The patient population

Nuclear medicine is the specialty responsible for the administration of unsealed radioactive substances to patients for the purposes of diagnosis, therapy or research. It is highly regulated, requires expensive and complex imaging equipment and for a variety of reasons, which include radiation protection concerns, is unsuitable for a community-based setting. The complexity of current day imaging studies and molecular radiotherapy (also known as targeted radionuclide therapy) is likely to mean that the vast majority of clinical reporting will need to remain with consultants with expertise in both advanced functional and structural imaging techniques.

Nuclear medicine services are mostly provided at the tertiary care level for oncology, cardiology, orthopaedics, nephro-urology, neurology, paediatrics, and acute internal medicine referrals. However, some services such as dual-energy X-ray absorptiometry (DXA) scanning, benign thyroid clinics, bone or lung scanning can be directly accessed by GPs.  

There are often inequalities in access for patients in the community to specialist services, unless particular efforts have been made to enhance case finding and engagement with the health services for vulnerable or needy groups. In general, people from deprived communities, those from ethnic minorities, people with severe mental illness or intellectual disability, individuals who misuse substances, prisoners and those who are homeless or from travelling families are most adversely affected. In some specialties this is particularly important because these individuals often carry the highest burden of illness.

Prevention of disease

As radionuclide tests require the use of ionising radiation they are not suitable for preventive screening. An exception is the use of DXA, a quantitative method of assessing bone density which uses a very small radiation dose (less than a hundredth of the annual normal background dose).

DXA measurements of bone mineral density (BMD) at the hip and spine (and occasionally forearm) are often provided by departments of nuclear medicine.

DXA scanning is widely recognised as being effective at identifying patients who are at a higher than average risk of fracture. Osteoporosis is defined in people over the age of 35 as a T-score of −2.5 standard deviations (SD) or below on DXA scanning. As a result, NICE guidance on secondary prevention of osteoporosis recommends easier access to DXA scanning for patients who have already had a fracture for secondary fracture prevention. DXA scanning is also indicated in cases of suspected osteoporosis and with associated risk factors for primary fracture prevention. These services are commissioned by clinical commissioning groups (CCGs) and often supplemented by local referral guidelines according to the current clinical pathway and complying with imaging diagnostic waiting times of 4–6 weeks maximum.

Planning effective services

All departments of nuclear medicine must have a comprehensive audit plan in place. These audits will look at both technical and clinical aspects of the work as well as patient perceptions of the service. In addition, the British Nuclear Medicine Society publishes specialty specific guidelines and indications and carries out multiple national audits including:

The majority of positron emission tomography-computed tomograph (PET-CT) services in England are enrolled in a national clinical audit with peer review of reporting standards which is administered centrally and is the responsibility of a national PET-CT guardian.

Service evaluation, improvement and impact on patient management studies have also been undertaken either at national level (eg SeHCAT service evaluation, 123 I-ioflupane audit, 51 CR-EDTA glomerular filtration rate measurement audit and PET-CT reporting audit) or on a trust or regional basis (including impact of FDG PET-CT on the diagnostic and therapeutic management of patients with cancer, large vessel vasculitis and pyrexia of unknown origin, sentinel node service, renal and myocardial perfusion imaging).