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Nuclear medicine
1 Description of the specialty and clinical needs of patients
Nuclear medicine comprises all applications of radioactive materials in diagnosis, treatment
and research, with the exception of the use of sealed radiation sources in treatment. Services are
delivered by a highly specialised team that is led by a well-trained nuclear medicine clinician.
Nuclear medicine deals with a wide range of pathologies across all age groups, but specific
clinical practice involves a major input in oncology, cardiology, nephrourology, orthopaedics,
rheumatology and neuropsychiatry.
The range and complexity of diagnostic investigations has increased considerably in recent years,
reflecting both continuing radiopharmaceutical development and the wider availability of
tomographic cameras and combined modality imaging: single-photon emission tomography–
computed tomography (SPET–CT) and positron emission tomography–computed tomography
(PET–CT). The use of receptor-specific ligands, monoclonal antibodies and small peptides means
that tracers are now available for tissue recognition at the molecular level.
Advances in drug radiolabelling and delivery systems have led to a parallel expansion in
unsealed source treatment, which has extended the range of conditions that can be treated with
this approach. These developments in treatment need to be accompanied by an increase in
clinicians trained in this area (as well as an increase in the number of shielded rooms capable
of allowing treatment of patients). Together with the expanding role of nuclear cardiology
studies in patients with coronary heart disease, the rising importance of PET in cancer staging
and follow up, and the delivery of sentinel-node imaging in patients with breast cancer and
melanoma, this will have a major impact on the workload patterns required in the future to
meet the needs of these patients without disadvantaging others.
In research, SPET, SPET–CT, PET and PET–CT are now seen as essential tools in the evaluation
of new pharmaceuticals. The field is involved in the development of new ligands for specific
syndromes (such as movement disorders, schizophrenia, Alzheimer’s disease, unstable plaques
of coronary artery disease and thromboembolic disease) and specific functional biological
signals (such as apoptosis, hypoxia and neoangiogenesis). Gene therapy is being monitored
with labelled vectors, with first applications emerging in cardiology.
Investment in the specialty has lagged behind that in other countries, which has resulted in a
fragmented service and poorly developed career opportunities. This is at a time when the
developments in radionuclide research and service should be stimulating an increase in
academic units and service delivery.
2 Organisation of the service and patterns of referral
A typical service
Nuclear medicine services are predominantly based in hospitals, with additional provision via
mobile PET–CT units. Service delivery varies between the different types of hospital, which
reflects differences in population size, casemix and centralisation of nuclear medicine.1,2 Small
243
departments that undertake a limited range of diagnostic investigations follow an outpatient
clinic model and are often organised within radiology departments. Larger centres that offer a
comprehensive range of imaging and non-imaging diagnostic procedures, as well as unsealed
source treatment, require day-care and dedicated inpatient facilities. Individual centres offer
bone densitometry services, specialist bone clinics for the management of osteoporosis and
thyroid outpatient clinics.
In most centres, nuclear medicine studies are performed in one department within the hospital,
but the service is delivered in one of two ways. Specialist nuclear medicine practitioners –
physicians or radiologists – may cover the full range of procedures or individual practitioners
may be responsible for specific clinical aspects aligned to their main specialty. Examples of the
latter would be several system-specific radiologists, a cardiologist for nuclear cardiology or an
endocrinologist for thyroid therapy – all of whom would have further training in procedures
involving radionuclides. Patterns of service provision in individual hospitals reflect funding,
local expertise and the interests of individual practitioners. When the service is fragmented, it
is valuable to have at least one trained specialist with a broad perspective to ensure cohesion, to
provide crosscover for absent staff and, most importantly, to ensure the whole service develops.
Modernisation initiatives are facilitating the development of other healthcare professionals to
allow them to obtain appropriate training to perform some of the tasks historically undertaken
by medical practitioners.
Sources of referral from primary, secondary and tertiary levels
Some areas have developed a form of the Royal College of Physicians (RCP)’s ‘hub-and-spoke’
model of provision, in which a large department, often within a teaching hospital, is linked to
a number of local district general hospitals (DGHs). Specialist services and inpatient facilities
are provided in the central unit, and consultants undertake sessions in central and outreach
hospitals. Even where there is no formal arrangement, most areas have a large department in
which nuclear medicine consultants with particular expertise may provide advice and receive
tertiary referrals from other centres for specific procedures such as PET, specialist tumour
imaging and therapeutic procedures. These units often provide routine services for hospitals
that do not have onsite nuclear medicine facilities and are ideally placed to develop the hub-
and-spoke model for local service provision.
Local and regional services
Not all hospitals have onsite nuclear medicine facilities, although these services are required in
most hospitals. It therefore would be appropriate for at least a basic diagnostic service to be
available in all acute trusts. Where a small local service is to be set up, the College’s hub-and-
spoke model should be considered, so that the service can maintain quality and progress with
new technologies and imaging methods.
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Consultant physicians working with patients
3 Working with patients: patient-centred care
Involving patients in decisions about their treatment
Provision of patient information is a vital part of good care, and detailed written information
is required, especially for patients who are undergoing procedures involving radioactive
treatment. This information is continually reviewed and revised, both locally and nationally.
The Joint Specialty Committee and the British Nuclear Medicine Society (BNMS) are pursuing
ways to provide a central information resource for patients.
The complexity of individual procedures and the limited availability of radioisotopes can make
it difficult to plan investigations according to patient preference. For example, direct booking
of appointments is problematic, as the Ionising Radiation (Medical Exposure) Regulations
(IRMER) require all investigations to be justified by the practitioner. Under this legislation, the
term ‘practitioner’ has a specific meaning: in nuclear medicine, the practitioner must be the
doctor who holds a certificate granted under the Medicines (Administration of Radioactive
Substances) Regulations. Authorisation by others against justification criteria set by the
practitioner is allowed, but the large number of people potentially involved in direct booking
makes training for this impractical.
Availability of clinical records and results
Patients are not currently sent the reports of their scans directly. These reports sometimes
contain unexpected information that provides only part of the clinical picture and that needs
to be put into context by the referring clinician, especially when malignancy is diagnosed. It is
felt inappropriate for patients to receive the results of nuclear medicine investigations in
isolation and without reference to the clinician who is managing their case. When the nuclear
medicine physician is managing the case – eg in patients who are undergoing radionuclide
therapy – the physician will be in a position to discuss the issues with the patient directly.
4 Interspecialty and interdisciplinary liaison
Multidisciplinary team working
Non-medical personnel are essential to the routine provision of a nuclear medicine service.
Staffing arrangements vary between departments, but the team may include:
� physicists and other clinical scientists
� medical technical officers
� radiographers
� radiopharmacists
� specialist nuclear medicine nurses, including nurse practitioners
� medical laboratory scientific officers.
Play specialists and cardiac technicians may contribute to the specialist services in centres with
a high paediatric or cardiac casemix.
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2 Specialties Nuclear medicine
There is a legal requirement for the provision of a medical physics expert and a radiation
protection advisor.
Local circumstances, particularly the level of overall clinical support within departments,
dictate regular clinical commitments to some specialist areas, such as nuclear cardiology,
endocrinology and paediatrics. Most nuclear medicine specialists undertake radionuclide
therapy and may be the lead clinicians in joint clinics – eg for the management of benign and
malignant thyroid disease.
Working with other specialists
As nuclear medicine can provide specialist services in support of virtually every other specialty,
clinicians liaise closely with staff from radiology, oncology, cardiology, neurology, nephrology,
urology, orthopaedics and endocrinology. Participation in cross-specialty meetings is valuable
for cost-effective service provision. The increasing importance of meetings of the
multidisciplinary team (MDT) in the delivery of cancer care has enhanced this role, allowing
the development of cross-specialty liaison within the framework of joint clinics for the
management of complex malignancy. It is essential that data from nuclear medicine
investigations are reviewed in meetings of the MDT by appropriately trained specialists who are
able to discuss the limitations of the method and give an informed opinion in the context of
new clinical information that arises from discussion of the MDT. Increasing collaboration
between larger and smaller departments and electronic data transfer allow exchange of
expertise and cover for absences.
5 Delivering a high-quality service
What is a high-quality service?
A high-quality nuclear medicine service relies on team work. It produces accurate results in a
timescale appropriate to the patients’ needs. It should have sufficient scientific support to allow
development in response to new evidence. The definition of explicit service standards provides
a framework for improving patient care.
Maintaining and improving the quality of care
It is a legal requirement that all procedures are carried out in accordance with written
procedures and protocols, which are usually derived from national guidelines (of the BNMS) or
European guidelines.3,4
The delivery of nuclear medicine services in departments in which there is no sessional
commitment to nuclear medicine is decreasing. Where this still happens, or where departments
undertake very few studies, there are implications for service quality and clinical governance. The
situation is compounded in some centres by the fact that a limited number of nuclear medicine
cases are divided between large numbers of consultants, which dilutes individual experience.2
Single-handed specialists who work independently cannot easily fulfil the requirements of
clinical governance. Within single-handed practices, a minimum overlap equivalent to 0.4 of a
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Consultant physicians working with patients
whole-time equivalent (WTE) is encouraged to avoid clinical isolation. In some cases, this may
be achieved by ensuring that the single-handed practitioner rotates to another unit as part of their
weekly commitment or that another practitioner rotates into the unit if that is more appropriate
to the caseload. The potential role of links with larger centres through tele-medicine is being
explored as a means of sharing experience and opinions between departments and allowing a
wider audit of performance than currently possible. The introduction of a national picture
archiving and communications system (PACS) may also help with this objective, although not all
PACSs deal well with nuclear medicine datasets. The use of tele-medicine and distant reporting
should not be seen as a substitute for local clinical involvement in the long term, however, as
issuing reports – although extremely important – is only part of the role of the nuclear medicine
specialist.
Facilities for PET–CT, SPET–CT and PET–magnetic resonance (MR) will require specialist
room designs, and PET services will require specialist waiting facilities. Children’s PET–CT
services may require areas for recovery after general anaesthesia. The design of the PET–CT
facility is highly specialised and not identified in this document.
For outpatient investigations, the following specialist facilities are required:
� two dedicated patient waiting areas – one for patients receiving radiopharmaceuticals and
one for those not receiving radiopharmaceutical materials and people accompanying the
patients
� separate areas for administration of radiopharmaceuticals
� dedicated toilet facilities
� examination rooms and a quiet counselling room for pregnant and breastfeeding
mothers, as appropriate to the casemix
� secure area for radiopharmaceutical storage
� area for image analysis
� data-reporting room
� educational and library area
� separate paediatric waiting or play area, as appropriate
� room for cardiac stressing, as appropriate (this may be a shared facility with cardiology if
organisationally more appropriate)
� imaging equipment appropriate for the casemix, which should be maintained to a quality
defined in the published literature
� radiation protection measures to comply with all relevant legislation
� space for administrative staff (receptionist and secretaries)
� office space for other staff
� adequate information technology (IT) facilities.
Inpatient unsealed source therapy must take place in a dedicated facility that complies with all
statutory requirements for radiation protection and waste disposal, and that is staffed by
appropriately trained nurses and physics personnel. Treatment rooms should have individual
shower and toilet facilities.
The UK has a major shortfall in the provision of inpatient unsealed source therapy beds.
Published data from a survey of 20 European countries highlights wide variations in access to
isolation facilities.3 In 1999, the UK provided one bed per 667,000 population compared with
the European average of one bed per 314,500 population, and this was inadequate to meet
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2 Specialties Nuclear medicine
workload pressures within acceptable waiting times. Subsequent increases in the range of
available isotope treatments and rising demand have exacerbated this position, and a
substantial increase in beds is required urgently. The proposed expansion of nuclear medicine
services within cancer centres would provide opportunities for closer cross-specialty liaison.
Shared use of purpose-built shielded facilities should be encouraged to ensure cost-effective
room occupancy.
Departments that offer treatment must have arrangements to support close collaboration with
relevant MDTs.
Service developments to deliver improved patient care
Nuclear medicine has developed rapidly over the last 10 years as the development of new
equipment and new radiopharmaceuticals has expanded its role. The nuclear medicine
physician has a significant part to play in leading these developments and bridging the gap
between clinical colleagues and patients on one hand and scientists developing the new
procedures on the other. Clinicians should expect to modify current protocols to improve
standards and to gain the expertise to introduce new techniques when evidence of their efficacy
becomes available.
The development of nuclear cardiology, PET and radioimmunotherapy are examples of recent
advances.
Surveys indicate that some trusts perform only a small number of non-imaging nuclear
medicine procedures annually, which raises questions over the quality of service.2 A hub-and-
spoke model was proposed on the basis of the existing specialist nuclear medicine departments
and cancer centre framework.2 It was recommended that priority be given to ensuring that
nuclear medicine specialist support is provided for all cancer networks in the UK. Central (hub)
functions would include development of protocols, the full range of imaging and non-imaging
tests and unsealed source therapy for benign and malignant disease; these were likely to be
provided from the cancer centre or the major specialist departments. Smaller departments
(spoke) would undertake radionuclide imaging and treatment for benign disease, where
appropriate. The introduction of foundation trusts and competition between them has made
this cooperation more difficult to establish or maintain. These recommendations still hold. The
strategy for provision of PET in the UK5 also holds true and was backed by the Royal College
of Radiology’s publication on PET–CT in the UK in 2006.6 The government should be investing
in fixed-site delivery of PET–CT around the country, although mobile provision may form an
interim measure while the role of PET imaging continues to be established.
The BNMS and British Nuclear Cardiology Society, together with the royal colleges, are actively
developing training curricula, standards and competency assessment measures to allow non-
medical healthcare staff to extend their current roles – eg into reporting and cardiac stressing
for myocardial perfusion studies. These staff will then be able to help improve local access to
nuclear medicine.
Education and training
Nuclear medicine is a multidisciplinary specialty. In addition to undergraduate teaching and
postgraduate teaching for nuclear medicine trainees and specialty registrars (StRs) in other
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Consultant physicians working with patients
specialties (eg cardiology and radiology), nuclear medicine consultants will have substantial
training commitments to non-medical staff, including physicists, radiographers, technicians
and specialist nurses – both for their traditional and extended roles. The small number of
specialists trained in nuclear medicine means that a disproportionate amount of education and
training will fall to the consultants when compared with many other clinical specialties. This
training often has to occur alongside clinical work, and those involved would require a reduced
caseload to allow for this. The time commitment to structured training of specialist registrars,
including documentation and performance appraisal, should be considered separately.
Professional leave should be allowed for the occasional formal teaching session; however, if a
physician has a regular, fixed, weekly teaching commitment, it should be included in the time
for supporting professional activities (SPAs) in the job plan. This is likely to be at least three
hours per week, on average, in departments that are involved in training medical and non-
medical staff.
The physician should also take an active role in collaborating with groups, including patient
representatives, to improve the written information available to patients. This can be a time-
consuming iterative process. The amount of time needed will depend on how much support is
available from other healthcare professionals.
Continuing professional development
Consultants are expected to spend at least 50 hours per year on continuing professional
development (CPD). Formal participation in interdisciplinary meetings is a requirement for
good clinical practice in all areas of medicine, and additional time should be allowed for
informal clinical consultation.
Clinical governance
Attendance at meetings of the cancer MDT is often required, with the nuclear medicine
consultant being a named core member of the group. The work plan should include protected
time for clinical audit, which will often be undertaken at regional or national level. Provision
may be required for some consultants to take a lead role in clinical governance. Given the rate
of change within the specialty and the relatively small numbers of consultants, attendance at
national or international meetings is often the best way to keep abreast of developments.
Research – clinical duties and basic science
Nuclear medicine techniques are used extensively in medical research. All consultants are
expected to take an active interest in research, although the time committed to this activity will
vary according to individual interest and hospital type. The need to develop academic
molecular imaging could be accommodated by updating of the training programme. The new
imaging techniques mean there is also a need to encourage research networks to move research
forward more quickly. This would enable the study of new imaging techniques and also health-
economic assessments.
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2 Specialties Nuclear medicine
Local management duties
Many nuclear medicine consultants have managerial duties as heads of department and budget
holders and undertake appraisal of medical staff. Protected time is necessary for departmental
and directorate meetings. Clinical service directors may have responsibility for service
planning, which will require the allocation of additional time. Nuclear medicine consultants
have unique legal responsibilities with respect to Administration of Radioactive Substances
Advisory Committee (ARSAC) certification for diagnostic, treatment and research procedures.
This, and their expertise in protecting patients from radiation, often requires their participation
on committees such as radiation protection and research ethics committees.
Regional and national work – eg royal colleges, Department of Health,specialist societies and deaneries
The small number of nuclear medicine consultants nationally results in an unusually strong
commitment to external duties that relate to educational and professional issues. Adequate
provision for local and offsite managerial duties and committee work should be included in the
job plan. Depending on frequency, this may, if necessary, be included as a weekly programmed
activity (PA), but agreement on how this leave for external duties will be handled should be
included in the job plan.
The time commitment to SPAs has been extrapolated from a published model.1 As this aspect
of workload varies according to local circumstances and hospital type, considerable variation
between individual consultants is expected.
Specialty and national guidelines
Generic quality guidelines for the provision of radionuclide imaging services in the UK have
been developed by the BNMS.4 These cover aspects of clinical effectiveness, safety and
timeliness and include explicit recommendations on appropriate facilities, equipment, staffing,
administration, prioritisation of referrals, performance and reporting of investigations. The
training standards for doctors who work in nuclear medicine and the related subspecialty of
radionuclide radiology are specified in curriculum documents,7,8 and the College’s nuclear
medicine training has been approved by the Postgraduate Medical Education and Training
Board (PMETB). The training scheme of the Institute of Physics and Engineering in Medicine
(IPEM) ensures appropriate training and experience for clinical scientists. The BNMS are also
developing guidelines on the training and experience required for extension of roles for non-
medical healthcare professionals. The guidelines offer a structure for the contracting process
and for peer review through the organisational audit programme of the BNMS.
The appropriate use of nuclear medicine services in specific circumstances has been referred to
in reports from the National Institute for Health and Clinical Excellence (NICE) into the
management of specific diseases – eg thyroid cancer and lung cancer. In addition, NICE’s
technology appraisal of myocardial perfusion scintigraphy identified guidelines for appropriate
use.9 The British Cardiovascular Society (BCS), British Nuclear Cardiology Society (BNCS) and
BNMS have jointly produced guidelines for recommending, performing, interpreting and
reporting myocardial perfusion studies.10
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Consultant physicians working with patients
The College has produced guidelines on the role of radioactive iodine in the management of
benign thyroid disease11 and thyroid cancer.12
The BNMS and the European Association of Nuclear Medicine have produced guidelines for
clinical and scientific procedures.13,14
6 Clinical work of consultants
How a consultant works in this specialty
Most nuclear medicine consultants have no direct clinical commitment to acute medicine. This
is especially true of the more recently trained physicians. A few are dually trained, however, and
still contribute to the acute on-call service, as well as supporting the routine clinics in general
internal medicine or another specialty – eg respiratory medicine or endocrinology. One
training post in the UK is designed specifically to train those who wish to continue this role.
The specialty does provide diagnostic services to acute physicians, however, and faces increasing
demand for rapid access to tests and reports. This is particularly true with the increasing use of
‘one-stop shops’ for outpatients and acute medical assessment units, and it is a pressure to
which the specialty is trying to respond.
Nuclear medicine is a consultant-delivered service. Nuclear medicine specialists are responsible
for the selection, supervision and reporting of diagnostic investigations, the administration of
unsealed source therapy and the provision of appropriate follow up. Subspecialist areas include
nuclear cardiology, oncology, metabolic bone disease, thyroid disease (benign and malignant)
and paediatrics.
The workload of nuclear medicine specialists covers a broad spectrum – ranging from reporting
non-imaging studies to undertaking complex tomographic imaging and radionuclide therapy.
Workload estimates must balance the time required for procedures grouped by type and should
allow for variations between consultants. The workload capacity of a consultant will also be
affected by the degree of support available from nursing, physics, technical and clerical staff, which
reflects the provision for delegation. The number of patients that can be dealt with by a consultant
therefore will vary according to the casemix of the department and the role of any individual
working within it. Procedures have been considered in categories according to their complexity.
The times listed in Table 1 are consensus approximations agreed by consultants working in depart-
ments of different types. It is assumed that figures will allow a balance to be achieved between
straightforward reports and procedures that require more detailed assessment or patient care.
The number of cases that may be dealt with in each clinical session of PA can be calculated from
the above numbers according to the department’s and the individual consultant’s casemix. They
are based on the time taken to undertake completed procedures including:
� clinical vetting and discussion of referrals (justification of requests is a legal requirement),
planning the procedure and consulting with the patient
� reviewing data to confirm that procedures are of a satisfactory technical standard (this
may involve further discussion with other professional staff or individual patients)
� reporting clinical data and reviewing clinical notes or results of other imaging modalities
� checking the written report.
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2 Specialties Nuclear medicine
When work is mixed during a PA, the clinical component can be apportioned pro rata. It is
emphasised that the workload estimates listed relate to uninterrupted clinical activity – with and
without the additional time taken with a trainee. No account has been taken of other
interruptions that might reduce efficiency. Efficiency will suffer if clinical sessions cannot be
protected. This is more likely to be an issue in small departments, when a single consultant may
be less able to delegate routine queries to other staff. In devising work programmes, consideration
should be given to the concept of fixed commitments. These include procedures undertaken on
a regular basis, such as outpatient clinics, special procedures, teaching and meetings of the MDT.
Duties such as administrative work, teaching and training and some reporting activities could be
considered as flexible commitments. Further adjustments are suggested when individual
consultants are also responsible for administering radiopharmaceuticals and are required to
monitor or oversee work delegated to others. It should be remembered that the reporting of
studies and supervision of trainees in a department has to continue during annual or professional
leave of a colleague, as studies will continue to be performed by technical staff in order to
maintain the diagnostic service. Time for prospective cover should be included within the PAs in
the job plan to recognise that, in some weeks, it may completely replace the SPAs that will then
be done in the allocated extra clinical time for the rest of the year. The exact allocation will depend
on normal workload intensity and local circumstances, but is likely to be one PA or more per
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Consultant physicians working with patients
Time required (minutes)
Non-training Training Procedure environment environment
Routine non-imaging studies, planar imaging and bone 10 13densitometry
Tomographic imaging (SPET and SPET–CT) 15 20
Complex procedures and image co-registration studies 30 40
PET 30 40
Stressing prior to cardiac imaging, including prior 25 30assessment and advice on drug treatment
Outpatient thyroid therapyNew patient 45 60Follow up 15 20
Inpatient therapy and other outpatient therapies Variable according to length of patient stay and amount of care shared with other specialties. On average, allow 40 minutes for a pretreatment visit, 60 minutes on day of administration and 15 minutes per day per patient on subsequent days or follow-up visits
Multidisciplinary meetingsPreparation 60–120 60–120Presentation 60–240 60–240
CT = computed tomography; PET = positron emission tomography; SPET = single-photon emission tomography.
Table 1 Time required for procedures
week. Further additional time will be needed for paediatric imaging and training. The additional
time in a training environment will vary according to the stage of training and the personal
competence and experience of the trainee concerned. The figures in Table 1 should be considered
an average guide.
Specialist on call
Few nuclear medicine departments are able to provide an on-call nuclear medicine diagnostic
service that requires access to out-of-hours radiopharmacy, physics, nursing and technical
support. A limited service should be available for urgent cases at weekends and on bank
holidays. Pressure to extend the hours of service availability to encourage efficient use of
inpatient beds and equipment is anticipated. This will place a significant burden on individual
specialists and will require an increase in consultant numbers. Centres that undertake inpatient
treatment provide some form of on-call availability.
Dual-accredited physicians should expect to be included in the rota for general medical duties,
including acute medical take.
Academic medicine
In the College census of 2003 there were a significant number of academic physicians in nuclear
medicine, with 40% holding at least a part-time academic contract;15 the latest census (2006–07)
does not contain this information. Academic physicians make a significant contribution to the
clinical work in their departments, but they have similar responsibilities in terms of teaching and
research as other academics, with the exact balance being determined locally.
7 Workforce requirements for the specialty
Current workforce numbers
In a recent census by the College, 56 college members entered nuclear medicine as their
specialty,15 but not all of these work full time in the specialty. The picture is complicated further
by the fact that some radionuclide work is delivered by specialists in other disciplines. Very few
of these appear in the nuclear medicine data of the College’s census,16 and most are
programmed to have only a few sessions per week in the specialty. A survey carried out in 2000
for the Intercollegiate Standing Committee in Nuclear Medicine identified about 190 trusts that
provide nuclear medicine services, with an average of 2.2 consultants per trust.2 This equates to
at least 400 consultants involved in providing nuclear medicine services. The survey did not
indicate how much of their time was devoted to nuclear medicine, however, and indeed some
trusts failed to identify any medical time at all for the service. There are about 230 individuals
on the General Medical Council’s (GMC) specialist register for nuclear medicine.
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2 Specialties Nuclear medicine
Required consultant programmed activities
An allocation of 300–350 WTE consultants for the UK was proposed in the previous edition of
this document.16 This number is now regarded as a bare minimum due to the increasing
complexity of work especially in specialised areas of activity described in section 6.9,13
Attendance at meetings of the MDT has also burgeoned over the years since the previous
edition of this document.16
The emphasis on CPD and mandatory training has also determined a level of time for SPAs that
cannot be ignored.
The time allocation calculated above relates to nuclear medicine activities carried out at
consultant level regardless of the specialty of the consultant. It does not distinguish whether the
time is provided by nuclear medicine specialists or other specialists with additional training –
eg radionuclide radiologists or cardiologists.
National workforce requirements
Retirement planning
The College’s census in 2006 indicated that 38% of the current nuclear medicine consultants
will reach the age of 65 years within the next 10 years.15 It is likely that a similar percentage of
other specialists who contribute to the service will do likewise. Surveys in 2000 suggested that
100–120 consultants would need to be replaced by 2010.2 Fifty percent of replacements would
need to be fully trained in all aspects of nuclear medicine (that is, imaging, non-imaging and
therapy procedures). This implies that 10–12 new consultants need to be trained each year. This
level of training is just sustainable within existing training numbers, taking into account the
increased numbers of radionuclide radiologists in training. The average retirement age is not 65
years, however, so the numbers required are likely to be higher than this.
European Working Time Directive
The College’s census in 2006 indicated that some specialists were exceeding the hours specified
in the European Working Time Directive (EWTD) and suggested that a 20% increase in current
numbers of consultant WTEs would be needed to meet the directive’s targets.15 This takes no
account of the radiologists who contribute to the service, and there is currently a severe
shortage in that specialty, which makes it likely that this figure is an underestimate rather than
an overestimate of the workforce required to comply with the directive.
Discrepancies with hours worked and contracted time
The College’s census also identified discrepancies between contracted hours and hours
worked.15 It was clear that many consultants were working in the specialty for periods well
above their contracted sessions, which indicates that a 20% increase in funded time was
required just to meet the current workload.
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Consultant physicians working with patients
Workforce numbers required
It is disappointing that the workforce has not changed dramatically since the previous edition
of this document.16 The WTE staffing for nuclear medicine needs to be increased. The previous
recommendation was to increase the number of specialists in the UK to 350. Using the hub-
and-spoke model, this would equate to about 100–150 nuclear medicine specialists within hubs
and 200–250 radionuclide radiologists or nuclear medicine specialists in spokes. As all existing
training places are required merely to replace retirements in the near future, there is currently
no training capacity for expansion. This issue will have to be addressed when further data are
available from workforce surveys from the Royal College of Radiologists (RCR) and the RCP.
These figures would allow for changes in work practice or workforce, with a possible increase
in part-time work for periods of an individual’s career. It would also enable adequate cover for
colleagues and sufficient members of the workforce to enable CPD and new ways of working.
These numbers would need to be revisited if work practice should change to a specialist- or
consultant-delivered service provided seven days a week. There would also be a critical need to
increase the numbers of colleagues in allied professions (physicists, radiographers, medical
technologists, radiopharmacists and administrative staff) to support such a service shift, and
they are already in serious shortage in some areas.
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2 Specialties Nuclear medicine
Programmed Activity Workload activities (PAs)
Direct clinical care
General nuclear medicine studies and Depends on casemix 2–3reporting*
Myocardial perfusion stressing* 8 patients 1
Myocardial perfusion reporting* 8 patients 0.5
PET–CT imaging and reporting* 8 patients 1
SPET–CT imaging and reporting 8 patients 1
Meetings to discuss X-rays and meetings 2 per week 0.5–2of the cancer MDT
Inpatient therapy* 2 patients 1
Outpatient clinics* 3 new and 7 follow up 1– thyroid, bone and medicine
Outpatient therapy† 4 patients 0.5
Clinically related administration for 0.5–1outpatients and miscellaneous letters
Internal cover arrangements‡
Total 7.5
Table 2 Consultant job plan
continued
References
1. Royal College of Physicians. Nuclear medicine: provision of clinical service. Working party report. London:RCP, 1998.
2. Intercollegiate Standing Committee on Nuclear Medicine. Nuclear medicine and radionuclide imaging: astrategy for provision in the UK. London: RCP, 2003.
3. Hoefnagel CA, Clarke SEM, Fischer M et al. Survey: radionuclide therapy practice and facilities in Europe.Eur J Nucl Med 1999;26:277–282.
4. British Nuclear Medicine Society. Nuclear medicine generic quality guidelines for the provision ofradionuclide imaging services. London: BNMS, 2007. Available at: http://bnmsonline.co.uk
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Consultant physicians working with patients
Programmed Activity Workload activities (PAs)
Supporting professional activities (SPAs)
Work to maintain and improve the quality Education and training, appraisal, 2.5of healthcare service development, audit,
governance, CPD, revalidation, research, departmental management
Other NHS responsibilities eg medical director, clinical director, Local agreement lead clinician, educational supervisor with trust
External duties eg work for deaneries, royal colleges, Local agreement specialist societies, DH or other with trustgovernment bodies
*These activities include justification of referrals, patient assessment, manipulation of drug treatment as appropriate,supervision of the test when required, telephone discussion with patients and colleagues, and reporting.†This involves time for consent and further discussion before treatment and confirming the correct patient is being treated.‡These PAs are subject to local negotiation.
Table 2 Consultant job plan – continued