Download Working together to achieve better faster cancer care

Working together to achieve
better faster cancer care
Speech and Presentation made at the
Midland Cancer Conference, September 2015
by Dr Nigel Murray
Chief Executive, Waikato District Health Board
Working together to achieve
better faster cancer care
The launch of the second Midland Cancer Strategy Plan sets the
direction and framework for a cohesive and coordinated approach.
The primary purpose of this plan is to lift our performance to:
• improve health outcomes for the people within Midland diagnosed
with cancer; and
• reduce the appalling inequities we have; and
• reduce the number and overall incidence of cancer.
Cancer is the leading cause of death in New Zealand – accounting for
nearly a third of all deaths.
For Midland this is a major challenge as our outcomes in many areas is
sub optimal in comparison to our colleagues elsewhere in New Zealand
and internationally.
Midland has dedicated health professionals and a strong foundation on
which to further develop our services as centres of excellence.
Our vision is by working together we will improve the performance of
our health systems by driving:
• Quality
• Improving the experience of care for our patients and family/
whanau
• Accountability for the care and outcomes
• Innovation and Value.
Speech and presentation by Dr Nigel Murray
Chief Executive Waikato District Health Board
Midland Cancer Conference - September 2015
I want to acknowledge that the New Zealand Cancer Plan 2015–2018
(NZ Cancer Plan) provides a strategic framework for an ongoing
programme of cancer-related activities for the Ministry, DHBs and
cancer networks so that all people have even more timely access to
excellent cancer services that will enable them to live better and longer.
The Midland Cancer Strategy Plan aligns with the national programme
as well as focuses on specific priorities for the Midland region.
2
Progress so far
• reduced our smoking rates
and harm
• HPV immunisation to
reduce cervical cancer
• delivering more specialist
services closer to home
• introduced new
technologies and services
• grown our specialist
workforce
• delivering more
diagnostics and treatment
• improved coverage and
functionality of MDMs
• implement standards of
service provision
• made service
improvements
Midland Cancer Conference - September 2015
Significant progress has been made with some major
service changes:
• The transition of Tairawhiti medical oncology,
radiation oncology and haematology services
to Waikato has resulted in a total review and
standardisation of these specialist services. There
has been an increase in specialist outreach services
in Gisborne and implementing a one-stop shop
concept to reduce the burden of travel for patients.
• The development of Bay of Plenty resident medical
oncology, haematology and radiation oncology
services has meant that more patients are receiving
care closer to home, with more people receiving
treatment.
• Late last year the Kathleen Kilgour Centre opened in
the Bay. This radiation oncology service is a public
/ private arrangement with additional new specialist
workforce, new state of the art facilities and two new
linacs for radiation treatment for the region.
We have implemented new technologies and services,
some examples include:
• A regional Oncology PET-CT and endobronchial
ultrasound. These new services have realised
improved diagnosis, staging and treatment planning
for our patients.
• Development of a regional adolescent and young
adult service with a key nurse specialist.
• HPV immunisation programme to reduce the
incidence of cervical cancer.
• The Network has facilitated building videoconferencing capability to enable new and
enhanced multidisciplinary meetings.
We’ve increased our workforce:
• Clinical nurse specialists and coordinators have
significantly grown.
• Increased our specialist oncology workforce
regionally.
• Focusing on growing our medical palliative care
workforce; Health Workforce NZ has just approved
another advanced trainee position.
• Started to recruit over 6 new psychologists and/or
social workers to better support our patients.
• Invested in research and clinical trials:
• Professor Ross Lawrenson and team recently
completed a three year Midlands Prostate Cancer
Research study within New Zealand.
These achievements
put us in a good place
to further build on
this progress.
3
Midland region;
cancer and equity
Midland cancer plan covers Bay of Plenty, Lakes, Waikato and Hauroa
Tairawhiti and an open invitation to our colleagues within Taranaki.
Midland has a population of over 765,500 people.
Midland has a higher Maori population with over 200,000 Maori and
35 Iwi.
Waikato
New cancers p.a. = 1832
Cancer deaths p.a. = 780
Lakes
New cancers p.a. = 569
Cancer deaths p.a. = 250
We are dispersed over 21% of New Zealand’s land mass with a mix of
urban and rural and remote areas.
We have a growing and ageing population. Our biggest projected
growth rate is in the 65 years and over age group – the group most
likely to be affected by cancer as we age.
Within our region generally a higher proportion of people live in quintile
five area – the most deprived.
Maori have a higher incidence of cancer – 20% greater.
Maori have a higher mortality – 80% greater than non-Maori.
Bay of Plenty
New cancers p.a. = 1311
Cancer deaths p.a. = 756
Maori are more likely to have their cancer detected at a later stage with
more widespread disease.
Frequently first presentation is via an emergency department. UK
data shows conclusively that cancer patients who first present via the
emergency department have a significantly one year survival rate.
There are wide variations in cancer survival between DHBs in New
Zealand.
Lung and colorectal cancers are a priority in Midland.
HauoraTairāwhiti
New cancers p.a. = 200
Cancer deaths p.a. = 87
Lakes has a higher lung cancer incidence. The Ministry wrote recently to
the Chief Executives with a recommendation to lift performance in this
area.
Lakes, Waikato and Tairawhiti have a higher mortality for lung cancer
compared to other DHBs.
Waikato has a higher mortality for colorectal cancer than the New
Zealand average.
Midland Cancer Conference - September 2015
4
Cancer risk factors
It is usually not possible to know
exactly why one person develops
cancer and another one doesn’t.
Tackling the “lifestyle” factors,
particularly smoking, which are
responsible for over a third of cancers.
Research has shown that certain
risk factors may increase a person’s
chance – like growing older, which
cannot be avoided.
We need to support our population
with knowledge so that they can take
responsibility to adopt healthy lifestyle
behaviours.
But others can … over a third of
cancers can be prevented through
modifiable lifestyle behaviours.
Going forward we need to understand
who, how and what is happening to
reduce cancer risk factors and how
we can further build on this work.
• Our Midland smoking rates remain
too high.
• Overweight and obesity is a
growing problem with over 30%
of our population being obese.
• In the media we hear about
the growing number of
people attending emergency
departments due to the hazardous
effects of alcohol drinking.
• The Cancer Society does a great
job promoting SunSmart however
our skin cancer and melanoma
rates are still increasing.
Nationally we are making some
progress to lessening the risk of
developing cancer however our
population continues to grow and
age.
The cost of cancer is predicted to
increase by more than 20%.
We live in a fiscally constrained
environment with competing
demands for all aspects of health care.
Prevention:
Tackling cancer starts with prevention
of known cancer risk factors, and
this is why I was pleased to see that
prevention is one of the strategic
objectives of this plan.
Midland Cancer Conference - September 2015
We need to detect and treat
precancerous conditions (that is
conditions that may become cancer)
or early, asymptomatic cancer.
Screening:
We have excellent cervical and breast
screening services, however we need
to lift performance to ensure we
continue to focus on improved access
and outcomes for Maori women.
Bowel cancer is one of the most
preventable cancers. Midland is no
where near ready to implement a
rollout of a national bowel screening
service. Our challenge is to be ready.
Early detection:
We know that the earlier people are
diagnosed with cancer the more likely
they are to survive.
Midland Maori are more likely to
present with later stage disease
and we need to address this major
concern.
Dr Charles de Groot the clinical chair
of the National Lung Cancer Group,
has Ministry supporting his national
clinical team of experts and the
Midland Cancer Network to facilitate
working with stakeholders to develop
national guidance on early detection
of lung cancer over the next year.
The Midland Lung Cancer
Work Group recommended
in the future that Midland
pilot an Early Detection
Programme within our
region to encourage
earlier presentation of
lung cancer. This would
mean the need to bring
together community,
Maori and primary with
secondary services to do
more to ensure our people
are aware of the signs and
symptoms of cancer and
appropriate actions to be
taken.
We need to explore this
innovative request.
5
RegistrationMortality
Midland has over 4,000 new
cancers diagnosed each year.
We have approximately 1,700
deaths from cancer each year
– this is too high.
These maps demonstrate that
Midland has a significantly higher
incidence rate in Bay of Plenty and
Lakes compared to the rest of New
Zealand.
Of more concern is that ALL
Midland DHBs have a significantly
higher mortality or deaths from
cancer than the rest of New
Zealand.
In addition, New Zealand is
lagging behind our colleagues
in Australia – New Zealand has a
higher mortality rate than Australia,
especially for women.
New Zealand survival rates are
lower than Australia.
This suggests further
improvements in recognition,
diagnosis and treatment of cancer
in New Zealand is possible. Issues
of early management in primary
care and time intervals to diagnosis
and treatment are important.
So in summary Midland has a BIG
challenge to first lift performance
to that of other regions within
New Zealand, as well as striving
to achieve similar performance
outcomes demonstrated
internationally.
Midland Cancer Conference - September 2015
6
Cancer Health Target
We have a new Cancer Health Target.
The Faster Cancer Treatment Health Target is
published quarterly.
We need to lift our performance to get our ranking
to the top – as we did with the previous cancer
health target Shorter Waits for Cancer Treatment.
There is some variability of ranking each quarter
but what this demonstrates is that we have a way
to go to ensure patients receive their first treatment
within 62 days of being referred by a GP when there
is a high suspicion of cancer and need to be seen
urgently within two weeks.
Publishing this target makes us accountable.
By lifting our ranking this provides public confidence
that we are functioning at the top of our game.
Midland Cancer Conference - September 2015
7
What our patients are telling us that’s important
Feedback from patients and their family provide good insight into how we are supporting them to get the care and treatment they need
Timely
Great staff, but
they’re always busy.
Always waiting;
difficult sitting in
waiting rooms always
waiting.
It’s emotionally difficult
and often I needed
more information and
support to cope.
My family/whanau
needed support to
help me.
Coordinated
Quality Care
& Compassion
Often my GP
didn’t have my
information.
Midland Cancer Conference - September 2015
Culturally
appropriate
Information
& Support
I needed support
through a Maori
worldview.
Now I’ve finished
treatment, what
happens?
Excellent
Communication
Breaking the bad
news that you have
cancer is not always
communicated well.
8
Midland FCT Health Target
This graph demonstrates we currently have a
huge gap to close.
While there has been significant effort to
implement and work towards achieving the new
Faster Cancer Treatment Health Target by the
Midland DHBs, we need to do more.
This target is challenging and complex however
we are:
• Not achieving the 62 day wait time target of
85%, which goes up to 90% in June 2017.
• We continue to struggle to report 15-25% of
new cancers within the Health Target.
• Midland Maori have a lower 62 day
achievement rate than the national average.
• Midland has a lower 62 day achievement rate
for some tumour groups than the national
average. This includes Midland lung and
colorectal - our priority cancers.
• Midland is not always demonstrating
achievement of delivering first treatment within
62 days compared to the national average.
• We know that the majority of first treatment
is surgery therefore we need to focus and link
with our elective processes.
What is happening to the bulk of our cancer
patients under the 31 day indicator prior to
decision to treat?
Are we providing timely and appropriate care up to
the
point of deciding treatment?
In addition to access and equity we need to also
focus on the other quality components.
We have started to implement tumour standards
of service provision. Each regional review has
highlighted areas for improvement and DHBs are
developing tumour specific improvement plans.
Midland Cancer Conference - September 2015
9
Colonoscopy urgent 14 days
Colorectal cancer is a priority
cancer.
We aren’t providing timely access to
colonoscopy services – this is one
example demonstrating we are not
always achieving the targets.
We are not in a ready state for
a possible roll-out of a national
bowel screening population.
The national Bowel Cancer
and Screening Team were
here yesterday discussing what
screening services might look like
and forecasting the impact on our
services.
We need to improve timely access
and work together to be in a state
of readiness.
Purchasing and implementing
ProVation is a classic example of
working in isolation and not being
integrated. ProVation was first
recommended in 2011.
A Regional Plan was developed
2013. All agreed it’s an essential
tool for quality clinical care but here
we are in 2015 and not all DHBs
have
the system in place.
We need to be open to doing
things differently and focusing on
more integration for the region, as
a screening programme will require
more integration with primary,
health promotion, radiology,
laboratories and private providers.
Workforce is a major challenge.
Good things have been happening
to improve access but often
isolated by service and/or DHB.
Current focus is secondary surgery
and gastroenterology.
We’re too slow enabling
information systems to support
clinical services.
Midland Cancer Conference - September 2015
10
Other areas where we need to improve
• Information for clinical decision making
• Standards of service provision for tumour
streams
• Reduce variation of practice
• Psycho-social support services
• Workforce development
• Health literacy
• Palliative care and last days of life no matter
where we live
• Late effects and living beyond cancer
treatment
When I arrived one of the first major challenges I heard from my cancer
colleagues was poor information to support clinical decision making, service
planning and improvements.
Prior to developing the FCT database staff had no idea who our cancer patients
were and where they were within our system.
The Network said they started knocking on Information Services’ door for help
back in 2007 – what real progress have we made?
Each DHB has a different approach.
In some DHBs like my own, secondary clinicians have had to develop standalone
tumour databases and pro-formas to obtain the necessary information to support
caring for our patients.
Integration with primary care – Dr Damian Tomic will speak to this later – but we
need to integrate and work closer together despite the boundary differences.
Most people prefer, if possible, to have palliative care and die in their own home.
We need to build the primary and community capacity and capability to meet this
consumer need no matter where you live within Midland.
The challenges are many, and our performance in some areas is sub optimal.
We are doing some great things; if we were
more integrated we could do better.
Midland Cancer Conference - September 2015
11
Core principles
By working together to achieve faster cancer care we want to live
by the following core principles for delivery of cancer care to our
patients and family/whanau; and demonstrate the behaviours
when implementing our strategy plan activities.
Care must be:
• patient centred
• culturally appropriate
• evidenced based best practice
• multidisciplinary
• coordinated
• delivered safely as close to home
• strong multidisciplinary team engagement
Midland Cancer Conference - September 2015
Strategies must be:
• equitable
• clinically led
• integrated
• sustainable
• collaborative with a partnership approach
• innovative & responsive to change
• research & knowledge driven
12
Patient-centred focus across
the cancer pathway
We want to support a seamless and integrated cancer pathway.
We want to acknowledge the value of detecting cancer early
and the needs of people surviving and living beyond cancer
treatment – this group of people should grow as we improve
our survival rates.
They have particular needs to support them with living a
productive and quality life – rehabilitation, addressing any
late side effects of treatment, psycho-social support.
Living
Beyond
Prevent
& Detect
Screen
Diagnosis
& Treat
Follow-up
Palliative
LDoL
Midland Cancer Conference - September 2015
13
Strategic objectives
• To reduce the cancer incidence through
effective prevention, screening and
early detection initiatives
• To reduce the impact of cancer through
equitable access to best practice care
• To reduce inequalities with respect to
cancer
• To improve the experience and
outcomes for people with cancer
The key Midland cancer strategic objectives are:
• Stop people getting cancer.
• Detect precancerous and identify cancer earlier.
• Timely and quality cancer treatment.
• Reduce inequalities.
• Improve the patient experience and outcomes.
The strategic objectives are supported by five system enablers:
• Infrastructure – having excellent facilities, high quality equipment
and clinical technologies.
• Information systems – improve the information technology
systems we have to support clinical services to delivering care,
necessary data to inform service planning, modelling and service
improvements.
• Workforce – have trained, motivated, credentialed and flexible
workforce.
• Supportive care – we’ll have workforce, systems and processes and
information to support our patients and family/whanau along the
pathway.
• Knowledge and research – research and clinical trials underpin
advancement in improving cancer care and improvements.
Improving the knowledge and health literacy of our community
to care for themselves is going to be critical to overcome the
challenges we face.
Midland Cancer Conference - September 2015
14
The challenge
In summary, we have made some progress, we have excellent staff and we are in a good
space to move forward.
Our current performance is sub optimal and we all need to be held accountable for
improving care and outcomes.
We have great staff but at times it’s so challenging trying to get the whole team working
together – often when we have not planned, don’t have the necessary equipment and
tools in place.
Great things are happening, but often in isolation and not
integrated.
Sometimes we don’t recognise that some areas are floundering or are in crisis.
Working together to achieve better, faster cancer care
The challenge is that we need to lift our performance to improve care and outcomes and
address Midland’s equity issues.
Engagement with consumers and Maori in co-designing new service delivery options is
critical.
A partnership model adds value. We must engage and involve stakeholders; to obtain
health gain attainments beyond what we could achieve alone, and to develop the best
services possible for our population.
Engagement with consumers and their involvement in co-design of innovative service
delivery options is critical.
Integration between organisations and services is essential. Integration with primary care
is required to explore options to keep people out of hospital and new ways of delivering
services.
Somehow we need to support improvement through development of our information
systems, we need to change our way of thinking to enable better clinical decisionmaking.
Research and well trained and integrated workforce are going to be critical.
The challenge I leave is that I want to empower our Midland health workforce to drive
this strategy.
This is more than a vision; it’s a commitment to work
together as a region.
Midland Cancer Conference - September 2015
15