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British Journal of Radiology 74 (2001),715-719 © 2001 The British Institute of Radiology

Full paper

Radionuclide radiologist directed nuclear medicine services in district general hospitals in the South Thames Region

B G Conry, MRCP, FRCR 1 R J Burwood, MD, FRCR 2 and on behalf of South Thames Regional Nuclear Medicine Specialty Service Committee

1Pembury Hospital, Pembury, Tunbridge Wells, Kent TN2 4QJ and 2Royal Sussex County Hospital, Eastern Road, Brighton, West Sussex BN2 5BE, UK


   Abstract
Top
 Abstract
Introduction
 Materials and methods
 Results
 Discussion
 Conclusion
 References
 
The equipment, staffing levels and imaging workload of all 14 radiologist directed nuclear medicine services in district general hospitals in the South Thames Region are presented. These are generally single camera departments providing a broad range of imaging procedures, including cardiac studies and white cell labelling, as well as the more usual renal, lung, thyroid and bone examinations. All departments have a high throughput, averaging 2358 examinations per year. Departmental staffing levels are variable, with some institutions having inadequate consultant radiology sessions free of other commitments as well as inadequate physics support. Potentially, these are important quality and legal issues that departments may need to address with hospital Trusts and Commissioning Agencies. Four small departments provided a service without any formally contracted radiologist sessions for nuclear medicine in the radiologists' job plans. The three medium sized departments have a closer match between sessions contracted and those actually worked, but in only one of these did the contracted sessional commitment equal the recommendation of the Nuclear Medicine Committee of the Royal College of Physicians. There is a disparity between the number of contracted consultant sessions and those actually worked in most institutions (86%), being at least two sessions in eight hospitals. Recommendations are made regarding the adequacy of some of the elements of provision in South Thames and the legal and safety implications for hospital Trust management and Commissioning Agencies.


   Introduction
Top
 Abstract
 Introduction
Materials and methods
 Results
 Discussion
 Conclusion
 References
 
The majority of nuclear medicine gamma cameras in the UK are in departments run by consultant radionuclide radiologists [1]; in South Thames the figure is 68%. Radiologists with an interest in nuclear medicine should be appropriately trained and licensed, and should have an adequate contracted sessional commitment to perform their tasks [2].

The report of the Nuclear Medicine Committee of the Royal College of Physicians (NMC.RCP) provides guidelines for the provision of a clinical service in nuclear medicine [3]. This report was prepared by nuclear medicine physicians and has been approved by the British Nuclear Medicine Society and the Royal College of Physicians. Assuming that the work time allocations for radiologists and physicians undertaking similar activities will be similar, then the report may also be regarded as setting guidelines for radionuclide radiologist directed departments.

The report identifies the expected sessional requirements and workloads of radionuclide consultants in five different hospital situations ranging from small district general hospitals (DGHs) to large teaching hospitals (Table 1Go). This paper is an analysis of a subset of information previously published by Wells et al [4], with full updated data solely on radionuclide radiologist directed nuclear medicine services (RRDNMSs) in South Thames DGHs plus additional data on consultant radiologist sessions and physicist input. The throughput, equipment and staffing levels in departments run by radionuclide radiologists in South Thames Region are presented for the year 1996–1997. The manner in which the service provision matches the Royal College of Physicians' guidelines is examined.


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  		Table 1. Expected and actual radionuclide radiologist sessional requirements and workload for five types of hospital (modified from reference [3])

 

   Materials and methods
Top
 Abstract
 Introduction
 Materials and methods
Results
 Discussion
 Conclusion
 References
 
The South Thames Regional Nuclear Medicine Specialty Service Committee was formed in 1994 following the merger of South East and South West Thames Regions. It represents nuclear medicine services covering a population of 6.75 million on 22 sites including three London teaching hospitals. There are 14 RRDNMSs in DGHs in the region.

Annual workload data have been collected in South East Thames for over 10 years, during which time a data collection proforma has evolved. This has been further refined to enable intercomparison between centres.

The proforma was sent to all centres, with subsequent clarification by telephone of any unclear answers. Extended Korner weighted codings allowed more accurate classification of examinations to secure absolute comparability [4].

Examination classification was generally straightforward. Myocardial perfusion stress and resting examinations were regarded as separate procedures; dynamic renal studies followed by an indirect cystogram were classified as two separate procedures, whereas renography with or without frusemide and with or without post-micturition acquisition was regarded as a single procedure. Renograms with and without captopril were classified as separate examinations.

Gamma cameras were classified as single or double head, with or without single photon emission computed tomography (SPECT) capability. Radiopharmaceutical enclosures and laminar flow cabinets as well as dual X-ray absorptiometry data were collated.

Medical staffing was based upon a whole time equivalent (WTE) of 11 notional half-days (NHDs) for a whole time consultant. 10 sessions were used in the assessment of non-medical staffing. A session was defined as equivalent to a NHD of 3.5 h. Physicist and radiopharmacist sessional commitments were collected, together with radiographic, technology and nursing staff details.


   Results
Top
 Abstract
 Introduction
 Materials and methods
 Results
Discussion
 Conclusion
 References
 
All 14 RRDNMS centres in the region provided a return (Table 2Go). They showed the following distribution of hospital types according to the classification of the NMC.RCP (Table 1Go).


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  		Table 2. Summary of radionuclide radiologist direct nuclear medicine services in South Thames 1/4/96–31/3/97

 
Only three departments have two gamma cameras, and one department has a dual head camera system. The remaining 10 cameras are single head. A SPECT-capable camera system exists at 9 (64%) centres.

One site has a part-time 3-day week imaging provision with a throughput of 1413 studies. The throughput in full-time centres varied between 1724 and 3541 studies (mean 2305 studies). Of the hospitals classified as small DGHs, the average workload of 2327 studies is significantly higher than outlined in the NMC.RCP report [3] and closer to expected numbers for a medium sized DGH, however this would not include therapy or in vitro work.

Four hospitals had no designated consultant sessions for nuclear medicine. A review of non-contracted consultant sessional commitments revealed that in most hospitals the total sessional commitment is significantly greater than that contracted. In those hospitals with less than one contracted session, the service is maintained by non-contracted out-of-hours and ad hoc arrangements.

Only two hospital departments performed therapy examinations. Both were oncology centreswhere the therapeutic administrations were under the Administration of Radioactive Substances Advisory Committee (ARSAC) licence of radiotherapists, not radiologists. Nevertheless, in both departments service delivery was the responsibility of the radiologists.

Only one RRDNMS has the number of consultant sessions recommended by the NMC. RCP, whereas teaching hospitals in the region as well as those departments led by a physician all reached the required level.

A wide range of nuclear medicine investigations were performed by RRDNMSs. The average departmental throughput of essential and more refined radionuclide procedures is recorded in Table 3Go.


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  		Table 3. Average departmental throughput

 
Seven DGHs undertook myocardial perfusion imaging (range 30–553 examinations), with 52% of all stress studies being pharmacologically induced and 96% of examinations utilizing SPECT. First pass gated equilibrium studies were performed in eight DGHs (range 1–88 examinations). White cell labelling techniques were performed in 10 hospitals, with six centres using technetium-labelled HMPAO (range 11–79 examinations) and seven performing indium white cell labelling (range 7–67 examinations).

One medium sized DGH has a part-time bone densitometry service that scans 1070 patients per year. It is run by the radiologists directing the nuclear medicine service and therefore contributes to their workload.

Physicist support is varied, with 43% of hospitals having only 1 day or ½ day per month of formal involvement.

All centres, except one, operate with radiographers rather than technicians. The technician/radiographer and nursing establishments are broadly the same for similar patient attendance.


   Discussion
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
Conclusion
 References
 
It is clear from the data that RRDNMSs have a large and varied throughput. This has previously been shown to be as great as that of nuclear medicine physician colleagues [5], but the workload intensity is greater owing to their poorer sessional allocation.

The increasing throughput in nuclear medicine is mirroring the increasing demands for all types of imaging in diagnostic radiology departments. Despite the Royal College of Radiologists' recommendation for 12 500 maximum examination workload per WTE radiologist [6], imaging demand continues to exceed capacity. With such demands it is vital that a radiologist with a subspecialty interest has sufficient contractual sessions to enable clinical and legal standards to be met.

Such protected sessional times are as important in nuclear medicine as in other radiology subspecialties, e.g. interventional radiology, mammography or paediatric radiology. Adequate sessional provision is present in only 7% of RRDNMSs. It is clear that in 29% of centres little or no formal sessional time is allocated and reporting is frequently performed at the end of a busy clinical radiological day.

Medium sized departments have better staffing than smaller ones, but there is a general under provision of consultant sessions, particularly in the smaller departments.

Only one hospital, which is a cancer centre, has the level of physics sessional input recommended by the recently produced guidelines on physics support [7]. Although some core and non-core activities of physicists may be performed by other staff groups, many tasks are clearly assigned to physicists, particularly those with statutory requirements including those necessary for ARSAC certification. It is difficult to understand how departments identifying one session or less of physicist time per week can satisfy the Ionising Radiations Regulations 1985 and 1999 let alone comply with the Euratom Directive 1999 [8].


   Conclusion
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusion
References
 
This data set of small and medium sized RRDNMSs provides a significant reflection of practice throughout the UK and allows extrapolation of general imaging trends.

It is important that radiologists use the opportunity provided by regular re-assessment of their work programmes and job plans to identify the need for a sessional commitment to nuclear medicine. If necessary, they should seek change in their work programme.


   Acknowledgments
 
The essential collating work of Dr C P Wells and Ms E J Forbes is thankfully noted, as is the secretarial and computing assistance of Nichola Hawkins and Elly Underhill, and the additional physicist data provided by Mr D Marshall.

The authors thank the following hospitals for providing data on nuclear medicine services provision: Ashford Hospital, Ashford, Middlesex; Conquest Hospital, St Leonards-on-Sea, East Sussex; Eastbourne Hospital, East Sussex; East Surrey Hospital, Redhill, Surrey; Frimley Park Hospital, Frimley, Surrey; Joyce Green Hospital, Dartford, Kent; Lewisham Hospital, Lewisham, London; Maidstone Hospital, Maidstone, Kent; Pembury Hospital, Tunbridge Wells, Kent; Princess Royal Hospital, Haywards Heath, West Sussex; Royal Sussex County Hospital, Brighton, West Sussex; St Helier Hospital, Carshalton, Surrey; St Richards Hospital, Chichester, West Sussex; and William Harvey Hospital, Ashford, Kent.

Received for publication April 11, 2000. Revision received January 2, 2001. Accepted for publication January 24, 2001.


   References
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusion
 References
 

  1. McCready R. Diagnostic radiologists and nuclear medicine. Clin Radiol 1990;42:225.[Medline]
  2. Miles KA. Nuclear medicine: radiologists must love it or leave it. Clin Radiol 1995;50:73–4.[Medline]
  3. Royal College of Physicians. Nuclear medicine: guidelines for the provision of a clinical service. Report of a Working Group of the Royal College of Physicians Nuclear Medicine Committee. J R Coll Physicians Lond 1997;31:384–8.[Medline]
  4. Wells CP, Burwood RJ, Forbes EK. South Thames Nuclear Medicine Survey 1996–97. South Thames Regional Nuclear Medicine Specialty Service Committee. Nucl Med Commun 1997;18:1098–108.[Medline]
  5. Elliott AT, Elliott FM, Shields RA. UK nuclear medicine survey 1992–93. Nucl Med Commun 1996;17:3–7.[Medline]
  6. Royal College of Radiologists. Medical staffing and workload in clinical radiology in the UK NHS. London: The Royal College of Radiologists, 1993.
  7. Williams NR, Tindale WB, Lewington VJ, Numan TO, Shields RA, Thorley PJ. Guidelines for provision of physics support to nuclear medicine. Report of a Joint Working Group of the British Institute of Radiology, British Nuclear Medicine Society. Nucl Med Commun 1999;20:781–7.[Medline]
  8. Council Directive 97/43/Euratom of 30 June 1997 on health protection of individuals against the dangers of ionizing radiation in relation to medical exposure, and repealing Directive 84/466/Euratom. Official Journal of the European Communities 1997; No. L180:22–27.



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