From my series of columns for BJS Academy
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The UK National Health Service (NHS) is a sorry state. Specialities are stretched, most beyond the point of elasticity. Many have snapped and are broken. It is not just left-wing rabble rousing or doctors having a good old whinge. NHS understaffing is completely genuine. Workload has grown as the populace lives longer, gets frailer and as healthcare grows in complexity. Funding has been either been cut in real terms or never reaches the front line. Productivity has dropped as the NHS becomes more difficult to work in.
How have we coped? We cope by working harder. Too hard, in actual fact. Which has resulted in an epidemic of burnout and general miserableness. We cope by make desperate attempts to boost productivity. But as soon as you cut through some red tape, more seems to grow back, like a fairy-tale magic forest.
We cope by employing additional staff. Ideally we employ new consultants, residents, fellows and associate specialists. But they are expensive and a rare commodity. Increasingly we employ other practitioners to pick up the slack; specialist nurses, physician associates and an increasing number of assorted therapists. When we are really stuck, we employ locums. But they are very expensive and of, erm, variable quality.
Radiology is not that different to surgery except for two differences
1) It’s consultant-delivered rather than consultant-led. Yes, we have some reporting radiographers and radiology residents but they contribute a minority of the overall work.
2) There aren’t enough residents in the pipeline. Advertise a consultant job and you are lucky to get one applicant. Getting a single suitably qualified applicant is rarer still. We have advertised one job four times over two years and it still sits empty.
The problem is fairly simple: it’s a three-decade long mismatch between growth in CT/MRI (~8% per year) and workforce growth (~4%). Other aspects of radiology have grown but they are side shows to the massive increase in cross sectional imaging, particularly ‘out-of-hours’ or emergency radiology. Which has been growing at over 10-20% annually.
Nothing has changed in UK medical practice this century more than out-of-hours radiology. Nothing comes close. Twenty years ago, radiology departmental shutters came down at 5pm and getting a scan after that was close to impossible. Unless there was, for example, votive sacrifices. Now, the shutters never close. Residents don’t even have to write request cards with their own blood anymore.
The Royal College of Radiologists has been pointing this staffing crisis for over twenty-five years. And they have been spot on in their predictions. The shortfall in consultant radiologists is currently 30%: about 2000 consultants short. One wag summarised the whole debacle: “NHS workforce planning is an oxymoron”.
Increasing radiology reporting capacity is difficult. We’ve tried to recruit. We’ve tried to retain. We’ve tried to insource. We’ve tried locums. But still the workload outstrips demand. Not only is there rising demand and an inadequate workforce but also increasing expectations. It is a Perfect Storm. It is also Perfectly Depressing. My beautiful speciality is on its collective knees,.
Increasingly, the answer is outsourcing to teleradiology companies. Hence the maxim of ‘all roads lead to outsourcing’. This feels like an admission of defeat. Rare is the radiologist that wants to give away their work. We are very aware of the optics. Outsourcing looks like local radiologists either just don’t care or are too lazy. Or both. But I can assure you that the very opposite is true. Radiologists absolutely do care. Most have an old-school work ethic and will work themselves to the bone, fully aware that their altruism is being exploited.
Without private outsourcing most UK radiology departments would be completely scuppered. 95% of UK hospitals now outsource at least some of their radiology. Without outsourcing scan reporting delays would spiral off into the distance. Delays of weeks would become months. This then causes the rest of the hospital to seize up. Radiology reporting delays cause patient harm in many direct and indirect ways.
Outsourced radiology is way more expensive than in-house reporting. The NHS has spent over £1Bn on outsourced radiology in the last decade. In 2024 the NHS spent over £200m on outsourcing, £29m on locums and £80m on insourcing, a 16% increase since 2023. Of note, this £325m would pay for the salaries of 3000 consultant radiologists, 1/3rd more than the current shortfall. This annual spend is forecast to grow to £550m in the next five years.
Anyone with a modicum of common sense or financial nous would look at this spiralling outsourcing bill and whistle through their teeth. It is obviously much cheaper to train more radiologists and therefore fill vacant existing posts. Except NHS higher management rarely plan anything beyond the financial year end. And I can tell you that training is absolutely the last consideration.
There are advantages to outsourcing radiology. It is flexible, ramping up or down as necessary. Difficult service delivery niches can be filled. And if you pay more, scans can be hot reported on a 24/7 basis. Which keeps out of hours radiology service provision alive in the UK. Overall, the companies offer a safe and valued service.
Except there is an elephant in the room. Every surgeon and every physician that I know hates outsourced radiology reports. It isn’t new, teleradiologists have been getting a kicking for decades. There is even a phrase for it - ‘telebullying’. I’ve no personal axe to grind myself. Some of my best friends are teleradiologists.
So why do teleradiology reports have such a bad rap? I have theories. I don’t think that teleradiologists are any worse than their local counterparts; they are all UK-trained and registered consultant radiologists. I don’t think it is because they rush their reports due to time pressures; this is same for all radiologists. I don’t think it because they are younger, more inexperienced or less trained; there are plenty of very senior radiologists working as teleradiologists.
But I have noticed that the problem lies with younger teleradiologists. They commit two cardinal sins of radiology reporting. First, they overcall like crazy, littering their reports with extraneous findings of dubious provenance. Second, they hedge like crazy, seemingly unable or unwilling to ascribe significance or lack of significance to their doom-laden reports.
These are the hallmarks of defensive practice. It stinks because the surgeon doesn’t know what to do with the report - are the findings real or spurious.? And so a local opinion is sought. Which creates work for the local radiologists - the very opposite of what was intended. But the frequency of such defensive reports tars all teleradiologists with the same brush. Which isn’t fair as the majority are fine.
So what to do? The answer is simple in my mind. Overcalls and unnecessary hedging need to viewed in the same way as missing a key finding. False positives are just as much as an error as false negatives. I’m not calling for fence-sitting teleradiologists to be beaten with their own shoes. Well, not too hard. And only briefly. I think that you just deduct a proportion of their reporting fee for each misdemeanour. Every overcall, all unwarranted hedges and every unnecessary vague statement deducts 25% of their fee. That’d certainly focus their attention. Certain miscreants would end up with a net loss. The problem of the poor teleradiology report would dry up overnight.
