All Roads Lead to Outsourcing

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.

The Low Incidence Problem

Part of a series of columns for BJS Academy

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Every few years a campaign is launched to improve the diagnosis of a particular disease. There is often a catchphrase such as, “Think x” or “Could it be y?”, with social media-ready hashtags and bright logos. Campaigns that spring to mind include aortic dissection, sepsis and, oddly, porphyria. 

The former two make sense but raising awareness of a rare metabolic disease seemed an odd battle to choose. That was until I learnt that it has the same incidence as acute aortic dissection and can be similarly unpleasant. Every day is a school day, eh?

These exhortations from Health Groups, Charities and Royal Colleges are all done with the best of intentions. The conditions all share similar features: uncommon, easily missed and both have considerable morbidity and mortality if untreated.

Such campaigns induce spikes in disease-related activity. For example, the rates of mammography screening in Australia doubled after Kylie Minogue was diagnosed with breast cancer. Porphyria? No Minogue effect yet, sadly. But there is considerable local variation. Some Emergency Departments (EDs) are aorta-mad: you merely sneeze in the waiting room, and they whip you for a CT aortogram before you can wipe your nose. 

It is a truism that any health campaign, new guideline, or ‘improved care pathway’ always leads to more scans. No guideline says fewer scans. Moreover, scans should be done faster; within two weeks, two days or two hours. Radiologists see such medical news headlines, roll their eyes and start joking about making the door to the ED hoop-shaped. Scan ‘em all as they walk in - it’d be quicker.

Incidence of disease in a scanned population is curiously quite variable, even allowing for fluctuations due to health campaigns. The major determinant is affluence. This isn’t a slight on the patients who I scan in the private sector - they have health anxieties like everyone else. It just so happens they usually have nothing seriously wrong with them. However, the NHS hospital that I work in serves a rather deprived area and every second scan is abnormal. 

Abnormal scan rate also depends on referrers. Scans are more often abnormal if they are asked for by someone who is (i) more experienced (ii) a generalist (iii) a doctor. I make no apology for this. It might not be politically correct, but it is evidence-based. It is the major argument against allowing all and sundry to request scans. Sure, the patient gets scanned quicker. Which seems to be everything these days. It doesn’t matter if costs go through the roof and both quality and incidence go through the floor, so long as everything happens quickly. 

Let us take, for example, aortic dissection. A nasty disease that kills unless treated urgently. It was traditionally suspected if the patient had two of three features - a high-risk history, high-risk physical examination features and high-risk predisposing conditions. Except it turns out that 36% of those with dissection only have one of three features. And 4% have none. So, it can be hard to diagnose. 

So, the threshold for CT aortography is now so low as to barely exist. Except dissection is quite rare, somewhere around 1 per 1000 patients pitching up to ED. But given that roughly 70% of those presenting to ED do so because of pain, scanning for dissection can be like looking for a straw-coloured needle in a mile-high haystack.

When any patient could have an aortic dissection, few patients actually do. The incidence of positive CT aortograms can be as low as 1 in 200. Which leads to two predictable adverse outcomes.

• Firstly, health services absorb another strain on their resources. Certainly the U.K.’s NHS has no magic radiology tree from which we pick full-formed radiologists and radiographers. Nor do most health services have endless scanners and other facilities sitting idle. Hence more scans for one condition means worse waiting times for patients with other conditions.
• Second, individual patients having unnecessary scans suffer. Each unnecessary scan gives each patient a decent whack of radiation. Each unnecessary scan adds to their burden of discomfort and inconvenience. Each unnecessary scan induces a delay to their eventual diagnosis by adding a detour to radiology.

But it is the unpredicted outcomes that fascinate me. Here are the main four unintended consequences:

1. Radiologist burnout. Although normal scans are quick to report, if over 99% are normal then it feels all rather pointless. When the NHS can neither recruit nor retain radiologists, adding a feeling of ever-decreasing accomplishment doesn’t help.
2. Surge in incidental findings. Incidental isn’t always trivial, but such findings need to be appropriately handled otherwise harm can result
3. Rise in false positives. Even a very good test that is 95% accurate will generate 5 false positives per 100 scans. Which, if your incidence is 1 in 200, means 10 false positive scans to every true negative. Hence the beautifully accurate scans that you are used to are now peppered with uncertainty and dubious results. 
4. Rise in false negatives. A colleague from another hospital admitted to me that two of the last three aortic dissections were missed on the CT aortogram. They couldn’t easily explain why this was. They theorised it was bias from all the true negative and false positive scans, leading the radiologists to disbelieve their own eyes. 

The upshot from this? When faced with a low incidence but serious condition, it is vital that both clinicians and radiologists put heads together. Health services cannot afford to scan patients where the chance of the condition is less than one in a hundred. Plus, it leads to a host of major predictable and unpredictable headaches. 

The answer is surprisingly simple - get experienced doctors to see and assess the patient before scanning them. Fewer scans are asked for, scan positivity rate soars, costs drop and everyone is happier. But surprisingly simple this approach can be remarkably difficult. Plus deploying more experienced doctors on the front line is not the current zeitgeist. So, the low incidence problems are here to stay, I’m sorry to say. Just don’t say I didn’t tell you.