CIRCS To champion safe and high quality care for people
affected by cancer
Fifth annual national cancer centre symposium
Melbourne 9 December 2013
• A centralised capacity and capability building team for regional cancer services in Queensland
• Why is there a need for a centralised capability development team? • The value of a multidisciplinary team • How we influence • Challenges and opportunities
What is CIRCS? • CIRCS is the Central Integrated Regional Cancer
Service • CIRCS is both a network of cancer service providers and
a team to build cancer service capacity • Successful application for Regional Cancer Centre
(RCC) funds: • $67 million for new building (including radiotherapy bunkers) in
Rockhampton • $17 million for new, larger facilities in Bundaberg and Hervey Bay • Plus Queensland Government operational funding (around $26
million over 2010-14) to fund service expansion and underpin integration between Royal Brisbane & Women’s Hospital (RBWH) and regional CIRCS facilities
What is CIRCS? • Team collaborating with Department of Health and
Hospital and Health Service (HHS) stakeholders to build capability and capacity in regional Queensland, including:
• contributing to development of innovative workforce models • planning for service growth and change across the CIRCS HHSs • providing advice in relation to funding and activity modelling • driving improvements in education for the cancer workforce • delivering clinical training for nursing and allied health • auditing and improving cytotoxic safety • supporting implementation of RCCs in Central Queensland, Wide
Bay and Metro North HHSs
• My focus will be this ‘incarnation’ of CIRCS
“Central” • Reflects former Queensland Health area health service
structure • Now no equivalent teams in north or south areas • ‘Default’ role as cancer service development and
advisory group in Queensland • Activities increasingly extend to statewide or multi-
regional level. Examples include: • Cancer service ICT scoping and project planning • Remote supervision of chemotherapy guidelines • Clinical training for nursing and allied health professionals,
statewide and in regional areas
• CIRCS’ geographic remit is expansive – covers five HHSs
• Brisbane (northside) to Central Queensland to NT border
• 71% larger in area than UK & Ireland
• Indicative driving times: • Rockhampton to Brisbane: 7 hours • Longreach to Rockhampton: 7.5
hours • Bundaberg to Kawana: 3.25 hours • Hervey Bay to Brisbane: 3.25 hours
Geography
Population and incidence • 2011 population: 1.65 million (37% of Queensland
population) • Around 850,000 live in Metro North HHS • About 12,000 live in Central West HHS
• Fastest population growth: • Sunshine Coast, Wide Bay and Central Queensland HHSs: 2% p.a.
• Total estimated 2013 cancer incidence: • 10,870
• Top five tumour types relatively consistent across HHSs: Prostate Melanoma Breast
Colorectal Lung
Demography • Covers relatively wealthy to very disadvantaged
• Metro North HHS (13% in lowest quintile) • Wide Bay HHS (56% in lowest quintile)
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Population in most
disadvantaged quintile
Private health insurance rate
(b)
Delayed access to health care due to cost or travel barriers
(c)
Selected socio-economic measures
Metro North
Sunshine Coast
Wide Bay
Central Queensland
Central West
Demography • Extends from quite youthful to quite old
• Metro North / Central Queensland HHSs (36% aged 45 years +) • Wide Bay HHS (49% aged 45 years +)
Service profile • Ranges from good to poor access to cancer services
• Major variations in surgical self-sufficiency • Metro North HHS: equivalent of 8 linacs, 63 day unit chairs, 64
beds • Central West HHS: no linacs, day unit chairs or dedicated cancer
beds; one oncologist visits two days annually
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Metro North Sunshine Coast Wide Bay Central Qld Central West
Cancer surgery self-sufficiency - selected procedures and tumours (2001-2010)
Breast conserving surgery
Mastectomy
Colectomy - for colon cancer
Anterior resection - for colon cancer Colectomy - for rectal cancer
Service profile • Significant reliance on outreach services
• Major facilities currently at RBWH and Nambour Hospital • Outreach within HHSs (e.g. 960 sessions p.a. within Metro North
(MN)) • Outreach across HHSs (e.g. 449 sessions from MN to CQ; 402
from MN to WB)
Governance • Structurally hosted by Metro North HHS • High level governance provided by board of five Chief
Executives • Day-to-day management and direction from:
• Medical director – senior radiation oncologist (0.5 FTE) • Nursing director
• Currently ‘dotted line’ link to Statewide Cancer Clinical Network by virtue of medical director chairmanship
Multidisciplinary expertise • Team comprises members with various clinical and non-
clinical backgrounds: • Medical • Nursing • Nursing education • Allied health • Finance and audit • Service management, development and improvement • Project management • Stakeholder engagement • Data analysis and management
• 10 team members (including 0.5 FTE medical director)
Influence without authority • CIRCS primarily:
• provides advice, clinical training and support • contributes to strategic and policy development for cancer care • collects and disseminates ‘benchmark’ and ‘best practice’ data • coordinates collaboration between disparate stakeholders • connects subject matter experts to those in need of insight • develops frameworks and guidelines to assist facilities adopt new or
enhanced service approaches
• We do not have: • authority to require HHSs to take action • an official role beyond our stakeholder HHSs
Why is CIRCS necessary? • HHS structure
• Isolates perceptions of demand, cost, value etc • Propensity to internal v aggregate view of ‘best’ decision
• Multidisciplinary expertise • Not feasible to have all skills engaged in each (especially small)
HHSs
• Efficiency • Specialised knowledge ‘on tap’ as required • Peaks and troughs within HHSs ~ stable demand across HHSs
• Some project-based need • RCC funds and implementation, but…
Why is CIRCS necessary? • Huge challenges posed by regional geography in
Queensland • Widely distributed demand • Expensive infrastructure • Tyranny of distance • Workforce attraction • Increasing private sector service delivery
• All these drive the need for a coordinated approach and integration
Approaches • Identifying collaborators
• Rural and Remote Network • Department of Health policy and planning teams
– Determining health need – Patient Transport Subsidy Scheme policy
• Non-CIRCS HHSs – Other metropolitan HHSs on issues commonly affecting both
• Subject-matter experts – Townsville HHS on cancer ICT – Cancer Institute NSW on clinical training materials and eviQ
Approaches • Clinical and workforce benchmarks
• Increases objectivity and consistency of activity and workforce estimates
• Additional robust tool to complement local knowledge • Baseline from which variations warrant justification • Focus on efficiency • Challenges status quo service models • But…one size does not fit all
Benchmark examples
Approaches • Telehealth technology
• Practice what is preached • Improve access and counter tyranny of distance • Build workforce capacity in often ‘forgotten’ facilities • Better cost calculus than face-to-face • Increase familiarity with technology
Telehealth technology examples
Leisa – in Brisbane
‘Chester’ – at Blackall Hospital
Approaches • Project management methodologies
• Adding rigour to service development projects • Identify ‘ripple effect’ and engage key stakeholders • Avoid re-work and scope creep • Continuous risk mitigation
• Seniority- and role-blind participation • Flat structure • Skills-based allocation of duties
Project management examples
Approaches • Ongoing engagement
• Conduit for relationship building and issue escalation • Establishing structures to assist drive progress • Cultivate support and communities of interest
Challenges • Interference on local ‘turf’
• Us (on the ground, in the know) v them (central, uninformed) • “But this case is special…”
• Meeting demands of metro and regional stakeholders • Frequently opposite sides of the same coin • Identifying systemic challenges to rally around • Objectivity and rigour
Challenges • Reliance on factors other than evidence
• Best guesses • Decisions at last minute – poor processes • Desirable v minimum essential resources • There is always evidence to the contrary but does it ‘fit’
– Is the distance the difference?
Opportunities to be more effective
• Increased focus by Department on regional service enhancement
Opportunities to be more effective
• State-based financial incentives to substitute some ‘fly in / fly out’ outreach with telehealth
• Financial limitations and increased need for rigour • Profile building by CIRCS
• Statewide cancer service strategy • Health service planning processes
– Global view, multiple perspectives, cancer focus
• New medical contracts and Right of Private Practice review
Opportunities to be more effective
• Health Workforce Australia • Cancer care • Rural and remote
• Tenacity and perseverance also helps!
Recent examples • Queensland Remote Chemotherapy Supervision
Guidelines • Wide Bay HHS radiation oncology service demand
analysis • Cairns and Hinterland HHS cancer service review • Standardised education resources
– CVADs – theory and simulation across Queensland through videoconference facilities
– ADAC – Queensland Cancer Education Program (QCEP)
Current major projects • Cancer service ICT platforms • Encouraging uptake and embedding remote supervision
of chemotherapy in rural and remote hospitals • Framework for multiple models of multidisciplinary care • Collaboration with Central Queensland HHS to develop
service model for new radiotherapy and expanded medical oncology services
• Continuing expansion of telehealth-based education to metro and regional cancer professionals
• Impact analysis of new regional radiotherapy services, including adequacy of existing funding models
The future… • Centre of expertise for cancer service development
issues: • Activity based funding • Workforce / activity planning • Service and MDT models • Procuring expert clinical advice • Education program management and delivery
• Statewide remit?
• Closing the access gap and improving quality and outcomes