical. Policy of theSociety and College of Radiographers (SCoR)22 has emphasised theimportance of the full implementation of the career progressionframework for the future development of the therapeutic radiog-raphy profession to enable the delivery of patient centred care inlinewith NHS strategy.10 The College of Radiographers has providedguidance on all aspects of the framework to assist radiotherapyservice managers with implementation of the framework. Howeverthe results from this survey suggest that current guidance on theScope of Assistant Practitioners18 in Radiotherapy and clinicalsupervision41,42 require updating. The SCoRwill also need to ensurethe findings from this audit are taken forward at the relevantnational forums13 to progress the development and expansion ofthe therapeutic radiography workforce in line with the currentnational health policy.10 The results also suggest that the SCoRshould monitor implementation of the career progression frame-work at regular intervals, given the disappointing level of imple-mentation to date.

S. James et al. / Radiography 18 (2012) 153e159 159

The results from this survey also support the following recom-mendations to radiotherapy service providers, education providersand commissioners; an increase in the number of assistant,advanced and consultant practitioners to enable the effective andefficient deployment of the appropriate skills mix across the entireradiotherapy pathway. This will necessitate improvements in theaccess and availability of relevant training programmes at all levelsto up skill practitioners so they can manage pathways of care. Thisincludes improvements in succession planning for future newRTSMs and leaders to enable radiotherapy service capacity expan-sion plans to be successful. It is also recommended that the main-tenance of the therapeutic radiography commissioning levels andcontinued reduction in the pre-registration attrition rates43 areboth critical to ensure the overall therapeutic radiographer work-force vacancy level drops and the number of registered practi-tioners rises. The SCoR already recommends that all radiotherapycentres employ clinical learning facilitators to support learners inthe clinical environment. As the professional body it will need tocontinue encouraging all service providers to employ clinicallearning facilitators along with providing clinical supervision andprotected study time as support mechanisms for learners andclinical staff.

Conflict of interest

No conflict of interest.

Acknowledgements

All the departments who responded to the survey. ProfessorAudrey Paterson. The Society and College of Radiographers

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