It is no secret that the National Health Service (NHS) is currently screaming along in fifth gear just to stay on a country lane: and we haven’t yet reached the motorway that lies ahead.
The NHS long-term plan couldn’t be more current, but it could perhaps have been more timely.1 Successive governments have watched our population changing shape and ageing over the last 20 years, but a powerful response to that looming ‘motorway’ of healthcare demand has only now materialised. The backlash of COVID-19 and the realisation of the impact of Brexit on NHS staff has become the ‘speed camera’ the NHS needed.
In 2022, the British Society of Echocardiography (BSE) commissioned Professor Alison Leary, Chair of Workforce Modelling at London South Bank University, to design a workforce survey that would allow us to fully understand the challenges facing the echocardiography workforce. This report and the policy report, which models solutions onto these data, can be read in full through our website (bsecho.org).2,3
This is my viewpoint on the messages contained within these gold-dust documents painted within the landscape of three years of fascinating conversations with many members of our profession and the national agencies we interact with.
The problems
First: we are leaking highly skilled workforce
The experienced Band 7 echocardiographer is the lynch-pin of every UK NHS echo service, acting as trainers, on-the-ground supervisors and quality assurers. Our data show that, far from recruitment being our major issue, there is a steady drip of senior workforce leaking from the profession. Departments with a high proportion of newly qualified echocardiographers risk a gradual decline in quality without adequate senior presence, the ‘rookie factor’ is simply too high.
Second: echocardiography is an advanced artistic and scientific skill
Performing an echo requires close patient contact and experience – every patient is different and acquiring, particularly transthoracic windows, effectively takes care and skill. If you are doing this more than 10 times a day on several days of the week you develop musculoskeletal injuries, which quickly begin to impact your life and your ability to carry on doing the job you love. Reporting an echocardiogram is an advanced skill requiring scientific and pathophysiological knowledge and experience. The clinical responsibility for each individual echo report lies on the shoulders of the echocardiographer alone.
Third: the profession of echocardiography is multi-disciplinary and has developed organically without a clear plan for advancement of the individual
Our workforce is composed of physiologists, scientists, cardiologists, anaesthetists, intensivists, emergency physicians, general practitioners and more. The only unifying influence on this diverse professional group are the BSE professional accreditations, which gate-keep quality in all clinical arenas and across all echo techniques. Medical members of our profession can access career development, but our scientific colleagues cannot point to a nationally described career development process with a relevant pay structure. Professional people are driven to develop as individuals. When you put individuals into a dead-end career structure they don’t thrive, they leave.
Solutions
There are solutions to these issues, but they are not quick fixes. Historically, quick-fix solutions to workforce issues fail. The quick-fix principles of ‘do more with the same but faster’ and ‘cut corners to work faster’ are fraught with danger, taking risks with patients that have never been considered reasonable before, and because they stress an already exhausted workforce to breaking point. We need to avoid this at all costs.
Instead, we need to intelligently rise above the temptation to focus on waiting-list initiatives and counting the time patients are waiting, and accept the real challenge in front of us: how do we raise the profile of this small but vital profession, and how do we build a career structure that focuses on career longevity and retention?
To answer this call to arms, we need to look at the profession from the inside out and not impose translated one-size-fits-all solutions: professional disengagement flourishes where there is a lack of individual control.
A key aim of our society is to act as the unified voice of echocardiographers across the UK and stop that from happening. Data and feedback from our members have shaped the following four key targeted changes, which we need for the echocardiography workforce to thrive.
Recognition and identity
The defining work of my presidency has been petitioning for a Royal Charter to metamorphose our existing society into a member of the Academy of Royal Colleges. The importance of seeking the Sovereign’s mandate to set up a new college and create a ‘body in perpetuity’ is clear from our numbers and structure. Qualified independently operating echocardiographers across the UK number just 4,800, but the richness of this highly skilled group comes from its diverse professional make-up.
I have no doubt that unifying echocardiographers through chartering of our society and, thereby, also creating the new title of Chartered Echocardiographer, will raise the profile of the profession to where it should be. We have reached this point through ground work and attention to governance, which extends far beyond the work of a society. It is vital to the future of our profession that we continue to seek appropriate recognition for every echocardiographer.
Re-valuing clinical teachers
The majority of Band 8 echocardiographer roles in the UK focus on management or research to elevate the individual out of the Band 7 bracket: and yet we know that the key members of echo communities of practice are the trainers.
The devaluation of trainers within medical clinical practice is a well-recognised phenomenon, which is clearly seen in action in the world of echocardiography. The recognition and re-valuing of clinical teachers is, therefore, key to the future of this workforce.
Two clear mechanisms that could be used to professionally honour this key group are through the formalisation of Band 8 trainer roles and the creation of a central trainer faculty group.
Identifying and up-banding a clear career structure
We need to be clearer about careers. A career structure needs to look like an attractive option for young bright individuals leaving university and looking for a satisfying job opportunity that will take them beyond just the first five years.
We need to attract exactly this group of people into the NHS, and specifically we want them to be interested in echocardiography. Echocardiographers from a scientific and physiologist background face an almost impenetrable bottleneck from Band 7 to Band 8: the current number of Band 8 echocardiographers in the UK being just 150.
This is out of step with the needs of the next generation and out of step with other small NHS professions, which have a clearer career structure and demonstrate career development to Band 9. Creating a national career structure for echocardiographers is a key priority.
Acknowledging the impact of inpatient demand on outpatient services
In 10 years’ time, each NHS Trust should aspire to run an inpatient echo team. Echocardiography is establishing itself as a core part of the care of the sick patient, potently reflected in the recently published Shock to Survival guideline.4
Establishing governance principles for inpatient echo services is a vital next step in preserving outpatient workflow: repeated interruptions to accommodate individual care provision on the wards or at the front door will shortly develop into a very significant issue for all outpatient echo departments. Now is the time to think about this growing demand and plan for it.
Leadership of the inpatient echo team should be expert. Inpatient echo services need national governance standards and should demonstrate equivalent service quality to a footprinted department, providing an echo service ‘without walls’.
Conclusion
Echocardiography sits at a crossroads, but, in fact, we are a microcosm of the crossroads facing the NHS as a whole. We can count, chart and berate; or we can recognise, re-value, develop and plan. I know where we are going.
Conflicts of interest
None declared.
Funding
None.
References
1. NHS England. NHS long term workforce plan. London: NHS England, 2023. Available from: https://www.england.nhs.uk/publication/nhs-long-term-workforce-plan/
2. Punshon G, Leary A. A survey of the echocardiography workforce in the UK. London: British Society of Echocardiography, 2022. Available from: https://www.bsecho.org/Public/Resources/Workforce/Report-1.aspx
3. Leary A, Punshon G. The UK echocardiography workforce. London: British Society of Echocardiography, 2023. Available from: https://www.bsecho.org/Public/Resources/Workforce/Report-2.aspx
4. British Cardiovascular Society and Intensive Care Society. Shock to survival. A framework to improve the care and outcomes of people with cardiogenic shock in the UK. London: Intensive Care Society, 2022. Available from: https://ics.ac.uk/resource/shock-to-survival-report.html
