PACIFIC WORKING GROUP MEETING

6 April 2017: 1000-1500hrs

Starship Blood and Cancer Centre, Level 7 conference room

Present:Jane Skeen(chair), Scott Macfarlane (minutes), Rob Corbett, Fiona McGill, Chrissy Bond, Peter Bradbeer, Lochie Teague, Janet Masina, Bridget Smith, Michael Sullivan (by TC and VC), Amanda Lyver, part (by TC and VC).

Guests: Elizabeth Powell, General Manager, Pacific health Development, Counties Manukau DHB and Dr Carl Eagleton, Clinical Director Medicine, Middlemore Hospital.

Apologies:Simon Lala

  1. Previous Minutes

The minutes of the meeting 13/04/16 had been previously circulated. Other subsequent meetings related to the organization of the Nadi Child Cancer Conference have also been held and minuted.

  1. Matters Arising

No matters arising not already on the agenda.

  1. Pacific Island Child Cancer Regional Conference

The Pacific Island Child Cancer Regional Conference held in Nadi, Fiji 1-2 December 2016 was widely judged to have been successful. The number of attendees exposed to educational content and discussion exceeded expectations. Scott observed that there had been little response to Melissa’s communications regarding the centre work plans. Mike is personally supporting one of the PNG paediatricians and is very enthusiastic about the potential for this contact.

  1. NZ Aid Medical Treatment Scheme Limited Funding

Liz Powell and Carl Eagleton spoke about changes in the funding arrangements from Health Specialists Limited to CMDHB. It was not yet clear what the funding priorities would be but these would be prioritized during forthcoming discussions with Pacific partners. Specifically, the contract with Samoa is a new 5-year contract for the NZ Aid to Samoa- medical treatment scheme emphasizing the importance of primary health and overseas child referral. The programme encourages competency growth using the new hospital as a nucleus and it is acknowledged that specialty services are growing slowly.

Paediatrics is a challenge. Samoa will continue to send cardiac kids to Starship. We inferred that child cancer would not receive priority. The programme also includes radiology in Kiribati, neonatal nursing education in Fiji and support for residents of Niue and Tokelau who need to come to NZ for medical care. Tonga, Vanuatu and Tuvalu are included. Liz reported that the money supervised by Dr Benjamin on behalf of the Samoan Government had been cut to a quarter (now around $NZ$1.25M). Carl talked about the Middlemore Grand Rounds going live to the Pacific and telemedicine links to Samoa and Cook Islands. 50 Middlemore consultants make themselves available for support to the Pacific to varying degrees. Encrypted skype (for business)is available. Carl generously invited our team to make use of the available communication facilities if this was thought useful.

  1. Capacity/Capability in the Pacific.

Fiji

Scott outlined his perception of the current care provision in Fiji, Suva in particular. Rob spoke to recent discussions which had taken place between himself, Amanda, Riga, Ili(Ilisapeci Tuibeqa) Khalid and Mike. These had led to a view that Lautoka should, for the time being, take on the treatment of all child cancer patients in Fiji. There was considerable discussion about the precipitants of this situation and what our response should be.

Mike said that he supported a current solution in Lautoka as the best solution for a situation where safety must be a concern for child cancer patients in Suva. Mike also confirmed that he supports adherence to NCCN guidelines on treatable cancers (although past activity has not been consistent with this statement). Mike indicated that he would support team direction and decisions. He does not aspire to be the sole support provider for Fiji.

Amanda felt that the current situation was at least partly a product of the involvement of 4 centres (Suva, Lautoka, Christchurch, Melbourne)where successful shared care (and twinning) was generally a partnership between 2 centres. She observed that there was the potential in such a situation for external advice to appear (or be) conflicting and confusing and this could be very destabilizing for relatively junior paediatric doctors who struggled with limited senior supervision. Amanda indicated that the 4 oncologists in Christchurch who are providing much of the support for Fiji with Rob’s reduced hours, are feeling disenchanted with the direction of child cancer capacity in Suva and are unable to commit to continuing support if the situation remains as it currently is.

Fiona reported on her recent experience of 2 weeks working with the paediatric team at CWM hospital on sabbatical. Fiona was asked to take over the child cancer care as part of her role at CWM. She did so as an experienced shared care paediatrician with a long history of working in combination with Christchurch as her tertiary child cancer provider and draws comparisons between the 2 situations. She reported that 5 of the 8 beds were occupied by extremely ill palliative care patients with the service struggling to meet their palliative care needs. Required infrastructure (plain XR, CT, MRI, Ultrasound, lab services) was only available intermittently. The ability to refer films and specimens to Christchurch for review is limited. Dr Ili, the only full time paediatrician is extremely busy with little time to supervise oncology. Dr Khalid has a very limited role and was not evident while Fiona was there. There is no clear sense of process. None of the previously supplied documentation (guidelines, protocols etc) is in evidence. There is limited awareness of the basics of oncology which we assume as a given for shared care. Infection control is difficult with LPs being done in a thoroughfare and no concept of extravasation risk. There is one sink with no hot water. There are 2 children who have received It therapy who are paraplegic without clear explanation. There is no ability to support nutrition with supplemental feeding. Clinical note taking is limited and there is no record which includes progress or plans. Nurses have less of a role in hands on care and decision making than their counterparts in NZ although they have excellent relations with families. There is a willingness to learn and improve but there is little time available for senior doctors to embed and support good practice. Even those who had previously been exposed to desirable practice appeared unable to deliver this in the current environment. On the other hand, the intensive care environment is competent with transfusions and inotropes and live saving acute care is competent.

The meeting thanked Fiona for her reflection on the current situation. This report was particularly valuable since there had been no visit from either Mike or Rob for 18 months following the cessation of Health SpecialistsLimited funding support for paediatric oncology visits. The universal feeling was that this represented a deterioration in capacity and confirmed concerns that had been growing over the last year with multiple personnel changes at CWM for child cancer and an apparent growing trepidation and loss of confidence in the staff working with these patients. The meeting expressed concern both about the ability of CWM to safely deliver curative therapy for child cancer patients at the present time and the vulnerable position of the twinning provider in Christchurch. No one involved feels comfortable or secure with fearful registrars in Suva and unwilling consultants in Christchurch

The meeting noted the existence of the Fiji National Child Cancer Plan November released in 2015 and the plan for a single national centre. The meeting felt that as far as we could tell, CWM currently fell below SIOP PODC service specifications for an entry level child cancer service

Several options were considered for addressing the current situation.

A recommendation that only Lautoka was in a position at present to attempt curative care for child cancer patients although palliative capability must be supplied wherever those patients were to be cared for.

Paediatrics at CWM should be vigorously supported by whatever means possible requiring both consideration of increased internal resourcing and increased external assistance. Lochie discussed the potential for a NZ based paediatrician to provide regular support by daily video link and regular visiting as a cost-effective solution to the current situation in Fiji. The same person could also support Lautoka, Tonga and Samoa. The available person is obviously a logistic barrier to this solution. An alternative would be to establish increased paediatric capacity through a virtually continuous presence of experienced NZ pediatricians through sabbatical leave, voluntary service. Since the whole concept of child cancer care in the Pacific is predicated on a robust general paediatric capability, anything which grows paediatric capability at CWM is a part of the solution!

Consideration of an NCCN style shared care service level agreement audit, based on the PODC standards for a paediatric oncology service

There was then considerable discussion addressing the next step and after several false starts it was agreed that our concerns about the current state of child cancer service provision in Suva should be discussed in the first instance informally between Rob and Riga to seek Riga’s advice on the most appropriate way to escalate these. Meantime, the situation where potentially conflicting advice came from Christchurch and Melbourne needed permanent resolution if the twinning arrangement between Fiji and Christchurch was to be preserved.

Subsequent to the meeting, further discussion has taken place and the suggestion is for an external review of the progress made by the PI project in FIJI during its first 10 years. A separate solution will be explored to reestablish a clear twinning partnership between Lautoka and Christchurch and Suva and Christchurch. Rob is encouraged to plan early resumption of visits with funding from WCCCT.

  1. Pacific Registry.

Mike reports the Fiji registry is held up at MOU stage (as the community nurse position appears to be!!). It is not reasonable to expect Suva to take on any registry activity at present. However, Lautoka could be able to back register all historic patients providing Kirsten Ballantine remains willing to spend some time doing this with WCCCT funding.

Tonga is keen to begin with a registry project and Jane supports this. It needs to be established where the registry will be housed and who will provide governance This requires an MOU and Mike will provide a sample to Jane to progress

  1. Early warning signs

Mike asked for and was given approval to utilize the early warning signs for Samoa and Tonga for PNG with appropriate changes.

Meeting closed 1500

Next meeting date to be arranged.