Can we build more resilience into our Nuclear Medicine services?

What a difference a day makes. Who would have predicted that, as I wrote my last blog on the train out of Norwich that, less than 24 hours later, I would get the news that the reactors which supply Curium would be offline for a period of around 4 weeks. My first response was that I wasn’t overly worried. I’ve been a Radiopharmacist for three decades, and during that time I have seen my fair share of shortages – one in particular back in 2009 when the Chalk River reactor in Canada was out of action was much longer than this one and each time, I’d managed to keep my service going.

However, this time was different and this was in the main because of the significant gap that there now is market share between the generator suppliers. Another factor was that those GE generators which remained were not evenly spread across the country, with quite a few in areas such as Yorkshire and the Northeast, a few down in Devon and Exeter, but none at all in many other areas. If you read the letters I wrote through the shortage, you will already know that this meant no generators going into Scotland, Northern Ireland, Central London, the South Coast and South Wales at all and not a lot in great swathes of the rest of the country.

So, the lack of Curium generators, even for a short time had the potential to cause a real problem for patients in many areas of the country.

What followed was unprecedented. This was because, instead of it being a first come first served situation, where some Nuclear Medicines got supply and others had none, we worked together to put in place a plan for Mutual Aid to try and make sure everyone had access to something for their most urgent patients.

I was completely bowled over by the response of you all. Our Nuclear Medicine community really pulled together to put our patients first. I am very very grateful to everyone who shared their generator activity and postponed their non-urgent patients, even though they actually had a generator delivery. Thank you.

In the end, Curium were able to sweat the Safari reactor and managed to secure some extra supplies. The Maria reactor came back online a little earlier than planned and the HFR reactor repair was completed not long afterward. This all helped a lot. However, do not be deceived, the Mutual Aid arrangements we put in place made a huge difference. We didn’t end up seeing increased waiting times for those more urgently needed tests and surgeries and that means the plans worked.

Going forward, it’s important to consider what we can learn from this. These are my thoughts.

Clearly, the schedule of reactor maintenance and how repairs are handled need to be looked at to reduce vulnerabilities. This is outside of our control, but I know that the companies involved are looking at this and the schedule for next year is better.

In terms of the things we can control, perhaps we could work better as regions and have a more resilient procurement strategy. How this can be funded is to be discussed, but we could make sure that in each region there are some generators from each of the two suppliers. This is certainly what I did in the West Midlands after the 2009 Chalk River problem. I ran a big unit and had 2 generator deliveries a week, so although it cost a little more to use two difference suppliers, it wasn’t significant and essentially, I badged this the cost of having a resilient service. Clearly this is more difficult for smaller units who only have one delivery a week, but it could work on a regional level if we are all working together. This is something that is being looked at in Scotland, whereby one Radiopharmacy will use both suppliers, and the others could then contribute to any increased costs.

The Mutual Aid arrangements enabled us to prioritise more clinically urgent patients with all Nuclear Medicine departments postponing their non-urgent patients, regardless of whether they had a GE generator supply themselves. This was mandated through the National Patient Safety Alert put out by NHS England. I think this gives us a model to work to in the future which is better for our patients.

It could also work if we see problems with supply because of more domestic problems, such as we had last year when two large Radiopharmacies were closed at the same time. Although we cannot mandate the Mutual Aid on a regional level without the Patient Safety Alert, maybe we could agree a regional contingency plan between ourselves which all Trusts sign up to.

Another important consideration is the possibility of the UK having its own reactor for medical isotopes. You will probably have heard of the Arthur project, as we have had updates on this at our conference. A domestic supply of Molybdenum would help, although there are considerations, as the Molybdenum needs to be processed and generators made. We would also need to work with our neighbours to support the supply chain. We may live on an Island, but no-one is an Island (as they say).

Resilience is not just about how to respond to emergencies or about procurement strategies. It is about ensuring we have properly resourced services. I don’t think we do at the moment. Many of our Radiopharmacies are ageing or have other problems with their infrastructure. Our workforce in Radiopharmacy and in Nuclear Medicine is vulnerable. It is hard to recruit to our specialist areas, and lack of staff means lack of capacity. We need investment in our greatest asset – our people and this doesn’t just need money (although it does need money), it needs a plan.

All of this is much bigger than one blog. But if after reading this, you decide to look into having a regional contingency plan, then we will have taken the first steps to better resilience and have a think about that plan – let me know if you have any ideas which could help. Until next time.

Ms Jilly Croasdale

BNMS President