Establishment of IRS 1984 and UK Initiatives
Integrated Radiological Services (IRS) Ltd was established in 1984 under the guise of the Mersey Region Radiation Protection and Quality Assurance Training Group (MRRPQATG) as a vehicle for running training courses in the developing field of QA in Diagnostic Radiology. It was established by a partnership of Trevor Henshaw and Mike Moores who were actively helping to develop this field of scientific support to medical imaging within the North West of England. Whereas scientific support in radiotherapy was well established and support to nuclear medicine was taking hold, this was not the case in diagnostic radiology. However, due to the time and effort required to sign cheques and make payments into the bank account that had been established for the training group, the name was quickly changed from MRRPQATG to IRS Ltd! Also, the two partners in this venture had already started to design, manufacture and market Quality Assurance test equipment for use in Diagnostic Radiology so a company with a wider remit was desirable.
Throughout the 1970’s the two partners had been actively developing standardised Quality Assurance and Quality Control test procedures in diagnostic radiology under the auspices of the Diagnostic Radiology Topic Group of the Hospital Physicist’s Association (HPA). The test procedures were subsequently published as standard test protocols with the first, aimed at Tubes and Generators, published in 1980. This was quickly followed by protocols for Image Intensifier/TV Systems, Photofluorography, CT as well as Film Screens and Processors. The CT protocol was developed in conjunction with a group led by Roy Parker who was a pioneer in the use of CT for treatment planning and who was working at the Royal Marsden Hospital at this time. He subsequently became Professor of Medical Physics in Leeds but his career was tragically cut short by his death in 1985.
As well as helping to standardise test procedures, a great benefit arising from the test protocols was the fact that they could be used to demonstrate, to the Regional Scientific Officers within the NHS, the role that Physics could play in supporting the field of Diagnostic Radiology, a primary diagnostic tool employed in medical practice. This field was also beginning to undergo major technical developments, led by CT, that helped to create the digital revolution in all aspects of healthcare with medical imaging operating at the forefront. Through these early activities, Medical Physicists could quickly establish updated test procedures for new technologies or developments in existing ones. This was evidenced by the development of test procedures for Mammography when the UK Breast Screening Programme was established in the late 1980’s as well as digital subtraction angiography in the 1990s.
It is worth mentioning some interesting asides associated with the development of the test protocol for Image Intensifier/TV Systems. A member of staff of the Mersey Region Radiation Protection Service, Kathy Stzanko was undertaking an MSc course organised by the University Department of Medical Physics at the Leeds Royal Infirmary. Trevor was visiting the Department in order to discuss her progress on the course. He happened to mention to George Hay, one of the lecturers on the course, who was a pioneer in the application of Medical Physics in Diagnostic Radiology, the work that was being pursued by the HPA Diagnostic Radiology Topic Group on a test protocol for Image Intensifier/TV Systems. George reached into his desk drawer and pulled out two test phantoms that he had developed in order to assess and standardise the performance if image intensifier/TV systems on the Leeds Royal Infirmary site. Trevor immediately realised the importance of these phantoms, which assessed image quality (noise, resolution and contrast detection) rather than any electrical or other parameters. For example, one assessment measurement being pursued at the time involved the removal of the TV camera from the intensifier. The light output (brightness) emitted from the rear of the intensifier could then be measured as a function of dose rate input. A tedious and long- winded approach. Consequently, the whole direction of testing of these systems was moved towards image- based methods.
Publication of the test protocols had three important outcomes. First of all, the Leeds Department of Medical Physics established a manufacturing facility to build and sell Leeds Test Phantoms including the associated development capability to create phantoms for new imaging techniques. This subsequently led to phantoms for use in mammography as well as digital subtraction angiography. This facility grew out of the proven need for test equipment for use in Quality Assurance in Diagnostic Radiology including test phantoms and subsequently became a very successful business as well as providing the UK with its own test phantom development facilities. Manufacturing of such test equipment subsequently became a major industry.
Secondly, at this time the Department of Health (DHSS) dealt centrally with the purchase and installation of all new X-ray equipment in England. When an installation was agreed and an order was placed, the supplier/manufacturer received 90% of the purchase price up front. The remaining 10% was paid once the equipment was deemed to perform satisfactorily. This was a bone of contention since manufacturers employed electrical techniques for testing performance, for example the kV applied to an X-ray tube was assessed by a potentiometer inserted across the transformer secondary windings. Consequently, test methods were governed by engineering practices and never attempted to measure X-ray outputs or even image quality.
With the arrival of the Leeds test phantoms the DHSS could now apply relevant quantitative performance criteria to new fluoroscopic installations based upon imaging performance. Equally, the development of test methods such as the Ardran-Crookes penetrameter helped to strengthen the use of in-beam test methods including the development of methods for assessing patient doses via a Dose Area Product (DAP) meter. This eventually led to the third important outcome. The manufacturers changed their methods for assessing equipment performance to in beam methods that were more relevant to clinical performance, which had been the basis of the approach adopted by medical physicists. In fact, a major market for modern test equipment is now provided by the X-ray equipment manufacturers for their service and installation engineers.
The European Connection
In 1984 a watershed Symposium on Criteria and Methods for Quality Assurance in Medical X-ray Diagnosis was held in Udine, Italy under the auspices of the EC Radiation Protection Research Programme. This was the beginning of a Framework programme of scientific research work in Europe funded by the Commission aimed at underpinning the development and implementation of EC Directives concerned with the Protection of the Worker and General Public as well as the Patient from ionising radiations employed in Medical Practice. Each Framework Programme ran for 3 years. Given the progress that had been made to date within the UK in this field the UK provided multiple key presentations including a number provided by IRS speakers. This trend continued with conferences held in Brussels, Wurtzburg, Oxford , Grado and Passau to name a few. It should be pointed out that the term EC (European Community) is employed in the text since the EU (European Union) had not yet been established.
The conferences served as a means of presenting outcomes from the Framework research programmes as well as helping to establish links between scientists throughout Europe. The research programme also provided the means for the establishment of working parties that produced relevant publications and documentation that could underpin the EC Directives in Medical Radiation Protection. The Directives were enacted within Member States in a format that was appropriate to individual national legislative frameworks. However, common guidance documentation helped to harmonise such legislation and IRS staff were active members of such initiatives.
The training course established in Liverpool in 1984 was subsequently used as a model by the EC Radiation Protection Training Programme for dissemination throughout Europe. Thus, IRS was asked to run courses in Paris (twice), Madrid and Passau and did so successfully, even providing slides in the host language. Translations of slide material were provided by the University of Liverpool translation services. It is perhaps worth noting that the original Liverpool Course established in 1984 recently held the 43rd edition.
Partners in the EC 5th Framework Research Programme attending a group meeting in Liverpool.
Ongoing Integration of research groups was ongoing during this period, which underpinned the eventual establishment of the European Union (EU), whereby a single political entity evolved. Consequently, research programmes then fell under existing European Networks or alternatively groups of national organisations. Since that time IRS has continued to pursue its own RnD programme, which has successfully underpinned its scientific and technical training programmes.
Mersey Region Radiation Protection Service – Privatisation
In 1988 as part of the establishment of an internal market within the NHS, the opportunity arose to privatise the Mersey Region Radiation Protection Service. This was facilitated by the fact that the Mersey Region had not regionalised its medical physics services within a single management framework. In most parts of the UK departments came under the management of a Regional Head of Medical Physics, normally on a hospital site that had a well-established medical physics presence. However, the Mersey Region had resisted this approach and each speciality (radiotherapy, nuclear medicine, radiation protection/diagnostic radiology, medical engineering) each had separate management structures led by an expert in each field. Consequently, it was relatively straightforward to separate out the budget and staffing for radiation protection. IRS then offered to reduce the existing costs of running this service as well as take over existing resources and their management.
It should be pointed out that since the establishment of radiation protection within the NHS in the 1950’s it had received minimal investment, particularly in the personal monitoring (film badge) services. It was for this reason that approximately 10 years later IRS led the way by subcontracting personal monitoring services to a major US supplier that had revolutionised badge design through the use of OSL technology. This technology permitted badges to be read by means of optical stimulation using lasers and eliminated the use of film technology that involved chemical processing with its associated hazards. A similar approach was subsequently followed in the X-ray imaging process itself, whereby imaging plates that had been exposed to X-rays were read by lasers and the subsequent signal digitized. This revolutionized plain film imaging (radiography) and permitted the complete digitization of medical imaging and subsequent deployment of PACS, digital archiving etc, which now underpins the application of AI and a new revolution.
The staff of the Radiation Protection Service were amenable to leaving the NHS and were not disadvantaged in respect of their terms of employment. Consequently, they ceased employment with the NHS one Friday and commenced employment with IRS the next Monday morning. So began an interesting and exciting journey.
EC Co-ordinated Research Programmes
IRS continued to play a full part in the EC Radiation Protection Research Programme so that RnD was an important and fundamental element of the training and development programme of scientific staff. In these early days research contracts were held by individuals, however, in the late 1990s the 4th Framework Programme established co-ordinated projects. The purpose of this approach was to help create much closer links between the partners as well as enable the pursuit of more ambitious projects. Thus began the closer integration of research activities within Europe.
IRS was invited to co-ordinate the 4th Framework programme and a project was formulated to develop image quality criteria based upon actual clinical images. The ultimate aim was to enable each clinical examination to effectively act as its own test phantom that could assess the quality of the image for measured patient doses as well as known radiographic techniques. The project involved 8 partners drawn from throughout Europe, with each bringing relevant specialist knowledge and skills. The project also, employed a panel of Clinical Radiologist experts to define key image quality criteria that should be fulfilled, in order to define an image that was suitable for diagnosis.
Each partner hosted a scientific meeting every 3 months so that results could be presented and discussed as well as any problems highlighted and tackled. The project was successful and moved the basic concepts along. In fact, it is quite possible that the approaches developed and research findings may well apply to the verification and testing of AI systems employed in image reporting programmes.
Based upon a successful outcome the Group were encouraged to apply for funding under the 5th Framework Programme and did so successfully. The second programme of work significantly strengthened the application of QA techniques, data collection and analysis methods including patient dose audit applications. An important element was also concerned with the application of rigorous statistical techniques to visual assessments of image quality, which are now applied routinely.
Partners in the EC 5th Framework Research Programme attending a group meeting in Liverpool.
Ongoing Integration of research groups was ongoing during this period, which underpinned the eventual establishment of the European Union (EU), whereby a single political entity evolved. Consequently, research programmes then fell under existing European Networks or alternatively groups of national organisations. Since that time IRS has continued to pursue its own RnD programme, which has successfully underpinned its scientific and technical training programmes.
Mersey Region Radiation Protection Service
IRS evolved from the Mersey Regional Radiation Protection Service and it is interesting to trace the lineage of this organisation through the people involved. Thomas Chalmers became head of the Liverpool Radium Institute and Lecturer in Radiology in 1938 and was a Founder Member of the Hospital Physicists Association when it was established in 1943. Prior to that he was a Physicist at St Bartholomew’s Hospital between 1932 to 1938 where he gained a PhD working alongside Leo Szilard, a major player in the production of the atomic bomb. In fact, Szilard conceived the nuclear chain reaction in 1933 and patented it in 1936.Szilard and Chalmers studied radioactive isotopes for medical purposes and in 1934 together discovered means of isotope separation now called the Szilard-Chalmers effect.
In 1938 Thomas Chalmers moved to Liverpool to take up an appointment as a Physicist in the Liverpool Clinic and Lecturer at the University of Liverpool. At the same time Leo Szilard travelled to the United States to take up a teaching appointment at Columbia University. Here he became instrumental in the development of the Manhatton Project, which led to the construction of the first Atomic Bomb, the basis of the successful movie Oppenheimer. In 1947 after the military detonation of the bomb in Japan, Szilard left physics for molecular biology working towards the peaceful use of atomic energy and international arms control.
After the war and with the establishment of the NHS Thomas Chalmers became head of the Mersey Region Radiation Protection Service until his retirement in 1970. Here he played a major role in establishing the Liverpool Diploma of Radiology to maintain a tradition dating back to 1920. In fact, following Thomas Chalmers retirement, staff in IRS continued to provide lectures on the Diploma Course, thus playing a significant role in the training programme for Radiologists
During the war a close colleague of Thomas Chalmers was Joseph Rotblat a Polish émigré who fled the rise of Nazism in Europe. He had fled from Poland and came to Liverpool in 1939 as the Oliver Lodge Fellow at the University of Liverpool becoming a Lecturer at the University in 1940 and later becoming the Research Director of Nuclear Physics between 1945 and 1949. During the war years Thomas Chalmers and Josef Rotblat both acted as Air Raid Wardens together enjoying one another’s company during fire-watching duties. This must have been a hazardous activity given the strategic importance of Liverpool to the war effort. It is interesting to note that any bombs not used by the Luftwaffe when attacking Liverpool were invariably dropped on Crewe during their return flight to Germany. Thus, two strategic targets could be considered during bombing raids. Indeed, the house next door to the author’s family home was destroyed in this way with loss of life.
Thomas Chalmers was extremely inventive. He developed a “clucking hen” radiation detector. To maintain a supply of radiation sources for interstitial radiotherapy, he moved the radon plant to the bottom of St James Street Underground station in order to manufacture radon seeds in safety from bombing, perhaps less so from radiation. He suggested the use of 125 I for implantation and pioneered work with radio-isotope tracers on Vitamin B12 metabolism and placental transfer of sodium.
In 1944 Josef Rotbat moved to Los Almos as part of a British Mission to work on the Manhatton project. However, he became disillusioned with the direction that the project was taking and on grounds of conscience returned to Liverpool in 1945. He received his PhD from Liverpool in 1950, becoming Professor of Physics in London University at St Bartholomews Hospital. From then on he became one of the most prominent critics of the nuclear arms race and was the, youngest signatories of the Russell -Einstein Manifesto in 1955. This led to his involvement in the Pugwash Conferences on Science and World Affairs that were aimed at reducing the danger of armed conflict. His involvement in such initiatives eventually led to a share in the Nobel Peace Prize in 1995 together with many other honours.
Another notable Medical Physicist with strong historical links to Liverpool was John Mallard who was an Assistant Physicist at the Liverpool Radium Institute between 1951 and 1953 following his PhD from Nottingham University. After a distinguished period in London teaching hospitals between 1953 to 1965, John Mallard became Professor of Medical Physics in Aberdeen University in 1965 at a young age. Here he established an internationally recognized department with forefront programmes of research in medical imaging culminating in the development of MR imaging systems. He established the first MSc course for training physical scientists to work in medicine as well as one of the very first course on MR imaging, which the author was able to attend. Equally, for many years John Mallard acted as the external examiner for the Liverpool Diploma of Radiology that involved lectures provided by staff from IRS.
Reference
The Szilard-Chalmers Reaction. Anas Shehu, International Journal of Innovative Science and Research Technology, Vol 3, Issue 8, (2456-2165), August 2018