Third-party politics – should ultrasound be outsourced?

Many health services are stretched to breaking point. The demographic profile of patients in OECD countries is ageing, which means more complicated health problems requiring long-term care and repeat visits.

A report issued two years ago by the Royal College of Radiologists – which is responsible for education in and monitoring of clinical oncology and clinical radiology throughout the UK – declared a crisis.

‘Radiology in the UK – the case for a new model’ observed that the UK had 48 trained radiologists per million people, a figure that had “remained static for almost five years”. It gave the figures for other European nations for comparison: for the same number of people, Germany had 78 radiologists, Sweden 107 and France 113.

Between 2009 and 2014, the report continued, “the year-on-year average increase in England has been 10.3% for CT and 12% for MRI. Despite this increase, imaging rates in the UK remain significantly below those found in other healthcare systems.”

It went on to explain that there were shortfalls with the traditional model employed by hospitals, whereby each had its own sonography and medical imaging departments, with codes of practice led by local administrators, and that there had been evidence of successful alternative systems.

The way things are going

In an earlier paper, Dr Devender Roberts of Liverpool Women’s Hospital – which specialises in obstetrics, gynaecology and neonatology research – wrote a report on the possible ramifications of outsourcing medical imaging services.

“Since 2008, a mix of in-house sonographers and those from a private company has delivered ultrasound services at the Liverpool Women’s NHS Trust,” she revealed. “The private company delivers technical capability, while the ultrasound equipment and ultrasound department are run by the hospital.”

Roberts is positive about the effect outsourcing has had on the hospital and its ability to function as a workplace and a place of care. “Most outsourcing of ultrasound services consists of the private enterprise providing the full service, including machines, staff and technical support,” she explained. However, there is evidence that outsourcing of ‘critical to fill’ technical positions, particularly in cardiac and vascular ultrasound, is increasing.”

The Liverpool Women’s National Health Service (NHS) Foundation Trust is a stand-alone maternity unit delivering approximately 8,000 babies every year, and is one of only two public health trusts in the UK focusing on women’s health and OB-GYN issues, and so requires extremely specialised equipment and staff.

“Outsourcing is used extensively in the US,” continues Roberts, “as is teleradiology, a system that uses remote electronic transmission of radiological studies, for the purposes of interpretation and/or consultation, to specialists located at other centres or, in offshore teleradiology, anywhere in the world.”

“We believe that ours is the first example of outsourcing in the UK where the technology and management remain the remit of the hospital while the sonographers are outsourced. The driving forces behind it were: the necessity of meeting the needs of the service; the national shortage of people training as sonographers, making local recruitment difficult; the increasing demand for and reliance on ultrasound for routine aspects of obstetric and gynaecological practice; and the loss of sonographers to private enterprise. The private company is contracted to deliver a fixed number of scans per week with additional payment for each scan performed over this number.”

Sound check

The key issues Roberts lists in the August 2010 edition of Ultrasound in Obstetrics & Gynecology as those troubling the running of Liverpool Women’s hybrid system were:

• knowledge of demand and timetabling of sonographer rotas to meet the demand appropriately
• clinical governance and adverse event reporting as: private companies usually have their own processes for dealing with adverse events but the identification of these events occurs at the hospital and clinical level; robust pathways had to be instituted to ensure that the relevant adverse events are identified and those affecting the private company are dealt with in liaison with the hospital teams to ensure closure of loops; and the responsibility for other governance issues had to be clearly delineated
• training and education – the department is currently concerned solely with the delivery of the service, leaving little room for training and education of trainee sonographers (a historic means of identifying potential recruits) and junior doctors
• clear team structures with a lead sonographer from the private sector dedicated to the trust. A lead sonographer is essential in providing leadership for the team and a pathway for discussion of minor everyday problems
• maintaining regular contact with the respective teams responsible for delivering the service
• clear pathways for referral
• maintaining the morale of the in-house team and rewarding their choice to remain within the service.

The listed advantages of these approaches seem to help the system in the way it is able to deliver services. Roberts notes that it took two or three months for the new outsourcing process to bed in but, once it was functional and the kinks had been ironed out, there were few problems and no efficiency issues.

“It has encouraged us to review our existing systems and benchmark them,” she said. “There have, however, been no obvious improvements in detection rates or obvious reductions in the number of adverse events. There has been no introduction of other services such as audit or training. The main consequence and disadvantage of outsourcing is the cost.

“Outsourcing services through effective partnerships are said to be cost-effective in delivering hospitals’ primary objectives; we have not found this to be so.”

It is also often the case, that in hospitals effectively pay up to twice the hourly rate for outsourced sonographers than they would if in-house technicians were used effectively. “The cost per scan is therefore more expensive,” observes Roberts. “In the current economic climate, our trust has therefore released funds to employ more in-house sonographers in an attempt to balance, and ultimately eliminate, the requirements for the hybrid. How successful we are in recruitment remains to be seen, and it is this that will determine the future of our ultrasound services.”

The US story

Outsourcing has been standard practice in US hospitals since the early nineties, and now accounts for 90% of radiology services. Some sources even estimate that nine-tenths of X-rays taken by third parties on behalf of US healthcare facilities in the past decade will have been read outside the country. Most hospitals in the US outsource a variety of other medical services besides radiology, including staffing for anaesthesiologists and emergency physicians.

“Hospitals buy physicians’ time from management companies,” explains Jonathan Clark, an assistant professor of health business at Pennsylvania State University. “They get dedicated physicians who, for the most part, only work for their hospital. This is not necessarily the same thing as outsourcing radiological services, where hospitals send images, which could then be read by one of 1,000 radiologists,”

Outsourcing brings economic benefits, and these may apply to healthcare. “Any time healthcare organisations can get better at what they do, whether that involves outsourcing or not, that’s good for the economy,” reckons Clark.

“When it comes to US healthcare – an industry with serious access problems – if we can become more efficient, and thereby reduce those access problems, that is a good thing.”

The continuing restructuring and reforming of the US healthcare system under President Obama may have done something to alleviate the problems of access by those most in need of its attention, but it has also created a compartmentalised system in which those in different departments may be employed by different companies, or healthcare networks, compromising cohesion and efficiency, and creating potentially problematic gaps in compliance and best practice.

Pros and cons

There are problems and benefits. Roberts reports that there hardly any adverse side-effects of largely outsourcing radiography services, other than a rise in cost. However, the latter issue is largely skimmed over in her report, and it is likely to be a significant stumbling block for many hospitals and public health bodies. Cutting back on services is often the only way of balancing the books.

By comparison, the Royal College of Radiologists was largely pessimistic about the prospects for UK radiology in its 2014 paper. It proposed that existing services should “collaborate to form networks of expertise serving a population of several million, rather than a few hundred thousand as at present. A grouping of, say, 150–200 radiologists would have the capacity to provide continuous 24-hour cover across the range of required specialties. There are a few examples in practice, particularly in relation to neuroradiology, demonstrating that collaborative solutions can work.”

The report said that the health service needed a cultural reformation in order to take its blinkers off and achieve financial stability: “The current workforce crisis is driving us towards the concentration of all specialist radiological expertise in a few centres of excellence. We do not believe that this is in the best interests of patients. Rather, our hope is that, in the future, most radiologists will work in a distributed network fulfilling a dual role as generalists to their local healthcare community and as an expert resource to a wider network in their specialist areas of practice.”

The report concluded that there was a “desperate need” to recruit more radiologists, as there were too few to deliver the requisite workload required, regardless of how they were deployed.

The industry is in flux; many support the use of outsourcing, just as many don’t. Outsourcing has clearly quietly started happening already, however. Global healthcare networks must now sit down and reassess their priorities, and identify the cultural and workforce barriers they are willing to address in order to get results.