1. Midland Cancer Network 2012 Clinical Performance Conference

2. Long term options for the Midland region for the provision of a gynaecological cancer surgical service OptionsProsCons 1.3 centre hub (current national model)  Increased sustainability of the hubs – clinical, financial  Economies of scale in terms of staff, infrastructure, etc  Reluctance to travel  Increased difficulty in meeting FCT targets  Inability to develop ‘local’ approaches to care  Diluted overall gynaecology service in non-hubs 1.4 centre hub (previously proposed national model)  Maintains current overall referral patterns  Was preferred option under earlier consultation  Reduces travel time and distance for patients  Ability to focus on Māori specific issues (in Midland region)  Provides co-ordinated service, with provision of service closest to the patient  Supports achievement of FCT targets by eliminating ‘double’ handling  Sustainability of smaller centres in terms of staff 1.Supra- regional hub with 2 hubs (with long term transition to a 4 centre model)  Supports subspecialisation across two sites  Allows for co-ordinated long term development of services across two sites  Increases base, allowing staff, trainees variety of location and workload  Supports increase anticipated in total gynaecology services across both sites  Increased need for good communication, data sharing and decision making

3. The current issues Workforce To develop and sustain an adequate gynaecological oncology workforce, the establishment and funding of RANZCOG-approved gynaecological oncology training positions in Auckland and Christchurch is seen an urgent priority. A similar focus on the development of special interest fellowship positions in radiation oncology, gynaecological pathology and medical oncology is also seen as important. The training of gynaecological oncology clinical nurse specialists is an additional key workforce consideration.

4. The current issues Targets/MDMs The DHBs are still unable to consistently meet the Health targets of 80% for the 62 and 31 day indicators. The current emphasis on targets and the need to progress women requiring referral on to Auckland means the DHBs are not able to focus on disease prevention (e.g. obesity management) which should be a focus for the future. Although improved over the last year, there are still some delays in reporting from Auckland that impede good clinical service at the post- operative follow up e.g. MDM full reports, operation notes, and results of tests not being available for the appointment. Waikato MDMs being cancelled due to radiologists/pathologists being unable to attend. This may cause ongoing delays in getting women to Auckland for treatment.

5. The current issues Equity Encouraging women, especially Māori, to travel to Auckland is difficult, in spite of some costs being covered. This creates both equity and access issues. A recent review of the National standards for gynaecological services identified many service improvements were required within Waikato, especially in the post-menopausal bleeding pathway for women. An increased risk of communication errors and misinformation with two sets of clinical teams – currently patients can experience three or more Clinical Nurse Specialists / Cancer co-ordinators, the local medical team and then the Auckland medical team etc. going between facilities.

6. The population projections

7. Considerations for a gynaecological cancer hub at Waikato Hospital for the Midland region Clinical Internationally, gynaecological cancer referral services are frequently organised around referral populations of about one million. As noted earlier, the Midland population is expected to be 785,000 by 2019/20 and 850,000 by 2032/33. (The Northern and Midland populations will increase at a greater rate than the national average resulting in greater demand for services). Total gynaecological inpatient activity (at Waikato Hospital) has also been increasing (12% between 2010/11 and 2014/15) and therefore would provide support for additional resources to be based at Waikato. These services already include a significant level of secondary/tertiary gynae-oncology surgery, as there are only 20-30 women referred to Auckland from Waikato DHB each year..

8. Considerations for a gynaecological cancer hub at Waikato Hospital for the Midland region Financial The caseweights associated with these patients have been increasing over the past few years and this trend is expected to continue. This funding is expected to continue to increase in terms of both volume and price. Given the anticipated increase in overall gynaecology, it will be necessary to ‘step-up’ the resources in the unit at certain points in time. These additional resources, together with any replacement staff could be targeted towards specialists with a subspecialist qualification in gynae-oncology

9. Considerations for a gynaecological cancer hub at Waikato Hospital for the Midland region Benefits Patient focus  Travel would be reduced for women in outlying areas.  Possibility of nurse led clinics and follow ups enhancing patient timeliness and satisfaction.  Increased psycho-social support for the patients leading to a higher level of satisfaction with the service. Population focus  A more localised service is likely to reduce inequities and inequalities.  Ability to focus on servicing the region’s population needs, providing continuity of treatment and support.  There would be opportunity to develop a specific approach for Māori women and their whanau. Systems focus  Ability to meet the FCT Health Targets with a less complex system.  Investment in service developed as part of overall increasing gynaecological service, including staged resource costs.  The ability to build on the new endometrial pathway.  Increasing ability to share skills and information with Auckland. The current model can be competitive with reluctance to share information. If Waikato establishes a centre that works jointly with the Auckland team it offers great strengths in sharing skills and information. Staff focus  Practitioners in Waikato strongly wish to support a service in Waikato, provided adequate staffing can be sustained.  An increased ability to attract medical and nursing staff into the unit.  An opportunity for growth for CNS.  Increasing number of NZ training positions overall. Facility focus  It fits with the distribution of the four Regional Cancer Networks and utilises current radiation treatment facilities.  There is the opportunity to coordinate with the newly proposed clinical education centre being built in the next 5 years, reaffirming the academic footprint within Waikato.

10. Considerations for a gynaecological cancer hub at Waikato Hospital for the Midland region Risks The ability to access the resources outlined in the Standards of Service Provision for Women with Gynaecological Cancer in New Zealand - provisional (2013) The ability to recruit a workforce that meets the requirements described in the Sapere report A lack of political will across the Midland DHBs to shift the service back if co-ordination with Auckland is working well and national targets are met Development of the service being seen as ‘competitive’. Good communication and consultation over a 5-10 year timeframe will be key to mitigating this risk A significant change in the forecasts of population, cancer incidence, etc National priorities that cut across regional and local planning.

11. Feasibility of a four centre model The key question that needs addressing is whether the Midland population (and therefore service volumes) are sufficient to maintain a critical mass – both for clinical competency and from a financial perspective. The Midland region comprises Bay of Plenty (BOP), Lakes, Tairawhiti and Waikato DHBs. Taranaki aligns with the Central Cancer Network for gynaecological surgical and oncology services. An analysis of the advantages and disadvantages of the different delivery options favours a four centre model, or a three centre model with a satellite centre in Hamilton. This model would offer the most patient focused solution. It is also clinically viable and supported by additional revenue flows.

12. Feasibility of a four centre model A full cost/benefit analysis has not been undertaken, but initial indications are that any costs incurred in developing a service could be ‘absorbed’ as part of an overall increase in gynaecology services. Over the next two years we therefore need to keep a watching brief on: - updated projections of population, cancer incidence, etc; –progress made towards the achievement of national targets; –the operation of inter-regional MDMs; –the number of patients referred to Auckland by Midland DHBs; –national progress towards increasing the numbers of subspecialty trained staff. This will inform our planning.

13. Recommendation In 2018, we need to undertake a full review of the situation. Based on an analysis of projected populations, cancer incidence and workloads, if it continues to suggest that a gynae-oncology centre based at Waikato Hospital is sustainable, the following should be completed first: –an updated feasibility study, including an analysis of the option of a satellite service in conjunction with Auckland DHB – either on a short or long term basis; –a full cost/benefit analysis of potential revenue and costs; –a gap analysis, identifying necessary resources, which are required for a centre but not currently available at Waikato Hospital; –a risk assessment.