Consultants prelims


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Consultants prelims

  1. 1. 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
  2. 2. 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. 244 Consultant physicians working with patients
  3. 3. 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: q physicists and other clinical scientists q medical technical officers q radiographers q radiopharmacists q specialist nuclear medicine nurses, including nurse practitioners q medical laboratory scientific officers. Play specialists and cardiac technicians may contribute to the specialist services in centres with a high paediatric or cardiac casemix. 245 2 Specialties Nuclear medicine
  4. 4. 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 246 Consultant physicians working with patients
  5. 5. 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: q two dedicated patient waiting areas – one for patients receiving radiopharmaceuticals and one for those not receiving radiopharmaceutical materials and people accompanying the patients q separate areas for administration of radiopharmaceuticals q dedicated toilet facilities q examination rooms and a quiet counselling room for pregnant and breastfeeding mothers, as appropriate to the casemix q secure area for radiopharmaceutical storage q area for image analysis q data-reporting room q educational and library area q separate paediatric waiting or play area, as appropriate q room for cardiac stressing, as appropriate (this may be a shared facility with cardiology if organisationally more appropriate) q imaging equipment appropriate for the casemix, which should be maintained to a quality defined in the published literature q radiation protection measures to comply with all relevant legislation q space for administrative staff (receptionist and secretaries) q office space for other staff q 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 247 2 Specialties Nuclear medicine
  6. 6. 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 248 Consultant physicians working with patients
  7. 7. 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. 249 2 Specialties Nuclear medicine
  8. 8. 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.10 250 Consultant physicians working with patients
  9. 9. 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: q clinical vetting and discussion of referrals (justification of requests is a legal requirement), planning the procedure and consulting with the patient q reviewing data to confirm that procedures are of a satisfactory technical standard (this may involve further discussion with other professional staff or individual patients) q reporting clinical data and reviewing clinical notes or results of other imaging modalities q checking the written report. 251 2 Specialties Nuclear medicine
  10. 10. 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 252 Consultant physicians working with patients Time required (minutes) Non-training Training Procedure environment environment Routine non-imaging studies, planar imaging and bone 10 13 densitometry 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 30 assessment and advice on drug treatment Outpatient thyroid therapy New patient 45 60 Follow 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 meetings Preparation 60–120 60–120 Presentation 60–240 60–240 CT = computed tomography; PET = positron emission tomography; SPET = single-photon emission tomography. Table 1 Time required for procedures
  11. 11. 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. 253 2 Specialties Nuclear medicine
  12. 12. 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. 254 Consultant physicians working with patients
  13. 13. 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. 255 2 Specialties Nuclear medicine Programmed Activity Workload activities (PAs) Direct clinical care General nuclear medicine studies and Depends on casemix 2–3 reporting* 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 0.5–2 of 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 0.5–1 outpatients and miscellaneous letters Internal cover arrangements‡ Total 7.5 Table 2 Consultant job plan continued
  14. 14. 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: a strategy 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 of radionuclide imaging services. London: BNMS, 2007. Available at: 5. Intercollegiate Standing Committee on Nuclear Medicine. Positron emission tomography: a strategy for provision in the UK. London: Royal College of Physicians, 2003. 6. Royal College of Radiologists. PET–CT in the UK. A strategy for the development and integration of a leading edge technology within routine clinical practice. London: Royal College of Radiologists, 2005. 7. Joint Royal Colleges of Physicians Training Board. Specialty training curriculum for nuclear medicine. London: Joint Royal Colleges of Physicians Training Board, 2007. Available at: Specialty/Documents/Nuclear%20Medicine%20Specialty%20Training%20Curriculum%20May% 202007.pdf (last accessed 21 April 2008). 8. Royal College of Radiologists. Appendix: structured training in clinical radiology. In: Structured training in clinical radiology. London: RCR, 2007. 9. National Institute for Health and Clinical Excellence. Myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction (Technology appraisal 73). London: NICE, 2003. Available at: (last accessed 21 April 2008). 10. Anagnostopoulus C, Harbison M, Kelion A et al. Procedure guidelines for radionuclide myocardial perfusion imaging. Heart 2004;90(Suppl 1):i1–10. 11. Royal College of Physicians. Radioiodine in the management of benign thyroid disease: Clinical guidelines Report of a working party 2007. London: RCP, 2007. 12. British Thyroid Association and Royal College of Physicians. Guidelines for the management of thyroid cancer in adults. London: BTA and RCP, 2002. 13. British Nuclear Medicine Society. Clinical procedure guidelines. London: BNMS. Available at: 14. European Association of Nuclear Medicine. Scientific guidelines. Vienna: EANM. Available at: 15. Royal College of Physicians. Consultant physicians working with patients: the duties, responsibilities and practice of physicians in general medicine and the specialties, third edition. London: RCP, 2004. 16. Royal Colleges of Physicians. Census of consultant physicians in the UK, 2002. Data and commentary. London: RCP, 2003. 256 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, 2.5 of 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 trust government 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