Associate Feature: Echoing warnings

It’s 10am and there’s a quiet hum of activity in a ground floor corridor at Edinburgh Royal Infirmary. 

Clinicians and scientists swish past in their blue scrubs while patients sit quietly with their thoughts. They are here for an echocardiogram (echo), a key diagnostic test for heart disease.

One by one, patients are ushered out of the brightly lit waiting area into a darkened room where the blinds are lowered against the white September sky. An expert cardiac physiologist then applies a probe to the patient’s chest, small enough to be inserted between the ribs, which uses ultrasound to get a picture of the heart’s structures. The results are relayed back to the attached computer to build up a complex picture of the organ and how well it is functioning. 

An echo in Lothian usually takes 45 minutes, but today one of the senior staff is training a new colleague so the slot is an hour; complex scans are also allocated an hour. 

These realistically timed slots ensure that Edinburgh meets the high standard of service to be accredited by the British Society of Echocardiography (BSE). Some services elsewhere in Scotland might allocate shorter times to each scan, yet Edinburgh has very low waiting times for echos. 

Sadly, Edinburgh is the exception. In some areas, echocardiography services are in the depths of a bona fide crisis. A vicious circle of rising demand, staff shortages, an ageing workforce, retention challenges and a lack of clear pathways into the profession is causing backlogs that have become chronic in some places.

Scotland-wide data on echocardiograms (echos), recently published by Public Health Scotland for the first time, revealed that over 21,000 people were waiting for an echocardiogram in June. Of them, more than one in five (nearly 4,500 people) had been waiting for more than a year. Patients in some areas can wait for up to two years. 

Patients experience different standards in different parts of the country, which can affect everything from waiting times to the level of training echocardiographers have.

And to make matters worse, the only undergraduate course in Scotland to train clinical physiologists, at Glasgow Caledonian University, has closed to new applicants, though existing students will be supported to completion. No replacement course is currently planned in Scotland, raising urgent questions about future staffing.

BHF Scotland warns that resolving this dysfunction is now one of the most urgent priorities facing the NHS. 

“Both patients and cardiologists, when we ask them, tell us that echos are the main bottleneck in the system when it comes to diagnosing and treating heart disease, the single biggest killer in Scotland,” says Jonathan Roden, policy and public affairs manager for BHF Scotland. 

“Some cardiologists tell us they feel they are having to treat some patients blind. They are trying to make big decisions about people’s treatment without the right diagnostic information.

“If you don’t get a timely echo, you may know you have heart failure, but you may not know how progressed it is. Patients may not be getting the optimal treatment.” 

Scotland’s Heart Disease Action Plan runs out in 2026 and investing in earlier diagnosis, along with preventing heart disease and providing more care in the community, is BHF Scotland’s focus for the next plan.  

Roden adds: “Healthcare science and cardiac physiology is currently unregulated so there’s no way for the Scottish Government or the NHS to ensure the standard of echocardiography across Scotland, or the standard of practitioners.

“The problems we’re seeing with excessive waits and staff burnout come down to workforce shortages, a lack of workforce planning and a lack of regulation and support to improve services. 

“Given how important echos are for tens of thousands of patients, the situation is completely unsustainable.

“We’d like to see all Holyrood’s parties commit in their 2026 election manifestos to tackling these chronic problems.”

If nothing is done, the picture will only worsen.

David Cusack is head of service for cardiac physiology at NHS Lothian. When he first arrived, he explains, NHS Lothian was performing 500 echos a month. That went up to 650 after Covid and is now 900 a month across five sites. 

The reasons for the rise are various – more cardiology clinics post-Covid to tackle the backlog; new drugs requiring patients to have regular echos; the diversion of patients away from scans involving radiation to echos instead; and the ageing population. Echos are often required in other contexts besides diagnosing heart disease, such as prior to surgery.

Jo Sopala, chief executive at the BSE, says the rapidity of change and the increase in demand is “absolutely terrifying”. 

One key way that demand can be better managed is by assessing whether referrals for scans are warranted in the first place. 

This triaging is good for the patient and the service, according to the BSE.

Sopala says: “One of the things that happens in Edinburgh but doesn’t necessarily happen in the rest of Scotland is that they follow the BSE triage guidance. 

“We have audit data that shows up to 30 per cent of referrals for echos are unwarranted. That simply means that an echo will not change clinical decisions for that patient; it’s of no benefit. So if you have someone who waits a year for an echo but it’s not going to help them, that’s the wrong thing for the patient, but it also just increases the waiting list.” 

In Edinburgh, echocardiographers decline some scans and explain to the referring doctors why the scans are unwarranted. “Eventually people understand that referring for that will not generate an appointment, so why bother?” says Sopala.

But this tantalising logic only works if there are enough staff in the first place to do the triaging.

Cusack has much sympathy with colleagues in other health boards who are battling high waiting lists and have little time to do anything else. He explains: “What other sites will tell you is they don’t have the staff and they don’t have the time to do triaging.”

But he adds: “If you allow doctors a free hand all the time to keep on requesting an echo, that’s how it gets out of control.”

More staff are plainly needed. But some boards are not funding roles for qualified echocardiographers, with anecdotal evidence of staff being trained and then told there is no post for them, even in places with long waiting lists. Such decisions reflect funding and health board management priorities.

Some cardiologists tell us they feel they are having to treat some patients blind

Training is a further challenge. Echocardiographers usually do a four-year undergraduate university course which involves spending time training on the job alongside studying. To specialise in echos, graduates then do a masters-level qualification with further on-the-job training.

The closure of Scotland’s only undergraduate route is a “huge concern”, says Sopala. “There aren’t enough echocardiographers in Scotland anyway and we’re not training people who are coming through.”

“I know how many staff are going to retire in the next five years, so I need to find new folk,” says Cusack. In two or four years’ time, he will have a significant problem on his hands and is having to look to England and Ireland for trainees.

Retention is another big headache because of the glass ceiling echocardiographers reach. The highest pay banding they can achieve is NHS Band 7 and some get there in their 20s. 

“The only progression pathway is to wait to go for the department lead when someone retires. Well, that’s not good enough in a department that has 20 staff,” explains Sopala.

The BSE has proposed higher banded specialised roles. These are an “echo educator” role, for skilled echocardiographers who train other staff, and specialists skilled enough to run scientist-led clinics. Doing these roles would require a third level of qualification and allow practitioners to progress to Band 8A, but their enhanced role would save cardiologist time and therefore NHS money. The BSE is currently seeking funding to run a pilot scheme for the clinics across the UK.

Without action, the profession will continue to leak skilled staff to the private sector, overseas and even out of cardiac physiology altogether.

But the wider issue of standards also needs addressing. Edinburgh is the only BSE-accredited department in Scotland, though there are lots in England and several in Wales and Northern Ireland. Some staff working in this field in Scotland have extensive experience but don’t have the specialist development qualification in echos. 

Accreditation says that a practitioner is keeping their education and skills up-to-date, while accreditation for a department signals that the service is of a high standard and efficiently run. “It’s a way of protecting the echocardiographers and it’s a way of protecting the patient,” says Sopala.

Yet while in England most NHS trusts will not employ staff who lack BSE accreditation, Sopala says there has been “less focus” on that in Scotland 

Gillian Martin, a senior echocardiographer at NHS Lothian, says: “To get everyone in Scotland that accreditation would be a massive task, but it would help so much.”

Clear training pathways in Scotland, better workforce planning, better rewards and higher standards are all required.

“Whoever we went to in the NHS would say there’s no money and that’s fair,” says Sopala. “But whether it’s a household budget or a board budget, we work with what we’ve got, don’t we? There are more effective ways to run services.” 

This article is sponsored by the British Heart Foundation. 

https://www.bhf.org.uk/