Midland Cancer Network 2012 Clinical Performance Conference

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

Following a review of this report, the Cancer Programme Steering Group (CPSG), uncertain about the ability of Waikato to attract gynaecology- oncology 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 work- up 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 4 th cancer hub be established. Auckland DHB ability to recruit a 4 th 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 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

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 years A range of improvements have occurred in the delivery of gynae- oncology 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