Brexit’s Nuclear Isolationism Threatens UK Cancer Patients
Withdrawing from the little-known Euratom Treaty jeopardizes the NHS's supply of medical radioisotopes — a quintessential case of "you don't know what you've got until it's gone."
“[UK] Ministers however seem to have inserted their heads firmly into the sand, hoping tricky problems will just go away.”
— Steve Bullock, former EU Negotiator for the UK
On the drizzly morning of June 23, 2016, few British voters were contemplating the future of technetium-99m (99mTC), a radioisotope essential to many medical procedures. At the National Health Service (NHS), however, concerns about the stability of the supply chain of medical isotopes would arise following the outcome of the Brexit referendum.
As chemical elements made from weapons-grade uranium, the production and distribution of medical isotopes are regulated by the European Atomic Energy Community (Euratom).[1] As part of Brexit, the UK Government has stated that it will withdraw from Euratom, threatening the country’s ability to import critical nuclear material unless new agreements are reached with exporting countries and international regulators.
Radioisotopes are used for medical procedures such as coronary disease diagnosis and cancer treatment. The NHS carries out more than 700,000 such nuclear medicine procedures each year, yet the UK has no domestic capacity to produce radioisotopes.[2] For the 10,000 patients across the UK whose cancers are currently treated with imported radioisotopes, then, a seamless series of events must occur for them receive proper medical care. [3]
Challenges abound: the amount of useful radiation from 99mTC halves every six hours, making it impossible to hold in a hospital’s inventory.[4] Instead, physicians obtain 99mTC through the decay of molybdenum-99 (99Mo), an isotope whose half-life of 66 hours makes it more suitable for transport and storage.[5] Daily or weekly shipments of this radioisotope, however, are still required to meet the medical needs of the NHS.
The supply chain begins much earlier—likely in Kazakhstan, Canada, or Australia, where three-quarters of the world’s uranium is mined.[6] After being enriched in Russia or the U.S., the uranium is purified in a nuclear research reactor to isolate 99Mo. Today, this production occurs primarily in the Netherlands (40%), Belgium (20%), and Australia (15%).[7] Until now, the Euratom Supplies Agency controlled the final transport of nuclear material on behalf of member countries, including the UK. Going forward, the UK Government must establish new agreements and mechanisms to replace the Euratom Treaty.
NHS faces political reality
Given the many points of failure in the radioisotope supply chain, it is baffling that the UK Government itself has brought on an interruption at the last stage of delivery. This has generated a thorny situation for the NHS, a civil service agency which cannot openly oppose its government. As such, the NHS has relied on industry experts such as the Royal College of Radiologists to raise public alarm and prevent access to radioisotopes from “slip[ping] down the negotiations list.”[8]
While the NHS has made no public statements with its response to Euratom withdrawal, the agency is likely advising the government on a new UK nuclear safeguard system and international agreements. This must occur before March 2019, when the UK is slated to withdraw officially from the EU. Stakeholders across academia and industry, however, have expressed skepticism that rewriting the myriad of nuclear regulations is possible within two years.[9] To prevent shortfalls of radioisotopes, the NHS may be pursuing a short-term strategy of advocating for a “soft” Euratom exit that would allow the UK to hold an associate membership like Switzerland’s.
Addressing long-term instability
In parallel with replacing Euratom, the NHS should budget for the cost increase of procuring radioisotopes in the short-term. With 97 percent of Euratom’s uranium purchases made through long-term contracts, the UK will likely face cost increases if it is forced to participate in the spot-market, even temporarily.[10] In recent years, spot prices have been up to twice as high as multiannual contracts.[11] These additional costs of renegotiations will cascade throughout every stage of the supply chain. Thyroid cancer treatment and bone scans carried out by the NHS, then, will become more expensive.
After Brexit formally occurs in 2019, the UK should pursue stable access to radioisotope supply, if not through domestic production, then through an international consortium. For instance, the NHS should explore whether UK investment in the two long-term projects to replace reactors in Belgium and the Netherlands—which are scheduled to be decommissioned by 2026—might help guarantee the supply of radioisotopes.[12]
Aligning civil service interests
Brexit and the associated Euratom withdrawal have surfaced the implications of isolationist policies that upend established supply chains in highly-regulated industries. Particularly delicate is the role of a public agency with split allegiances. How should the NHS respond to Brexit given the clear misalignment of interests in which its “shareholders” are the members of UK public while its “Board” is the UK Government? The consequences of failure are high.
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[1] Andrew Ward and Alex Barker, “EU Exit Spurs Call for Deal on Radiotherapy,” Financial Times, February 23, 2017, https://www.ft.com/content/185175e4-f9cd-11e6-9516-2d969e0d3b65.
[2] UK Parliamentary Offices of Science and Technology, “Supply of Medical Radioisotopes,” July 2017.
[3] UK Parliamentary Offices of Science and Technology, “Supply of Medical Radioisotopes,” July 2017.
[4] “Radioisotopes in Medicine | Nuclear Medicine – World Nuclear Association,” accessed November 14, 2017, http://www.world-nuclear.org/information-library/non-power-nuclear-applications/radioisotopes-research/radioisotopes-in-medicine.aspx.
[5] “Radioisotopes in Medicine | Nuclear Medicine – World Nuclear Association.”
[6] European Commission, “EURATOM Supply Agency Annual Report 2016,” 2017, http://ec.europa.eu/euratom/ar/ar2016.pdf.
[7] “Radioisotopes in Medicine | Nuclear Medicine – World Nuclear Association.”
[8] “RCR Statement on the Potential Impact of Leaving the Euratom Treaty | The Royal College of Radiologists,” accessed November 14, 2017, https://www.rcr.ac.uk/posts/rcr-statement-potential-impact-leaving-euratom-treaty.
[9] UK Parliamentary Offices of Science and Technology, “Supply of Medical Radioisotopes.”
[10] European Commission, “EURATOM Supply Agency Annual Report 2016.”
[11] European Commission, “EURATOM Supply Agency Annual Report 2016.”
[12] UK Parliamentary Offices of Science and Technology, “Supply of Medical Radioisotopes.”
Seemingly stuck between a rock and a hard place in more ways than one, NHS must decide which of its customers, “shareholders” or “Board” take priority in the face of this misalignment. While that is clearly much easier said than done, I would argue that given it was “created out of the idea that good healthcare should be available to all, regardless of wealth,” that it serves 64.6 million people in the UK, and 3 out of its 7 core principles are about putting patients first, shareholders are the customers to focus on in the face of the challenges Brexit presents. (https://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx)
That said, such a focus does not mean a dismissal or inability to serve its “Board” customers within the UK government. Positioning their desire to deliver on their promise to UK citizens should be a compelling reason for the UK government to collaborate with the NHS on how to arrive at the best solutions to prepare for and mitigate the effects that Brexit will have on access to technetium-99m. In some ways, this conversation can hopefully open the door to general conversations for how the NHS can work with the UK government more proactively to discuss the implications of any imminent or future trade decisions that drastically affect their ability to offer health care in accordance with the values they espouse.
Very interesting article Anna! It is a clear example of how governments do not provide an holistic picture of the consequences that certain public decisions can have. In the past, following previous radioisotope shortages, the NHS has reduced the amount of radioisotopes used through efficiency savings. A question that came to me was whether they can continue doing this to mitigate the supply chain challenges they will be facing, and if not, do they have the capabilities to develop the new technologies needed to produce radioisotopes? Is the latter even financially sound?
Fascinating example of a potentially unintended consequence of Brexit that has a tangible impact on the UK’s healthcare system. While the NHS’ “Board” may be the UK government, both NHS and the UK government are responsible to the general public. In fact, Brexit was directly supported by the general public, who should therefore expect to experience a range of effects (some mix of positive and negative) in all aspects of the economy. So while NHS should strive to recalibrate its operations to provide stable and cost-effective access to radioisotopes, the public who endorsed Brexit should be willing to accept the near-term shocks of adjusting to the new regime. I would also ask if there are any positive repercussions from Brexit for NHS that may allow the system to offset the new costs imposed.
Unfortunately, I’m not sure there is much the NHS can do other than continue to highlight the sense of urgency required to getting an appropriate Euratom-type treaty in place, most likely with the EU itself. Even were the NHS to have a strong voice, it has very little capacity to mount a campaign due to undermanning and underfunding. And until the current political quagmire around the divorce bill, the Irish border, and EU citizens in the UK (and UK citizens in the EU) are settled, it seems everything else is on hold and the UK government won’t have the capacity to listen to their messages either.
I particularly like your suggestion that the promise of investment for the Dutch or Belgian reactors may help convince the EU to maintain a supply of radioisotopes. It may be the case that such solutions are the best available option to persuade the EU to allow the UK access to the market in the short term, as it seems unlikely the UK will be able to establish long term agreements with the EU in time for March 2019, especially considering the lack of progress to date.
Anna,
This is a great example of the unintended and potentially devastating trickle-down effects of a far-reaching decision like Brexit. It is becoming clear that Brexit is not just the UK’s departure from the EU, but rather an untangling of a complicated web of interconnected agencies. While I recognize that Theresa May has committed to severing all ties with the European Court of Justice, I can’t help but ask: is maintaining membership in Euratom an option? Euratom is not technically part of the EU, and giving this regulatory body special treatment should be considered [1]. The potential rise in the cost of life-saving medical treatments following the UK’s Euratom departure makes this decision, in my opinion, a human rights issue. That should be reason enough for May to put the isolationist agenda aside and focus on human life.
[1] Dan Roberts, “What is Euratom and why does it matter?” The Guardian, July 10, 2017, https://www.theguardian.com/politics/2017/jul/10/what-is-euratom-and-why-does-it-matter, accessed December 2017.