Diagnostic Imaging Modernisation Project

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                                  Ultrasound Training Group

                                                  Report for

          The National Diagnostic Imaging Programme Board

1. Overview:

The Imaging Modernisation Board (the precursor to the National Imaging
Programme Board) agreed the establishment of the Ultrasound Training
Group to consider the development of ultrasound training in Wales and to
establish how training can be delivered in the current funding climate

The purpose of this paper is to document the findings of the Group.

2. Executive Summary

Sonographers are expected to hold a Postgraduate Certificate or a
Postgraduate Diploma in Medical or Clinical Ultrasound. These qualifications
have been available from selected Universities in the UK since the early
1990s and superseded the Diploma of Medical Ultrasound (DMU), awarded
by the College of Radiographers.

There is a UK wide problem with a shortage of sonographers that is leading to
severe difficulties for many NHS Trusts and Health Boards in meeting
increasing demand and government targets.*

According to a recent UK survey1 of clinical departments by the Society of
Radiographers, the number of examinations per department has increased on
average by 7.9% year-on-year. In addition ten per cent of sonographer posts
are unfilled and some departments are reporting vacancies lasting more than
six months.

Recent developments in service delivery such as fetal anomaly screening, the
guidance on the management of stroke and transient ischaemic attacks, and
the growing use of ultrasound to investigate patients where cancer is
suspected, are adding further to workloads. Furthermore Sonographers are
increasingly becoming involved in the provision of training for other
professions.

Assistant Practitioners may also have a limited role to play in targeted
ultrasound work in Wales in the future. However, their role will necessarily be
limited as good ultrasound practice requires the person performing the
ultrasound examination to issue and take responsibility for the report.



*
 This particular statement refers to those radiographers qualified in ultrasound. There are other clinicians who use
ultrasound in the course of their practice. Not all of these clinicians will be in possession of an accredited ultrasound
qualification but they are not considered in this paper.



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Care needs to be taken in defining roles which assistants could undertake,
given what is sometimes considered routine can have less routine aspects for
example dating scans will assess the foetus not just take a single
measurement.

Examples of ultrasound examinations currently considered suitable for
assistant practitioners6 include Abdominal aortic aneurysm (AAA) screening
where a single organ is scanned and measurements taken and recorded.

Whilst these developments will require Assistant Practitioners to be trained
the role they will be able to play is limited thus their training requirements will
be limited. Nevertheless, the training needs of this group may still have to be
met by the existing Sonographer workforce unless for example the AAA
screening programme takes a similar stance to that of England and the
screening programme itself makes the necessary training arrangements.

Sonographers are increasingly finding it difficult to meet service demand, look
after their own safety and undertake continuous professional development
activities. They are known to be at risk of musculo-skeletal disorders (MSD)
due to their work and the reported incidence of this is growing.

There is disenchantment that is contributing to an increase in the numbers of
sonographers taking early retirement, reducing their hours of employment or
leaving the service completely4.

There is currently no national strategy for postgraduate development of
radiographers4 although Scotland is taking steps in this direction. Many
employers (including those in the independent sector) will only employ
qualified sonographers and so do not contribute to training, supply or funding
of this group of staff. It is not uncommon for organisations to invest time and
money in training sonographers only to see them move to another employer.

The current training level, as of April 2009, is about 10 per year averaged over
the previous three years with only 8 per year averaged over the most recent
two years. This is much less than the projected need of 19 per annum as set
out in section 5.3.

However, the prospect of maintaining the level of training indicated above
(and the consequent problems of staff release, both to train and provide
training that goes with it) within the current training model, is becoming
increasingly unlikely given both the pressures of extended working hours /
weekend working and general service delivery pressures – Access 2009
waiting time targets etc.

A number of options exist to tackle this issue and ensure secure workforce
supply for this essential service. However it is principally the view of the
ultrasound training group that not one single option can be employed, instead
a multi faceted approach needs to be taken.               It is therefore the
recommendation of the group that a short, medium and long term approach is
taken in parallel to resolve the present situation. This will involve taking
forward the following measures recommended in this paper:

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      Financial measures to encourage recruitment and training of the
       existing workforce including central funding for short focussed
       ultrasound courses;
      Welsh Assembly Government to procure and provide a mechanism
       which allows for the provision of bursaries to students wishing to
       undertake post graduate ultrasound training shortly after graduation in
       a healthcare discipline.
      Commissioning of post graduate entry programme which accepts a
       wider range of applicants without healthcare related degrees.
      Commissioning a direct entry (BSc Hons) sonography degree
       programme.

These recommendations are consistent with recommendations also made by
SCoR in August 2009 in the document Developing and Growing the
Sonographer workforce: Education and training needs.

3. Background

As the work of initially the Diagnostic Imaging Modernisation Project in Wales
progressed between the summer of 2005 and March 2009 and then latterly
the Diagnostic Imaging Service Programme from March 2009 to date it
became recognised that there was (and still is) a growing problem in relation
to ultrasound provision and training, and consequently service delivery.

In December 2005 a workforce steering group was established with
representation from professional bodies, radiologists, radiographers,
radiography service managers and education. The outcome was a
comprehensive report identifying a number of workforce issues deemed to be
important to the development of the diagnostic imaging workforce. As part of
the summary report there was a review of ultrasound services which
highlighted:

      Pressure on the service
      Increasing demand for training
      Lack of training in Wales

In May 2007, as part of the Imaging Modernisation Project, a workforce
development project team undertook a Training Needs Analysis based on a
questionnaire survey to service departments which indicated that
approximately 10-12 Sonographers needed training across NHS Wales. This
was, however, felt to be an underestimate, and subsequent work indicated an
under-reporting of need based on:

      Lack of funding to train and replace staff
      Lack of funding leading to a reluctance to submit workforce planning
       numbers for staff in some organisations
      Risks associated with MSD




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In the same year, a report by the North Wales Imaging Services2 indicated
growing demand for ultrasound services and the need for additional
resources, including sonographers, to meet that demand.

In February 2008, the Imaging Modernisation Board accepted revised figures
from service managers showing a need for approximately 2 training places
per Trust per year or an all-Wales total of approximately 26. Actual training
was about half this estimated requirement which recognised a need for more
working flexibility from sonographers in order to prevent musculo-skeletal
injury and to provide a more sustainable service.

As a consequence the Imaging Modernisation Board agreed the setting up of
the Ultrasound Training Group to consider the development of ultrasound
training in Wales and establish how it can be delivered in the current funding
climate.

Ultrasound in a Community Setting:

To a certain extent this is currently available but additional services may be
required in the future. Therefore, it is imperative that future ultrasound
requirements are established in light of reconfiguration of the NHS in Wales
and the shift towards delivering care in the primary care and community
setting.

Diversifying the Ultrasound Workforce:

There has been an increase in the number of requests from other specialities,
(e.g. urology and obstetrics and gynaecology) to imaging departments asking
for sonographers to provide training for other professions. Such requests are
expected to increase further given marketing to GPs and others of new highly
portable miniaturised ultrasound systems

Many different professionals could be trained to deliver specific ultrasound
services (and indeed in July 2009 CASE agreed to accredit shorter „focused‟
ultrasound courses) but common standards would be required. Competency
based qualifications should be readily available and of consistent quality.
These would be available to existing employees learning in the workplace.
Costs would therefore be lower, but the scope of accredited practice is well
defined and less flexible.

The drawback of multi-specialty ultrasound delivery is that it does not confer a
great benefit in workload reduction as the examinations performed tend to be
supernumerary to current service. There is also the issue of the cost
effectiveness of purchasing and maintaining an array of ultrasound machines.

There is a major governance issue as well as a financial issue for
organisations. Currently anyone with access to a machine (regardless of
whether the ultrasound machine receives appropriate servicing or
maintenance) can perform a „scan‟ regardless of training received. The Welsh
Scientific Advisory Committee has recently produced guidance “Ultrasound


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Clinical Governance in Wales” to address this issue which is available in the
guidance section of the Committee‟s web site.

4. The Ultrasound Training Group

The Imaging Modernisation Board agreed the establishment of the Ultrasound
Training Group to consider the development of ultrasound training in Wales
and to determine how training can be delivered in the current funding climate.
NLIAH was tasked with overseeing this part of the project,

The Terms of Reference of the Ultrasound Training Group were defined as:

      To review evidence regarding adequacy of ultrasound training for imaging
       department staff† in Wales
      Agree an option appraisal methodology to meet ultrasound training needs.
      Agree preferred option.
      Make recommendations to the National Imaging Programme Board on the
       future approach to ultrasound training in Wales in line with WAG policies.
      Consider the appropriateness of the preferred option for other professions
       undertaking ultrasound investigations e.g. midwives.

The membership of the Ultrasound Training Group is-

•      Owen Crawley (Chair)               WAG
•      Sharon Evans                       ABMU
•      Colin Davies                       Cwm Taf
•      Andy Thomas                        Cardiff & Vale
•      Tony Clarey                        Hywel Dda
•      Bethan Bigwood                     Betsi Cadwaladr
•      Kay James                          Aneurin Bevan
•      Helen Jones                        Betsi Cadwaladr
•      Kevin Tucker                       SCoR
•      Marie Hatfield                     Hywel Dda
•      Neil Pugh                          Medical Physics, Cardiff & Vale
•      Martin West                        Cardiff University
•      Barry Carver                       Bangor University
•      Angie Lloyd-Jones                  Betsi Cadwaladr
•      Will Oliver                        NLIAH

Data was gathered by questionnaire in February 2009 and meetings took
place in February and March at which the group principally identified two inter-
linked problems:

i) Lack of access to ultrasound training in Wales
ii) Lack of trained sonographers to deliver services increasing the strain on
    existing staff to meet targets, thereby increasing the risk of muscular-
    skeletal injury



†
    defined as staff within radiology departments and within medical physics departments

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5. Service and training issues

5.1 Lack of access to ultrasound training in Wales

Ultrasound is principally delivered by Radiologists, Radiographers and
Sonographers. However other professional groups, particularly Midwives,
also undertake ultrasound scans.

No central funding for ultrasound training exists in Wales and the picture is
patchy in other parts of the UK.

In Scotland Ultrasound services have been supported in the form of ad-hoc
funding initiatives to meet a particular need.

The following is a list of recently provided ultrasound support packages in
Scotland:

2007 -funding package for "advanced practice in radiography"

2009 –funding package for "ultrasound" over a period of 2-3 years. Split into
two 2 phases and is supporting circa 8 radiographers to study PgC, PgD or
MSc in ultrasound with the aim being to increase ultrasound workforce
capacity to help the 18 week RTT

2009 also saw a commissioned education course at Glasgow Caledonian
University to deliver (in 2010) education courses in ultrasound screening to
support the 1st and 2nd trimester and the Triple A service provision for NHS
Scotland.

In Northern Ireland there exists no central support.

In England there are some local initiatives including funding of Sonography
training by West Midlands SHA that will provide 18 additional training places
over three years and Essex Cardiac & Stroke Networks funding in July 2009
of extra Sonographers to carry out carotid Doppler examinations.

All Imaging services in Wales remain under great pressure to meet and
maintain Access 2009 targets, but the pressure on ultrasound is intensified
because of the relatively small workforce. Surprisingly though, ultrasound
has not been registered as a risk in meeting and sustaining the targets with
the overarching Access 2009 Project Board.

Representations have been made by both the Society of Radiographers and
the modernisation project team to the Minister for Health and Social Care and
the head of Human Resources (Health) WAG. The NHS Wales Partnership
Forum has also investigated the funding of post graduate / registration
programmes and training across all non medical professional groups, but, to
date, there is no central / ring-fenced funding for ultrasound.



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5.2 Workforce planning position in February 2009:

The latest data collection was carried out in February 2009. This showed that
there were 142 sonographers in Wales; this equates to 110.25 whole time
equivalents (wte). 65 (46%) are full time, while the remaining 77 (54%) are
part time.

At that time there were 21 radiographers in Wales undertaking Ultrasound
training.

2007 Academic year (i.e. currently in the second year of training):          15
2008 Academic year (i.e. currently in the first year of training):           6

Following a further canvassing of organisations in March 2010 it was
confirmed 10 individuals began / would begin Ultrasound training in the 2009
academic year.

The training output can thus be averaged out at approximately 10 per year
over the last three academic years and 8 per year over the most recent two.

There were 15.5 whole time equivalent (wte) vacancies which is equal to
10.91%. This is a high vacancy rate for a specialist group of staff. A further
37 sonographers are expected to retire in the next 10 years.

Only 2 of the main imaging departments in Wales did not report an increase in
demand for Ultrasound investigations.

Of the remaining 11 departments, there has been an increase of just over
20% in demand for Ultrasound investigations.

Despite this, ultrasound departments have continued to meet the short term
goal of achieving waiting time targets, but the consensus has always been
that medium to longer term strategies are desirable to ensure flexible, efficient
and sustainable services in Wales and the status quo should not be allowed
to continue for any longer than is immediately necessary.

5.3 Projected future position

According to a recent UK survey1 of clinical departments by the Society of
Radiographers, the number of examinations per department has consistently
increased on average by 7.9% year-on-year.

Therefore from a baseline of 142 current trained sonographers (as stated
above) if this trend continues as anticipated this would equate to a need for
11.4 extra sonographers per year, or combined with a typical wastage rate of
5% year, a total training need of about 19 per year. On top of this would
also be the catch up to fill the existing 15 vacancies




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5.4. Sonographer Registration

The Society and College of Radiographers (SCoR), which merged with the
UK Association of Sonographers (UKAS) IN January 2009, has a Public
Voluntary Register of Sonographers. This register allows members of the
public to confirm that the sonographer undertaking their examination or
treatment is appropriately qualified. The register is also being used to support
the current application to the Health Professions Council for Sonography to
become a regulated profession and „sonographer‟ and „ultrasonographer‟ to
become protected titles. The register is currently being further developed to
continue to support this application.

Any health care practitioner involved in the practice, education and research
of ultrasound can apply to be registered. This includes sonographers,
radiographers, midwives, clinical scientists, technicians, researchers,
educationalists, service managers and application specialists involved with
medical ultrasound. Exceptions are those individuals who are practicing
medicine and are currently regulated by the General Medical Council (GMC).
Acceptance on this voluntary register does not authenticate competence or
fitness to practice.

Whilst voluntary registration is not necessary for individuals already registered
with the HPC (or the NMC), this additional registration of sonographers should
help strengthen support for pursuit of regulation for all ultrasound
practitioners.

5.5 Radiology changes.

Radiologists involved in the provision of ultrasound services increasingly tend
to undertake lists of patients that pertain to their special interest - e.g.
musculoskeletal, gynaecologic, vascular, Urological, Head & neck - rather
than general abdominal ultrasound. Furthermore, radiological training
increasingly concentrates on cross-sectional imaging, with trainees less
involved with performing ultrasound and thus supporting the general
ultrasound workload.

The consequence of both these trends is less radiological involvement in
general abdominal ultrasound.

5.6 Current Training Situation:

Ultrasound postgraduate programmes exist at Masters Level. They require
lengthy periods out of the work place and intensive training and supervision
within the work place. The combined course fees and salary for the 2-year
training period is approximately £60,000 to £70,000 per individual, with
additional travel and subsistence costs where relevant.

However, it has long been recognised that ultrasound education is also
demanding on the clinical educators‟ time, with some estimates placing a
figure of 50% decrease in the workload / throughput of patients. This is a


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disincentive for individuals and departments to offer training to external
trainees, and often limits the time that is available to internal trainees.

The recognised standard for Sonography training is the Consortium for the
Accreditation of Sonographic Education (CASE). This is a consortium of the
following bodies:

      British Medical Ultrasound Society
      British Society of Echocardiography
      College of Radiographers
      Institute of Physics and Engineering in Medicine
      Royal College of Midwives
      Society of Vascular Technology of Great Britain and Northern Ireland

Following the cancellation of a CASE accredited course at Bangor University
there was until recently there were no further CASE accredited programmes
in Wales, and organisations have been sending a limited number of staff on
training programmes in England - either Bristol or Liverpool. At Bristol the
Post Graduate Certificate in Ultrasound is obtained after 1 year with the Post
Graduate Diploma in Ultrasound the qualification given by both Universities.

The University of Glamorgan now offers CASE accredited courses (PgC, PgD
& MSc) in Medical Ultrasound. Cardiff University also now runs suitable
CASE accredited courses, one MSC in Medical Ultrasound and MSC in
Obstetric and Gynaecological Ultrasound.

5.7 Current position regarding delivery of ultrasound services

Sonographers are now the key deliverers of general and obstetric ultrasound.
They are a valuable asset with the potential to develop their practice further to
the benefit of the service and patients. They have already led the way in
developing advanced radiography practice and demonstrate a higher and
broader level of clinical knowledge and responsibility than many other
reporting radiographers. The close clinical interaction with each patient and
the often intimate nature of the examination are specific to the sonographer
role.

Because of their multi-professional skills, sonographers are also key trainers
of all staff requiring ultrasound training - not just fellow radiographers. This
will become an increasingly onerous responsibility though as accrediting
bodies such as the RCOG and RCS require competency based assessment
of trainees by designated and trained assessors. However it is worth noting
that that in February 2010 the RCOG did formally approach SCoR with
regards to the training of Obstetric and Gynaecology trainees.

5.8. Likely future position regarding delivery of ultrasound services:

There is likely to be an increasing demand for imaging services over the
weekend which will inevitably lead to pressure for 7 day working. This will
require a larger workforce pool to ensure adequate cover. At this stage 24
hour working does not seem desirable or achievable. A simple estimation for
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delivering a 7 day service is a 40% increase in staffing, if the existing level of
weekday service remains the same.

Currently, evening working seems to be principally a function of meeting
immediate waiting list targets, extension to the working day indefinitely though
is not a feasible long term option at present because of the shortage of
sonographers. However, the concept is patient friendly - especially in the
context of partial booking systems and is thus a dynamic which needs to be
considered moving forward.

Should it be that evening working / longer days are to be implemented in the
future without the current staffing situation changing services risk increased
demoralisation of staff and work related MSD (see below).

National Screening Committee recommendations for antenatal screening
services will require increased responsibility by a lead sonographer (up to
consultant sonographer status) to maintain the validity of a recognised
antenatal screening centre. This role is recognised to be different from that of
a superintendent sonographer and will be time consuming.

5.9 Musculo-Skeletal Disorders:

Sonographers understand the need to take care of their posture and working
environment whilst scanning and clinical departments in Wales have made a
concerted effort to reduce MSDs. Sonographers also have a professional
responsibility to ensure that the time allocated for an examination is sufficient
to enable it to be carried out competently.

However, there is mounting evidence that MSDs are becoming increasingly
associated with ultrasound practice. In a recent UK survey1 of clinical
departments, 28.3% of the qualified sonographers from the responding
departments suffered from MSDs. This is considered to be due to two major
factors –

      Escalating patient referrals and the resulting pressure to increase
       throughput. This ultimately culminates in reduced natural breaks which
       are required to minimise risk of MSD.
      The increasing body mass index of the population3.

As a result many staff currently operating in Wales have actually had periods
of absence and indeed in some cases there have even been successful
claims by sonographers for work related injury.

Welsh Health Risk Pool has confirmed that                  MSD     claims     from
Ultrasonographers are viewed as a significant risk

It is critical to patient management that no ultrasound examination is
compromised by departmental and/or government targets. As such Health
Board guidelines need to include strategies to minimise the risk of work
related MSD, including appropriate management of workload to ensure the


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pressure of throughput and targets do not undermine the health of this section
of the workforce or place patients at undue risk.

5.10. Ultrasound as a Career:

The situation described earlier in this paper which has created this shortage of
sonographers- a lack of training opportunities (due to the lack of financial
support) and risk of MSD is further compounded by the differential financial
reward and status that ultrasound training gives these radiographers when
compared with radiographers in specialities such as MRI and CT. These
specialities have been rewarded with similar AfC pay bands to
Ultrasonographers, and these career paths are now viewed as easier options
by many.

The end result is that the numbers wishing to undertake the long periods of
study required for ultrasound training have fallen dramatically, with some
departments reporting no interest even when training is offered. Ultrasound
managers believe that steps need to be taken to make ultrasound training
more attractive to radiographers.

6. Options:

The College of Radiographers has previously outlined the various training
options for addressing sonographer education and training needs 4. The
document considers potential additional workforce development pathways
such as First Degree direct entry, postgraduate direct entry, distance learning
and modular training. The same document recommends short, medium and
long term strategies.

In the context of this paper, five principle options are available to NHS Wales.

Option 1 - Do Nothing

Health Boards to continue to fund their training requirements.

Option 2 - Introduce Financial Incentives to Encourage Recruitment

Health Boards to continue to fund their training requirements and apply Annex
U of Agenda for Change terms and conditions to the training of sonographers

In addition Health communities explore the possibility of applying the
„Principle‟ profile for sonographers in Wales

In addition to this, the Welsh Assembly Government could fund CASE
accredited short „focused‟ ultrasound courses to develop ultrasound skills in
relevant members of the current workforce.

Option 3 – Implement a Medium Term (1 -3 years) Solution

3a) For those in possession of a healthcare related degree.


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Welsh Assembly Government to procure and provide a mechanism which
allows for the provision of bursaries to students to undertake, for example,
postgraduate programmes at the University of Glamorgan in its MSc / PgD /
PgC Diagnostic Clinical Ultrasound (Abdomen and Small Parts), (Obstetrics
and Related Gynaecology), (Gynaecology), (Musculoskeletal), (Clinical
Echocardiology) course. Or alternatively the CASE accredited scheme
currently in existance at Cardiff University.

Health boards would need to assist in the provision of clinical placements for
such courses if this option was to be viable.

There is anecdotal evidence to suggest that, in the current economic climate,
a number of students are graduating in Healthcare related undergraduate
programmes (which would qualify them for entry onto the above courses) but
are then being unable to secure a job in their chosen speciality.

With the burden of student loans there exists the risk that these students may
be lost to other non-healthcare professions. An incentive (such as a bursary)
to return to post graduate study in any area where there is a demonstratable
shortage of staff may encourage students who had not otherwise considered
a career in ultrasound to train in this area. This will not only help address the
shortage of Sonograhers in Wales but also help retain healthcare graduates
within NHS Wales.

3b) For those in possession of a degree that is not healthcare related

Commission bursary supported postgraduate entry programmes (as 3a
above) but require Higher Education Institutions (HEI) to accept a much wider
range of applicants than has traditionally been the case. Such programmes
would be very similar to the existing CASE accredited programmes and would
be of 18 months duration following which a preceptorship year would need to
be considered.

Option 4 – Implement a Longer Term (3 – 5 years) Solution

Commission direct entry (BSc Hons) programmes with a preceptorship year to
follow.

7. Conclusion and Recommendations

Sonography is a strategic post registration skill which warrants specific
workforce planning and education commissioning. Sonographers need to be
highly trained. Without adequate training, ultrasound scanning and
interpretation could be misleading and dangerous to patients. The
professional standards3 expected of sonographers are correspondingly high.

Targets are currently only being met through the dedication of the ultrasound
workforce. A more flexible, sustainable service across Wales is essential.

There is no quick fix available and health boards need to plan several years in
advance if the quality of the service is to be maintained. It is therefore the

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recommendation of the ultrasound training group that a multi faceted
approach is taken.

This would involve taking forward options two, three and four (a short,
medium and long term approach).

In summary these options involve:

      Encourage recruitment amongst the existing workforce including
       central funding for short focussed ultrasound courses.
      WAG procuring and then providing a mechanism to allow for the
       provision of bursaries to students wishing to undertake post graduate
       ultrasound training shortly after graduation in a healthcare discipline.
      The commissioning of a post graduate entry programme which accepts
       a wider range of applicants without healthcare related degrees than the
       traditional model allows.
      The commissioning of a direct entry (BSc Hons) degree programme.

Failure to embrace and take forward these options will mean a number of
material risks will continue to exist within the service and over time further
manifest themselves. Principally these include:

      A continued depletion in the ultrasound workforce in Wales though
       retirement and moves away from the career.
      A lack of newly trained staff coming into the profession due to lack of
       financially accessible training opportunities.
      Increasing proportions of the remaining workforce becoming affected
       with MSD resulting in absences from the workplace.
      A failure to sustain waiting time targets.
      Ultrasound services increasingly being undertaken in unsafe
       environments which are created by the unreasonable pressures being
       placed on existing staff.

References

1. Analysis of ultrasound workforce survey. SCoR (October 2009)
2. Workforce Planning to Meet the Additional Pressures Associated with the
   Access 2009 Waiting List Targets. North Wales Imaging Services
3. Guidelines For Professional Working Standards: Ultrasound Practice,
   United Kingdom Association of Sonographers 2008
4. Developing and Growing the Sonographer Workforce: Education and
   training Needs. SCoR (August 2009)
5. Agenda for Change Terms & Conditions Handbook (2009)
6. The Scope of Practice of Assistant Practitioners in Ultrasound SCoR
   (2008)




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