The Importance of Regulation of Healthcare Services

“You have the right to expect NHS bodies to monitor, and make efforts to 

improve continuously, the quality of healthcare they commission or provide. This 

includes improvements to the safety, effectiveness and experience of services” – 

The NHS Constitution 

Figure 1. WHO guidelines (51)

  The National Health Service (NHS) provides care for 1 million patients every 36 hours (1). This report will assess how this complex healthcare system strives to treat all patients equally and with high quality, through regulation (2).
Regulation is the ‘sustained and focused control exercised by a public agency over activities which are valued by a community’ (3). Regulation within the NHS aims to attain consistent, high quality care (4) across all services by the use of legal frameworks (5) and accountability which uses clear, simple guidance
alongside clarifying the roles and responsibilities as health-care providers (5). A large majority of NHS patients encounter the Medical imaging department and therefore it is vital to assess whether these departments are providing optimal care to these patients.

The need for regulation reform was recently publicised in the media in cases where reports of negligence within NHS services caused avoidable harm and death to multiple patients (6) (7) (8) (9) (10). These reports highlighted areas which needed vital attention in the services provided, such as improved inter-professional working, staff training and increased awareness of accountability in order to provide high-quality, equal and compassionate care, for all (6).
These reports also made it clear that current regulation and monitoring methods must be adapted and improved, primarily in structure. For example “in the case of Mid Staffordshire, the regulatory regime that allowed for overlap of functions led to a tendency for regulators to assume that the identification and resolution of non-compliance was the responsibility of someone else. Effective accountability to the public demands a simpler regime of regulation” (6)

The reports which begged for better regulation 

There have been multiple cases within the NHS where patients were not treated with the care and rights that they are entitled to. These reports highlighted that increased knowledge, resources and reduced workload were key to improving care, however, effective communication was paramount (4).

Victoria Climbié was seen by multiple healthcare professionals who should have noticed she was being abused, before she was murdered. Her death sparked the formation of the Children’s Act 2004 (13) and the ‘Every Child Matters’ initiative (14). It was summarised that her abuse was not noticed due to racism; a cultural attitude of staff believing it was “not their job”; and disorganisation throughout management. Regulation ensures patients are treated equally and that staff are adequately trained and accountable to their actions.

Neglect to those with learning disabilities was highlighted with reports into the Winterbourne View care home (8) and Steven Hoskin’s death (10). These cases brought to light the importance of communication between different organisations and departments, as lives could have been saved (10) if public service workers communicated better. The CQC now monitor the appropriate usage of the Mental Health Act to safeguard those who are not mentally capable to fully look after themselves (15).

The Keogh Report(2013) investigated unacceptably high death rates at fourteen UK hospitals. This report suggested four key principles to reduce incident rates: improved patient and public participation; improved listening to the views of staff; openness and transparency and co-operation between all public service organisations (9).

The ‘straw that broke the camel’s back’, in regards to the need for better regulation, was the Francis Report(2013) (6) which investigated the monitoring of Mid Staffordshire Foundation Trust and how nacceptable practices had not been identified and acted upon. This report cried out for restructuring of
NHS regulation as the previous system wasn’t effective at ensuring patient safety and care; it tolerated a culture which accepted poor working standards from other staff and reprimanded whistleblowers. The Berwick report was a response from the Department of Health (DoH) to the Francis Report which looked at methods “to make zero harm a reality in our NHS” (16).

These inquiries stated that regulation had to be improved as, although regulation occurred in the departments which were investigated, it was not substantial or objective enough. As a result of this, better regulation, public awareness and regulatory bodies were founded (17) (18) (19) (20).

Main regulatory bodies 

All regulatory bodies make use of the and statutes such as the Human Rights and Health and Safety at Work Act (23). Regulatory bodies are accountable to the Government and public for all healthcare services’ actions and try to adhere to targets and protocols set by government to optimise efficiency and care. The National Institute for Health and Clinical Excellence (24) provides evidence-based protocols and guidelines which hospitals should adhere to, in order to set a high standard of healthcare which is accessible by all.

The Care Quality Commission (CQC) (18) is the main independent regulatory body which commissions all healthcare providers and was established by the Health and Social Care Act(2008) (17) to provide a governing body which ensures all providers of the NHS meet essential standards of quality and safety (25). Healthwatch England is an independent consumer champion for health and care which works at a local and national level as a mediator between the public and the CQC. The CQC must listen and respond to
Healthwatch England’s views on how services are being run (26).

Monitor is similar to the CQC, they regulate and provide licenses to Foundation Trusts in order to “make the health sector work for patients” (20).

The United Kingdom Accreditation Service and their sub-section, the Imaging Services Accreditation Scheme (ISAS) provides accreditation to departments who have met internationally agreed standards (27). The Health and Care Professions Council (HCPC) regulates healthcare professionals by implementing registration to those who are qualified and adhere to their professional, behavioural and health-focused guidelines (28). Those who are not registered by the HCPC are not legally allowed to work for the NHS using HCPC protected titles, such as, ‘Radiographer’ (29).

Clinical Governance is a systematic approach to improvement and development within the NHS with focus on the patient’s experience(30). Ongoing monitoring is a requirement of regulation, alongside methods such as pre-arranged and unannounced inspections, audits and patient/staff feedback to assess the quality of care that the NHS provides (31). Clinical audits are evaluations of pre-existing care using an objective, systematic review of data against explicit criteria (32). If an audit finds that the desired high quality practice, as set by legislation, is not being carried out, a plan or framework is put into place to achieve the correct standards. Frameworks can include training and education, financial incentives or improved legislation; unexpected results from an audit may also trigger new research into that area.

Inspections, carried out by all regulatory bodies, are unannounced and are performed routinely or as a response to concerns and conducted by trained inspectors alongside clinical experts and experts by experience. During inspections, facilities, equipment, staffing, care- plans and protocols are checked and discussions with service-users and staff ensures fair appraisal of the day-to-day experiences within departments (15). Regulation structures and supports the development of policies through impact assessment, where the goal is to continually improve care and efficiency (33).

Self-evaluation of healthcare professionals is crucial in attaining individual high standards of professionalism and patient care by adhering to legislation, protocol and codes of conduct, such as those set out by the Society of Radiographers and the HCPC. Continuous Professional Development is a mandatory requirement of HCPC registration (34) and its purpose is to improve the healthcare professional’s knowledge and skills. Professionals are required to adapt accordingly as research, priorities, systems and knowledge change. The HCPC regulates this every two years to ensure members are up-to-date with best practice. An individual must work within their job remit, carry out adequate training and are obligated to raise concerns if they are not satisfied with others or their own practice through whistleblowing (35).

Purpose of Regulation 

“Regulation is intended to guard against quality deficiencies” (36)

Regulation’s primary purpose is to improve a health service’s quality of care, ensuring every service which it provides is completely patient centred. Accountability is an integral part of professional practice; every health service provider and their employees must be responsible, by law, for their actions.

Regulators evaluate whether a service is failing to meet set standards and if so, they can intervene with immediate termination of the service and/or disciplinary action. Regulatory bodies assess why the requirements are not being met, and what can be changed to aid improvement of the service. A common reason for failure to meet objectives is the lack of staffing or inadequate facilities, and once the regulatory bodies establish this, measures can be put in place to ensure this is no longer a problem. Regulation can also
improve knowledge, both within the work-force and publicly, so that people are more aware and qualified to deal with certain situations. An example of this is the awareness of improved infection control practice, with increased training for professionals and public advertising:

The Human Rights Act (21) states that all persons have a right to a life which is free from violence. Mistreatment and negligence in healthcare services have caused breaches of this act, where violence, humiliation and torture have necessitated public inquiries (10). All patients should be treated equally and
protocol ensures that everyone is treated by one set standard, promoting a better experience for the patient. Every hospital is required to have a Patient Advice and Liaison Service, where if the patient has not had a satisfactory experience then they have access to a non-judgemental, independent body to raise their complaints (37).

Regulation ensures that the 7 core principles of the NHS and the Government Standards of Care are being followed, and as ‘The NHS belongs to us all’ (11) patients have to right to know what care they can expect to be treated with.

Regulation in the Medical Imaging 

Diagnostic “radiographers are at the heart of modern medicine” (38)

Radiographers are regulated by the HCPC and as part of their registration, all radiographers must perform best practice at all times in accordance to their codes of conduct(35). This involves a commitment to the health and safety of service users with professional competency, integrity, honesty and continued self-development especially in regards to ethics and behaviour (39).

Regulation within the medical imaging department ensures that staff treat patients autonomously, with beneficence and non-maleficence and that they use justification to assess whether the benefit of treatment outweighs any risks (40). As medical imaging staff use ionising radiation, they must ensure that they are adhering to protocol appropriately in order to reduce any harm to the patient. Auditing and inspections within the medical imaging department ensures appropriate radiation protection technique is being used and that the
best equipment available for each procedure is being used, according to protocol. Departmental protocol ensures that all staff know how to undertake all procedures and react to possible scenarios and the HCPC states that staff are to work within their remit, so if they do not feel competent at performing an examination, they should raise awareness and undertake further training. Monitoring and documentation of doses to patients and staff, with agreed acceptable limits by law, ensures optimal radiation safety and allows for
research into new imaging techniques and protocols.

Independent assessment from ISAS for medical imaging departments offers accreditation for departments who meet specific requirements in regards to clinical standards, patient experience and resources (27). The aim of ISAS is to set an international benchmark, driving departmental improvement and therefore patient and staff satisfaction. Clinical assessment promotes rapid and accurate diagnosis and treatment through monitoring of Quality Assurance methods, protocol evaluation and management of radiation safety. Appropriate facilities and resources should be available and used effectively, and there should be adequate, motivated and competent staff to accommodate demand. ISAS evaluate feedback from patients and staff to
ensure patient-focused and safe care (27). Medical Imaging departments have a high amount of interprofessional working and regulation must be in place to ensure this is done properly.

Clinical Commissioning Groups (CCG’s) have been established by NHS England and can commission Any Qualified Provider (AQP’s) to provide the best service for their patients (41). This allows the patient more choice in regards to their care, whilst being ensured the best quality of care is still provided (42). Commissioning of imaging services has implications to the NHS because, if services which they previously have provided become commissioned to AQP’s then, financially, NHS departments become disadvantaged. An example of this is if a community hospital’s imaging services are closed down and replaced with a private company. To reduce the amount of services which are commissioned away from the NHS, departments aim to increase the quality of their services and care. Regulation provides public awareness of this improvement and therefore patients are more likely to choose departments who have the best outcome after regulation. This motivates the departments to perform better for increased budgets and job security.

Excellent management is essential in the restructuring of the NHS; the Francis, Berwick and Keogh reports ll highlighted lack of leadership within the NHS (6) (9) (16). Regulation of management ensures that hospitals are primarily influenced by patient welfare and not solely motivated by financial gain, target fulfilment and political influence. The Health and Social Care Act(2012) (41) stated expectations that all hospitals will be Foundation Trusts by 2014 (43). Foundation Trusts have more power over their budget and how they spend it, which reduces the amount of political influence over NHS services (36) and also allows for more local control over what services are provided.

Advantages and Disadvantages of improved regulation to NHS and Imaging Departments 

There are innumerable advantages to improved regulation within the NHS as previously mentioned. However, there are also implications of regulation.

Prevention of NHS services (such as MRI and CT scanning) being outsourced to private companies, is occasionally counteracted by the cost of meeting regulatory targets for each hospital, alongside the cost to the NHS, of performing regulation. Having inspiring leaders and management within Imaging Departments further prevents this (44). The Healthcare Leadership Model helps to incorporate a more united NHS, where employees feel valued and confident to raise any concerns.


The CQC perform spontaneous inspections, providing a true evaluation of services. ISAS, however, perform pre-discussed inspections, which is not as effective as, if departments know when inspections and audits will be performed, there is an incentive to temporarily improve services for the inspection rather than maintain high quality, patient-centred care. Once the inspection has been completed, standards may drop much below the acceptable level and this would go unnoticed.

Enforcing better regulation costs time and money, as there are multiple procedures which have to be followed such as: research, approval, sending laws to parliament, government approval and enforcement. Also, there will always be some political influence over the structure of the NHS and therefore staff satisfaction and patient care. Financial implications can also include the cost of recruiting specific people to carry out regulation, such as an audit leader.

Disagreements between regulatory bodies (such as Monitor, CQC, HCPC) regarding best practice, protocols and methods should be counteracted by having set laws and legislation – and having the DoH as the over-ruling regulatory body(18) (20). Alongside this, the NHS Confederation provide a membership body for all NHS organisations to help standardised policies and aims(25), and the NHS Trust Development Authority provides support and governance for all NHS Trusts(50) . Set laws and protocols allow both
employees and service users to know exactly where they stand and what is expected for best practice (35). This improves the meeting of targets (i.e. infection control and waiting times) and therefore staff and patient satisfaction.

The greatest influence regulation has is that neglect similar to that highlighted within the Mid-Staffordshire trust will hopefully not happen again (6). There should now be a greater acceptance to whistle blowing where unacceptable care is seen (45), and openness within the NHS (46).

Conclusion  

Regulation is crucial in providing a universal standard of quality within NHS and other healthcare services for service users. When caring for any patient, their best interests are paramount; final control of healthcare should always lie with the patient, wherever possible. Healthcare systems must ensure safeguards are in place to prevent maleficence (47).

Regulation within the medical imaging departments, ensures that ionising radiation is used appropriately, according to law and protocol, and provided on a risk-benefit basis. All staff using radiation must be qualified and regulated by the HCPC to ensure that they follow best practice for radiation safety, patient care and continuous professional development (35). As medical imaging staff carry out a large majority of their work within a multidisciplinary team, interprofessional communication is a vital skill to develop.

“The law requires a fair and reasonable standard of care and competence” (48); 

patient care and safety should be at the core of everything the NHS does, and 

regulation ensures this.   

References 

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2. Walshe K. The rise of regulation in the NHS. British Medical Journal (BMJ). 2002 April; 324(7343).  

3. Selznick P. Focusing Organizational Research on Regulation. In Nolls RG, editor. Regulatory Policy and the Social Sciences. Berkeley: The University of California; 1985. p. 363-367. 

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9. KBE Keogh. Review into the quality of care and treatment provided by14 hospital results in England: overview report. London: NHS; 2013. 

10. Margaret C. Flynn. The Murder of Steven Hoskin A Serious Case Review. Truro: Cornwall Adult Protection Committee; 2007.  

11. The National Health Service. The NHS Constitution. Government Document. London: Department of Health; 2013. 

 12. Care Quality Commission. National Standards. [Online].; 2014 [cited 2014 May 27th. Available from: http://www.cqc.org.uk/public/what-are- standards/national-standards.  

13. Parliament Great Britain. Children Act. Act of Parliament. London:; 2004.  

 14. Great Britian Treasury. Every Child Matters London: Stationary Office;2003. 

 15. Care Quality Commission. Monitoring the Mental Health Act. Newcastle upon Tyne: CQC; 2011/2012. 

16. Department of Health. Berwick review into patient safety. London:Department of Health; 2013 

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Available from: http://www.cqc.org.uk/.  19. Parliament Great Britain. Health and Social Care (Community Health 

and Standards) Act. London: Parliament; 2003. 

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[cited 2014 May 28th. Available from: http://www.monitor-nhsft.gov.uk/. 

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24. NICHE. National Institute for Health and Care Excellence. [Online].; 

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26. Healthwatch. Healthwatch England. [Online].; 2014 [cited 2014 May 28th. Available from: http://www.healthwatch.co.uk/.  

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May 29th. Available from: http://www.hpc-uk.org/.  

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the new NHS in England. British Medical Journal. 1998 July; 317(7150). 

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34. HCPC. Standards of conduct, performance and ethics. London: HCPC; 2012. 

 35. HCPC. Standards of proficiency Radiographers. London: HCPC; 2012. 

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 39. Society of Radiographers. Code of Professional Conduct. London:; 2013. 

40. Beauchamp TCJ. Principles of Biomedical ethics Oxford: Oxford University Press; 2001. 

41. Parliament Great Britain. Health and Social Care Act. London:Parliament; 2012. 

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43. British Medical Association. Understanding the reforms. NHS trusts and foundation trusts. London: BMA; 2013. 

44. Snelling I. The development of regulation of acute hospital in England: leadership challenges. Leadership in Health Services. 2010; 23(2). 45. Department of Health. No Secrets: guidance on protecting vulnerable 

adults in care. London: Department of Health; 2000. 

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 47. Gosney M. Safeguarding Vulnerable Older People (Abuse and Neglect).London: British Geriatrics Society Policy Committee; 2009. 

  48. Shenoy G. Law Demands "Care" - Not "Cure". Journal of Gynecological  Endoscopy and Surgery. 2009 Jul-Dec; 1(2). 

  49. Civil Society. CPR Publicity Advert. [Online].; 2014. Available from: http://www.civilsociety.co.uk/fundraising/news/content/12092/bhfs_hard_and_fast_cpr_ad_overcomes_public_complaints. 

 50. Trust Development Authority [Online]. 2014 [cited 2014 April 1st.] Available from: http://www.ntda.nhs.uk/ 

 51. NHS Leadership Academy [Online]. 2014 The Healthcare Leadership Model [cited 2014 April 1st.] Available from:http://www.leadershipacademy.nhs.uk/discover/leadershipmodel/ 

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Clinical Governance - Auditing

Clinical Governance is the NHS's focus on constantly improving care through research and audits. The NHS have an obligation to account for the quality of their services through systematic and critical analysis of the standards of their clinical care. They are accountable to fix any deficiencies within the NHS.

There are elemental differences between research and audit which we'll now look at.

Both research and audit start with a question, use formal data collection through appropriate methods and designs, and then expect the answer to influence practice. Both improve professionalism and define good practice.

Research

Research is a fundamental aspect of providing evidence based practice, to ensure that the practice Healthcare professionals undertake is relevant, it is crucial to continuously advance professions and the protocols we adhere to, in order to provide optimal patient care. Research is usually one off, it can allocate patients into random treatment groups which can use placebos or new treatments, and can disturb the patient beyond their clinical treatment.

Audits

Audits, however, are on-going and doesn't disturb the patient at all. Audit provides development of professional education and regulation within the NHS, it increases care, accountability, motivation, inter-professional working and clear assessment of need. Audits support our status as autonomous professionals.

Structure

1. Set out a clear criteria 
2. Clear standard assessment
3. What's it's relevance to clinical practice? (reference to literature to justify) *Why?
4. Preparation and planning *How? *What? *Who?
5. What are the proposed changes?
6. How successful was the audit?
7. How successful were the changes?
8. What did you learn?
9. Where does the department go from here?
10. REPEAT



 Audits are not about performance appraisal, needs assessment, research, competition between departments/professionals, statsitics or disciplinary actions. Audits just assess

"What should be happening?

"Is this happening?

"Why not?

"How can we improve this?

Within your departments there should be clinical governance and audit committees which meet regularly and have high numbers of participants (according to the RCR)

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Radiography Structure and Roles

The Four Tier model in Radiography states there are four main roles within a Radiography Department since the Agenda for Change enforced pay-band changes (Employees were to be paid according to their skill and competence, rather than their professional status).

Assistant Practitioner - Undertakes specific roles under supervision from a registered professional

Practitioner - Undertakes a wide-range of tasks and has professional accountability, Continuously develops practice (CPD)

Advanced Practitioner - Autonomous in clinical practice within a defined field and defines scope of practice for others - CPD

Consultant Practitioner - Clinical, professional leadership through research, education and development in practice within a specific field. Partakes largely in Interprofessional Working as their role crosses over other's roles also (must partake in MultiDisciplinary Team Meetings), 50% of their time must be clinical practice - undertaking (and reporting of) procedures - CPD 

According to the Department of Health the Four Tier structure betters patient outcomes, develops career opportunities (such as Consultant Radiographers), develops workforce, retention of expertise and improves leadership. It improves Clinical governance (audits, protocols, CPD), patient pathway and national policies.

Although the Four Tier framework allows for clearly defined roles, Constultant Practioners must overlap roles and work together in order to provide a more efficient, patient focussed NHS. 

We must all go the extra mile. Just put in that little bit more time and make someone else's life easier. You never know when you'll need their help.

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User Involvement

User involvement has become a fundamental aspect since the Health and Social Care Act stated NHS reformation due to the Francis, Keogh and Berwick Reports. The NHS constitution states the rights of the patient, what the NHS promises to provide and what patients should expect from the NHS.

"The NHS belongs to us all" - The NHS consitution

User involvement ensures this is the case.

It improves patient care, experience and outcomes alongsidge hospital services, accountability, partnership between patients and providers. Users include Patients, Relatives, Carers, Friends and representatives.

There are several forms of involvement:

• Informal - through comments and suggestions
• Formal - Surveys, PALS, Service User groups, Patient representation on hospital committees.
• Statutory - Complaints to Trusts, involvement on Healthwatch England or Foundation Trust Governors boards

User Involvement gives service users a voice; it gives value to the patient's opinion to implement change within the NHS. Patient Led Assessment of Clinical Environment allows for the fact that often, hospitals and it's staff can become blind to problem areas, whereas service users have the ability to see areas which could be improved for the sake of both patients and staff. It allows for openness and transparency - user involvement can be used as a platform to promote ideas, complaints and response.

"Expert Patients" can be involved on the CQC inspection boards which regulate the quality of care provided by hospitals. Patients can be involved in the design and delivery of services and influence change within services for a better, safer NHS.

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Structure and services of the NHS

The structure of the NHS is so that service users are at the centre of everything we do.

There's the Governmental sections:

Department of Health - Creators of policies, legislation, law 

Parliament - Passes these laws

The Non-Departmental and Regulatory Bodies:

NHS England - Set out from the Health and Social Care Act'12

 runs the day-to-day life of the NHS including finances and budgeting

 Care Quality Commission - Regulate all NHS services through inspection 

to ensure they meet protocol, law and legislation 

 Monitor - Regulate all Foundation Trusts through inspection

 to ensure they meet protocol, law and legislation

 Health Research Authorities - Regulates research within the NHS to protect patients,

 ensures evidence based practice.

The National Organisations: 

Clinical Commissioning Groups - Commission Any Qualified Provider 

for patients to choose their care from.

HealthCare Professions Council - Provide protected-title registration for

 Healthcare Professionals who meet their standards.
Healthwatch England - Local health groups which raise awareness
of patient's concerns to the CQC 

The Local Services:

Primary Care providers - Provide prevention, advice and

 initial treatment (GP's, Dentists)

Secondary Care providers - Provide acute treatment (Emergency Departments)

Tertiary Care providers - Provide care for chronic illnesses (Oncology departments)

Finally, the most important:

Service Users - Patients, Carers, Family and Friends.

The White Paper'10

The NHS has committed to constantly improving it's services to provide the best care possible, best value and better efficiency. The White Paper (2010) set out the NHS to become more efficient and less bureaucratic. The White Paper changed Primary Care Trusts to Clinical Commissioning Groups of general practice, who are responsible for choosing and buying health services from AQP's. £80 billion of the NHS budget will be held by GP's (who need to be trained in financial and managerial aspects of commissioning). CCG's allow for more user involvement when planning service delivery and allow the patients to have a better choice of care. Also, by allowing healthcare services to be commissioned away from the NHS, it increases motivation within departments to be better, so that the patient would choose their service.

The Patient Advice and Liaison Service (PALS)

PALS provides general advice to patients about their care, but also is platform for patients to raise concerns and complaints about the care they have received. Every hospital must have a PALS department, and must advertise it's existence and encourage it's usage. 

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Leadership within the NHS

Lack of leadership within the NHS has been highlighted in reports such as the Francis, Keogh and Berwick.

Well established chains of command, structure and management is important within a healthcare organisation, however, individual leadership of all staff members is also vital to establishing a well-motivated and efficient National Health Service. 

The difference between management and leaders? We're all called to be leaders.

Managers administer and maintain previously existing views and is very much focussed on the system and control, with a short term view. They ask the questions such as "How?" and "When?"

Leaders innovate and develop ideas whilst inspiring trust; they're more people focused and look to the long-term. They ask questions such as "What?" and "Why?"

Organisational culture, the shared attitudes and values of an organisation and it's members, gives the NHS, it's departments and hospitals, a sense of identity. By individuals having leadership qualities, they can aim to affect the management style which is effective to the group, the organisation's decision making processes and it's determinants of success. 

Previously, the NHS was focused on:

• The needs of the business
• Functional aspects of care
• Efficiency, productivity and clinical outcome
• There was no emphasis on feedback
• Management (not staff) empowerment

Transactional leadership was the main method of organisation. This involved emphasis on the chain of command, authority and obedience to such, target meeting and based on a reward/punishment scheme. 

However, since 2011, the aim is to be:

• Patient focussed (with user involvement in planning of pathways and service provision)
• Relational and emotional aspects of care 
• Staff experience and empowerment
• Integrated care
• Better feedback handling
• Better information sharing

By the NHS being supporting leadership within the NHS, they are empowering staff to become more proactive, innovative and involved. This moves the NHS towards Transformational leadership, this is where a leader adopts and expresses the whole group's goals and values, it enables us to advance one-another in best practice, it allows for intellectual stimulation with greater emphasis on Continuous Professional Development and takes into account each individual's needs. Transformational leaders become influential through respect instead of necessity, they inspire motivation through a clear vision.

Professional Autonomy teaches us to challenge and question, to implement change and audit the effectiveness of our practice. This increases higher standards and gives each individual a voice -thereby bringing a cudltral change. This change is represented through the Healthcare Leadership Model  

This model brings leadership through a change in care, by sharing the vision of the NHS and integrating our services with better communication and information sharing. 

We're accountable to our actions as Healthcare professionals - so why not make those actions make a difference?

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Interprofessional Learning

Interprofessional learning, where several groups of healthcare professionals join together to improve the service of care they provide, is essential for the NHS to break down barriers between professionals. Protectiveness and territorialism amongst the NHS reduces patient care and outcome, staff moral and efficiency as people just won't communicate.

"The application of principles of adult learning to interactive, group-based learning, which relates collaborative learning to collaborative practice within a coherent rationale which is informed by understanding of interpersonal, group, organisational and inter-organisational relations and processes of professionalism" - Barr (2001)

Aims:

• To improve knowledge of the service
• Learn how to better patient care and safety
• Improve patient pathway
• Integrate systems better
• Improve communication and collaboration

How?

Within universities, training days and qualification attainment IPL has greatly impacted interprofessional working outcomes. Modules, lectures and seminars are catered not to specific departments, but for the overall healthcare profession, which creates one universal understanding of what is expected from everyon -this improves set standards for protocol and legislation which everyone adheres to.

Why?

Patients deserve to know that their care is being provided by the best-qualified people for the job, as part of registration, communication and IPW is a fundamental aspect of a healthcare professional's role.

The NHS constitution (2009) has core principles which state:

• To provide a comprehensive service to all
• Access is based on clinical need not financial ability
• Patient centred care and involvement when planning services
• Interprofessional Working
• Accountability

QIPP (Quality, Innovation, Productivity and Prevention) developed by the Department of Health drives to improve quality of care and can reduce £20 billion expenditure by 2015. This can be accomplished by improving how organisations are run, staffed and supplied (and commissioning of these services). To improve how organisations are run, there must be a Organisational Culture which focuses on improving patient care, information sharing and communication between departments and primary and secondary care givers (GP's, Hospitals).

Cases of neglect and mistreatment within the NHS (such as that at Winterbourne View care home, Mid-Staffordshire Foundation Trust and seen through the Keogh and Berwick reports) could have been prevented if professions communicated better; IPL and IPW can prevent neglect like that seen within these cases from ever happening again. IPW can increase the acceptance of whistle-blowing within the NHS - if unacceptable practice is seen, through having better ties between departments, it becomes easier to be able to raise concerns about other's practices. 

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Hindsight!

Nearly two years ago, I had just started my first placement, and wrote this:


"On Monday I was petrified to even talk to a patient, now I'm confident enough to carry a full chest X-ray without butterflies; the more examinations I carry out, the more I'm enjoying myself. The most important aspect of patient treatment I'd say is communication, never underestimate what a smile and positive attitude can do, it makes the patient much more confident and co-operative.


The hardest thing I've found is trying to get a diagnostically good image from a patient who is very unwell and unable to move or even talk. If they can't understand what you're trying to achieve, they may be extremely uncooperative as the position you need to put them in may inflict further pain. This is where you (and the patient) have to make the tough decision to continue the examination."

It's nice to reflect and realise that nearly two years on, I'm still adamant that just smiling and telling someone that they're doing really well can go a long way...

...and I still love what I do.

Even when there's a dear old lady, who suffers from dementia, curled up in the foetal position on her bed, refusing to be X-rayed - she just won't stay still... when she looks up at you with those child-like eyes with such pain, confusion and sadness - that's when you realise - she's had person after person poke and prod her, not explaining what they're doing, and even if do explain - she'll most likely forget in a few minutes. All she knows is that she's in pain and she doesn't know who you are, she just wants to go home.

Every day brings a new challenge and I still come away every day knowing that I've done good. You don't go into Healthcare Professions for money, you do it for love.

"Be the change you want to see in the world" - Ghandi

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Equipment

The main design of equipment should consider:

• Safety of the Patient, staff and carers
• Patient comfort
• Ease of use

The tube should allow:

• Ease of movement
• A wide range of positions and angles
• Accurate positioning using locks

Table design should allow:

• A floating table top
• Vertical movement
• Carbon Fibre construction (strong and light)

Lead Screen should be:

• Lead equivalent of 2mm
• Allows clear visualisation of the patient

Control Console should allow:

• Setting of exposure factors
• Selection of correct x-ray tube
• Selection of bucky
• Control of automatic exposure control

Lead Protection for patients:

• Reduce Patient Dose
• Protect radiosensitive areas
• Reassurance that the patients safety is considered

Lead Protection for staff:

• Lead rubber aprons of 0.35mm (not for primary beam)
• Thyroid Collars
• Lead Glass Glasses
• Lead Gloves

Positioning aids can be used such as radiolucent foam pads and sandbags (radiopaque)

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Clinical Imaging

There are 3 main goals of Diagnostic Radiography:

• Production of images of dianostic quality to determine the existence of a pathology determining the correct treatment and care for the patient
• Dose is to be minimised as much as possible (As Low As Reasonably Achievable) to prevent the ionising radiation causing stochastic and nonstochastic effects on a patient.
• Patient/staff safety in regards to positioning and infection control 

The X-ray source needs to produce a uniform beam in terms of their kV (energy) set by the radiographer. kV causes the amount of contrast on the image; due to the penetration through the object (patient).. mAs causes the Blackening of the X-rays due to image density. The X-ray beam attenuates after being distributed, it is either absorbed or scattered, once interacting with matter the properties of the beam alter and the object becomes magnified or distorted.

When electrons are produced from a cathode (the source of electrons - made of a filament and a focusing cup) they are then accelerated through thermionic emission towards the anode target usually made of tungsten (melting point of 3410 degrees), as it approaches the target it is suddenly decelerated by braking radiation and produces an x-ray photon. X-rays should come from a point source, should be controllable and safe.

Typically we want X-rays to come out at a point source to reduce penumbra (fuzziness of xrays) this is created by a small anode angle (17degrees) but this then produces the Anode heel effect. This effect states that as the x-ray photons come closer to the anode angle (C) there is less intensity as it is parallel to the anode and the inverse square law. This says that the further away the object is from the anode, the more diverse the x-rays become therefore more penumbra is produced.

Fine focus produces less penumbra and a more detailed X-ray image, due to the source being smaller this is used when geometric factors limit image quality and this reduces tube loading. Broad focus is used when less detail is needed (Abdominal X-ray) but dose produce more penumbra (Figure H) This image is limited by patient attenuation,there is higher tube loading and more heat dissipation.

Fine Focus

Broad Focus

The use of filters can reduce X-ray dose by removing the low kV X-rays, filters typically are made of aluminium and low penetrating X-rays are 'absorbed' by the aluminium.

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The Thorax

When looking at a chest X-ray it is important to remember that we are not only looking at the thorax but everything inside it too; the lungs, their markings and anatomy, the heart, boney anatomy (sternum, ribs) and soft tissue anatomy (liver). It is also important to remember that inspiration/expiration on taking a radiograph will have an affect on the appearance of it.

The Respiratory System

We should be able to see the apex/base of the lungs, the trachea and bification of such, the bronchi and the Hilum (the point at which the bronchi, blood vessels, nerves diverge from. Held together by pleura and connective tissue)

Lung markings are due to blood vessels and are important as absence of such can indicate pneumothorax and more prominent markings indicate other pathologies.

The Bronchial Tree - commences at the bification of the trachea (upper border of T5). The Right main bronchus is wider, shorter and more vertical than the left one, this means any foreign bodies may lodge in this one. The left Bronchus passes behind the arch of the aorta and in front of the oseophagus. The bronchi within  each lobe of the lung divide into smaller branches and lobules.

The right lung is separated into three lobes (Superior, medial and inferior lobe) whereas the left is only in two (<5% of people have an extra azygos lobe) Oblique (bottom) fissures and transverse (top) fissures seperate these lobes, fissures are infolding of pleural membrane which protect each lung (alongside the parietal pleura layer) These membranes contain a lubricating fluid (serous fluid) which reduces friction in respiration.  Each lung is further divided into bronchopulmonary segments composed of lobules which are wrapped in elastic connective tissue (Alveoli, Nerves, Lympathic vessels, branches of pulmonary and bronchiole arteries and terminal bronchiole).

The Heart

The heart lay inside the Mediastinum - a collection of tissues between the lungs, it is a broad partition medial to the lungs and extending from sternum and includes all contents of thoracic cavity (minus lungs).

Superior Mediastinum contains Arch of aorta
Anterior Mediastinum contains Right main pulmonary artery, left atrium, left atrial border, inferior vena cava and the right ventricle.
Middle Mediastinum contains Birfurcation of trachea and the main bronchi.
Posterior Mediastinum contains Thoracic part of decending aorta, Oesophagus, thoracic duct and lymph glands.

The ventricles of the heart have difference cardiac muscle thickness depending on how much pressure is generated (the left which supplies the whole body has a much thicker wall). Atria have comparatively little muscle wall as the pressure is a lot less there.

There are two coronary arteries which branch from the ascending aorta: the left divides into ventricular and circumflex branches. The anterior interventricular branch is in the anterior interventricular sulcus and supplies oxygenated blood to the walls of both ventricles. The circumflex lies in the coronary sulcus and distributes oxygenated blood to the walls of the left ventricle and atrium.

The right coronary artery supplies small branches to the right atrium and continues inferiorly to the right auricle dividing into posterior interventricular and marginal branches. The posterior interventricular branch supplies the walls of the two ventricles and septum with oxygenated blood. The marginal branch in the coronary sulcus transports oxygenated blood to the myocardium of the right ventricle.  

The Oseophagus

Extends from the laryngopharynx through mediastinum, diaphragm and to the superior portion of the stomach.

Composed of 4 layers 

1. Outer areolar layer (elastic fibres - attaches it to surrounding structures)
2. Muscular coat (muscle fibres - enables swallowing)
3. Submucous coat (loose areolar tissue - contains vessels, nerves and muscous glands)
4. Inner mucous coat (stratified squamous epithelium - folded rugae when empty)

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Muscoskeletal system

JOINTS

There are several types of joints:

Fibrous

These joints are fixed and move minimal amounts.

Sutures are dense fibrous connective tissue found in the skull of babies and are the 'soft spots' on their head. In older age these sutures ossify and become fixed (synostosis). The irregular interlocking edges allow for additional strength and minimise possible fractures.

Gomphosis joints (GUMphosis) bind teeth into their bony sockets of the maxillary and mandible. The connection between tooth and socket is called the periodontal ligament.

Syndesmoses joints are found between the articulated surfaces of the tibia and fibula, made up of considerably more fibrous connective tissue than sutures and are united by interosseous ligaments.

Cartilaginous (symphysis and synchondrosis)

Cartilaginous joints have no joint cavity and are held together between cartilage, they allow more movement than in the fibrous joints but less so than synovial.

Symphysis joints such as the pubis symphysis and the external vertebral bodies are made up of broad fibrocartilage

Synchondrosis joints are made up of hyaline cartilage and can be found in epiphyseal plates, found between the first rib and the sternum. 

Synovial joints

1. Ball and socket 2. Ellipsoid joint 3. Saddle joint 4. Hinge Joint 5. Pivot Joint

These joints have a joint cavity and are subclassified by their movements, they are also usually accompanied by accessory ligaments which allow two bones of different shapes to tightly fit and stablizes the joint. Inside the joint cavity it contains synovial joint fluid which reduces friction (similar to bursae) it also supplies nutrients and removes metabolic waste and waste formed from wear and tear of cartilage by phagocytes. The articular capsule has two layers; fibrous outter layer and articulated inner layer (formed by synovial membrane). The fibrous layer allows for movement and its tensile strength reduces changes of injury and dislocation. 

Ball and socket moves on three planes; rotation, flexion/extension and abduction/adduction.

Hinge joints such as the knee consist of a convex bone surface fitting into a concave bone surface and usually only flex/extend

Saddle joints such as the first carpo-metacarpal joint consist of a saddle shaped articular surface and a concave/complex opposing surface. Flexion/extention, Abduction/Adduction and Circumduction.

Gliding joints such as the patellofemural are flat articulated surfaces which are restricted by ligaments so can only move side to side and back and forth.

Pivot joints can be found in the radioulnar which allow full rotation: pronation and supination.

Ellipsoidal (condyloid) joints such as the wrist joint allow two plane movement (flexion/extention, cirumduction, adduction/abduction)

Hyaline cartilage is a pearly white cartilage which is found at the ends of bones and in your ears and nose, trachea, bronchi and parts of the larynx. It provides smooth surfaces for joints to move without friction, it has a high tensile strength and is avascular so is supplied by surrounding synovial fluid.

Bursaes are fluid filled connective tissue (similar fluid to synovial fluid) which reduce friction in areas of high movement such as the knee joint.

Tendons and Ligaments

A tough band of connective tissue made of collagen fibres, they usually connect muscle to bone at periosteum; very strong and pliable. Tendons do not move at all but ligaments do to accommodate for joint movement. Tendons are inclosed by sheaths to allow them to move back and forward without friction.

 

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