In a multi-part series juniordoctorblog.com looks in-depth at the potential impact a No Deal Brexit will have on the NHS.
UPDATED with the latest No Deal planning paper from Govt. “Civilian Nuclear regulation if there’s no Brexit Deal”.
In Part 1, we looked at the potential disruption to the supply of vital medicines. In this part, we will look closely at the use and supply of radioactive isotopes in the NHS, and how a No Deal Brexit specifically will impact this.
What do you mean radioactive?
We use radiation a lot in medicine. The term conjures images of radiation burns and nuclear warfare, or perhaps super-powered arachnids, but in controlled doses for the right reasons radioactive substances are a vital part of many types of healthcare. We can use radioactive therapies to diagnose conditions, monitor treatment, and even as treatment itself. From breast cancer to heart disease to thyroid cancer there are dozens of uses for nuclear derived radioactive material.
Where does it come from?
Nearly all nuclear material for medicinal use is imported. The commonest, Technetium-99m, is made in several reactors in Europe. We perform over 600,000 radioactive imaging procedures a year involving Tech-99m alone. The production, transport and storage of radioactive material is obviously very heavily regulated. The agency responsible in Europe is called EURATOM.
What is Euratom?
The European Atomic Energy Community is responsible for the safe use and distribution of all nuclear material- from the tiny diagnostic isotopes we use, to the nuclear reactors that generate power for cities. Unlike the European Medicines Agency, we currently do not have a local equivalent in the U.K.
Why is that important?
Well, in a No Deal scenario we have no equivalent agency of infrastructure to manufacture, import and export, distribute and store, radioactive isotopes.
UPDATED: in the latest government technical paper on civilian nuclear material, responsibility will move to the Office for Nuclear Regulation. Importing nuclear materials, as with medical isotopes, still has no plan at this time. Under the relevant header the paper reads: “importers may need to obtain an import license” and will “provide further guidance” at an undisclosed interval. So, still no plan as yet.
The Lords voted to stop our withdrawal from EURATOM in 2018, but a No Deal scenario would leave us out regardless. The rationale for leaving EURATOM as its “legally joined” to the EU has been derided as dubious as best. Currently it’s unclear what will happen in any Brexit scenario.
To illustrate the potential impact on the individual let us look at a specific example: the use of Technetium-99m in breast cancer, in a technique called Sentinel Lymph Node Biopsy. When diagnosing breast cancer we need to know several things: is there a tumour there, how far advanced are the cells in the cancer process, how far it’s spread in the breast itself and how far it’s spread to other places, firstly the lymph nodes in the armpit. These ‘sentinel’ nodes play a huge part in prognosis, and determining the need for chemotherapy and radiotherapy. Sentinel Lymph Node Biopsy uses radioactive isotopes to very accurately diagnose cancer spread to the armpit, determining the need for chemotherapy and radiotherapy. Without the isotope the potential to miss spread to the armpit skyrockets, as the next best diagnostic test is far more likely to make a misdiagnosis. Missing spread and reducing treatment means a curable cancer could become an advanced one, or even a deadly one. These are the stakes at play here.
Have these isotopes ever run out before?
Yes. There was a series of reactor maintenance stops in 2008-9. At the time there was sufficient supply for most units to delay or borrow isotopes from other hospitals. There is also a predicted shortage from 2016-2020.
Why is No Deal Brexit different?
The scale of the issue this time has never occurred before. Additionally the new requirement for customs infrastructure will have major implications as these isotopes cannot be stockpiled- they decay to become non-useable after a number of weeks. Procedures such as thyroid cancer treatment, palliative treatment for bone pain and heart scans would all be halted, temporarily or even long-term while inferior alternates are used.
in summary, leaving EURATOM does indeed appear to be the nuclear option: it’s needlessly extreme with no legal basis and will have widespread and long-lasting ramifications. There’s a high probability you will personally know someone who will be negatively affected. As a doctor, I have to admit I didn’t know most of this a year ago. I’m flummoxed how anyone outside of the industry could have. None of us were “informed”. Until now.
With less medicine and no isotopes we face a rocky future in the NHS. None of that will matter however without any staff.
See Part 3: We, The People (Coming soon)
References
https://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-8036
https://arxiv.org/pdf/1501.03071
https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:12012A/TXT
https://www.cancer.gov/about-cancer/diagnosis-staging/staging/sentinel-node-biopsy-fact-sheet
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