Christmas Challenges and Some Cheer (at last)

As we approach Christmas, it is generally seen as a time of celebration for many. And I sincerely hope this will be the case for you.

However, it would be disingenuous not to acknowledge that many in our Nuclear Medicine community have had a very tough time over the last few months which has inevitably had a negative impact on some of our patients.

Most of you will be aware that there has been a significant and widespread shortage of Technetium-99m radiopharmaceuticals since October, and unlike other shortages, this has not been related to reactor problems or difficulties getting any materials into the country. It has been as a result of a perfect storm of a number of Radiopharmacy closures, for various reasons. And to complicate things even more, some of them were acting as a contingency supplier themselves before closing.

The upshot of this has not just been delayed or limited supplies. For some Nuclear Medicine departments, it has meant NO supplies. And not just for the occasional day. For some, it has been for several days, running over the weeks and months since the beginning of October.

There was a similar problem a few years ago in 2019, but to a lesser extent because it involved just one large Radiopharmacy. And that was bad enough. After that the BNMS and the UK Radiopharmacy Group highlighted the clear problems we have nationally in the UK with spare capacity to supply and the lack of good contingencies in place for our patients. Whilst some Radiopharmacies around the country have provided some contingency supplies, this has been limited by a number of factors. For example:

• Staffing capacity within individual Radiopharmacy units to supply – Radiopharmacies have a regulatory responsibility to work within defined capacity limits

• Isotope capacity within the limitations of local Permit

• Impact of increased workload on individual radiation exposure

• Availability of trained and approved drivers

The problems experienced in 2019 led to the 2021 national review in England of Radiopharmacy services, which was based on similar principles to a review which had previously been conducted on Pharmacy aseptic services. Unfortunately, there hasn’t been much progress for a number of reasons. Many of the things which need to change or improve need time - for example, improving ageing infrastructures, increasing availability of a suitably trained workforce.

And then we ended up in the position we have seen this year, and I don’t feel it is an exaggeration to say it has come to crisis point for many of us, and it is now very clear that these things, and others, need to be addressed as a matter of urgency.

So to move towards more positive news. We are now finally starting to see light at the end of the tunnel for many of us. One of the large units is starting to resume services from the 27th December onwards, so many of us can look forward to a happier and more plentiful (from a Technetium-99m supply point of view) New Year. This is not the case for all, but for the units who remain affected by other closures, hopefully this will release some capacity for ongoing supplies to them.

Recent months have made it clear that there is a significant risk to patients when the Radiopharmacy itself cannot operate. And because of this, BNMS and the UKRG will continue to work hard behind the scenes with our partners at NHS England and within the devolved nations to try to improve things for our patients and for our community.

So I would like to end this month’s blog by saying thank you to all of you who have kept your services running through such a difficult time. To those of you who have reassured worried patients. Who have had to deliver bad news to surgeons about not being able to support their lists. Who have borne the brunt of disappointed patients when having to deliver the news their scan has had to be delayed.

I’d also like to thank those Radiopharmacy colleagues who have stepped in to try to support services where they can. You’ve been amazing. And to the Radiopharmacy staff at the affected centre who have worked hard to re-open their unit, I know it’s been a tough few months, but I know you’re looking forward to being able to do what you do best – providing a reliable and effective Radiopharmacy service.

I’d like to finish by quoting American writer and artist, Agnes M Pharo, who gave us this definition of Christmas: ‘What is Christmas? It is tenderness for the past, courage for the present and hope for the future. It is a wish that every cup may overflow with blessings rich and eternal and that every path may lead to peace.’ Whether you celebrate Christmas or not, that sounds like a pretty decent aspiration.

Or alternatively, this quote by Maya Angelou, American memoirist, poet and civil rights activist: ‘I’ve learned that you can tell a lot about a person by the way he/she handles these three things: a rainy day, lost luggage, and tangled Christmas tree lights’. And maybe we should add to that ‘Technetium-99m shortages’!

I do hope you manage to have a break to enjoy some time with your friends and family. And please join me in wishing us all a very happy, healthy and successful 2024 (Let’s aim high and hope for the best, as Agnes says!)

Ms Jilly Croasdale

BNMS President

We can all strive to be an Icon of Nuclear Medicine!
I’m in a very reflective mood today. I’m thinking about the legacy we all leave behind us. As a number of you will have heard, sadly Dr. Keith Harding, or ‘LKH’ as he was affectionately known, passed away recently. He was an absolute giant of Nuclear Medicine (and I don’t just mean because he was very tall, which he was) and had huge influence on the practice of Nuclear Medicine in the UK and beyond. 

The first time I met LKH, I must admit, I was a bit scared of him. I was in my first job as a trainee Radiopharmacist at City Hospital, Dudley Road. I was very green and wet behind the ears. He was very tall (as I said!) and I really was a bit intimidated by his no-nonsense manner. He always asked questions – as many of you will remember from BNMS conferences, if you were there. Not always easy ones. He challenged things and had an expectation that you would do the same. So ever so slightly terrifying at first!

As I got to know him, however, I realised what a kind and supportive man he was. He would invite the Nuclear Medicine team to BBQs at his house in the summer. He made sure we all had the chance to go to conferences. He was generous with his time and encouraged us all to be better. He raised the standard – in fact, he often set the standard. After finding out he had passed away, so many people responded to say they owed him their entire careers. He was that sort of man.  

He did so many things over the years. He was instrumental in starting up our Nuclear Medicine department, and worked there for his entire career. He was the first chair of ARSAC, and indeed, was instrumental in setting that organisation up. He also led in establishing the carer and comforter regulations, without which treating our benign radioiodine patients on an out-patient basis would have been much more difficult. He had an influence beyond the UK, from sitting on a European Commission to look at early radiation protection law to being instrumental in setting up the IRMER regulations. And I’m sure many other things I don’t know about. 

He was a BNMS Treasurer, and BNMS President – same as me. I don’t think I would have been so involved in the BNMS if it weren’t for him, and my career would have definitely been the worse for that (I love the BNMS, in case you hadn’t already realised!)

There have been many other people who have been role models for me, but he was the first, and he made one hell of an impression. 

Maybe we won’t all go on to be as influential as LKH. We shouldn’t be comparing ourselves with other people anyway. But we can all aim to be the best we can be, within the roles we occupy. We can all challenge the status quo. We can all aim to raise the standard. We can all create our own legacy.

Every single time you go the extra mile for a patient, for another service or for a colleague, you are making a difference. You probably don’t think of it very often, but every day that we come into work we are in a position to encourage or discourage someone else, to be a role model - whatever our job is in the department. How we treat other people can have a huge impact, so if there is a kind way to do something, I think we should be kind. That doesn’t mean to say you shouldn’t challenge poor behaviour or performance, if appropriate, or discuss difficult subjects. It’s hard to say some things, but if messages are delivered with honesty and kindness, they can be something which helps people grow, not knocks them down. Honestly, you don’t ever make yourself look any better by belittling anyone else. But if you support your team, then everybody wins. 

We all have the potential to be an icon of Nuclear Medicine, and I think this is the greatest compliment we can pay to those who have influenced and encouraged us. So my thoughts today are that I want to be more like LKH, and I would highly recommend you try to be too. Ask the questions, challenge the status quo, raise the standards, create your legacy. But above all, be kind. 

So go be iconic!

If you would like to practice some LKH-style BNMS conference questioning, please join me at the Autumn BNMS meeting on Tuesday 31st October. I’d love to see you there!

Ms Jilly Croasdale
BNMS President

What does quality look like? 
Part 1: Communication

I must start by saying that my experience of Nuclear Medicine departments is that we generally look after our patients beautifully while they are in our departments. And if you don’t think that’s true for your department, then you should make your feelings known, whatever your role.

However, I have recently been thinking a lot about how good our patients’ overall experience is. What do they consider to be a quality service? Is there anything that we can do better?

I think it can be easy to forget, when we talk about our patients, that sometimes WE are the patients.  Like many of you, I’ve had this experience. Not in Nuclear Medicine, but in other areas. And in most aspects, our wonderful NHS has been brilliant. But there were some opportunities to improve – for example in communication and the interface between different services and organisations. I’d like to share some of these experiences, as some of it may give some food for thought:

1. I like to think I’m a fairly intelligent woman, and I really don’t like being called sweetheart by someone I don’t know. In fact, I’m not that keen when it’s someone I do know. My brother-in-law, who I like very much, occasionally gets away with it. I’d rather someone used my name – and gave me theirs. This irritates me a lot, and I know I’m not the only one. 

2. I don’t like things being done ‘to me’. One example of this was when my 3 year old son was in traction for 4 weeks and had to stay in hospital. He was well looked after, and the nursing and medical care was good, but looking after a young child and keeping him occupied in hospital for that length of time was a challenge. We ended up with quite a lot of ‘stuff’ in the bed bay. I kept it very organised and for that time, it essentially became home. However, one day the nurses, without anyone saying anything to me, started moving everything. Suddenly having someone start to handle all our things without knowing why was alarming and upsetting. We were being moved to another bay, which was fine, but a simple conversation beforehand would have alleviated the upset. Letting patients know what is happening to them and why is important.

3. Another thing I really don’t like is when things have to repeated for what seems no good reason – what a waste of resource. My mum has recently been unwell and saw her respiratory consultant at her local hospital. He ran some blood tests and contacted us to say she needed to go to A & E that day. He wanted her put on a drip for severe dehydration and dangerously low potassium levels. We took her in to the emergency department (at the same Trust) and had to wait for hours to be seen, after which time, all the blood tests had to be repeated before anything could be done. My poor little mammy – 86 and confused, waiting all that time, and not going to the toilet even once because she’s so dehydrated (she’s normally a very habitual user of the facilities). She went to A & E at teatime, and it was past midnight before she was put on a drip. Why did it take so long, considering a consultant at the same organisation had said for her to go in, and why did we have to repeat blood tests? I know this isn’t directly relatable to Nuclear Medicine, but the communication between departments within our hospitals and the interface between different organisation is definitely something that can be improved in my experience. And it may be that the poor communication comes from other departments, but as far as the patient is concerned, they don’t see where it arises. It’s worth a review to see if we can affect any improvements. How educated are the ward and medical staff about Nuclear Medicine tests? Could we improve this, and by doing so, improve the experience of our patients? 

I consider the visit to our Nuclear Medicine departments as the meat in the referral sandwich. There is a slice of bread before they arrive, and this is the part where we communicate the details of the test or treatment they are being invited to have. How good is that communication? How many of us are communicating the appointment information in the patient’s own first language, for example? In the area where my Trust is located, for a large proportion of the population we serve, this isn’t English. Wouldn’t it be more reassuring and welcoming if some of our direct communication with them also provided some information in their own language? You may think this is too difficult, or maybe even disagree, but have you asked your patients about it? 

The final slice of the sandwich is what happens after the patient has been for their appointment. If I have a test for something at the hospital and don’t get the result for 5 months, do I really view this as a quality service, even if the people were lovely? If the result is likely to take a long time, are we giving the patient realistic time frames? And if a result slips through the net and for some reason, is late being reported, are we being open about it and apologising?
So going back to the question about whether you have asked your patients – many of us do gather feedback, but it can be quite passive. We sometimes get lovely thank you letters (and occasionally even sweet treats). We may have a box for suggestions, and we respond to any complaints received. But do we actively ask them for feedback? I know it takes time to process when it is returned, so it may not be something we’re able to do continuously, but could you consider how to do this in some way, if you’re not already?

If you’re wondering where to start with this, the BNMS can help. We have a patient advocate named Adrian Hardy on the BNMS Council, and who better to help us gather feedback from patients. He has put together some questions he feels would give us a better overview of how patients feel about their experiences. He has made this available on our website for you to give to your patients. Patients need only answer the questions that they see as relevant to their experience. Adrian would like to co-ordinate the feedback on a national level, so please ask your patients to send their answers to Adrian at apaulhardy@aol.com or if they’d like to speak with Adrian send him a text on 07707 901953 and he will get back to them.  

You can find the information at: 
https://cdn.ymaws.com/www.bnms.org.uk/resource/resmgr/patient_information_leaflets/v2_patient_experience_feedba.pdf

I hope you’ve found this interesting! Find me on X (formerly known as Twitter) @PresBnms

Ms Jilly Croasdale
BNMS President

The BNMS could be good for your health!

Countless psychology studies have investigated the underlying factors which support happiness and wellbeing. One such factor is gratitude. Gratitude is defined in the Cambridge dictionary as ‘a strong feeling of appreciation to someone or something for what the person has done to help you’, and that sums up how I feel about the part the BNMS and the people I have through it have played in my life and career. 

I first attended a BNMS conference in the early 90s, when I worked as a trainee Radiopharmacist at what was then Dudley Road Hospital in Birmingham. The conference was held at Imperial College, London – and was in fact, the last of a number of meetings held there. I remember sitting in the various sessions in awe of everyone – not just the presenters, but also the audience. The interactions, questions and debate coming from the audience totally impressed, and slightly terrified me. I so wanted to put my hand up and comment but was too shy in those early days. However, BNMS is full of people like Dr. Keith Harding, past BNMS President and my first Consultant back at Dudley Road - innovative, questioning, clever but also down-to earth and encouraging. I continued to be involved in BNMS through the rest of my time in Birmingham, whilst at Leicester Royal Infirmary and at the Royal Free Hospital, and then when back in Birmingham once more. I was so lucky to work with some wonderful people in each of these places. I grew in confidence and with the help of the BNMS, enjoyed not only learning about the wider world of Nuclear Medicine, but also making useful contacts both with other Nuclear Medicine professionals and with Industry colleagues. 

The BNMS is about a lot more that the conferences it puts on – although these are great, as anyone who managed to join us in Harrogate will hopefully attest to. It is about a unique community of professionals, all working together to achieve the same goals and all respecting the part they all play in the care of patients. It’s about all those Technologists and Radiographers who put the patient at ease, ensure the scans are of suitable diagnostic quality and much much more. It’s about the Radiopharmacy staff who work to ensure safe, effective and high quality Radiopharmacy services are provided. The Physicists who ensure our cameras are working to their optimum capability and that we are working safely within the boundaries of good radiation protection, for example. It’s the nurses and support workers who care for our patients whilst they are in our departments, and our doctors who ensure the test the patient receives is suitable as well as providing that important final report. Of course, all the people I mentioned do many other things, but the point I’m trying to make is that everyone plays an equally important part in the care, diagnosis and ultimately treatment of the patient. And I think that’s pretty unique, and to be frank, pretty fantastic. 

BNMS does many things behind the scenes to help and support our community. Elected council members, co-opted experts and our wonderful BNMS staff help provide guidance and leadership - you may have read some of our guidance documents and I hope you have found them useful. One which springs to mind is the guidance developed during the first COVID lockdown. BNMS worked with colleagues from all our different disciplines to pull together practical advice for how to manage our services during that challenging time. We represent the interests of our Nuclear Medicine community to government – for example, in trying to mitigate the potential impact of Brexit on our services.  More recently we have been working to put together a manifesto for PET CT commissioning, and going forward, I hope that we will play a key role in further developing Molecular Radiotherapy (MRT) services in the UK. We really are living in exciting times, and I feel we are on the cusp of something potentially game changing for many of our patients. There has never been a better time to work in Nuclear Medicine. 

So, I’d like to end my first newsletter article as BNMS President by bring this back to gratitude and the impact it has on health. I would like to say thank you to the BNMS for the opportunities it has afforded me. I’d like to say thank you to all the Radiopharmacists, Physicists, Nurses, Support Workers, Technologists, Radiographers and Doctors I have met, not only in the various departments I’ve worked but also through the BNMS, for their help, encouragement and friendship. 

Thank you. Two small words, but a very big meaning. 

As I said when I had the President’s baton handed over to me in Harrogate, I feel very grateful and very healthy! I sincerely hope that reading this prompts you to reflect on your BNMS experiences, and that you go home tonight feeling the same. Please consider joining us at the Autumn meeting at the Royal Society of Medicine (Wimpole Street, London) on Tuesday 31st October  for another dose of health and happiness!