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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