Classification: Official

To:

• trust and integrated care board (ICB) medical directors
• trust and ICB imaging and diagnostics leads
• trust and ICB nuclear medicines teams
• trust and ICB oncology leads
• trust and ICB cardiology leads
• trust and ICB gastroenterology teams
• trust and ICB heads of emergency preparedness, resilience and response (EPRR)
• trust heads of procurement
• regional chief pharmacists
• regional medical directors
• regional pharmacy leads
• regional diagnostics and imaging leads

cc:

• regional deputy directors of EPRR

Dear Colleagues

Shortage of Mo99/Tc99 generators used in the preparation of radiopharmaceuticals for diagnostic procedures, imaging, and some cancer surgeries

There is currently a Europe-wide shortage of Mo99/Tc99, which is used by Curium to manufacture generators used by radiopharmacy units in the preparation of radiopharmaceuticals for diagnostic procedures, imaging, and some cancer surgeries.

This is due to all three of the nuclear reactors used by Curium to source these products being offline for a combination of technical issues and essential planned maintenance works. The most severe reduction of supply is currently expected to last from 21 October to 14 November, with some supply returning thereafter. Isotopes used for therapeutic treatments are not affected. More information can be found in the national patient safety alert.

While disruption to these supplies have been seen previously, and the nuclear medicine and pharmacy community developed methods to manage constraints on supply during the Covid-19 pandemic, the length of this disruption means that the NHS will need to clinically review and prioritise patient care over this period. Mutual aid arrangements already in place will also need to be formalised and strengthened. New mutual aid arrangements may need to be supported in some places, including potentially the movement of patients to facilitate access to imaging.

GE Healthcare also supplies these products to the UK. They are unimpacted by this shortage. They are unable to increase their own levels of production but can distribute their stock in a different way. As such, the delivery of these generators will be managed nationally to ensure patients across the UK can still access urgent imaging studies. It is vital that all trusts providing these services prioritise patient access and participate in mutual aid arrangements.

To support the objectives listed below, NHS England is working with The British Nuclear Medicine Society (BNMS), devolved administrations, and the Department of Health and Social Care (DHSC) to engage the two main suppliers and to develop mutual aid arrangements and mitigation options.

Our objectives are to:

1. Minimise avoidable harm through effective use of available supply and switching to diagnostic or therapeutic alternatives where clinically appropriate.
2. Ensure equity of access: no patient should be adversely impacted due to their location, or their hospitals’ choice of suppliers.
3. Clinically prioritise use of available supply, based on risk.

Actions for all NHS provider trusts with radiopharmacies

As such, we are now asking that all trusts, regardless of supplier, do the following:

• review your patient appointment lists as soon as possible and prioritise your urgent patients and postpone those which are less urgent, considering alternative imaging modalities where appropriate
• work with your BNMS/UK Radiopharmacy Group nominated regional coordination lead to participate in mutual aid arrangements (see annex B for list)
• keep accurate records on any appointments which are postponed or amended to ensure all impacted patient care is covered when addressing the backlog
• begin recovery planning and decide processes for rebooking those patients who have had appointments postponed once the supply situation begins to stabilise, noting that supply will not be all restored at once

Actions for NHS England regional teams

• provide oversight, check, and challenge as mutual aid arrangements are established
• provide a route for patient safety and other risks to be escalated via trusts. These should then be regionally collated and escalated the NHS England National Operations Centre before 15:00 each day by emailing nationaloperationscentre@nhs.net
• engage with your nominated regional mutual aid coordination lead (listed in annex B) and support the with mutual aid arrangements

Clinical prioritisation and mitigation guidance

To aid clinical prioritisation, NHS England has worked with clinicians to adapt the British Nuclear Medicine Society’s initial advice to its members to provide guidance. The full prioritisation algorithm is set out in annex A.

Mutual aid arrangements and management of supply

There is a DHSC-led expert group overseeing allocation of incoming GE supplies across England and the devolved administrations. The BNMS have identified regional coordination leads (see annex B) and regional coordination hubs. BNMS colleagues will follow up with individuals to explain the approach over next 48 hours.

Regional chief pharmacists and EPRR teams are asked to liaise with, and support this conversation with, sites.

Weekend or other alternative working patterns

Trusts should consider moving to implement weekend working (or other alternative working patterns) where beneficial to maximise the use of existing generators (irrespective whether their supply is from Curium or GE Healthcare).

Regulatory compliance

More information on regulatory compliance can be found in the national patient safety alert.

Escalating issues/concerns

NHS England regional EPRR teams will be in touch with trusts to outline how escalation processes from trust to regional team will work in each region.

Given this is a nationwide issue, it is important that emerging issues are identified centrally and fed back to suppliers in a coordinated manner. Therefore, trusts are asked to refrain from contacting suppliers directly regarding redirected incoming supply and restoration dates.

Thank you for all your efforts and cooperation.

Yours sincerely,

Dr Adian Fowler, National Director of Patient Safety

Dr Mike Prentice, National Director for NHS Resilience

Annex A – guidance on clinical prioritisation

Annex B – British Nuclear Medicine Society/UK Radiopharmacy Group (UKRG) nominated regional coordination lead

Publication reference: PRN01648