The NHS Echocardiography Crisis

The second quarter’s issue of ECHO (Journal of the British Society of Echocardiography) has just been distributed, and President Rick Steeds used his ‘President’s Message’ column to address the acute shortages of skilled echocardiographers in the UK. He quotes a statistic from the Picker Survey, showing a 43% increase in demand on echocardiography departments over the past six years.

He addresses the key role the BSE plays in upholding standards of echocardiography in the UK, but sees the BSE’s responsibility for addressing the skill shortage as one of “highlighting” the problem to other organisations – but not necessarily something the BSE can tackle directly.

Can the BSE do more?

There are two considerations here. One is the overall shortage of echocardiographers in the NHS. The second is, as Dr Steeds states, “the ability of departments across the United Kingdom to deliver good quality, timely echocardiography.” Dr Rick Steeds identifies the staff shortage as the major threat to this goal, and it is, but the link may not be so direct. The BSE article implies that, in the absence of qualified echocardiographers to fill the positions, the positions simply do not get filled (quoting the Picker Survey’s statistic that 68.3% of echo departments have at least one unfilled vacancy). Of course, this omits mention of the fact that agencies are making a lot of money filling in many of these gaps with ‘temporary’ staff (who can often stay in the same hospital for many years).

So where do agencies find their staff?

If the NHS can’t find echocardiographers, how is it that agencies can?

Locum echocardiographers are a mixed bunch. Many are very skilled and experienced cardiac physiologists or dedicated echocardiographers who are simply tired of running an entire department on £40k a year, when they could work the hours they want, with no overtime and no added responsibility, on £65k a year. Some are conscientious workers who just can’t find the right full-time post for their life circumstances – maybe they’re a parent and cannot work full time or regular hours, or perhaps they have other work commitments and need the flexibility that agency work can provide.

However, it cannot be denied that some of the people on the agency ‘books’ are none of these things. Whilst NHS posts invariably ask for BSE or equivalent, agencies are happy to take on unaccredited staff. This is not necessarily a criticism (for reasons which will be explained below*), but the issue that then arises is if you’re willing to take people who have not achieved the only real measureable ‘gold standard’ we have in British echocardiography, what becomes the minimum requirement for placement? And how diligent are agencies in verifying this, anyway? I write from personal experience of witnessing individuals lie about their qualifications in an attempt to get a full-time NHS job (and who surely would have no scruples about doing the same to an agency), and two people actually secure locum work with their only prior echo experience a fail in their Masters degree (they forgot to mention the “fail” part). These people are placed straight into busy hospitals where they are scanning and reporting independently, with no quality control in place. Busy managers don’t pay agencies ridiculous sums of money to have to train and check their locums. When you locum, you’re on your own.

*Why agencies can’t be blamed for employing non-BSE accredited staff

So are the agencies the bad guys? They could be more diligent, for sure, but they’re simply profiting off a situation that is not of their making. The entire system is broken when an unaccredited individual can start in an NHS post at Band 6 on £21,000 a year, or legitimately walk straight into an agency job on £60,000 a year. If anything highlights the inefficiencies in the way funds are allocated within the NHS, it’s the fact that departments cannot raise the salaries of permanent staff, but are allowed to pay £50 an hour to agencies for Band 6/7 level staff. The agency hourly rate for consultants doesn’t bear thinking about.

Yet, the BSE could do more. For those who do choose to work within the NHS for whatever reason (ethical, job security, training and career progression), there is little extra support. BSE practical examination dates are heavily oversubscribed, and the BSE makes no distinction between people needing their qualification to progress in their NHS careers, and people sitting it just to make an extra £5 an hour on their locum paycheques or even as something to decorate their curriculum vitae with as they return to their home country. Similarly, it makes no distinction between full time echocardiographers and doctors who are simply looking to add another string to their bow.

None of this is to say that doctors or people working outside of the NHS are not entitled to pursue accreditation. Achieving a standard of proficiency is just as (arguably more!) important for these people as for full time NHS echocardiographers. But in the debate about how the BSE can improve standards and staff availability within the NHS, at least some kind of quota system to ensure access to the examination within a given timeframe for NHS workers, would not be unreasonable.

As it is, there is little accountability within the BSE to its members. The Society will readily take membership fees and payments to attend annual conferences indefinitely, without any promise in return to allow that particular member even the opportunity to gain accreditation. Booking a place on a practical examination day is like trying to get hold of Adele concert tickets – you open the booking page on every electronic device you own, spamming refresh until booking opens, frantically fill in the booking form the second it becomes available… only to find that there are no spaces left. How many careers are being held back by this system? How many people may want to progress, further their skills and education, specialise in something like paediatric, congenital or transoesophageal, enable their department to run a weekend service, but instead – due to a roll of the dice as opposed to any lack of dedication on their part – are left somewhat disillusioned in Band 6 posts?

In Conclusion

The British Society of Echocardiography does a fantastic job in maintaining standards in echocardiography. It has positioned itself as the gold standard, the guarantor of quality control. But with this comes a duty to deliver a fair and accessible service to its members. When examinations are made prohibitively difficult to attend, let alone pass, supply finds a way to meet demand through other channels. There is now a general acceptance in all but the most in-demand workplaces to take unaccredited sonographers without any assessment of competency. This undermines the entire system, and could potentially bring the reputation of the industry into disrepute.

At the same time, echocardiographers working within the National Health Service and staying late in the evenings to update their BSE logbooks and video case presentations with no guarantee of even obtaining a place on an assessment day, are seeing friends and colleagues earning 4-6x their monthly salary, completely unburdened by the constraints of lack of accreditation. This further undermines morale and may ultimately tempt people away, frustrated by their inability to progress, further shrinking the pool of skilled individuals willing to work directly within the NHS.

The British Society of Echocardiography has improved its accreditation process immensely, but has created a choke point in the supply of accredited and willing staff for the National Health Service to employ. If the ‘first come first served’ system is not providing a fair distribution of places on examinations, setting aside a certain number of places for echocardiographers working within NHS departments should be considered.