Professionalism in healthcare

Anna van der GaagAnna van der Gaag, Chair, Health and Care Professions Council, explores the link between multidisciplinary teams and thriving professionalism.

The most recent British Social Attitudes Survey suggests that patient satisfaction with accident and emergency services is at a six-year low. Across professional health regulation, complaints are at an all time high. Many of these complaints are about behaviour, ethics and professional conduct. Why is this trend occurring and what can we do to address poor practice before it leads to a complaint?

It is likely that the increase in complaints and decrease in levels of satisfaction with services have multiple causes. The pressures on the system, resource issues and staff being asked to do more with less inevitably impact on the number of complaints. The growth of social media as a mechanism for comment, available 24 hours a day, internet sites like and Patient Opinion, which give people new opportunities to say what they think about their health professional or hospital service, are also contributing factors. We have seen a rise in complaints about breaches of confidentiality on social networking sites, and health professionals using social media as a mechanism for criticising colleagues. This type of online unprofessional behaviour is on the rise, as the lines between personal and professional lives become more blurred. Changing social norms and new ways of communicating are important influences on professionalism and how it plays out in everyday life.

The HCPC commissioned research to improve our understanding of this complex area. The first HCPC report suggests that ‘professionalism’ is seen not so much as a discrete competency but a situational judgement, a set of behaviours influenced by context, rather than a fixed characteristic. These behaviours are strongly influenced by the particular care group and peer group as well as the knowledge and skills of an individual.

The second phase of this work is ongoing, but its findings have led us to generate further debate about the centrality of ethics and conduct in day to day practice. For example, our work suggests that professionals find it more acceptable to discuss issues of competence than conduct with their peers. They find it difficult to challenge each other about how they talk to patients, whereas comments about technical aspects of competence are much more common. This depends very much upon the nature of relationships, and the level of trust and mutual respect which exists between individuals and within teams. Where there are high levels of trust and strong team working, professionalism thrives.

In his vision of the future, Don Berwick talks about the centrality of team based care where the hierarchies between professions have lost their edge, where people are genuinely respectful of each others skills and expertise and their primary aim is to work together for the good of the patient. In these environments, there is a constant search for new technologies to improve care and a respect for the patient as an equal partner in the process, with expertise, with insight, with knowledge that no professional can ever have.

Changing expectations, social norms and new technology will mean that more is demanded of us as health professionals wherever we work. We need more, not less, talk about professionalism and values in the 21st century. Radiological professionals, with their well established team-based models of care, can be leaders in these much needed conversations.

Anna van der Gaag, Chair, Health and Care Professions Council, UK

About HCPC

HCPC is a UK wide regulator of 320,000 professionals from 16 health and care professions, including radiographers and clinical scientists. Its role is to protect the public by setting and monitoring standards, quality assuring education programmes, and investigating complaints.

The 2014 Welbeck memorial lecture at UKRC in Manchester was given by Anna van der Gaag, Chair of the Health and Care Professions Council (HCPC).

Looking back on the life of Professor Robert Steiner

image Robert Steiner

Professor Robert Steiner

Robert Emil Steiner CBE MD FRCP FRCR
BIR Past President
(born 1 February 1918, died 12 September 2013)

As the world of medical imaging moves on with great rapidity, we mustn’t forget those great pioneers who helped us achieve the breakthroughs we take for granted today.

Here, Professor Graeme Bydder of the University of California, San Diego, reflects on the life of the man he knew and admired.

Robert Steiner, former professor of Radiology at the University of London and chairman of the Department of Radiology at the Royal Postgraduate Medical School, Hammersmith died after a long illness on September 12, 2013 at the age of 95.

Professor Steiner established and ran the leading academic Department of Radiology in the UK for many years. He was president of both the British Institute of Radiology and the Royal College of Radiologists and had a major role in the development of cardiac and pulmonary angiography as well as that of magnetic resonance (MR) imaging.

He was born in Prague in 1918 which was then part of the Austro-Hungarian empire, and moved with his family to Vienna at the age of three. He began studying medicine at the University of Vienna in 1935. He was about to complete his preclinical studies at the time of Anschluss, the political annexation and military occupation of Austria by Nazi Germany on March 12, 1938. Members of his medical class who expressed an objection to this simply disappeared. He needed a further two months to complete the first part of his medical degree, and after doing this, escaped through Italy to Dublin in May 1938.
He finished his medical training in Dublin in 1941 and worked in the Emergency Medical Service in the UK from 1941 to 1945. He trained in radiology at the United Sheffield Hospitals from 1944 to 1950.

He was appointed Assistant Director of Radiology at Hammersmith Hospital, London in 1950. At that time much of the equipment in the department was of pre-war vintage and the Director had radiation damage to his hands. Over the next 10 years, Professor Steiner became Director, recruited new staff, replaced equipment and established a very active teaching program.

He was appointed the first professor of Diagnostic Radiology in the University of London in 1961. He established a research program concentrating on cardiac and pulmonary angiography. This was essential for the assessment of valvular disease in the newly developing speciality of cardiac surgery. He also encouraged senior faculty within the department such as Peter Lavender, David Allison, John Laws, and Thomas Sherwood to develop their own areas of expertise to international level.

Tutorials were held on Monday evenings often with radiologists from around London bringing problem films. They were also held on Friday afternoons at 5pm in case any trainees had the idea of going home early. Private practice was banned. This meant that there was generally more consultant time available for teaching and research than at other London teaching hospitals where this was not the norm.

Professor Steiner helped train a succession of radiologists who went on to occupy senior positions in departments throughout the world. These included John Laws (Kings College), Thomas Sherwood (Cambridge), Lenny Tan (Singapore), Constantine Metreweli (Hong Kong), Andy Adams (Guy’s and St. Thomas’s), Brian Ayers (Guy’s and St. Thomas’s), Maurice Raphael (the Middlesex), John Stevens (St. Mary’s and Queen Square), Dennis Carr (the Brompton), Gary Lawler (Melbourne), Tony Leung (Sydney), Nandita deSouza (the Royal Marsden), Peter Dawson (UCH), Walter Curati (Ealing), Derek Kingsley (Queen Square), Rolf Jager (Queen Square), Takayuki Ouchi (Chiba), Alina Greco (Monaco), David Robinson (Abergavenny), Adrian Thomas (Bromley), Mary Ann Johnson (Edmonton), Susan Peterman (Atlanta) and Steven McKinstry (Belfast).

There were also paediatricians (Lilly Dubowitz, Francis Cowan, Mary Rutherford, Linda de Vries and David Edwards), and physicians (John Brown, Mark Doran, Maria Barnard, Simon Taylor-Robinson) who benefited from his training. He strongly supported research radiographers (Jackie Pennock, Linda Banks, Di Spencer, Janet Sargentoni, Anne Case, Angela Oatridge, Susan White, Elaine Williams, and Serena Counsell), scientists (Jane Cox, Jimmy Bell, David Gadian, Richard Iles, Louise Thomas), psychiatrists (Basant Puri, Eve Johnstone, David Owens), and anaesthetists (David Menon, Carol Peden, David Harris), who worked within his department as well as Margaret Kirk, Patricia Hamilton and Dulcie Rodriguez.

Professor Steiner established very fruitful collaborations and exchanges with faculty of leading radiology departments in the United States, British Commonwealth and elsewhere in the world. He hosted numerous senior radiologists on sabbatical leave including Richard Greenspan (Yale), John Doppman (National Institutes of Health), Robert Fraser (Birmingham, USA), Ian MacKay (Hartford), Michael Vermess (NIH), Harold Davidson (Oklahoma), Bob Berk (University of California, San Diego) and Moshe Graif (Tel Aviv). These visitors made a substantial contribution to the department.

He was elected president of both the British Institute of Radiology (1972-73) and the Royal College of Radiologists (1977-80), as well as the Fleischner Society (1973) an international multidisciplinary society dedicated to the diagnosis and treatment of diseases of the chest. It was named after Felix Fleischner a chest radiologist who also left Austria after Anschluss, and worked at Massachusetts General Hospital.

During the 1950s and 1960s there was what seemed an inevitable shift in radiological leadership from Sweden to the US, but quite unexpectedly Sir Godfrey Hounsfield FRS produced the first head clinical computed tomography (CT) scanner in 1971. It was a spectacular success. This was followed by body CT scanners in 1974 and 1975, and the beginning of the modern era of radiology. Britain was at the centre of it, led by a company, EMI (Electric and Musical Industries Ltd) with a remarkable record in acoustics, electronics, TV and radar going back to Alan Blumlein in the 1930s, but no previous experience in the medical field or in x-ray technology.

This was followed by the initial development of MR imaging heralded by the first image published by Paul Lauterbur in 1973. Much of the subsequent development of the technique was performed by groups in the UK based in Aberdeen, Nottingham and London (EMI). There were many difficulties and the first international conference on MR imaging held at Vanderbilt University, Nashville on October 26-27, 1980 was only a limited success mainly due to the lack of convincing clinical results. What was necessary for MR imaging to receive the large scale investment needed for future progress was a major medical application in which the new technique had a substantial advantage over state of the art CT. This Professor Steiner achieved with Ian Young FRS and his team from EMI, in the MR imaging of plaques in the brain in multiple sclerosis (MS). These were shown on a scale not previously seen except at post mortem. MS was a disease that had not previously received significant radiological attention and it seemed an improbable starting point, but MS has since become the single disease of the body most studied with MR. The system the work was done on used the first whole body cryomagnet built by Oxford Instruments, a university spin-off company founded by Lady Audrey and Sir Martin Wood FRS.

The work was remarkable in other ways. During this period EMI sold its CT business to General Electric at a knock down price following its unsuccessful venture into the US, and was trying to sell its MR business. The Medical Research Council (MRC) closed down its CT operation at Northwick Park Hospital, London in 1980 and soon after closed down its ultrasound research there. The MRC would not support clinical MR work at Hammersmith and the leader of the Hammersmith MR group, Frank Doyle suffered a catastrophic stroke before clinical studies began, and never worked again. The only significant outside support came from Gordon Higson, Director of the Scientific and Technical Services Branch of the DHSS.

The success with MS was followed by other major applications of MR including diagnosis of disease in the posterior fossa (where CT was degraded by beam hardening artefacts, 1982-3), use of the heavily T2-weighted spin echo sequence which provided very high soft tissue contrast (1982), paediatrics (no ionizing radiation, 1982-3), the first clinical study with gadolinium-DTPA (opening up the MR study of intracranial tumours, where previously the use of intravenous iodinated agents had given CT a major advantage (1984), high contrast fat signal suppressed sequences for body and musculoskeletal applications (1985). These developments helped keep the UK at the forefront of clinical MR research until, and beyond the ISMRM (International Society for Magnetic Resonance in Medicine) meeting at the Barbican, London in 1985. It also provided time for other groups to mobilise including those led by Donald Longmore (the Royal Brompton), Ian Isherwood (Manchester), Donald Hadley (Glasgow), Ian McDonald, George du Boulay and David Miller (Queen Square), Ian Kelsey Fry (St. Bartholomews, London), Jonathan Best (Edinburgh), Paul Goddard (Bristol), Adrian Dixon (Cambridge), Peter Cavanaugh (Taunton), Stephen Golding (Oxford), Philip Robinson (Leeds) and others to add to the radiological work already done by Frank Smith (Aberdeen) and Brian Worthington FRS (Nottingham). Oxford Instruments expanded rapidly and captured most of the world market for whole body cryomagnets.

The success with MR showed that the earlier success with CT could be repeated, and major developments in other areas of radiology followed including remarkable advances in ultrasound, nuclear medicine, interventional radiology, PACS and digital radiography. These helped transform the speciality of radiology and create the modern era of imaging.

Professor Steiner contributed in many different ways to these developments. He brought to the many tasks he undertook very high standards, and a wide ranging strategic vision, but it was his sense of fairness and justice that endeared him to people at all levels, and led them to trust him without reservation on personal and professional matters.

He was appointed CBE and was the recipient of the gold medals of the Royal College of Radiologists and the European Society of Radiology. He also received honourary degrees, fellowships and memberships from universities and radiological societies around the world.

He was strongly supported by his wife Gertie. She is remembered with great affection as a gracious hostess as well as a source of encouragement and wise counsel by generations of staff, faculty and visitors to the department. Gertie and Robert met in Dublin and married in Sheffield in 1945. They had two daughters, Hilary and Ann. Hilary has two children Christopher and Sarah, and one grandchild. Ann has three boys Tim, Will and Bertie. Robert had two sisters, who together with their families escaped from Vienna to Australia where they settled, and a brother Herbert who studied physics at Cambridge, and remained afterwards in England. Robert’s father and stepmother spent the war years in France, then went to England before returning to Austria.

About Professor Graeme Bydder

Graeme Bydder was born in New Zealand in 1944 and trained in medicine at the University of Otago, Dunedin. He graduated in 1969. He subsequently trained in medicine in New Zealand under Keith Macleod before receiving a Nuffield fellowship to train in CT under Louis Kreel at the MRC Clinical Research Centre, Northwick Park Hospital, London in 1978. His main work was on CT attenuation values in fatty disease of the liver, iron overload, and bone disease.

He worked at the Royal Postgraduate Medical School, Hammersmith Hospital under Frank Doyle and Professor Steiner from 1981 onwards. His main research activity was technical development and clinical application of magnetic resonance (MR) imaging in conjunction with Ian Young FRS and his team.

Professor Steiner provided strategic and tactical direction for clinical MR imaging at Hammersmith from its inception in 1981 to his final retirement in 1998.

Graeme moved to the University of California, San Diego (UCSD) in 2003 and since then has worked on MR imaging of short T2 components in tissues, qualitative and quantitative approaches to MR imaging, and MR microscopy of the musculoskeletal system.

In addition to the benefitting from working under Professor Steiner, Graeme was fortunate enough to work for two of the “three wise men” (Louis Kreel, Frank Doyle, and Jamie Ambrose) who did early experimental work on Godfrey Hounsfield’s prototype CT system and advised the DHSS to proceed with development of the technique in 1969.



The journey to a single RIS-PACS environment

JJ Alberts2  Main logo and main strapline

Dr Johann Albert, Associate Director, Business Solutions at Alliance Medical, discusses the challenge of varying client requirements in a private diagnostic imaging setting.

Unlike most NHS Acute Trusts, who tend to have large static diagnostic imaging departments located around a single or a small group of hospitals, private diagnostic imaging providers tend to have numerous static locations, a central patient management centre and varying fleet sizes of mobile scanners that move around on a daily basis. Private diagnostic imaging providers also have to contend with varying requirements from their customers that include scan-only services, book-scan-and-report services, or even report-only services. Service levels vary from customer to customer and the actual process of managing a patient differs between NHS, self-pay, medical insurance and medico-legal customers.

RIS PACS Icon logoThis variability highlights the fact that any clinical system deployed within a private diagnostic imaging provider needs to be able to cope with different workflows within the same location. It also implies that the clinical systems need to manage the end-to-end patient pathway in a manner that is completely separated from a fixed geographical location, as different parts of the patient pathway can take place in different locations. An example of this is where a patient calls the patient management centre to make a booking, the scan takes place at one of the scanning locations and the clinical report is completed by a tele-radiology provider. The clinical systems should therefore understand the concept of a workflow and a distributed network of scanning locations, as well as have the ability to move information seamlessly among various locations in accordance with the desired pathway.

The customer base of a private diagnostic imaging provider also varies from a commercial perspective. There are significant differences in customer requirements for management information, payment calculations and billing processes. This is on top of more intricate billing requirements such as factoring, zero-rated VAT or VAT exempt treatments that apply to some, but not all customers.

The realities of a business built up over time
Some of the private diagnostic imaging providers in the market started out in the pre-digital era and in the early days most diagnostic images were captured, stored and reported based on film. Over time RIS and PACS clinical applications appeared and of course private diagnostic imaging providers adopted these as appropriate. Since these technologies were still in their early phases of development, the designs tended to reflect the limitations in technology at the time and it was focussed on serving the needs of specific contracts. Some of these providers also grew by acquiring other smaller companies with their own legacy systems in situ.

These contributing factors typically result in a variety of RIS and PACS applications installed in the same organisation, all of which serve different purposes, different contracts and manage different parts of the patient pathway. To any manager the obvious implications of this scenario are, amongst others, large management overheads, a high degree of complexity in the technology solutions, various manual processes and an inability to rapidly change to accommodate customer needs.

Procuring a single RIS-PACS

To move from a situation where there are multiple RIS and PACS applications in place to a single unified system carries some significant challenges. Engrained manual business processes, distributed staff locations, radiologist availability and varying customer expectations are all significant challenges to overcome and manage. This is not even talking about the technical and logistical issues that a project of this nature would face.

Understanding the customers’ needs must form the core of any such change process and this must be layered on top of the requirements from the relevant operational teams. One of the key decision points in the design and deployment of a unified RIS-PACS environment is the balance that needs to be struck between flexibility and standardisation.

The flexibility within the system to accommodate operational needs and customer requirements is very important for any commercial organisation. On the other hand it is no use accommodating different customer requirements if these cannot be delivered to a consistent level of quality and to a consistent service level. Although there is a degree of overlap, these two system properties tend to be opposing forces in terms of the demands they place on a clinical systems platform. A good balance can only be achieved through proper engagement with customers and the relevant operational teams.

The procurement of a RIS and PACS system, at least from a private diagnostic imaging provider’s perspective, needs to fulfil several criteria and these include:

• It must have an integrated billing engine that can cope with all the requirements from different customers.
• It must manage the entire end-to-end patient pathway in the absence of a hospital information system (HIS), which includes multiple inbound channels and multiple outbound channels.
• It must allow for different workflows to be accommodated within the same clinical application that is a specific property of the contract associated with the patient.
• It must understand and cope with a distributed network of scanning facilities, some of which are static and some of which are mobile.
• It must allow for electronic interfaces and for the integration of any new developments to take place in a consistent way that is easy to manage.
• It must allow the private diagnostic imaging provider to change and configure the system as an inhouse function and not one that requires vendor intervention to the degree it is prevalent today.
• It must accommodate different clinical workflows that include scan only, scan and report, report only, double reads, report audits and also remote reporting.

This list is not meant to be comprehensive, but it is intended to highlight the requirements that a private diagnostic imaging provider will view as essential, as opposed to most radiology departments within a hospital setup. This set of criteria does point out the fact that most of the incumbent RIS vendors, and to a lessor extend the PACS vendors, do not meet all the criteria. It is therefore inevitable that some degree of customisation and development will be required for any clinical systems platform to be successful.

The implementation process
Once the appropriate systems have been procured, attention needs to turn to the implementation process. It goes without saying that a formal project methodology must be followed to have any hope of a successful implementation. Instead of providing an account of all the formal elements that a project of this nature requires, we would rather want to share our experience of the top four learning points:

Change: with any new system, there will be an element of change. The obvious example is the fact that staff members will be using a different clinical system to manage their daily workloads. There is however several areas of change that often get overlooked in a project of this nature. These include items such as the mechanism for how radiographers can move an image from the scanner to a specific radiologist. This is a simple task, but one which is core to the operation of any diagnostic imaging unit. The overall system might work very well, but if the key tasks that staff members need to perform on a daily basis are overlooked then it is easy to undermine the success of the entire project.

Process standardisation: implementing a single unified RIS and PACS implies that the same business process will be followed at each location. To assume that each scanning unit operates in exactly the same way will be a mistake though. Local business processes will have evolved over time and are a function of location-specific factors, customer-driven preferences, individual staff influences and of course head office standard operating procedures (SOPs). There must be a high degree of focus on ensuring business processes are standardised at each location, in order to accommodate a single RIS and PACS application. Deploying a system that enforces a standardised business process on a business environment that operates in a variety of ways, has the potential to stall the entire project.

Communication: with a workforce scattered around the country and a large proportion of it serving a mobile fleet, it is no surprise that communication is one of those tenacious challenges that needs constant attention. No single communication method will suffice in this situation and it is up the project team to use any and all means available to ensure the relevant messages reach the correct target audience. These methods can include anything from formal letters, face-to-face meetings and even social media. Social media is of course playing an increasingly important role in most people’s daily lives and it is a very useful tool in the business environment as well. External stakeholders need to be included at the appropriate times.

Coordination: the nature of most private diagnostic imaging providers is such that different parts of the patient work flow can take place at different locations. The payer of the service is mostly the determining factor that dictates which element needs to take place where. This is however a moving feat for the simple reason that patients from multiple contracts can be scanned at any scanning unit. The respective units therefore need to cope with different contract workflows at different times throughout the day. The implications for implementing a RIS and PACS as a unified platform is therefore that it is easy to undermine the company’s ability to service a patient if the implementation of all the different supporting systems are not well coordinated.

The latest technologies around work flow management will allow most private diagnostic imaging providers to improve productivity as well as quality at the same time, but it is important to realise that any project of this nature and scale requires just as much energy to manage the business change process as it requires to change the technical system. Even though the journey to a single RIS-PACS platform might have its challenges, it is our firm opinion that the benefits far outweigh the costs and the risks.

About Dr Johann Alberts

JJ AlbertsDr Alberts is a qualified medical doctor and his main clinical experience is in emergency medicine, both in the UK and South Africa. his experience includes private, public and military healthcare systems. In 2007 he made a career choice that deviated away from clinical medicine towards healthcare management. His passion is to design and implement healthcare services to ensure that more patients can benefit from what is already a scarce resource.

After completing an MBA at Oxford University, Johann joined BMI Healthcare as a Programme Director, where he managed four divisions that included Physiotherapy, Health Screening, Speech and Language Therapy and Occupational Health.

Johann joined Alliance Medical in 2012, first working at group level designing a quality strategy, implementing benchmarking and assisting on various projects around the company. At present Johann is directing the RIS-PACS implementation project, which will be completed in early in 2015.

Powerful partnerships

Sophia Anderton, Head of Publishing, BIR

Sophia Anderton, Head of Publishing, BIR

Sophia Anderton, BIR’s Head of Publishing reflects on a week of diversity and partnership at RSNA 2013 in Chicago.

They say Chicago’s the windy city, but last week it was more like the freezing metropolis!

Fresh back from RSNA, one of the world’s largest medical conferences, boasting 20131205_150111more than 30,000 delegates, I’m reflecting on not only the scale but also the diversity within radiology and its allied sciences. The sheer size of the event—so many people gathered together all for the sake of radiology—but also the variety of different disciplines represented were inspiring to say the least. I wonder what Wilhelm Röntgen would have thought of it all?!


BIR stand on Publishers’ Row

The BIR had a stand in a prime location on Publishers’ row so I was lucky enough to meet with a vast array of different people from around the world, working in diverse disciplines across the field (consultant radiologists, trainees/residents, radiographers, physicists, students and representatives from manufacturers). Everyone had a different story to tell.


Professor Andrew Jones (left) with the Indian Radiology and Imaging Association President Elect, Bhavin Jankharia

There was great interest in both the BIR and BJR; we were giving away free copies of Best of BJR, highlighting some of the best articles from the last year (they’re all free to download to all until the end of the year at What really caught people’s attention was our interdisciplinary ethos. As a society and journal uniquely covering all disciplines relating to radiology, there really is something for everybody. We now offer an international membership package and it was a real joy seeing people realise that the BIR could really be for them, and we look forward to working with lots of new people in the future.

With so many people, societies and companies represented, the BIR took the opportunity to make contact with as many of them as possible. For some it was the start of a new relationship, but for others it was an opportunity to reacquaint themselves with long-standing connections. One of the BIR’s newest partnerships is with Health Management ( which will be available free of charge to all BIR members from 2014. Look out for the interview with our President, Andrew Jones, early in the new year.


Grant Witheridge from corporate subscriber AGFA meets up with Professor Andrew Jones

RSNA’s key theme this year was The Power of Partnership and I think that really sums up what I was hearing last week. Working together with energy, vigour and strength to have an influence on the radiological sciences is an important message. In distributing over 1,400 copies of Best of BJR and talking to even more people about publishing, education, events and membership, the BIR is doing its part in promoting the influence and diversity of radiology.

I’m now looking forward to next year and the centenary meeting of the RSNA.