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NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital.

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Presentation on theme: "NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital."— Presentation transcript:

1 NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital Canterbury District Health Board 23 rd August 2010

2 NEUROSURGERY (Neurological Surgery) OPERATIVE and NON OPERATIVE management

3 WHAT TYPES OF CONDITIONS/OPERATIONS DO NEUROSURGEONS TREAT/PERFORM ?

4

5 Pituitary tumours Spinal surgery Head & spinal trauma Epilepsy Vascular - craniotomies & endovascular Skull base Paediatric neurosurgery Surgery Brain tumours Peripheral nerves Neurosurgery for pain Movement disorders Neurosurgery subspecialisation: better surgery: better outcomes: succession planning Public expectations Healthcare expectations

6 Hudson brace, perforator & conical burr Tools, Equipment and Instrumentation Sugita aneurysm clips & applicator Stereotactic frame Image Imtensifier Operating microscope Shunt valve for hydrocephalus Coil for aneurysm Vessel stent Endoscopic tower Fibreoptic endoscope OT of the near future

7 Neurosurgery in Christchurch – 1981/1982 to 2009/2010 Growth of a Specialist Service

8 NEUROSURGERY and NEUROSURGICAL UNITS in New Zealand Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital 21 st August 2010

9 Auckland (1945) Hamilton (2006) Christchurch (1981) Dunedin (1943) New Zealand Neurosurgical Units 3.3m 1.027m 5 units for 4.327 m population Wellington (1965)

10 North Island Neurosurgical Services in New Zealand Auckland Neurosurgical Unit incl Starship – 6 neurosurgeons Wellington Neurosurgical Unit – 5 neurosurgeons (one currently partial clinical) Waikato Neurosurgical Unit – 4 neurosurgeons South Island Christchurch Neurosurgical Unit – 4 neurosurgeons (+ one in sole pp) Dunedin – O neurosurgeons – using sole locums 14 (15) 1 NS Per 253,846 (220,000) 5 (6) 1 NS per 205,400 (171,166)

11 Neurosurgical Services in New Zealand 1979: Decision made by Dept/Ministry of Health to commision a Neurosurgical Unit in Christchurch (1 st Review) In the 1970s  changing population demographics in the South Island  continuing growth of Christchurch as the major tertiary referral centre in the South Island – The neurosurgical unit in Christchurch was established in August 1981 and was able to function as a fully-equiped independent unit in April 1982 – The Minister of Health stated at that time that: “the Dunedin Neurosurgical Unit would function on a week to week basis with there to be no replacement of neurosurgeons as they retired” South Island – Christchurch Unit now has 4 neurosurgeons (747,000 people) – Dunedin Unit has no permanent neurosurgeons – using locums (280,000 people

12 Reviews of the provision of Neurosurgical Services since 1979 2 nd : 1988 “Hospital/Area Health Board Service Planning Guidelines Neurosurgery” June 1988 This was the first of two specific reviews of the requirements for/of a Neurosurgical Unit in New Zealand and the provision of neurosurgical services (population, staffing, bed numbers, affiliated surgical, medical, allied health, support services, equipment, radiology etc). Basis for neurosurgeons was 1:300,000 Minimum population to be served by a unit was 900,000 with 3 neurosurgeons in a Unit Graham Martin, Martin MacFarlane, Owen Mooney (AHB), John Mills (OHB), Liz Webb (Nursing, AHB), Dr Ray Dowden (PMO, DoH), Ray Collinge (DoH) with input from Sam Bishara, Graeme MacDonald To ensure equitable access to neurosurgical services for the whole population Minimum of 8 adult beds per 300,000 - plus ICU beds, paediatric beds and rehabilitation beds

13 Reviews of the provision of Neurosurgical Services since 1979 3 rd : May 1995 “TERTIARY SERVICES ISSUES PAPER Neurosurgical Services” p15:Looked at ratios of neurosurgeons to population: 1:100,000 in US (Congress of Neurological Surgery) 1:400,000 in UK (SBNS) 1:250,000 previously in Australasia to 1:175,000 (Neurosurgical Society of Australasia) p15: “Neurosurgery cover should be available on a 24-hour basis due to the semi-urgent nature of the surgical intervention and nonsurgical consultation. Because of this, the recommended minimum number of neurosurgeons per unit is three. Fewer than three neurosurgeons per unit may reduce quality outcomes. (It has been noted by the Core Services Committee that ‛centres that currently meet quality criteria but have fewer than three neurosurgeons per unit may be at serious risk of compromised quality if there are changes of key staff, particularly neurosurgeons’)”

14 Reviews of the provision of Neurosurgical Services since 1979 4 th : Nov 1995 “Recommendations for the configuration of Tertiary Services in New Zealand A report from The Tertiary Services Committee November 1995” Re Neurosurgery: “The Tertiary Services Committee agreed with the recommendations from professional bodies and clinical groups, both in NZ and overseas, that the interests of the NZ patient would be best served by having three neurosurgical centres, with a minimum of three neurosurgeons per centre, and with each Neurosurgeon performing a minimum of 100 major neurosurgical procedures a year.” “The Tertiary Services Committee’s preferred option is that RHAs purchase neurosurgical services from three centres – in Auckland, Wellington and one in the South Island”.

15 The neurosurgery workforce in Australia and New Zealand Discussion “The NSA has attempted to maintain a balance between competency, accountability and quality of life for the surgeon, and has nominated a surgeon to population ratio of 1:175,000. Notably, this figure is markedly different from the ratio in the US (1:61,000) And from the whole world (1:230,000), but not dissimilar from that of the UK (1:181,500. Additionally, this figure may need to be reconsidered over time as the practice of neurosurgery and medicine in general changes”. 1996

16 Reviews of the provision of Neurosurgical Services since 1979 5 th :1996/97 “Policy Guidelines for Regional Health Authorities 1996/97” Tertiary ServicesCurrent service configuration Preferred option Neurosurgical Services Four centres – Auckland, Wellington, Christchurch and Dunedin Three centres – Auckland, Wellington and one in the South Island. Affiliation of satellite units possible if quality criteria are met

17 Reviews of the provision of Neurosurgical Services since 1979 6 th : 1997

18 “Looking at operating statistics from 1996 and 1997 from Dunedin Hospital, there are between 6 and 10 cases each year requiring urgent neurosurgical intervention. Of these, less than half are from the Dunedin are, with surgical stabilisation already performed in some cases in Invercargill by the general surgeons prior to transfer to the (Dunedin) neurosurgical centre for definitive treatment. This does raise the issue of excess morbidity in a few cases each year due to a change in service. …there is likely to remain a few cases each year that need some form of life-saving surgical intervention prior to transfer” Discussion document for Neurosurgery Services, South Island, New Zealand Andrew Law and Nicholas Finnis, Neurosurgeons, Dunedin 1998 Considered positives and negatives for: Dual Site Service: Dunedin 2 neurosurgeons, Christchurch 4 neurosurgeons Single Site Service: Christchurch 6 neurosurgeons with appropriate outreach and professional and other linkages 7 th : 1998

19 Reviews of the provision of Neurosurgical Services since 1979 8 th : 2001

20 Safe Neurosurgery 2000 A Report from the Society of British Neurological Surgeons All neurosurgical units must provide a full twenty-four hour consultant-led service and be staffed accordingly, i.e. a minimum of 6 WTE consultant surgeons increasing with populations of more than 1.5 million Thirty neurosurgical beds and four dedicated neurosurgical intensive therapy beds per million population are needed to provide safe practice Every neurosurgical unit should have at least two fully resourced operating theatres; those serving a population of more than 2 million need three Neurosurgical units should be situated within a multi-disciplinary Neurosciences Centre and on a General Hospital site. Each unit must provide a full core neuro- surgical service before any subspecialties are developed For maintenance of neurosurgical expertise and satisfactory training there must be an adequate volume and diversity of work and sufficient population to generate this. Whilst this must be reconciled with equity of access, a 1 million catchment population should be the minimum

21 9th: 2009 Reviews of the provision of Neurosurgical Services since 1979 June 2009: Prof Spencer Beasley  Draft Neurosurgical Service Plan given to the SI DHBs DHBs agreed: that there would be a single integrated Neurosurgical Service for the South Island that a single interim clinical leader would be appointed to the Service for 12 months to recommend future configuration of the Service Dr Ian Brown appointed as clinical leader February 2009 – meeting of all six SI DHB CEOs and others incl clinicians from Dunedin, Christchurch, Spencer Beasley and MoH personnel

22 10th: 2010 Reviews of the provision of Neurosurgical Services since 1979

23 Neurosurgery for the South Island – the Present Guidelines from the RACS (Royal Australasian College of Surgeons) and the Neurosurgical Society of Australasia: 1 neurosurgeon to 175,000 1 in 4 on-call roster (max) Minimum of 3 neurosurgeons required for a neurosurgical unit but note: 1 in 4 on-call 747,000 with 4 neurosurgeons = 1 to 186,750 and 1 in 4 on-call 280,000 with 1 sole locum neurosurgeon = 1 to 298,000 and 1 in 1 on-call

24 Neurosurgery for the South Island – the Future One Service One site: Christchurch 6+ neurosurgeons: 1 to 171,166 Appropriately resourced Good & robust Outreach Suitable transport links 1,027,000 population Neurosurgical services to international standards for the people of the SI Funding advantages for high tech equipment and staff Will attract appropriately-trained staff Allows for subspecialisation Allows for succession planning


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