Published 13 July 2020

Referral pathways for imaging examinations have changed due to Covid 19. Many referrers are not seeing their patients face to face and are now using video conferencing or telephone assessments before making a referral.

Organisations should have in place a clearly documented referral process for managing virtual referrals which includes an up-to-date list of authorised referrers.

The SoR has identified the following reference sources to support departments in assuring their governance processes to maintain quality and safety in the new way of working.

1. The Quality Standard for imaging(1)

CL1

‘An agreed process should be in place to ensure all relevant information is supplied within each referral, including: the patient’s name; contact details; date of birth; NHS number; all clinically relevant information; and full contact details for the referrer. An agreed template would be helpful. This may include a registration number or PIN unique to the referrer. Acquiring clinically relevant information from patients should be done in a sensitive manner and in an appropriate environment. Staff should respect patients’ knowledge and understanding of their own experience, their own clinical condition, their experience of their illness and how it impacts on their life (see also standard statement PE4).  

All referrals should be vetted, justified, authorised and prioritised. Vetting ensures that the patient receives the right examination or procedure, with the correct imaging protocols, in the right circumstances. Each referral should be subject to a justification process taking account of clinical indications and the requested imaging modality.

Where the examination involves ionising radiation, it must be justified by an entitled IR(ME)R Practitioner or authorised under guidelines issued by the Practitioner, to ensure that the benefits to the patient of each examination or procedure outweigh the risks associated with ionising radiation. The process must include consideration of alternative modes of imaging and should be in consultation with the referrer and patient.

A procedure should be in place for documenting the process in the patient’s record and include dealing with requests that are not justified, or for recommending alternative examinations or procedures where appropriate. Referrals should be prioritised to ensure the most urgent cases are dealt with first, to meet specified timescales. Procedures should be regularly reviewed in the light of audit information, safety notifications and developments in clinical practice.’¹

2. IR(ME)R 2017(2,3)

IR(ME)R 2017 does not specify that the referrer has to see or physically examine the patient but what they must do is comply with regulation 10 (5) The referrer must supply the practitioner with sufficient medical data (such as previous diagnostic information or medical records) relevant to the exposure requested by the referrer to enable the practitioner to decide whether there is a sufficient net benefit as required by regulation 11(1)(b).²

For sensitive imaging examinations such as the medical exposure of children Regulation 12. Optimisation may aid in directing referral pathways.  For example, these types of referrals might be Consultant to Consultant or paediatric specialist to paediatric specialist and need to be reviewed as part of new virtual pathways.

In addition to this the employer must ensure they can comply with the condition of schedule 2 1. (b) to identify individuals entitled to act as referrer or practitioner or operator within a specified scope of practice;In effect this means good governance in terms of IT access, not sharing passwords or using generic passwords for referrals.

Where a Non-Medical Referrer is entitled under a system of work or scope of practice linked to referral rights from a specific clinic or physical location this will need to be updated using the usual governance processes to reflect a virtual referral.

3. Referrals for MRI(4)

Referring clinicians have a responsibility to complete the relevant safety section on the referral form and/or submit any safety information known to them about the patient (ideally at the time of referral, in consultation with the patient).

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(Continued from above)

4. Summary For all referrals

Referrals should include a detailed clinical history and clearly state the examination(s) being requested.

Organisations should have in place a clearly documented referral process for managing virtual referrals which includes an up-to-date list of authorised referrers.

Referral forms should be signed and dated and include the date of request and the signature of the referring clinician.  In in the case of an electronic referral the referring clinician must be clearly identified .

An audit process for auditing virtual referrals should be developed and implemented.

Consideration should be given to:

• the communication process should there be queries from the referrer, the practitioner, the operator or the patient
• safeguarding issues that might otherwise be missed due to the virtual process e.g. domestic abuse, suspected physical abuse in children
• consent issues
• risk-benefit discussions

 5. Future support

A new Clinical Imaging Board IR(ME)R audit project , led by RCR should be published before the end of this year. The SCoR is involved. The new process has a section for auditing vetting and justification of referrals. 

Work on updated Non Medical Referrer (NMR) guidance led by the Royal College of Nursing (RCN) with input from SCoR is due to be published although there is currently no date for this.

Bibliography

1.        Royal College of Radiologists, and College of Radiographers (2019). The Quality Standard for Imaging (formerly ISAS) | Society of Radiographers. Available at: https://www.sor.org/about-radiography/quality-standard-imaging-formerly-isas [Accessed July 9, 2020].

2.        The British Institute of Radiology, The Royal College of Radiologists, Institute of Physics and Engineering in Medicine, The Society and College of Radiographers, and Public Health England (2020). IR(ME)R Implications for clinical practice in diagnostic imaging, interventional radiology and diagnostic nuclear medicine (London) Available at: www.rcr.ac.uk [Accessed July 10, 2020].

3.        Government, U. (2017). The Ionising Radiation (Medical Exposure) Regulations 2017 (London, UK) Available at: http://www.legislation.gov.uk/uksi/2017/1322/pdfs/uksi_20171322_en.pdf [Accessed July 9, 2020].

4.        The British Association of Magnetic Resonance Radiographers, and The Society and College of Radiographers (2019). Safety in Magnetic Resonance Imaging 1st ed. (London: SCoR, BAMRR) Available at: www.sor.org [Accessed July 10, 2020].

Published 13 July 2020

HCPC’s advice for current registrants includes information on self-isolation, unfamiliar roles and restrictions on practice. Please see here, for more information

To view guidance on considerations for registrants applying each of the Standards of conduct, performance and ethics during the COVID-19 pandemic, please see the HCPC website. 

If your employer asks you to provide a sick note then you should call NHS 111. Further information is available here. 

Where SoR members are required to follow national public health guidelines to self-isolate but are not displaying any symptoms of Covid-19, they should not be penalised and should continue to receive full pay. Additionally, such absences should not be used in regards to the triggering of formal sickness absence procedures. This is confirmed on the NHS Employers website. 

All NHS staff are given priority testing as laid out in government guidance. 

Please refer to the government advice for pregnant employees. 

Although there is no evidence that staff who are less than 28 weeks pregnant are more likely than non-pregnant staff to contract Covid -19 the consequences of an infection might well be serious.

It is the SoR’s advice that pregnant staff at any gestation should be offered the choice of whether to work in direct patient-facing roles during the COVID-19 pandemic. A risk assessment on each individual should be carried out and implemented. The risk assessment should include the ‘fear of catching covid’ factor which could cause undue stress which might affect the pregnancy.

Staff over 28 weeks pregnant, or with underlying health conditions, should avoid direct patient contact and are recommended to stay at home.

NHS Employers have guidance for staff with co-morbidity, who are 'at risk', or at 'higher risk'. 

Q: The plastic apron I have been given to cover my uniform doesn’t cover my sleeves and potentially other areas. I’m concerned that although I change my apron between patients I might pass Covid-19 on to the next patient if it is on my uniform particularly when I have to help patients to move e.g. mobile imaging, getting patients out of chairs or sitting them up on a stretcher. What can I do as management say that there aren’t enough long sleeved gowns to go round?

A: Although there isn’t, at present, any evidence to show that Covid-19 is being passed to patients on staff uniforms it is something that is concerning the World Health Organisation, particularly because of the rapid spread in nursing homes. The Society of Radiographers advises members to raise their concerns about this potential method of infection with their management and ask them to clarify whether this possibility has been considered in risk assessments? If the management instruction is to continue to work using plastic aprons rather than full sleeve gowns then members have fulfilled their professional responsibility. As long as the PPE provided is sufficient to protect staff then it is the Trust’s responsibility to ensure that the working practices are sufficient to protect patients.

Some members of my team have beards which can impact upon their ability to wear some types of PPE to protect themselves and others. What is the SoR advice to members?

There are some protections under the Equality Act 2010 that protect people’s rights to have beards. However, as stated in HR Expert:

Although the Equality Act 2010 prohibits discrimination because of the protected characteristic of sex, para.2 of sch.22 to the Act in effect provides that any action taken to comply with health and safety legislation that concerns the protection of women in relation to pregnancy or maternity, or any other circumstances that give rise to risks that specifically affect women, will not amount to unlawful discrimination. Similarly, para.1 of sch.22 to the Equality Act 2010 in effect provides that any action taken to comply with health and safety legislation will not amount to discrimination because of the following protected characteristics: age, disability, religion or belief, sex or sexual orientation.

In effect, health and safety trumps the Equality Act 2010. In these unprecedented times, radiographers, more than ever, have a duty to ensure the safety of their patients and also of themselves so that they are able to minimise the risk of them having to go off sick. Therefore, they should comply with reasonable requests from their employer.

The Department for Health and NHS have guidelines that show how it is possible to wear some facial hair and standard safety masks and all staff will be expected to comply with this. Where staff choose to grow beards for fashion or self-expression reasons, they will be expected to co-operate with reasonable requests to stay within these guidelines, or remove their beard. Reasonable risk assessments can be carried out to ensure this is reasonable. If there are reasonable alternative masks, ie available and not considerably more expensive, then they should be issued instead.

This also applies to staff who grow beards for religious reasons, although the employer might justify extra expense on these grounds. 

New or different PPE could be used as long as it is still safe. Usual PPE standards apply and risk assessments should be carried out on any changes to normal practice. The test will be if the equipment is reasonable and safe to use with patients in the circumstances.

Members with specific concerns should raise these first with their line manager and, if this doesn’t resolve the issue, contact the SoR team for specific advice and support

The SoR understands that it can be very daunting for members who haven’t worked in a particular area for many years to be asked to do something different or new, especially at a time of high stress.

Everyone who is doing a particular aspect of radiography/radiotherapy must be competent and confident in that area of work, just as normal. The employer does have the right to ask you to work in another area but they must ensure that you are competent and confident to carry out that work to the required standard. The employer must provide adequate re-training and supervision and the area must be within the Scope of Practise of a radiographer.

You should also be paid at your substantive grade if the pay for this work is lower than your normal work.

As employees, members must carry out reasonable instructions given to them by management and raise any concerns they have about their ability to do the new duties (including health concerns) with their manager in the first instance. If this doesn’t resolve the issue you can ask for specific advice and support from the SoR.

Being asked to ‘volunteer’ should be exactly this. No one can be forced to work beyond their contracted hours/rota.

However, it may be that you want to try to help when you can so you will want to consider the following:

• Will my ‘volunteer’ extra shifts/different place of work etc. be truly voluntary? Make sure that you are clear with your manager, in writing, that you are not agreeing to take on these changes on a permanent basis. The issue is likely to affect many members so talk to your local SoR rep so they can negotiate a collective agreement which covers everyone.
• Only volunteer for what you can actually commit to. It is better to say no rather than saying yes and feeling too tired or resentful.
• Make sure a risk assessment is done if you are taking on extra or different work.
• What is the pay rate for the extra work? If you take on work at a higher grade then you should be paid at this rate but if you agree to do work which is generally done by someone of a lower grade you should be paid at your substantive rate.

How do I raise concerns related to what I consider to be serious risks and unprofessional conduct, especially if the usual channels through line management are breaking down and/or part of the issue?

If you are aware of actions that you think are seriously unprofessional and/or put you, colleagues and or patients at risk, then usual reporting channels are still in place and you’d be expected to make use of them.

This would be reporting through the line management chain initially or higher if the manager is the “issue”; making use of the Freedom To Speak Up Guardians or the Independent National Whistleblowing Officer (INWO) if in Scotland; and contacting the SoR to support and advise you specifically – either via our local Representatives or the SoR TUIR team.

Only those who have retired in the last three years should be contacted and there is absolutely no compulsion to agree. Before doing anything, you would need to receive return to work training, dependent upon how long it is since you practised.

The SoR would also expect that all re-registration fees are met in full by the employer.

Pay rates should be as dictated by current NHS banding based on job evaluation.

Volunteers may be directed to different areas of work from those where they were previously registered. If this is the case the appropriate training must be provided. 

The government advises that children with at least one parent or carer who are identified as a critical worker can be sent to school if required.

For full details, please read the government’s ‘Closure of educational settings: information for parents and carers’ guidance.