Download Dr Lois Eva - Midland Cancer Network

Midland Cancer Network
Midland
Cancer
2012
Clinical Performance Conference
Network
Why do we have a
three centre model and
where are we now?
National Background
• In 2011, the Ministry of Health published the Report
on a Proposed National Service Improvement Plan
for Gynaecological Cancer Service (Sapere
Research Group, 2011). The report recommended
a hub and spoke model of service delivery based
on four regional centres. Regional centres would
provide comprehensive gynaecological cancer care
and link, via the hub and spoke model, to local
units. This is illustrated in the following diagram:
National Background
National Background
• Following a review of this report, the Cancer Programme Steering Group
(CPSG), uncertain about the ability of Waikato to attract gynaecologyoncology staff, expressed concern about the feasibility of implementing
a four-centre model.
• A sub-group of the National Gynaecological Cancer Working Group (the
sub-group), hosted by the Southern Cancer Network, was
commissioned to carry out a detailed examination of alternatives:
namely two and three centre models.
• In February 2014, the sub-group submitted a report to the Ministry of
Health – National Gynaecological Oncology Service Provision Models.
Following assessment of each option, the consensus view was that a
three centre model (the proposed centres being Auckland, Wellington
and Christchurch Hospitals) is the most appropriate within current
resource and workforce constraints (Southern Cancer Network, 2014).
Change to the Model of Service
To implement the 3 centre model a project was set up to ensure there was
support for all Midland women to have equitable and timely access to
evidence-based and best practice gynaecological cancer services that are
clinically and financially sustainable, leading to improved health outcomes.
In scope was:
• Adult gynaecological cancer services for Lakes, Bay of Plenty, Tairawhiti, and
Waikato DHB (Midland DHBs) inclusive of:
• surgery
• radiation oncology
• brachytherapy
• chemo-radiation
• medical oncology
• multidisciplinary meetings (MDM)
• all Midland patients referred to Auckland DHB gynaecological cancer surgical
services and associated MDM clinical investigation and diagnostic services
• palliative care (referrals out)
• supportive care
Change to the Model of Service
The Midland gynaecological cancer model of service project 2014/15
objectives were to:
• refer all Waikato ovarian cancers RMI>200 to Auckland MDM and
surgery
• improve the coverage and functionality of MDMs between Auckland and
Midland DHBs
• improve and ensure Midland DHBs receive timely information from
Auckland i.e. MDM summary and full MDM report, discharge summaries
• ensure pathology slides are sent to Auckland, particularly if held by
Dunedin, in agreed timeframes
• align systems and processes with the Bay of Plenty new radiation
oncology service, the Kathleen Kilgour Centre opened 1/10/14
• develop clinical pathways and improve the referral and diagnostic workup pathway
Change to the Model of Service
• agree the processes when Auckland DHB makes requests to Midland
DHBs for additional investigations and/or pre-operative workup,
including management of the revenue/cost
• improve the systems and processes related to transport and
accommodation for Midland women who need to have services in
Auckland
• ensure Auckland data related to FCT is obtained for Midland FCT
database for reporting and monitoring
• work towards ensuring Midland women achieve the FCT health
target/wait time indicator
• to implement strategies to ensure coverage for Waikato generalist
gynaecologist when on leave and establish succession plan
• meet with HWNZ regarding medical recruitment, retention and advanced
training issues
• undertake a feasibility study on Waikato developing a regional
gynaecological cancer centre hub in five years
Agreed patient flow – key themes
A full day workshop meeting was held 25 June 2014 with Auckland,
Waikato and Midland stakeholders to discuss patient flows (the majority of
patients would go from Midland to Auckland). Key themes from the meeting
were:
• Lakes and BOP DHB gynae oncology surgery volumes that had
previously come to Waikato had shifted to Auckland DHB
• Data to inform service planning and patient flow is poor.
• Midland DHBs to refer to Auckland MDM and surgery as agreed at
MDM.
• Midland DHBs agreed all tertiary cervical cancers requiring full Fletcher
suite/HDR service will be centralised at Waikato radiation oncology (as
per national report recommendation)
• Patients with ovarian cancer or high suspicion of ovarian cancer,
cervical cancer greater than stage 1a1, high risk endometrial cancer
(deep myometrial invasion or grade 3 tumour), vulval cancer greater
than stage 1a or vaginal cancer would be referred to Auckland.
Agreed patient flow – key themes
• Waikato continue to operate on stage 1a cervical, vulval or vaginal
cancer or women with low risk endometrial cancer (grade 1 or 2 stage
1a). Waikato continue all endometrial cancers and ovarian tumours with
RMI <200. This builds on what is already occurring, with a Waikato
patient flow change of an estimated 20 ovarian cancers to go to
Auckland MDM and surgery.
• Given the proposed Waikato patient flow change the service reviewed
the national service change protocol and deemed that the proposed
volumes didn’t meet the threshold for formal service change.
• A significant number of service improvements were recommended for
implementation in particular - supra-regional and regional MDM, DHB
clinical leads, succession planning for Waikato, improved
communication between Auckland & Midland DHBs, generic patient
pathway, improve supportive care for women/family when travel from
DHB of domicile, feasibility on fourth hub
National Workforce Issues to be addressed
• Current national shortage of gynaecological oncologists - 13 FTE
recommend , currently there are 7 FTE within New Zealand. This
workforce gap has significant impact on Midland ability to recruit in
future should a 4th cancer hub be established.
• Auckland DHB ability to recruit a 4th gynaecological oncologist to meet
Midland demand within FCT wait times
• Improve and increase the number of New Zealand training positions in
particular at Auckland DHB.
• Midland/Auckland had a meeting with the Ministry of Health Cancer
Team and Health Workforce NZ –31 October 2014. Purpose was to
discuss shortage of surgeons, recognition of training with current SMOs,
improve training – Auckland not accredited to train. There has been no
action by Health Workforce NZ to date
Where are we at now?
A number of service improvements have been achieved, key highlights
being:
• The establishment of the supra-regional MDM for gynae-oncology
cases;
• An enhanced working relationship with Auckland DHB and continued
discussions towards decision making on the national strategic direction
for the development of cancer centre hubs;
• Communication pathways established for follow up services for women
to return to their DHB of domicile for clinic appointments;
• Significant improvements in the Faster Cancer Treatment targets
relating to time from referral to treatment. (Note further improvements
are required).
Gynaecology activity data for Midland domiciled patients at
Waikato and Auckland Hospitals
Table F2: Midland domiciled patients discharged from gynaecology services at Auckland
Hospital
Fiscal Year
2011/12
Volumes CWD
2010/11
Volumes CWD
2012/13
Volumes CWD
2013/14
Volumes CWD
2014/15
Volumes CWD
Total
Volumes CWD
Gynae Cancer (C51-C58)
27
52.64
39
76.52
40
77.44
47
95.19
55 102.49
208 404.28
All Cancer Discharged
from Gynae
31
57.9
43
83.43
40
77.44
49
99.29
60 112.29
223 430.34
All Gynae
162 130.66
179 186.95
181 206.21
854 840.49
167 155.92
165 160.74
Gynaecology activity data for Midland domiciled patients at
Waikato and Auckland Hospitals
Table F1: Midland domiciled patients discharged from gynaecology services at Waikato Hospital
Fiscal Year
Gynae Cancer (C51-C58)
All Cancer Discharged
from Gynae
All Gynae
2010/11
Volumes CWD
2011/12
Volumes CWD
2012/13
Volumes CWD
2013/14
Volumes CWD
2014/15
Volumes CWD
Total
Volumes CWD
67 114.50
72 140.58
69 125.23
76 132.54
80 125.07
364 637.92
76 134.63
78 151.49
78 143.69
84 141.45
84 128.05
400 699.31
2498 1924.43
2527 1961.52
2832 2119.82
2808 2134.94
2868 2161.01 13533 10301.73
Where are we at now?
• The new model of service has only been in place just over twelve
months. The numbers remain small although are starting to increase.
• Midland women presenting at MDM in Auckland for the period July 14 to
May 15 was 137
• Some women are reluctant to travel to Auckland for services, potentially
exacerbating an already existing inequity in access.
• Projections of both population and cancer registrations for the Midland
region show an anticipated increase over the next 10-20 years
• A range of improvements have occurred in the delivery of gynaeoncology services in the Midland region over the last few years, but
issues remain in: service co-ordination between DHBs; the achievement
of Faster Cancer Treatment national targets, and; emphasis on meeting
targets for intervention rather than a focus on prevention.
• Auckland have employed a second gynae-oncologist