South Island
Neurosurgical Service
Planning Report
June 2009
Acknowledgements
Acknowledgement is made to the individuals who have provided information and assistance in the development of this report.
In particular the support and input of the following individuals is acknowledged:
Professor Spencer Beasley, Chair, Neurosurgical Services working party
Mr Martin MacFarlane, Clinical Director Neurosurgical Service, Canterbury DHB
Mr Martin Christie, Locum Neurosurgeon, Otago DHB
Mr Richard Bunton, Chief Medical Officer, Otago DHB
Mr Nicholas Finnis, Neurosurgeon, Canterbury DHB
Mr Ronald Boet, Neurosurgeon, Canterbury DHB
Helen Williams, Service Manager, Surgery, Otago DHB
Rosey Doyle, Service Manager, Neurosurgery, Canterbury DHB
Judith Sugden, Senior Business Manager, Hospital & Specialist Services, Canterbury DHB
Table of Contents
1 Executive Summary & Recommendations 5
2 Introduction 7
2.1 South Island Health Services Planning 7
2.2 Neurosurgical Service Definition 8
2.3 South Island Neurosurgical Services 8
3 Demographic Data 10
4 Current Neurosurgery Activity 11
4.1 Canterbury DHB 11
4.2 Otago DHB 11
4.3 Role Delineation 12
4.4 Neurosurgical Service Data 13
4.5 Other Neurosurgical services 16
4.6 Related Services 16
5 Nelson Marlborough DHB 18
6 Neurosurgery Standards 20
6.1 Service Standards 20
6.2 South Island Service 21
6.3 Other New Zealand DHB Neurosurgical Services 21
7 Changing Trends in Demand for Neurosurgical Services 23
7.1 Demand for neurosurgical services is changing 23
7.2 International experience that the viability of small neurosurgical units is under threat 23
7.3 Predicted changes in the demand for neurosurgical services 23
8 Configuration Options for a South Island Neurosurgical Service 26
8.1 Model A 26
8.2 Model B 26
8.3 Model C 26
8.4 Model D 26
8.5 Outreach clinics to other centres 27
8.6 Support Structure 28
8.7 SWOT Analysis 28
8.8 Recommended Model 29
8.9 Feedback 30
8.10 Transition 37
9 Appendices 39
APPENDIX ONE – Minutes of South Island Neurosurgical Services Meeting 19 Feb 2009 39
APPENDIX TWO – Otago DHB Comments and Feedback 44
APPENDIX THREE – Canterbury DHB Comments and Feedback 57
APPENDIX FOUR – Other Comments and Feedback 61
References 63
List of Tables
Table 1 / South Island Health Services Plan Principles / 6Table 2 / Role Delineation Model for current South Island DHB Neurosurgery Services / 10
Table 3 / South Island Patient numbers & caseweighted discharges by DHB of domicile & DHB of service / 11
Table 4 / Canterbury & ODHB Inpatient and Outpatient Volumes 2007-08 / 12
Table 5 / Patients requiring urgent neurosurgical operations for life-threatening conditions (needing and getting their operation within 2 hours of admission/diagnosis) / 14
Table 6 / NMDHB neurosurgical inpatient admissions by type to Canterbury and Capital & Coast DHBs / 16
Table 7 / Neurosurgical Standard Recommendations / 19
Table 8 / Neurosurgeon Current and Recommended Levels (based on Safe Neurosurgery 2000) / 21
Table 9 / Comparison of Inpatient Neurosurgical Service Rates per 100,000 population (raw data) / 21
Table 10 / South Island domiciled Neurosurgical inpatients admissions by age group for the 2005-2008 period / 22
Table 11 / Predicted changes in the demand for cranial & complex spinal neurosurgical services from Ontario and New Zealand / 23
Table 12 / Investment Required for a 4th Neurosurgeon at CDHB / 37
List of Figures
Figure 1 / South Island DHB Population Predictions 2006-2021 / 8Figure 2 / South Island Population Predictions by age / 8
Figure 3 / Neurosurgery inpatient numbers by DHB of domicile, delivered in New Zealand / 12
Figure 4 / Neurosurgical Conditions treated at Christchurch Hospital in 2007-08 / 13
Figure 5 / Nelson Marlborough DHB Neurosurgical Patients Numbers treated at Canterbury and Capital & Coast DHBs / 17
Figure 6 / Neurosurgery CWD - NMDHB patients treated at CDHB and CCDHB / 17
1 Executive Summary & Recommendations
In late 2008 concern was raised that the Otago District Health Board (ODHB) service was having difficulty in recruiting a full complement of neurosurgeons. Since that time the one fulltime neurosurgeon left in January 2009, a locum neurosurgeon commenced work in February 2009 but left on four months leave late April. A second neurosurgeon has been appointed but as at mid-June was still awaiting New Zealand registration. A locum neurosurgeon is commenced in May to provide 3 months locum cover.
A teleconference of key stakeholders held in December 2008, lead to the acceptance that an agreed plan for a South Island approach to neurosurgery needed to be developed with some urgency. A meeting of key stakeholders was held on 19 February 2009 with the following agreement:
1. The need to provide the South Island with a neurosurgical service that best provides for the population distribution and topography of the South Island:
2. Equity of access to quality advice and treatment to be a fundamental principle
3. The importance of the configuration of the service being viable in the longer term, and minimising the risk to each DHB
4. The service must fit in with North Island services
5. The exact involvement with Nelson Marlborough DHB had to be established
6. The configuration of neurosurgeons, i.e. how each clinician would be involved.
It was also noted that once the model is agreed it should be supported and a commitment made to ensure it works and that the service plan should reflect the SI HSP principles.
Recommendation One:
The recommended neurosurgical service configuration for the South Island is one service based in Christchurch, with a comprehensive Outreach programme. The advantages of a strong and viable single unit (in terms of location), includes:
· The provision of up-to-date and state of the art neurosurgical equipment and instrumentation (e.g. Image Guidance/frameless stereotaxy) and other expensive operative equipment.
· Allows employment of Neurosurgical trainees (into RACS SET training posts) with recognised experience and in sufficient numbers to assist in 24 hour management of patients.
· The ability to develop robust and appropriate subspecialisation, collegiality / peer review, research, teaching of other professional groups, ability to conduct research and effective audit.
· Provision of reliable on call cover and being able to cover for absences / leave / sickness etc.
· Sufficient staff to be able to provide a comprehensive outreach service to the South Island (including Nelson).
· Such a configuration would probably be able to provide the highest levels of care for most conditions.
· This would necessitate there being 6 neurosurgeons based in Christchurch.
The main issue relates to how extensive the Outreach component of the service could be, and there are different views on this. The importance of retaining services “close to home” wherever possible was accepted, and it was agreed that carefully constructed clinical guidelines may be required.
A diminished presence in Dunedin might also have some effects on other services including Neurology, Endocrinology, ICU, ED, General Surgery and Medicine, Paediatrics and possibly Stereotactic Radiotherapy in that centre, which may require a transition process. The ability of Canterbury District Health Board (CDHB) to meet the increased resources (physical and workforce) may also take time, and necessitate a transition period.
It would also require a reliable and accessible transport system for emergencies although this is an issue that affects multiple specialties throughout the South Island, and is not confined to neurosurgery.
General surgeons in other provincial hospitals already have some neurosurgical capability for emergencies – those in Dunedin would require some up-skilling. This situation is not unique to Dunedin, and occurs in many other countries where neurosurgical expertise is located at major centres and where distances and times exceed those in the South Island.
It was agreed that this model obligated a substantial ongoing presence in Dunedin, probably up to 3 days a week. The exact details of this requirement would have to be determined.
Recommendation Two:
That the service is named the South Island Neurosurgery Service and employment of SMO’s and other relevant staff should be made to the service with the recognition that there will be an outreach component within the South Island.
Recommendation Three
That the employment of a fourth Neurosurgeon and support staff at CDHB should take place as soon as possible to overcome the current issues of an overstretched workforce, particularly while it attempts to provide cover across the South Island. This would represent the first stage of staffing the service to the level required as determined in this report.
Recommendation Four:
On agreement of the preferred service configuration the next step should be to establish a working party representing key stakeholders to develop an implementation plan that includes:
· Consultation & communication plans.
· Timeframe for transition.
· Resource requirements and identification of timeframe for implementing the preferred model.
· What cases can safely be delivered in ODHB over the transition period?
· Development of a single elective service waiting list.
· Outreach clinic options and contract negotiation.
· How the neurosurgical team would function e.g.
- Supervision
- Peer support
- Policies and procedures.
· Identification and training of staff from other services in specific procedures.
· Addressing pertinent issues identified in ODHB Neurosurgical Services paper[1] for related services.
· Funding model for regional service.
· Consideration of the establishment of a SI Neurosurgery Clinical Network.
2 Introduction
2.1 South Island Health Services Planning
The South Island District Health Boards (DHBs) have agreed to the development of a South Island Health Services Plan (SI HSP), recognising the need to collaborate to support sustainable health and disability services for the population of the South Island.
The South Island DHBs agree that access to timely and accessible health and disability services, of a high quality, is a right that all New Zealanders have regardless of where they live. Services will only be accessible if they are sustainable. Services will only be sustainable in the medium to long term if they are of a high quality and reflect contemporary evidence based practice. The correct balance of accessibility, quality and sustainability may be difficult to achieve when determining the optimal configuration of health and disability services across the South Island, as is the case throughout New Zealand. This dichotomy ultimately results in the need to balance demands of local provision of services in an unsustainable environment with that of centralised services which are of high quality and viable but may be less conveniently located for patients in the regions.
The objectives of the South Island Health Services Plan are to:
· reduce inequalities in access to health services across the South Island
· enhance the quality of health services across the South Island
· enhance the sustainability of all health services for the South Island population that are appropriately delivered in the South Island
· engage with key stakeholders to ensure understanding and acceptability of South Island Health Services.
In undertaking South Island Health Service Planning, the desirability of provision of care as close to the patient’s home as possible is recognised, as is the requirement that some services, particularly those which are complex and of lower volume and the more specialised procedures that demand high levels of care, will not be able to be undertaken at all locations.
The principles that underpin all South Island Health Services Planning activity are shown in Table 1.
Table 1. South Island Health Services Plan Principles
Equity of Access / Clinical engagement / Quality & safety / Clinical sustainabilityPlanning will be based on the health needs of our constituent communities
Historical demand and service provision will not determine future needs.
Planning for health services relates to recognising and planning for changing demand and providing an equitable level of service for the population catchments with a continuing focus on reducing inequalities in health status. / Clinician input, through active clinical leadership, into the planning and decision making process is recognised as a critical component of the success of the SIHSP / The health consumer is the primary focus of any model of health care quality management
Health treatment and care is based on the best available evidence with appropriate monitoring and evaluation.
All health care providers have access to systems that enables outcomes of care to be assessed
Quality of care systems that focus on: safety, access, effectiveness, efficiency, acceptability, appropriateness, and consumer participation. / The identification of future need and supply of clinical skills.
Design of service delivery models that allow appropriate access, meet credentialing requirements, support evidence based practice, and are consistently delivered to a high standard of quality & safety.
Clinical education and ongoing training for all health care providers must be considered to ensure quality service delivery.
Patient centred consumer involvement
Health care services will be co-designed with service users including the patient.
This will be a collaborative process allowing a sharing of perspectives and experiences.
Māori health service needs / Community engagement / Continuum of care / Fiscal sustainability
We recognise our commitment to partnership with Maori
We recognise that Māori in our communities do not have equal access to health care or equal health outcomes.
We aim to reduce health disparities by planning for services to address these / The Community will be informed and involved so that they have an awareness of the SIHSP, the drivers of sustainable health services that may result in changes to health service configuration and can accept the outcomes as being in the long term best interest of the population / SIHSP will consider the full continuum of care
Continuum of care refers to services and integrating mechanisms that guide & track patients/clients over time through a comprehensive array of services spanning public health through to tertiary & including supports required to enable service delivery / Acknowledgement that efficient and effective use of resources will be required across the SI.
Resources include workforce, facilities and infrastructure (including: information systems, clinical equipment, and transport) to deliver the models of care within the allocated funding system.
2.2 Neurosurgical Service Definition
Neurosurgery (also called Neurological Surgery) is the treatment (both non-operative and operative) of diseases and conditions (congenital and acquired) of the nervous system - the brain, pituitary gland, spinal cord and peripheral nerves, and their coverings. The coverings include the meninges, the skull, the vertebrae and the overlying soft tissues of the scalp, muscle, subcutaneous layers and skin.