Former ESR President Prof. Adrian Brady has a vision of the future: The level of care provided to patients when accessing radiology services is identical across Europe, with uniform standards of education, training, and staffing.
Prof. Adrian Brady.Photo courtesy of ESR.
In this Q&A interview, former ESR President Prof. Adrian Brady explains how the European Union Radiation, Education, Staffing & Training (EU-REST) initiative can help to achieve this objective by promoting harmonized training and workforce standards across the EU.
Q: What do you regard as the most important achievements of the EU-REST initiative?
A: Despite increasing harmonization of education and training standards for professions engaged in the medical use of ionizing radiation across EU members in recent years, no single set of uniform recommendations and guidelines existed for curricula, duration, and content of training and education, maintenance of continuing education standards, etc. prior to completion of the EU-REST project. Such standards have now been established for these professions, and accepted and published by the European Commission (EC).
Secondly, there was no uniformly applicable method of determining the required workforce to deliver necessary services before this project. Now, we have developed and published clear EC-approved and EC-accepted methods of defining and determining how many professionals are needed in each setting to cope with demands. The precision of these standards varies among the professional groups involved in the project, depending on their particular circumstances. For diagnostic and interventional radiology, a very clear formulaic method of calculating radiologist number needs has been developed, which is readily adaptable to different practice settings, locations, and activity levels, and which is adaptable and scalable in the future. This should allow EU member states to plan for and resource appropriate and necessary workforce numbers in the future.
Q: What disappointments or setbacks have you encountered?
A: Looking solely at the situation with respect to radiologists, we were not surprised, but we were nonetheless disappointed to discover just how few radiologists were available in many countries to manage ever-increasing demands for services. The project identified an EU average of 127 radiologists per million inhabitants across the 27 EU member countries (there was an issue raised about the radiologist numbers provided to us by the reporting agency in one country, which appears to have inadvertently included both qualified and trainee radiologists in their numbers, but this does not substantially change the overall numbers).
Disturbingly, 16 of the 27 member states have radiologist numbers that fall below this average, even as demand increases significantly year on year. To realize the potential of radiology to do good in healthcare, this under-resourcing must be recognized, and steps must be put in place as a matter of urgency to provide for an adequate future workforce.
Q: How close are you to achieving your goal of harmonized standards for Europe on training and workforce?
A: EU-REST recommended a harmonized duration of training for radiologists of five years, followed as appropriate by one or more one-year further fellowship training schemes. Our data showed that specialty training within the EU currently ranges from four to six years, with an average of 4.9 years, very close to the five-year recommendation.
Wider variations exist for the length of time specifically devoted to radiation protection (RP) training within the five-year training period; some of this variation relates to whether RP training is undertaken as a stand-alone module or is integrated as a periodic topic among other elements of training. There is considerable scope to standardize this.
Likewise, much work remains to be done to standardize certification of completion of training, both in RP (currently, 13 of 27 countries require specific certification of RP training) and in general. We have included recommendations for the minimum required numbers of European Credit Transfer System (ECTS) and cases/procedures during training for each subspecialty. Recommendations are also included for harmonization of training curricula -- ideally based on or congruent with the ESR European Training Curriculum (ETC) -- and for a standard examination as part of certification of formal completion of training. Wide variation remains in these areas.
Q: How much work still needs to be done and in which areas? Who will do this work now EU-REST has wrapped up?
A: As explained, some areas covered by the project require little change to achieve the desired harmonization, while others remain widely variable in their application and standards. With a shared sense of purpose and a recognition of the ever-growing centrality of radiology to healthcare delivery, we believe services can be maintained and developed across the EU by implementation of the recommendations and guidelines (which have now been accepted and published by the EC). Harmonization of education and training is the easier element of the project’s outcomes to achieve, with close collaboration among countries’ training bodies and healthcare systems.
More commitment is required to meet the needs for an adequate workforce; additional resources will be needed for those many countries currently substantially underserved in terms of radiologist numbers, to train enough radiologists for the future, to employ them in health services, and to equip them to provide what their populations require and demand. Decisions to support these efforts cannot be postponed; given that training a radiologist requires an absolute minimum of five years, immediate expansions of trainee numbers will not have the desired impact on service delivery for a number of years (by which time increasing demands are likely to have created further, additional workforce requirements).
Retirement age is another significant parameter looked at during the project. Assuming a retirement age of 66, an average of 19% of radiologists currently in practice are scheduled to retire in the five years from 2022, with nine EU member states having above-average retirement expectations. In seven countries, more than 50% of radiologists are over 51 years of age. These numbers suggest potential demographic cliff-edges, with potential diminution of available workforce numbers, rather than the required increases. This, too, must be addressed if services are to be maintained and developed appropriately.
All these necessary actions will be for individual member states to enact. Neither the EU-REST consortium nor the EC has the power to make things that need to happen actually happen. We have now set out the roadmap; individual countries must now take action.
Q: Your analysis found there is an average of 127 radiologists per million population across Europe and 16 countries fell below this average: Are you optimistic that these nations can catch up any time soon?
A: As answered above, it is a matter for each country to determine if and how the EU-REST outcomes are followed and implemented. I cannot express an opinion as to how any country may deal with these issues. However, every EU member state has the best interests of its people at the heart of its agenda. Delivering modern healthcare that is adequately resourced is a key element of serving each population. Harmonizing healthcare standards across the EU is a key component of EU policy. These considerations should ensure that all member states will strive to meet the challenges posed by the EU-REST recommendations and guidelines.
Q: Have the national societies been supportive and responsive?
A: The ESR has communicated with our national society members throughout the project, through stakeholder consultations, direct briefings at conferences, dissemination of results through papers and bulletins, etc. We believe that all national societies understand the goals of the project (goals, it must be emphasized, set not by the project consortium, but by the EC when commissioning the project in 2022) and have common interests in supporting those goals to improve standards across the EU and beyond. National society leaders have expressed enthusiastic interest in the project’s recommendations and guidelines, and we believe these Societies will use the project’s outcomes to advocate strongly for their implementation in their countries.
Q: Overall, what do you think is the main legacy of EU-REST?
A: If, some years downstream from completion of the EU-REST project, we can demonstrate that the level of care provided to patients when accessing radiology services is identical, regardless of where within Europe those services are delivered, with uniform standards of education, training, and staffing, we will have achieved our goals. EU-REST has now established the appropriate standards, and it has drawn up a clear roadmap for their adoption and delivery. What is now required is the necessary commitment and resources in each country.
Q: Where should readers go for more information on the project?
A: I would encourage everyone to watch the video produced at ECR 2025. Also, three recent papers in Insights into Imaging summarize the project from the radiology perspective (go to the ESR website). In particular, there's a link in the supplementary material for Paper 3 to a workable spreadsheet for those who want to try out our formula for calculating radiologist number needs; I suspect this will be the key outcome for many readers.
One final point: my answers relate almost exclusively to radiology, but it’s important to remember that the EU-REST project also covered radiation oncology, nuclear medicine, radiography, radiation therapy, and medical physics. My answers relate to the ESR, both as the society leading the project and representing radiology, but the European Society for Radiotherapy and Oncology, European Association of Nuclear Medicine, European Federation of Radiographer Societies, and European Federation of Organisations for Medical Physics were also closely involved.
