Download Lessons learnt in the implementation of a Cancer Care Network in

Recto Running Head: Lessons from the implementation of a cancer care network in Catalonia
Verso Running Head: Josep M. Borras, Alan Boyd, Mercedes Martinez-Villacampa, Joan
Brunet, Ramon Colomer and Josep Ramon Germa
<cts>Lessons learned in the implementation of a cancer care
network in Catalonia
<rec>Received (in revised form): 3rd December, 2008
<aus>Josep M. Borras, Alan Boyd, Mercedes Martinez-Villacampa, Joan
Brunet, Ramon Colomer and Josep Ramon Germa
<abh>Abstract
<abs>Cancer care across different levels of a health system is a key issue in planning cancer
management. In Europe, cancer networks have been proposed as a model of care, thereby
changing the traditional informal relationship between healthcare providers to formal coordination
among professional organisations. This paper presents the experience of the Catalan Institute of
Oncology (ICO), which began developing cancer care networks in two Spanish regions in 1998.
The regions, which provide healthcare for about 2 million inhabitants, include 11 hospitals owned
by different nonprofit providers of public healthcare. This paper discusses the value added by
cancer networks in a Southern European healthcare context with a diverse range of hospitals.
Establishing a shared model of care, based on multidisciplinary tumour committees and clinical
guidelines, helped ICO to manage that diversity. An inclusive and cooperative approach, founded
on personal contact, respect and understanding between different stakeholders was important,
coupled with the flexibility to make agreements that suited local circumstances, while respecting
the fundamental principles of the model. The importance of human factors is also highlighted by
consideration of the boundary-spanning role of the medical oncologist.
<bio>Josep M. Borras specialises in epidemiology. Formerly Director of the Catalan Institute of
Oncology, he is now Director of the Regional Government of Catalonia’s Cancer Plan and
Scientific Coordinator of the Spanish Ministry of Health’s Strategy on Cancer.
<bio>Alan Boyd is a research associate. He has been at Manchester Business School since
2003, and previously worked in the health and social care sectors for over 15 years. His research
interests lay in the organisation of local government and healthcare services, particularly the role
of democratic governance in service improvement.
<bio>Mercedes Martinez-Villacampa is a medical oncologist. She is the clinical coordinator for
the oncologists working in the in the Costa de Ponent hospital network and responsible for medical
oncology in one of these hospitals.
<bio>Joan Brunet is a medical oncologist. He was formerly coordinator of the oncologists
working in the Girona hospital network and responsible for medical oncology in one of these
hospitals. He is now Head of the Medical Oncology Department at the Catalan Institute of
Oncology Cancer Centre in Girona.
<bio>Ramon Colomer is a medical oncologist and former Head of the Medical Oncology
Department at the Catalan Institute of Oncology. He is now Medical Director of the MD Anderson
Medical Centre in Madrid. He is also President of the Spanish Society of Medical Oncology.
<bio>Josep Ramon Germà is a medical oncologist. He is the Head of the Medical Oncology
Department in the Costa de Ponent Cancer Centre of the Catalan Institute of Oncology, and Past
President of the Spanish Society for Medical Oncology. He is also Professor of Oncology at the
University of Barcelona.
<corres>Josep M. Borras
<corres>Catalan Cancer Plan
<corres>Av Gran Via s/n Km 2,7
<corres>08907-Hospitalet, Barcelona
<corres>Spain
<corres>Tel: +34 932 607 820
<corres>E-mail: [email protected]
<key>Keywords: cancer, networks, health policy, organisation of cancer care, implementation
<AS>Introduction
<ful>One of the most important issues in planning resources for cancer care for a defined population in the context
of a public healthcare system is how to organise the clinical journey of the cancer patient between different
physicians and levels of care. Two or more levels of care are usually involved in cancer treatment and follow-up,
ranging from primary healthcare to university teaching hospitals. Some components of the treatment for common
cancers are usually carried out in community or intermediate hospitals, while others, such as radiotherapy, are
usually centralised in more specialist hospitals, for reasons of quality and efficient use of resources. There is some
evidence that treatment within specialist teams is associated with better outcomes for low-incidence cancers or
where highly-specific therapies are used.1–3 On the other hand, centralisation of cancer care might make services
less accessible to patients, and has been associated with a more advanced stage at diagnosis and poorer survival.4
While the debate between centralisation and decentralisation has been predominant in cancer policy in
recent years, as exemplified by the report by the Institute of Medicine and the literature reviews produced for that
report,5–7 several cancer plans have also recognised the importance of coordinating cancer care among different
hospitals and levels of care.8–10 The policy framework outlined in the Calman-Hine report,11,12 for example, both
defined specific roles for hospitals providing different levels of cancer care and proposed multidisciplinary care
with tumour specialisation; it has also been associated with improved cancer outcomes.13–15
Networks in cancer care have tended to evolve from the ‘hub and spoke’ model towards a more integrated
16
model. Healthcare has traditionally been based on networks of informal relationships between professionals,17 and
managed clinical networks, such as those for cancer care in Scotland,18–20 aim to build on existing referral patterns
and professional relationships in order to organise cooperation more formally. These networks are intended to
facilitate ‘working in a coordinated manner unconstrained by existing professions and health board boundaries’.21
This is easier said than done because such boundaries are often deeply embedded in institutions, cultures and
individual professional identities.22 A similar approach has been developed in France with the aim of promoting
equity of access to cancer care, involving different hospitals and physicians in a region with an emphasis in
promoting multidisciplinary care and implementation of clinical guidelines.23,24
Research on the organisation and functioning of cancer care networks has largely been focused on Northern
Europe and the UK in particular, so it is important that conclusions based on that research are tested by considering
experiences from other countries and organisational contexts. This paper does this by presenting a case study of two
related networks of cancer care, organised among hospitals in two healthcare regions in Catalonia, Spain by the
Catalan Institute of Oncology (ICO). The paper focuses on the lessons learned in implementing those networks
from an organisational perspective.
<AS>The study
<ful>In 2004, one of the authors (AB), undertook semi-structured face-to-face interviews with network staff,
including the then Director of ICO (JMB), managers of each network (RC and JRG), and an oncologist from one of
the networks, as part of a larger research project investigating ways of organising cancer services. The interviews
were taped and transcribed, and a thematic analysis was performed and presented back to the interviewees in the
form of a report. Subsequent feedback and reflection by all of the participants identified their theories about the
causal mechanisms that were at play, and these were compared and contrasted with theories generated by previous
research on managed clinical networks, drawn from a literature review.
This paper first gives an overview of the Catalan health system in order to provide a context for the
description of the objectives and organisation of the networks that follows. It then discusses the outcomes of the
networks for the hospitals involved, for patients, and for staff, particularly medical oncologists. The paper ends by
identifying what network participants believe to be the key success factors, highlighting what learning may be
transferable to cancer networks elsewhere.
<AS>The networks
<bs>Overview of the Spanish healthcare system
<ful>The 17 regions of Spain are autonomous with regard to healthcare, each deciding their expenditure priorities
within the common framework established in the country’s constitutional right to universal access to care and a
common basket of health services.24 In Catalonia, it was decided to build community hospitals so that every citizen
would be no more than 30 minutes away from a hospital. As a result, there are now 68 publicly funded hospitals for
a population of 7 million people, of which 14 are university teaching hospitals. Municipalities own most hospitals;
consortia of municipalities and other institutions own some, and voluntary organisations such as the Church own
the rest. The makeup of the boards of directors depends on the ownership, but typically involves representatives of
the municipality, community organisations and Catalan Health Service officials. The Catalan Health Service pays
hospitals prospectively, through contracts that take into account overall activity and case-mix complexity.
ICO is a nonprofit public hospital, which offers specialised cancer care, including medical oncology,
radiotherapy, clinical haematology and palliative care for three healthcare subregions with a total population of
about 3 million people. In each subregion, cancer surgery is offered in partnership with a neighbouring university
teaching hospital. ICO’s first network, in the Costa de Ponent subregion on the southern edge of the city of
Barcelona, was established in 1996 and covers 1.4 million people. A second network, covering 0.6 million people,
was established in 2001 in the Girona subregion in the northern area of Catalonia. A third network, covering the 0.8
million inhabitants of the Barcelones Nord-Maresme subregion on the northern edge of the city of Barcelona, was
established in 2003, but was still in process of being developed at the time of the study, and is not covered by this
paper.
The Costa de Ponent network comprises six community hospitals and a cancer centre. One hospital is about
10 km from the centre, while the others are between 30 and 60 km away. The Girona network comprises five
community hospitals and a cancer centre. One hospital is about 5 km from the centre, while the others are about 40
km away. All except one of the community hospitals in both regions have between 125 and 250 beds.
<bs>Objectives and organisation of the networks
<ful>The networks aim to provide high-quality care as close as possible to where patients live, in line with the
Cancer Plan of Catalonia. In isolation, community hospitals find it difficult to provide high-quality care: there is an
insufficient volume of patients (and thus accompanying resources) to enable staff to develop specialist expertise,
and the lack of such opportunities can lead to a vicious circle of high staff turnover and workforce shortages. In
addition, without some centralisation, costly new technologies and treatments become prohibitively expensive. The
networks are seen as a way of addressing these issues while also maintaining person-centred care and facilitating
research (enrolment of patients in clinical trials), principally through improved communication.
The hospitals seek to share a common, multidisciplinary approach to cancer care based on tumour
committees26,27 and clinical guidelines, as per the Cancer Plan of Catalonia.28,29 This approach was established at the
outset as an essential component of the network agreement between ICO and each community hospital. A medical
oncologist and a radiotherapy oncologist from the cancer centre attend the committees, which have two different
roles: to develop and review protocols, and to discuss the new cases diagnosed in the hospital, including whether
treatment should take place in the hospital or at the cancer centre. Relatively simple treatments, follow-up and
uncomplicated palliative care are provided in the community hospital, with more complex treatments and most
acute inpatient care in the cancer centre. Patients included in clinical trials are usually treated centrally during the
study protocol.
The community hospitals do however vary greatly in terms of their catchment area, capacity and
infrastructure. This means that the cancer centre needs to make specific arrangements with each community
hospital. There are hospitals that for reasons of funding, or difficulties in managing adverse effects, have decided to
restrict themselves to specific chemotherapies, and in three cases, it is not still possible to give chemotherapy.
Information systems are not connected between hospitals, and in several cases there is no computerised database
available for the clinical record.
Ideally, the multidisciplinary tumour committee discussion should take place at the very beginning of a
patient’s treatment, but some surgeons (generally those operating on urological cancers) present their cases only
after surgery. ICO and medical directors of the community hospitals are working to change this practice. The Costa
de Ponent network organises a monthly meeting (which lasts two hours on average) of specialists and doctors from
community hospitals, where cancer cases, clinical protocols and the new clinical trials that have started are
presented, together with any results that may be of interest. Clinical guidelines shared between hospitals have been
discussed in an annual meeting with all physicians of every hospital involved in the multidisciplinary cancer
treatment. Every year the meeting is focused on a particular tumour and takes place in a different hospital. Each
network now also has a drug committee, with participation from key clinicians and hospital pharmacists, to consider
every new cancer drug in the hospital-approved drug list.
A key element of the network relationship is that a medical oncologist from the cancer centre spends part of
their time (typically two or three days per week) working at a particular community hospital, and the rest of their
time working at the cancer centre. On the days when the oncologist is in the cancer centre, they focus on a single
type of patient or tumour, so that they have continuous access to up-to-date oncology research and practice. In the
community hospital, the oncologist does ‘a bit of everything’, seeing all types of cancer patients in an outpatient
clinic, as well as administering chemotherapy (eg adjuvant therapy for colon and breast cancer), and participating in
tumour committee meetings. A nurse who works with the medical oncologist in the community hospital acts as a
‘navigator’, guiding patients through the whole cancer care system.30 To maintain the integrity of the model, it is
important that the oncologist’s workload is commensurate with their allocation of days at the community hospital,
and that they can spend at least two days each week at the cancer centre, doing more specialised work and
facilitating communication between the community hospital and cancer centre in order to prepare specialised
surgery. Relationships developed through the network have facilitated the introduction of an extra oncologist shared
between five hospitals. This arrangement has provided necessary additional oncologist time at those hospitals and
helped with staff cover, while still allowing oncologists to spend sufficient time at the centre. This has been
beneficial overall, but there has been some loss of the continuity for patients and staff in the community hospitals.
Management of each network is based on the clinical leadership of the departmental heads of medical
oncology and radiotherapy oncology in the corresponding cancer centre. The medical and radiotherapy oncologists
working with community hospitals are drawn from and are managed through these departments, but they liaise
directly with the medical director of the community hospital when working there. An annual meeting of the medical
director and executive manager of the community hospital, and from ICO the manager responsible for the network
(nowadays, the head of the medical oncology department) and the director, reviews the agreement between the
community hospital and ICO, including any changes that could result in improvements, and the financial
arrangements. The results of these meetings are communicated to the relevant Catalan Health Service executive to
consider when setting the prospective payments for the coming year to the community hospital and to ICO.
<AS>Discussion
<bs>Outcomes
<ful>The cancer networks have benefited the healthcare system by facilitating the provision of higher-quality,
evidence-based care, being instrumental in trying to reduce inappropriate variation in oncological practice by using
clinical guidelines, and in making better use of scarce expertise.31 Community hospitals benefit from economies of
scale, access to expertise, and learning from others in the network, via the cancer centre; cancer centres reduce
inappropriate referrals, streamline referral processes, and increase recruitment into clinical trials.32 The ratio of
follow-up visits to new patients has tended to increase over time as the relationship with oncologists from the cancer
centre has developed.
The networks also have several strengths from a patient perspective. First, patients wait for a shorter time
when being referred for an appointment with the medical oncologist or the multidisciplinary care team at the cancer
centre, because the medical oncologist takes the referral in person at the community hospital and feeds it directly
into ICO’s appointment system, cutting out a layer of bureaucracy. In addition, patients have better access to any
special diagnostic or therapeutic procedures. There is also greater continuity of care, as it is generally the same
oncologist who sees patients both in the community hospital and in the cancer centre. This can be a big relief for
patients, particularly from rural areas, who are faced with a diagnosis of cancer and having to visit a large hospital
in the city. When the patient comes to the cancer centre for the first time, they already have some idea of what is
going to happen, and the doctor already knows something about that patient.
There can be benefits for staff too. The common early career pattern of an oncologist gaining broad
experience and then specialising is facilitated by the network arrangement, but without the disruption arising when
oncologists move on from one hospital to another to follow their career. There may also be longer-term issues,
however, that need to be considered with regard to career planning and manpower planning.
The work environment for the oncologist varies radically between the cancer centre and the community
hospital (see Table 1). There are opportunities for both organisations to learn from such insights if they can put in
place suitable feedback mechanisms to facilitate constructive discussion about doing things differently. The table
also emphasises that spanning the boundary between two organisations is demanding and requires particular skills.
Such individuals need support and commitment from the organisations, to ensure that they are not
disadvantaged,33,34 particularly during the early days of working in a new organisation when they may feel isolated
both in the community hospital and in the cancer centre.
<bs>Success factors
<ful>The Catalan experience reinforces previous research suggesting that successful networks have at their
foundation good personal relationships characterised by trust and reciprocity,35,36 yet do not rely overly on a small
number of particular individuals.37 From the outset, ICO sought to promote trust and a long-term relationship
among all hospitals joining the networks. One key aspect of this has been to make it explicit that referrals are twoway: whenever patients no longer need specialist care, the centre refers them back to the community. This has
helped the network to gain acceptance from the directors of community hospitals, because they no longer ‘lose’
patients, and the accompanying funding, to the centre. ICO has also stressed that costs should not be shifted
between hospitals through, for instance, changing the place to administer high-cost chemotherapy due to budgetary
instead of clinical reasons. The focus is on ensuring that everybody sees benefits from the arrangement —
community hospitals gain access to an experienced oncologist, the cancer centre coordinates its area of influence,
and each level of care is focused on what can be done better. In order to achieve this, a flexible approach has needed
to be taken to the different organisation and priorities of each community hospital.38
A culture of cooperation has been emphasised through consistent application of cooperative and inclusive
39
norms, and by including in the network agreement a procedure to discuss problems in the relationship either at
hospital or clinician level. Active involvement and hence ‘ownership’ of key personnel has been sought, particularly
from medical directors in community hospitals, who provide valuable support to ICO oncologists working in the
hospital through regular meetings, where they discuss both particular and more strategic issues, such as developing
protocols. The annual meeting between senior managers of each hospital and their cancer centre counterparts also
provides a mechanism for constructive development of the network. Additionally, by involving officials from the
funding body, the Catalan Health Service, the initiative has been instrumental for the expansion of the networks.
Professionals from different hospitals have regular opportunities for interaction, either focused on a clinical
case, as in tumour committees; on guidelines for tumour therapy, presented in an annual meeting; or on pathways,
new protocols or trials, in monthly meetings. This sharing of experiences has helped to build a common
understanding of cancer care across organisational and professional boundaries. Pre-existing professional
relationships have been instrumental in building the network; most important was the fact that many surgeons and
internal medicine physicians in community hospitals were trained as specialists in the tertiary university teaching
hospital with which ICO is associated, facilitating professional relationships and clinical leaderships.
This inclusive and cooperative approach, which consciously attempts to manage internal and external
stakeholder relationships from the inside out and from the outside in40 appears to have established, or at least
reinforced, a culture and ‘organisational field’41 that has helped to overcome some of the organisational and
professional barriers that have inhibited cancer networks elsewhere.42–45 A fundamental difficulty is that different
organisations or professions brought together through the network may have different priorities, cultures and
working practices, and it may not be straightforward to bridge these differences and facilitate constructive working.
This can further complicate the logistical problems of coordinating the inputs of a large number of different
professionals, and of maintaining expertise as oncologists no longer have so much contact with one another.
<AS>Conclusion
<ful>The ICO experience shows that cancer networks can add value in a healthcare context that involves a diverse
range of hospitals. Establishing common systems across a network, such as tumour committees and clinical
guidelines, can help to manage that diversity, but requires genuine, ongoing involvement of the managers and
clinicians of each hospital, which may not be easy to achieve. An inclusive and cooperative approach, based on
personal contact, respect and understanding between different stakeholders (particularly managers and clinicians in
different organisations) is important, coupled with the flexibility to make arrangements that suit local circumstances,
while respecting the fundamental principles of the model.46 In Catalonia, this was facilitated to some extent by preexisting clinical relationships and a supportive regional health body, but it may well be achievable even in less
auspicious circumstances if time is taken to build constructive relationships at the outset. Finally, the boundary
spanning medical oncologist role is a complex one, with concomitant opportunities and dangers, which may not be
recognised without suitable feedback mechanisms. Organisational networks need to pay as much attention to
human factors as to structures and processes.
<AS>Conflicts of interest
<ful>The authors declare no conflicts of interest.
<AS>Acknowledgments
<ful>The authors would like to thank to all the physicians (medical oncologists, radiotherapy oncologists and
clinical haematologists) and nurses involved in the networks. This paper was partially supported by the Cancer
Research Network of the ‘Instituto Carlos III’, Spain (RD06/0020). A preliminary version of this project was
presented at the ‘Improving cancer services’ conference, organised by ESO/EHMA, in Milan, March, 2005.
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Table 1: Comparison between working in the cancer centre and the community hospital from the
perspective of a medical oncologist
Aspect of work
Cancer centre
Subspecialisation Developing expertise in one tumour area
Experts in other tumours can
always be asked if appropriate
Resources
Any test can be done, although the
process may be bureaucratic and
time-consuming
Community hospital
Using general concepts and ‘common sense’,
with no specialists to call on
Fewer resources (eg CT scan, ultrasound),
but results may be obtained within the same day
Multi-disciplinary
working
Accessibility
to/for patients
Responsibility
Discussions are between clinicians with
similar subspecialisations, and the
outcomes tend to be predictable
Patients tend to interact with different
members of the team, with fewer
opportunities for personal communication
between patient and doctor
Discussions are with surgeons and pathologists,
who may have a general perspective,
requiring the oncologist to talk in ‘another language’
Doctor, patient and sometimes the family,
meet in person more often
The patient can talk about problems from their
perspective (ie the practical implications for them
as a family member, employee, community
member etc); although this can take time,
the oncologist gets extra information,
helping decision making
Large team, with the danger that some
Smaller team (eg doctor, nurse and outpatient
problems may not be addressed because assistant), which functions more as a team,
nobody takes ownership of them
with clear responsibilities for each member