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