Evolving practice and shifting boundaries in gastrointestinal tract imaging

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CHAPTER 1 Evolving practice and shifting boundaries in gastrointestinal tract imaging

Julie M. Nightingale, Myke Kudlas, Liza Ricote

Advances in GI imaging

Fluoroscopic techniques to image the gastrointestinal (GI) tract have been available since the early 20th century, although it was not until the 1970s (with the introduction of image intensification and double contrast techniques) that their effectiveness as a diagnostic tool was firmly established. While some fluoroscopic procedures have remained dominant as the method of choice for investigation of particular pathologies, a number have been replaced by alternative procedures, or are experiencing challenges to their position as a first line investigation. The barium meal, for example, has largely been replaced by endoscopy, with the double contrast barium enema (DCBE) being challenged by colonoscopy and computed tomography (CT) colonography. While fluoroscopic investigations have always been the examination of choice for investigating the small intestine (being difficult to access endoscopically), they also are being challenged by CT and MR enteroclysis techniques, as well as direct visualization by capsule endoscopy.

CT has been the mainstay of staging for most GI cancers, although we are seeing an increasing role for ultrasound and magnetic resonance (MR) imaging, particularly in peri-rectal imaging. PET (positron emission tomography) and hybrid scanning methods are also likely to have an expanding role in the assessment of more complex cases, particularly in the investigation of cancer recurrence or identification of an unknown primary cancer.

Many radiology departments have also introduced an increasing array of interventional and therapeutic GI procedures, especially for palliation of cancer. These have included esophageal and colonic stenting and balloon dilatations for different types of stricture. More recently, fluoroscopic guidance and radiological expertise for gastric banding is being used to assist in the management of patients with obesity, demand for such involvement being likely to increase in developed nations. While being time consuming and resource intensive for the radiology department, such procedures provide hospitals with the ability to support effectively those unsuitable for major surgery.

Throughout the 20th century, the GI radiology service has involved a multiprofessional team of radiologists, radiographers, radiology nurses and health care assistants. During the 1980s, the skills mix within the fluoroscopy department began to change and the following section will consider how this affected radiology departments within the UK.

Shifting professional boundaries

The gradual refinement of fluoroscopic techniques, coupled with the progressive exploration of new imaging modalities, has resulted in a much wider contribution of radiology to the gastrointestinal (GI) patient care pathway. Over the last three decades, there has been a huge shift in the role of the professions that are involved in providing the GI radiology service, particularly in the UK (Nightingale and Hogg, 2003a, 2007). However, the UK is not alone in this, with gradually shifting professional boundaries being seen within other English-speaking countries, including the USA, Australia, New Zealand and Canada.

The health services of the world are highly complex organizations, often being among the largest national employers. Introducing radical change into such organizations is challenging, as they often have many stakeholders with different needs to satisfy. Analysis of a number of historical role developments, both within and outside radiology, suggests that a range of overlapping drivers is necessary to implement the changes effectively (Box 1.1) (Nightingale and Hogg, 2003b). In the early 1990s, a major shift in professional roles began to take place within UK radiology departments. One of the most rapid to be adopted was the introduction of radiographer-performed double contrast barium enema (DCBE) examinations (known as the air contrast barium enema examination in the USA). The introduction of this role will be explored further, considering the relevant drivers that came together to result in successful implementation on a national scale.

BOX 1.1 Drivers promoting successful introduction of new roles

A perceived deficiency in the service

A proposed solution

A legal framework within which to introduce the change

A ‘champion’ of the change, at national and local level

Evidence (research) that the change will be effective

A benefit to stakeholders (interested parties)

A perceived deficiency in the service

According to the UK professional body, The College of Radiographers (2006), diagnostic imaging and interventional services have increased by 2.5–5% per annum over the last 10 to 12 years. This continuing rise in demand for imaging services, coupled with a shortage of radiologists, led to UK radiology services being severely over-stretched. The shortfall in radiologists was estimated by the Royal College of Radiologists in 2002 to:

Need to double just to match existing workloads, let alone take into account future service pressures.

Not surprisingly, perceived deficiencies were noted within the service. These included excessively long waiting times for complex examinations (including the DCBE) and radiological reports turned around too slowly to affect patient management, or not reported at all (Audit Commission, 1995). The DCBE examinations were often single reported, even when double reporting was considered to be best practice (Markus et al., 1990; Leslie and Virjee, 2002; Halligan et al., 2003). This raised serious concerns for patient care and the impact upon their prognoses, particularly where cancer was suspected. The shortage of radiologists also inevitably held back the further development of the service at that time, with less time available for audit, research and the introduction of new services.

A possible solution

Radiographers had expanded their pre-registration education to degree level (from a 2-year diploma course) and experienced radiographers had begun to explore postgraduate master’s level opportunities. Radiographers have long been perceived to be working below their potential (Swinburne, 1971), often moving into managerial or education positions due to a lack of challenging opportunities in clinical practice. One solution, to train radiographers to undertake DCBE examinations, as these had unacceptably long waiting lists in many hospitals, offered an important new challenge and yet could be ‘easily described within a protocol’ (Somers et al., 1981).

A legal framework within which to introduce the change

A number of changes to legislation and professional body guidance was introduced within the 1990s, some acting as a catalyst to encourage role development and some, inevitably, being brought about in response to what was already happening at a local level. These included the introduction of the Ionising Radiation (Medical Exposure) Regulations (Department of Health, 2000a) and Department of Health publications such as the NHS Cancer Plan (2000b). The professional body and trade union for radiographers (the Society and College of Radiographers) was very supportive to radiographers wishing to develop their roles, issuing a series of guidance documents between 1996 and the present day (e.g. The College of Radiographers 1996, 1997, 2006). In essence, these documents suggested a framework in which radiographers could potentially develop any role, as long as they were appropriately trained, worked within agreed protocols, audited their practice and maintained their competence through continuing professional development (CPD). Protocols have been found to be appropriate frameworks within which radiographers can safely and effectively practice advanced roles (Nightingale, 2008). The Royal College of Radiologists (RCR; the UK radiologists’ professional body) has also been supportive towards radiographer role development, although with a slightly more cautious approach (RCR 1996, 1999, 2007). This is understandable when their members are delegating existing tasks and may still bear the ultimate responsibility for the delegated role.

A ‘champion’ of the change, at national and local level

There has to date been no direct professional body steer to introduce a particular role development across the UK. However, as with most new roles, there is often a champion at national level. For the introduction of radiographer-performed DCBE, this champion has arguably been the national gastrointestinal radiographers’ special interest group (GIRSIG), which has both promoted and supported radiographers involved in these roles for several years (Nightingale and Hogg, 2000). However, it is not clear if the role would have been introduced so successfully across the UK if it had not been for the presence of radiologist champions, promoting radiographer role development both within and beyond radiology (e.g. Chapman, 1997; Robinson et al., 1999; Thomas, 2005b). The radiologists appeared at that time to be the ‘gatekeepers’ to service development and this largely appears to be the case today. The radiologists provided clinical training and supervision for the radiographers, who had access to a short course or Master’s level module for theoretical underpinning.

National drivers for role development have also emerged in the wake of a series of government targets, most notably the introduction of a maximum waiting target of 2 weeks from referral to diagnosis for suspected cancer (NHS Executive, 2000) and, more recently, the 18 week maximum from referral to treatment (Department of Health, 2006). With medical imaging being heralded by the Government as the primary bottleneck resulting in failure of hospitals to meet these targets (Department of Health, 2005), it is little wonder that modernizing services and new ways of working are being championed in political circles.

Evidence (research) that the change will be effective

Published evidence that the role change is effective is vital to promote the widespread introduction of a new service. While UK radiographers have been rather reticent to engage in research, where the DCBE examination has been concerned, one finds a wealth of literature supporting the new role. This has included a number of studies comparing radiographer performance in performing and/or reporting DCBE examinations with trainee radiologists (Mannion et al., 1995; Schreiber et al., 1996; Davidson et al., 2000) or with consultant radiologists (McKenzie et al., 1998; Culpan et al., 2002; Murphy et al., 2002; Vora and Chapman, 2004). It also includes performance against pathology databases (Law et al., 1999, 2008) and national surveys of practice (Bewell and Chapman, 1996). While most of these studies have concentrated on small numbers of individuals in single-center studies, they nevertheless provide very useful and plausible performance data across large numbers of patients.

A benefit to stakeholders (interested parties)

However, without there being a clear benefit to the relevant stakeholders, it is unlikely that a new role will be introduced. The benefits to radiology departments have been clear, with vastly reduced waiting lists for DCBE and, where radiographer reporting has been introduced, quicker turnaround for report writing. There are potential cost savings, with the hourly rate of a radiographer being considerably less than that of a consultant radiologist (Brown and Desai, 2002). Surprisingly little published literature is focused upon patient acceptability, although in practice many unpublished patient surveys have suggested that patients are happy to be cared for by a radiographer without recourse to a radiologist. The patient benefits directly from these improvements, reducing anxiety with shorter waits and having a potentially better prognosis associated with a shortened referral to diagnosis timeframe. The benefits to the radiologist are clear, in that they have more time to fulfil their other duties or to introduce new services. Anecdotal evidence would suggest that, for most radiologists, the rather unglamorous aspects of the DCBE procedure have not been missed from their portfolio of duties!

So what about the radiographers? Again anecdotal evidence would suggest that performing these complex procedures has given them a great deal of satisfaction, in particular in relation to improved patient care and team working. For many who have continued their training to include reporting on the images and the performing of other GI procedures, they have increased their confidence and esteem, becoming highly valued members of the multidisciplinary team. This has led to re-grading and increased salaries for many radiographers within the new career framework.

Beyond the DCBE

The radiographer-performed DCBE role has been so well received that radiographer-led services are now the norm across the UK National Health Service (NHS), with recent estimates suggesting that over 1200 radiographers have been trained to perform DCBE (Nightingale and Hogg, 2007); 82% of hospitals surveyed by Price and Le Masurier (2007) had implemented a radiographer-led DCBE service. Many such radiographers have gone on to undertake postgraduate training to enable them to write an official report on the DCBEs, with published data supporting this practice (Law et al., 1999; Murphy et al., 2002). While most of the available courses prepare and assess radiographers to report independently, in practice, many will report as part of a double reporting system, whereby two people view the images independently and then compare reports. Double reporting is recommended in the UK for the DCBE procedure, as it is associated with a high level of potential perception errors (Markus et al., 1990; Leslie and Virjee, 2002).

Some radiographers have further expanded their role to perform and report barium swallows and meals, videofluoroscopy swallowing assessments, small bowel studies, proctograms and other non-GI fluoroscopy (e.g. hysterosalpingography) (Law et al., 2005; Nightingale and Mackay, 2009). While most DCBE radiographers have further developed their role within the confines of the fluoroscopy room, increasingly GI radiographers are crossing traditional imaging modalities to run a CT colonography service, often in conjunction with a CT radiographer. Some are not only working across imaging modalities, but have also crossed professional boundaries to work with teams outside radiology. Although nurse-performed endoscopy is far more common (Maruthachalam et al., 2006, Kelly et al., 2007), a handful of UK radiographers have trained to undertake sigmoidoscopy or colonoscopy, with the potential advantage over nurses of being able to offer continuity of care with combined DCBE and direct visualization on one day.

However, despite the exciting opportunities presented, relatively few UK radiographers have developed their role beyond the DCBE examination (Price and Le Masurier, 2007). This may be because the required drivers for effective role changes (see Box 1.1.) are not firmly in place. In Table 1.1, we present possible reasons, based upon both published and anecdotal evidence, regarding the apparent stalemate in the adoption of further role developments and advanced practices.

Table 1.1 Criteria for effective implementation of role changes beyond the DCBE examination since 2000

Driver for change	Evidence for the presence of the driver
A perceived deficiency in the service	The waiting lists for other GI examinations and their report turnaround times are reasonably short The shortage of radiologists is no longer as acute as in the 1990s Additional funded radiology training places results in competition for training sessions in some hospitals

A proposed solution Radiographers could take on new roles. A legal framework within which to introduce the change There are concerns about the greater risks involved in some procedures (e.g. endoscopy) A ‘champion’ of the change, at national and local level

Some examinations are not attracting interest from the government, compared to others which are seen as high priority (e.g. examinations for colon cancer screening)

While special interest groups and professional bodies still support role development, there is a lack of appropriate education and training for new roles

Evidence (research) that the change will be effective There is a lack of published evidence that radiographer-performed studies other than the DCBE are safe or effective A benefit to stakeholders (interested parties)

Radiologists do not want to give up these procedures

Radiographers already rewarded within the career structure for doing an advanced role (advanced practitioner level) are unlikely to receive any additional payment for taking on a new role (and new responsibility)

Clearly from Table 1.1, a number of drivers for effective implementation of widespread role changes are not currently in place. While a clear service need for other GI advanced practices may exist within any given hospital, the role is unlikely to be adopted as national standard practice without there being a perceived service deficiency, coupled with a champion at national level.

At the time of writing, it appears that we are once again on the threshold of a new role change for radiographers, which may well be implemented on a national basis. CT colonography (CTC) (alternatively known as virtual colonoscopy), a relatively new technique to examine the bowel, has been extensively researched around the world. Advocates of this procedure are proposing that it will eventually replace the barium enema for symptomatic work and may have an important role to play in bowel screening. For this reason, the government and professional bodies have also taken a keen interest, with a national working party currently developing a framework for implementation. A UK wide study (SIGGAR 1 trial) comparing CTC to barium enema and colonoscopy for bowel cancer in older symptomatic patients is soon to report its findings (Halligan et al., 2007). Nevertheless, hospitals around the UK have already introduced this procedure to varying degrees, with many proposing that radiographers play an important part in both performing the procedure, managing the scanning protocols and, in some way, contributing to the reporting process. Table 1.2 considers the presence or absence of drivers for implementation of radiographer involvement in CTC.

Table 1.2 Criteria for effective implementation of radiographer role development in CTC, as of 2008

Driver for change	Evidence for the presence of the driver
A perceived deficiency in the service	Insufficient capacity on CT scanners New 18-week targets from referral to treatment in force and difficult to meet Expensive procedure in terms of radiologist involvement to perform and report examinations Possible need to double report, yet limited radiologist time to do so
A proposed solution	Radiographers who currently perform DCBE examinations already have many transferable skills for performing the procedure (e.g. rectal catheterization and IV cannulation) Radiographers skilled in CT have the expertise to manage the CT examination, and may be skilled in IV cannulation DCBE radiographers who report on their examinations may have transferable skills to report the intraluminal findings of the CTC examination Both CT and GI radiographers can be trained to interpret the extraluminal findings Radiographers will be cheaper to employ than radiologists, could work extended days to offer additional lists, and could contribute to a double reporting system
A legal framework within which to introduce the change	Supportive to role developments
A ‘champion’ of the change, at national and local level	Attracting interest from the government and professional bodies for radiology and radiography, for both screening and symptomatic groups National working parties set up to consider nature of any implementation A number of training courses offered, with several master’s level courses under development
Evidence (research) that the change will be effective	Whilst there is a lot of evidence to support CTC, limited data is found regarding the radiographer role
A benefit to stakeholders (interested parties)	Radiologists have more time to concentrate on reporting CTC, or have additional ‘back-up’ from a double report by a radiographer GI radiographers have an opportunity to diversify their role beyond fluoroscopy CT radiographers have an opportunity to develop their role in an advanced practice area Radiographers already rewarded within the career structure for doing an advanced role (Advanced Practitioner level) are unlikely to receive any additional payment for taking on a new role (and new responsibility)

While CTC presents an exciting opportunity for radiographers (and possibly radiology nurses) to expand their role beyond the DCBE, a number of radiographers have already developed a ‘package’ of expertise that has enabled them to attain the highest level of clinical speciality in the UK – that of consultant radiographer status. At the time of writing, there are 26 consultant radiographers in the UK, five being GI sub-specialists. While the ethos of the consultant practitioner role should be applauded, 5 years since their introduction the actual numbers achieving this accolade are still woefully low (Price and Le Masurier, 2007). Their roles vary depending upon local needs, but predominantly their post is concerned with service development, including aspects of expert clinical practice, research and involvement in education (College of Radiographers, 2005). They often work alongside GI advanced practitioners, radiographer practitioners, assistant practitioners and radiology nurses within the GI service (see Table 1.3), with several crossing professional boundaries to work within the gastroenterology or endoscopy departments. It is likely that the numbers of advanced and consultant GI practitioners will grow in the next few years, although funding such posts will always be a major issue.

Table 1.3 The career framework for radiographers within the UK

Inevitably, the role of the radiologist will also continue to evolve, with medical imaging always being central to clinical medicine. However, it is likely that, similar to the situation within radiography, radiologists will continue to specialize to ensure they can provide the best care for their patients and will need to introduce innovative solutions to respond to changing patterns of care, including a move towards a 24/7 department and increasing opportunities in molecular imaging (Thomas, 2005a).

International perspectives

Having outlined the historical and current situation in the UK, we will now consider how these compare to shifting professional boundaries within selected other countries, and will attempt to ascertain why any differences exist. Cowling (2008) offered a global overview of the changing roles of radiographers, suggesting that the UK has led the way in widening their scope of practice and is unquestionably the world leader in advanced practice. She outlines four different levels of role advancement, with the UK and the USA being in the first tier, having implemented an effective system of role advancement. In the second level lie countries such as Australia and New Zealand, Canada, South Africa and Japan, where the driving forces are the same but implementation has not yet happened to any great degree. The third level countries have made moves towards having formal recognition for their profession, with role development being their next step, and the fourth group have yet to achieve formal acceptance of radiography as a distinct profession. The situation in the USA, Australia and New Zealand will now be explored further in terms of gastrointestinal imaging role advancements and will be compared to that of the UK.

The United States of America

In the USA, the practice of GI radiography varies widely from state to state. In some states, radiographers are able to perform many examinations independently, while in other parts of the country radiographers are limited to more of an assistant’s role. There are few national statutes regulating the practice of GI radiography, however, the American Society of Radiologic Technologists (ASRT) has developed practice standards and the American Registry of Radiologic Technologists (ARRT) designed a task inventory that provides general guidance to radiographers in the performance of GI exams (ASRT, 2007a; ARRT, 2004). These principles would be further defined by the individual states, whose law supersedes those of the national Societies.

According to the practice standards and task inventory mentioned above, radiographers in the USA are able to obtain a patient history, confirm a proper preparation for an exam, take a lead role in radiation safety during the GI exam and set the technical factors on the radiographic and fluoroscopic equipment. In addition, the radiographer may perform particular non-fluoroscopic (over-couch) projections, including individual images of the esophagus and upper GI series and abdominal images as part of a small bowel series and barium enema.

The radiographer’s role in a majority of these studies is to assist the radiologist during the fluoroscopic portion of the exam and perform any additional over-couch follow-on images independently. The most notable exception to the role of the radiographer compared to the situation in the UK is results reporting. Fluoroscopy can be performed by a radiographer, as long as there is no reporting connected to the procedure (ASRT, 2007a).

Within the last several years, however, the role of the radiographer in GI imaging has been evolving, in large part due to the developing role of the radiologist assistant (RA). The RA is a relatively new role for radiographers in the USA that can actually trace its development back to the 1970s. The idea of an additional rung on the career ladder for radiographers in the USA has gained a great deal of support recently when, in 2002, the ASRT began to explore an expanded role for radiographers. The RA concept was approved by the American College of Radiology (ACR) in 2003 and the ARRT began offering a certification exam to radiologist assistant graduates in June of 2007.

The additional role of the RA was developed for several reasons: to provide a career ladder for radiographers; to increase the job satisfaction of radiographers; to reduce radiographer attrition; to address the radiologist shortage; to increase efficiency; and to reduce expenses (Smith and Applegate, 2004; McLeod and Montane, 2006; Carlos and Keast, 2006). These drivers for change are not dissimilar to those culminating in role developments within the UK. The concept of a radiologist assistant was also developed because there was a wide acceptance that properly trained radiographers could perform specific examinations independently. Arguably, the area of imaging identified where RAs could make the greatest impact was in GI imaging. Several studies performed in the USA indicate that properly trained radiographers can perform fluoroscopic GI examinations to a level comparable to radiology residents (Schreiber et al., 1996; Davidson et al., 2000) and, in some cases, even practicing radiologists (Van Valkenburg et al., 2000; Thompson et al., 2006).

In their new roles, radiologist assistants are able to perform an expanded array of procedures in GI radiology and the ASRT and ARRT have consequently expanded the guidelines for RAs, allowing them to perform many examinations with some degree of independence. According to the ARRT’s (2005) Registered Radiologist Role Delineation, RAs may perform the following GI procedures without the physical presence of the radiologist in the room (although they must be immediately available for consultation if necessary):

Nasogastric or oroenteric feeding tube placement.

Although the exam can be performed by the RA and preliminary findings can be reported to the radiologist, the RA is still prevented from rendering a final diagnostic reading of the images (ASRT, 2007b). Similar to the ‘Red Dot’ system utilized in other countries, the RA may strictly point out areas of concern for the radiologist but the final report is approved by a board certified radiologist. This limitation imposed upon radiographers is perhaps understandable while these new roles are in their infancy, particularly in the absence of published literature supporting radiographer reporting in the GI field. However, one approach strongly advocates that the person undertaking a dynamic, real-time examination is in the best position to write a diagnostic report on the findings, as they have been party to the fluoroscopic findings which may not have all been captured on static images (Halligan et al., 2003). Perhaps the fact that the USA operates a fee per service system (including the report) may influence the professional latitude awarded to the radiographers. Within the UK National Health Service, a fee per service system does not affect the pay and awards of an individual radiologist. However, over time, it may be possible to develop the radiographers’ reporting skills to enable them to contribute fully to a double reporting system, where they write the report, which is then verified by the radiologist.

By November 2007, there were 59 radiologist assistants who had graduated from 10 educational programmes (May et al., 2008). Early evaluations showed that there was the potential to save radiologists an average of 100 minutes per day, with a resultant cost saving, even though RA salaries are some 62% higher than radiographers (Wright et al 2008). Based on evidence such as this, radiologist support for the RA program is growing (May et al., 2008).

Regardless of the degree of performance in GI radiography, all radiographers in the USA must understand the general principles behind GI radiography, GI anatomy and how the examination is performed. This knowledge is vital whether the radiographer is performing the examination or assisting the radiologist. The ability to anticipate the needs of the radiologist and to act as a second pair of eyes during the GI examination can sometimes make all the difference in providing a quality examination for the patient.

Australia and New Zealand

At the time of writing, Australia and New Zealand has no formalized system of either role extension or expansion. In a national system where private healthcare and fee for service is well entrenched and has dominated the greater percentage of not only imaging services, but healthcare provision generally for many years, the incentive for change and the change itself is made considerably more difficult.

It may be considered that Australia is perhaps somewhere in the order of 20 years behind the UK in the area of radiographer role development. In comparison to the UK, Australia is a very large country with a number of states that act as their own governors; thus regulations vary from state to state. Most imaging services are delivered within private radiology groups, some operating in very remote places. While a limited extension of the scope of practice is occurring in small pockets around Australia (e.g. IV cannulation, contrast injections and Red Dot flagging), it has normally come about through approval at hospital level as a result of local need, rather than as part of a coordinated national approach (Smith et al., 2008). In Australia, there is currently little radiographer involvement in GI procedures beyond acting in an ‘assistant to the radiologist’ capacity, although in New Zealand, two radiographers are currently performing DCBE examinations.

The topic of radiographer role development is gathering momentum, however, with a continuing shortfall of radiologist numbers required for timely service delivery, coupled with an increase in the demand for imaging services in light of technological evolution and the aging population (Smith and Baird, 2007). Journal and press articles raising awareness and concern are increasing in number, detailing reporting backlogs, unmet service demands and associated risks regarding patient welfare and diagnostic outcomes (Patty, 2007). In New Zealand, a high rate of colorectal cancer, coupled with difficulties in providing a responsive service in some of the more remote areas, would seem to be potential catalysts for future radiographer-led GI services. However, the current fee for service system seems to work against radiologists delegating the examinations and, in particular, the reporting aspects, to radiographers. As has been evident in both the UK and the USA, the radiologists continue to be the gatekeepers to the role development of radiographers.

The Productivity Commission’s Health Workforce Report of 2005 (Productivity Commission, 2005) examined the impact on healthcare services taking into account the supply and demand of trained health practitioners, and the current workforce’s ability to meet service demands. As has already been established in other countries, the question of limited task transfer in some professions within Australia has been identified as holding the key to alleviating some of the current stress (Smith and Baird, 2007). To date, an advanced practice model has been developed and implemented within the Australian Nursing Profession.

The Australian Institute of Radiography (AIR) is Australia’s leading national body representing radiographers, radiation therapists and sonographers. In anticipation of the escalation of this mis-match of supply, demand and increased patient risk, AIR is actively working towards implementation of an advanced practice model to suit the Australian workforce environment. The AIR is simultaneously negotiating with the Australian government and with the Royal Australian and New Zealand College of Radiologists (RANZCR) to propose a new hierarchical structure that includes an advanced practitioner tier. RANZCR’s position, in a similar stance to that of the USA professional organizations, is that a radiological report cannot at this time be provided by anyone who is not a trained medical practitioner and who has not subsequently undergone training as an imaging specialist (Kenny and Andrews, 2007).

In 2005, the AIR, committed to this initiative, commissioned the Professional Advancement Working Party (PAWP). The aim of PAWP was to identify a pathway of role evolution for radiographers and radiation therapists that would ultimately improve the healthcare status of the patient, the functioning of the healthcare team and add value to the role of the radiographer (PAWP report 2006). Subsequently, the AIR has commissioned the Advanced Practitioners’ Working Group (APWG) which is currently working to further the recommendations of the PAWP report and will be active until April 2009.

In New Zealand, however, the previously ‘ad hoc’ role developments have gained national interest, culminating in working groups specifically set up to look at the future skills mix in radiology departments. Reports from both the New Zealand Institute of Medical Radiation Technology (NZIMRT) and the District Health Boards of New Zealand were due to be published in 2008. The NZIMRT has approved a recommendation to introduce a three-tier career framework, including assistant practitioners, practitioners and advanced practitioners. It is anticipated that the first advanced practice roles will be introduced before the end of 2008 (Smith et al., 2008).

Change takes time, but it is hoped that, in the future, workforce restructuring in the delivery of Australian and New Zealand medical imaging and radiation therapy services will allow for an improved patient focused care and delivery.