'Beyond Bricks and Mortar - Building Quality Clinical Cancer Services' Symposium 2011
Symposium 2011 - Day 2, Thursday 11 August 2011
Table of contents
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Recap of Day 1
Norman Swan:And not too many casualties along the way from what I can see. Just a quick summary from a sort of impressionistic summary that's completely biased and not at all disinterested, and so take it in that vein, but just on a personal level some of the things that stand out for me, and I suppose the number one is the repeated story about variation and outcomes. And this of course pervades the system - it's not unique to us, but it is a major issue which needs to be confronted and that means measurement. And measurement with feedback and systems change, going back to Cliff Hughes' presentation. This is not about individuals, it’s not about bad eggs, it’s about systems which don’t deliver the capacity to deliver the best care, and that requires systematic analysis, measurement and feedback.
There’s an issue sitting out there that we haven’t even touched on, which David Currow raised, which is really poor outcomes in Indigenous communities, controlled for a stage of diagnosis, although there is at least in New South Wales and to some extent in Queensland, to a lesser extent in Queensland, that the poor outcomes in rural and regional areas is due to later stage in diagnosis. And that some of the responsibility for that has to be sheeted home to how we do primary care, and public health in this country, that we are not picking up people earlier in the country with this disease. And that means that when you’re involved in a Regional Cancer Centre you’re actually involved in the whole patient journey. If you don’t advocate in regional centres and I realise that not everybody here’s from a Regional Centre, for the whole patient journey from health through to illness, nobody else will. And so it’s a repeated story of systemic issues.
I think Bruce Mann’s talk which spoke about capacity credentialing, well he didn’t really use the word credentialing in fact, but scope of practice in a sense, and being clear that informed consent, and I think Ian Roos might have raised this as well, and David Currow, is that informed consent is actually a systems thing rather than, as well as an individual consent from an individual practitioner.
But if you know your outcomes are three times worse than if you go into the city, that should be part of informed consent, and you should be giving that information to your patients, so they know there’s a trade-off between travel and going into town. And that’s again, not about individuals. People have a right to know about variation in the system. We know that state of the art care is multidisciplinary team based care, where everybody’s at the table, not necessarily all the time and sometimes we over do it in major centres where they are falling over themselves the multidisciplinary teams, you know, and every patient comes before multidisciplinary team conference where probably they don’t. So modulating that in major centres and actually getting it working at all in regional centres is a huge issue, and we heard time and again yesterday that telehealth is one solution, but in some places it’s clunky and clinicians don’t want to use it, but it could make a huge difference.
A very important event yesterday which was the launch of the Standards, which is going to make over time a very big difference, but only if in fact the culture changes across services, and that is a major challenge. We heard of a slick presentation from The Cradle, the maternity group here in Melbourne, and despite Tony Wince's decrying of slogans, I think that one reason it probably works is because of slogans, and here we’re talking about the message. The message that everybody who comes into work in your centre knows what your business is, what your aims are and it cannot be said often enough.
Coming back to Standards, the subtext I think in the presentation from Jen Bichel-Findlay was yesterday I think, syncing up their standards to your practice, you know, your practice standards, not you syncing to them, them syncing to you. And that will be a lobbying, a discussion - that will be a toing and froing. So that when ACH surveyors go into a radiation oncology facility, they’re speaking the same language as you are in terms of your standards; you’re not doing one thing for another. And that will in itself probably raise the compliance rates or the involvement of radiation oncology groups in ACH’s accreditation.
Supportive care was a major issue which we came back to again and again, a need for that and intersection with the primary care sector which we are not very good at in the cancer field, because so much of what we do can only be done in specialised centres. But it leaves the GP out of the loop when the GP could be, and increasingly with Medicare locals who which are supposed to evolve into larger scale multidisciplinary teams based in primary health care, the resources for what you need for supportive care should evolve in Medicare locals. There’s an important role for the cancer sector in Medicare locals, because they’re just forming, they need res ondetre,, they need a clinical focus rather than a bureaucratic focus. So moving into Medicare locals to encourage them to develop the sort of services that you need, and maybe even transfer of some resources to allow that to happen, will probably make supportive care more appropriate.
I have to say, having listened to the excellent project environment of the Cancer Link nurses, I do wonder though the relative priorities when patients in Barwon are not being case managed consistently, why you’d use scarce nursing resources to give supportive care which could be given by others, when you probably need expertise of nurses to actually case manage.
Case management wasn’t mentioned much at all yesterday, but the transitions between care and patients falling between the gaps was mentioned again and again and again. Some of your services are case managing consistently, some of them are not. It’s a really important issue. When you talk to people, to consumers, who’ve got chronic complex illness, and the difference things make to them, yes, sympathetic ears make a big difference no question, not decrying that at all. But when they come across a case manager who shepherds them through the system, they are almost pathetically grateful for that process. And as I say there are some standout cancer centres around the country which are committed to case management top to bottom, side to side.
Sharing data was one of the points that David Currow made, and everybody in this room buys into that, but you’re also going to have to buy into a lobbying exercise to make sure that jurisdictions stick by it, and good luck to you from Western Australia.
Private/public is a recurring, it’s not private versus public, it’s private and public, and that’s a major transition, and it’s not one or the other. It’s both. If we go the way of the United States, medical oncologists in the private sector are now amongst the most highly paid medical specialists in the United States, just think about that. They’re amongst the most highly paid medical specialists in the United States. And if we go that way there will be perverse incentives not to give evidence based care. So there is an issue to do with the private sector, and it’s getting evidence based care. Now most people want to do a good job and this comes back to systems, it comes back to collaboration, it comes back to communication, and it may eventually come back to regulation in some shape or form.
Benchmarking was another recurrent theme yesterday, is how do you compare your performance to others without fear of retribution, of admitting where things are not right and be able to move forward? That simply requires courage, it requires organisational commitment, which I think again was mentioned again and again yesterday, and the organisational commitment is to back you and not to run for cover when suddenly you discover two patients have been underdosed or a couple have been overdosed, I’m not minimising that problem at all. But it’s you know, one has to actually deal with the more systemic problems which is, you know, the percentage of patients who are not getting radiotherapy at all, for example.
Anyway, that’s my take on yesterday, like it or lump it, and today the main the focus today leading towards the panel discussion is the options paper. When is that being launched Abel? When are people going to be able to see that?
(inaudible response)
Right, and we’re not going to distribute it beforehand?
Abel MacDonald:
We can distribute that at lunch time if they like but Leigh is going to speak to the issues around the panel discussion.
Normal Swan:
Right. I actually think the sooner people get it the better, so they can leaf through it, unless you’re feeling that’s not appropriate.
Abel MacDonald:
No that should be okay. It's just Leigh will give it a good context, so. But we'll make it available at morning tea.
Norman Swan:
Top of page
So just with that context with Abel, the options paper is just an options paper. And what Abel would be worried about is you'll take it off and think this is the Bible, it’s not the Bible, it’s floating ideas of how you might move forward. It’s a very well written paper which gives the options for evaluation and assessment against the Standards. And it gives you the pros and it gives you the cons and moving through, and I don’t think anybody, any reasonable person really could think this is it set in stone. This is a discussion document. And I think it’s going to be important that you understand the content of that, because that’s what I’m going to be drilling down into during the panel discussion at the end, ‘cause I think we have to work out from here is how do we evaluate against the Standards, so we don’t create another bureaucracy, we don’t add huge costs to the system, but we improve in the way we need to improve.