'Beyond Bricks and Mortar - Building Quality Clinical Cancer Services' Symposium 2011

An MDT Toolkit - What's in the bag? - Ms Shoni Colquist

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Manager, Qld Cancer Control Analysis Team (QCCAT), Queensland Health

Download powerpoint presentation by Ms Shoni Colquist (PDF 2368 KB)

Introduction by Norman Swan:

So here's a talk that a lot of you have been waiting for: an MDT Toolkit. What's in the bag? We're all agog waiting to find out from Shoni Colquist. She's the Manager of Queensland Cancer Control Analysis Team at Queensland Health and in particular she is going to be talking about today's web based tools to help you along. Shoni.

Ms Shoni Colquist:

Thank you and good morning everybody. When I was asked to give this presentation, the topic which was given to me was tools and technology but as I listened to the presentations that were given yesterday and Norman reinforced that again this morning, we heard an awful lot about the need for data, measurement, feedback, good interactions with our clinicians in terms of closing that loop and getting information back to them. So I’ve taken a slightly different slant on that this morning. We are going to have a look at those tools and technologies but it’s not just about the MDT toolkit and what’s in the bag. It’s also going to be a little bit about our experience in Queensland and how we’ve approached that really thorny issue of how do you involve people in these activities, to try and progress a safety and quality agenda. So the context for us in Queensland is no different than it is for anybody else.

Over 20,000 people a year are diagnosed with cancer in Queensland. It’s the largest premature cause of death and disability for us in Queensland and we do see that variation in outcome. We know there are differences between urban and rural survival rates. We know there is variation in treatment practices but how do we respond to those challenges and time and time again we heard how important it was going to be to have cancer staged to help us really interpret that variation in practice, to be able to really tackle it.

So we will unpack that MDT tool kit and we will have a little peer inside, but we also will focus on that approach that has resulted in Queensland in addressing it. One of the key factors for us in Queensland is this somewhat actually quite delightful situation we find ourselves in, with a very specific piece of legislation. That context is set back in about six years ago, when we first started this journey, if you want to call it that, and the then government of the day made a commitment to the establishment of the Queensland Cancer Control Analysis team, who I work with, but also then the subsequent establishment of a gazetted quality assurance committee.

There’s a piece of legislation in Queensland in the Health Services Act which allows parliament to gazette a quality assurance committee for the purposes of monitoring and evaluating health care services. This specific legislation really supports the involvement of clinicians in that retribution free environment. So they can have those tough conversations, get all those curly issues out on the table, thrash them out and think about how they are going to manage them, without any fear of anybody looking over their shoulder or questioning those types of conversations they are going to have. They are exempt from FOI, for example, the powers as explained to me by the group who manages this legislation in Queensland administratively is that they are probably more extraordinary, in a sense, than police powers. It gives them extraordinary access to data and information to bring that together, for the purposes of making an improvement. So broadly speaking, the purpose of our partnership that was established six years ago, was to facilitate that participation by clinicians and administrators in those sorts of conversations across the state. We have a specific role in the collection and co-ordination of that data and then also the analysis, reporting and feedback of it. That’s really what we’re going to have a look at today with the tools and we also then have a role in negotiating the development and uptake of the strategies, in terms of how we’re going to address those gaps that appear, in relation to safety and quality issues.

Cancer is a complex condition, we all know that, so it was going to take a variety of approaches to start to address that and we’ll focus on five things today. We’re going to look at how we utilise the electronic sources, the existing sources of data that exist, something that David Currow spoke about yesterday. How there really was a need to respond to the need for cancer stage to start to help us to make sense of that unexplained variation. It also soon became apparent that there was a need for some collection of that missing clinical data, there is really important prognostic factors, or there’s pieces of clinical information which aren’t routinely stored in any other sort of electronic system which we could access. It had also been demonstrated in Queensland early on in our evolution, in a patterns of care study that was conducted by the partnership, that patients who are reviewed by a MDT, and at that point in time it was only 19% of the population in the state, were more likely to receive a far greater range of treatment options, and in particular radiation therapy. They were also far more likely to have a documented cancer stage than patients who were not reviewed by an MDT and so the best chance of success seemed to lie in combining all of these activities with that best practice multi-disciplinary care.

The fifth area focus we will look at is the development of the tools for that analysis and reporting of the data.

So what sorts of tools and technology do we have? For the technically minded people we developed an enterprise service bus, or a way to facilitate the exchange of data between multiple systems sitting on multiple platforms in a variety of formats, ranging from HL7 messaging right through to Oracle and SQL and Excel and stuff on a CD or something sitting in a clinician’s office on his PC. We spent an awful lot of time overcoming the technical barriers to the issue of a unique identifier, which we hear a lot about nationally and developed a patient matching and linking engine to draw all of those patient demographics together. The challenge really was to be able to track a patient through the system. When we have a look at some of that source data later, we will see that most of the patients in Queensland are represented in at least 10 or 11 of the 30 odd systems that we access. So it was really important to be able to identify them all and to continue to track them throughout that system.

Of course data standardisation and normalisation had to be considered so that we could have apples and apples. Data integration was important because we needed that data to be able to flow from one end of the system right through to the front end user and then back again. We also needed cancer specific data sets and I swear that every single clinician and every single clinical team has a completely different view on what’s important to collect in their data set. Nevertheless, we got there and we have a minimum data set for every single gender specific group in Queensland. So, a minimum data set can now be collected on every person who has cancer. All of this information is then housed in our Queensland Oncology Repository, which is administered by the partnership.

So, what did it look like – I might skip past this. In practice, what does it look like? Well, we have over 30 odd systems that connect in our environment, I think it was 36 at last count and about 35 million rows of data flow into our repository from all of these systems. So they represent a whole range of information, from real time pathology through to diagnostic information from say our cancer registry investigations type data, clinical data and information, demographic data, treatment information, prognostic information, death information from death registries, so on and so forth. This all comes into our big matching and linking environment, where we now have a unique identifier for over six million people. Yes, many of those people are now deceased in Queensland. Nevertheless, our records are still important to us, especially when we start to look at trends over time.

Out of that, there are some nearly 400,000 people with cancer and we have made an attempt to link the last eight years of incident data in Queensland, resulting in a set of over 150,000 patients linked to their clinical information. The data has been standardised and we have the minimum specific data sets that we spoke about, so we now know that when we’re talking about a diagnosis it means the same thing for every single patient, for example. The data is integrated and it flows into the system, flows right through the system from the very bottom layer right through to the top, to our application suites and in our application suite we have a variety of applications, but the two key ones I will focus on today are Queensland Oncology Online, which some of you may be familiar with. Certainly the Queenslanders will be and the Oncology Analysis System.

What do these in a general sense provide? Well, it’s accessible patient summarised information that’s really the key aim here. We’re able to provide that to anybody within the Queensland Health network, but also to anybody outside of that network who is a legitimate member of a multi-disciplinary team or group involved in the care of those patients.
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So Queensland Oncology Online – what is it, what does it do? Well, it’s a customised tool that has been built specifically for clinicians by clinicians. It’s had their involvement and input right from day dot six years ago. It doesn’t behave like a traditional silo or database. It sits across all of those other source systems that we saw earlier. It’s widely accessible by all the MDT members, including primary care should they choose to be involved. The relevant information is integrated from all of those numerous source systems, standardised and brought together in one common format. It also gives the teams the ability to capture cancer stage in particular at that point of decision making, with some inbuilt stage calculations. It helps us to start to make sense now of those disparate sources of data, which didn’t routinely traditionally talk to each other, everyone locked up in those silos.

We also have an R&D arm, if you like, so we partner with groups like CSIRO through the Australian E-Health Research Centre and one of the activities we are doing with them currently is the extraction of cancer stage from text based pathology reports. That’s looking extremely promising with a high degree of accuracy and this holds great promise for the future when you’re attempting to do something on such a large scale, make sense of information and do it in a much more timely fashion. So we’re getting really good results out of that in relation to tumour and nodal status in particular. So we have, like I said, tumour specific data able to be captured for all cancers across the state and there are modules developed specifically for the large volume cancers and a more generic module which captures all of these smaller volume cancers. The relevant information is available real time and since the introduction of QOOL over that six year period we now see, in fact this has gone up even more recently – remember we started earlier with about 19% of patients being reviewed by a MDT, that we could find a record for and they had about a 30% stage capture rate at that point then too with those patients. We now see that improved to 50% and just recently I looked at this again and that rate has increased to about 76% now across the state.

So a significant improvement in a relatively short period of time and the MDT’s are to be congratulated for their efforts in that area. The cancer notification and staging system that I talked about earlier, we did a lot of pilot testing on that in relation to lung cancer initially and we are now at the stage where we are wanting to expand that to particularly the large volume cancers, as it starts to rapidly improve.
So there are data sets for all of the cancers, breast up there, for example, melanoma, lymphoma, (inaudible) is pretty popular with the lymphoma group. The tool is customised specifically for each multi-disciplinary meeting around that specific data set of interest and so diagnostic and staging information is collected for each patient at the point of, or during, the discussion in those meetings. The investigations information which gives us for example that real time pathology and this is where we are at the beginnings of extracting that cancer notification and staging information.

So QOOL was developed really to support clinicians to participate in multi-disciplinary care across the state and to support the information needs of the clinical networks and the clinical teams that they also have to work with and negotiate with on a day to day sense. So this state wide clinical registry, I suppose, aims to link that patient information from those multiple sources and facilitates that sharing of information across the state. Regardless of where that patient is, where that clinician is, or where that hospital is, that patient may currently have a relationship with. So it auto-populates the demographic and diagnostic data from all of those routine electronic sources where possible, combines it with the clinical data, provides an online clinical summary. You can produce summaries out of it which you can share with general practitioners or specialists or outcomes of those MDT’s and it enables clinicians to record that critical missing clinical information which can go back into the big pot to be used by the team again, for their future analysis.

So what sort of information do we see that comes to us from those routine sources? Well, it tends to be the information from the Cancer Registry, admitted patient data collection feeds into it, which gives us very good state wide population wide surgical information, reasonable radiation information in the public sector, less so in the private sector, reasonable pharmacy information, again tends to be in the public sector, less in the private. Extremely good public pathology information. There are some technical hurdles to overcome in terms of accessing the private pathology information, nothing to do with the private providers, more to do with Queensland Health and their rules and regulations around sharing information and death information. All of this finds its way into QOOL clinicians and the team can add that missing information.

So we now see these online clinical summaries being shared across the state. It helps to facilitate that communication between the cancer centres and we now see over 50% of patients with a documented treatment plan. Again, that has increased again just recently. We ran another lot of figures to over 70% now across the state as well. That’s an example of the way one of the teams structures their information to be shared across the whole multi-disciplinary team and to share with their general practitioners and other specialists. This has been one group at Nambour.

So by combining all of the tools and technology with all the best practice multi-disciplinary care, we do see a lot of this data now being returned to that repository and the implications of that are enormous and we will look at a little of it in a minute. The information can be captured anywhere, 24/7. So if you have a computer you can get to, your patients’ data, your patient’s information and you can get to your analysis tool. Helps to strengthen those relationships between the public and the private sector and Mike, for example, in Toowoomba, hosts several meetings in the centre there which are a true public/private collaboration around multi-disciplinary care. The other thing that MDT”s can do now is start to monitor their own activity, in terms of their own progress and start to compare themselves to others.

So who is involved and how many people? I think there is 43 multi-disciplinary teams now state wide participating. That means that about 800 new patients each month are now receiving a multi-disciplinary review. We weren’t in a position to know this six years ago. There has also been a commitment from the broader cancer community group and the government to support the introduction of multi-disciplinary meeting co-ordinators so they have dedicated support for the administration of their meetings and so in the last three months there are about 600 odd users who are authorised to access QOOL and so that means about 350 staff across 24 facilities on a three month rotation, as they work through their meetings.

This is just a little screen shot of one of the groups in particular, we’ll follow through the head and neck example from the Royal Brisbane Hospital and Liz, I’ve taken the liberty of highlighting your name here in the blue bar. That’s just to show you that Liz Kenny is a member of several multi-disciplinary teams and she is able to manage her own access and her own account within the system so that that information becomes accessible to her electronically, regardless of where she is and at the important time. You can refer your patient to an MDT, again regardless of where that patient is or where you are and you choose the MDT of interest, based on your own usual referral patterns. You can monitor your own activity and this is particularly important at the moment in Queensland because we also have another project running where patients who have a complete record within the system, those MDT’s actually attract an incentive payment for the completion of that record and that’s been particularly successful. This is about one of Mike’s meetings in Toowoomba and so they’ve managed to earn themselves some funds there.

So the importance of feedback and measurement, as we’ve heard earlier, cannot be over-stated really and alongside of QOOL is all well and good to have information being able to be shared and clinicians being able to participate and add their information to the pot, but they also need to get something back out of it. So we’ve developed an online analytical tool that sits alongside QOOL, called OASYS and it gives you the ability to look at online clinical indicators, aggregate population data, do some comparative analysis, flexible querying and what this gives you is your real Queensland data and your real Queensland context. It’s linked for an 8 year period, based on incidence years from the cancer registries, so that we know we’re dealing with a known cancer population. So there’s over 150,000 linked cases in there. It enables you to start setting some realistic targets and estimate those cancer measures with better precision based on your own local context. If you have a particular interest in a small sub-group for example, you can start to combine numbers now. So while you in your centre might only treat very few of these patients, once you start to put them together you start to build bigger data sets. You can also start to find the real tail of the curve and know where you stand in relation to everybody else. It also has the additional ability to provide a really good quality resource for research and audit.

So we’ll follow through with the head and neck meeting at Royal Brisbane, just for example, and this is their activity for the first quarter of 2011, so they reviewed 170 patients in that period and so they can get to that information and start to analyse their own case mix. They can examine their treatment patterns, in this case their surgical rates broken down by the patient’s residence and where those patients came from. There is also then the outcome for those people from that particular group, in this case we’re looking at mortality across Queensland with some geo-coding. To be able to audit your practice and see how you stack up, compared to other people in a de-identified way, and this little graph represents 30 day mortality post-surgery for people with larynx cancer who have undergone a laryngectomy. You can also plot your cancer survival and start to compare that by something like urban and rural populations. So they’re just some examples, some taste of what’s there and what ability it gives the staff who are involved in QOOL and with OASYS but where does all that leave us now.

These strategies and approaches, I guess, in relation to our tools and technologies have brought us a long way, and that’s for certain, in a relatively short time, so the whole thing started less than six years ago. But these approaches also fall short, to some degree and a clinician who was involved in some of our quality assurance committee activities recently said this to me, that in his darker moments, he wondered whether all the work that he is doing will now fall on deaf ears.

So what impact does data have in actually stimulating change? We had a really good patterns of care document, for example, in Queensland which had really good useful information in it, but at the end of the day has that really been able to assist an executive director of a medical service in a regional area to actually examine his local practices. What’s resulted from knowing that an MDT review appears to increase a patient’s chances of seeing a specialist within 14 days. So we’ve now got a veritable mountain, a goldmine really, of information. Maybe even information overload and while this information and technology and measurement are critical, they are like the good foundation in the building we heard about yesterday. We’ve also got to be prepared for what’s coming next. So how are we planning to meet these challenges now in terms of using this and starting to address that actual variation in outcome.

I’d like to share with you now a little illustration from one of the groups who have actually started to try and tackle this head on. This group were able to come together in that privileged environment of the quality assurance committee under the banner of the partnership and start to compare their performance to others across the state without that fear of retribution, without that fear of anybody questioning how they were approaching that. This multi-disciplinary group were examining the effect of annual case loads on patient outcomes. And so as we take a walk across Queensland, I guess, from left to right, we’re starting in the south east corner and as we move further away from the metropolitan areas, case loads fall and outcomes also worsen, as we get into smaller and smaller centres.

So there was a corresponding increase in the adverse outcomes. So centres to the right of B have poorer outcomes than those to the left of A. So the current approaches would allow the B issues to be dealt with in a reasonably straightforward manner, and there might be, say, an edict issued by the department saying thou shalt not do this particular thing any more. Centres to the left of A to be commended for their efforts, they’re doing very well, their outcomes are particularly good. Centres to the right of B with these minimal caseloads of say less than one case per year with significant adverse outcomes may, for example, just consider the application of a clinical services capability framework and make a decision in a relatively straightforward way, that maybe they’re not going to perform, or provide, this particular type of service any longer. But the centres between A and B present additional challenges for us. They are not quite big, they are not quite small, they represent the regional centres across the state and it’s not reasonably feasible, is it, to dilute those services and potentially disadvantage a whole population, based just on location.

So the traditional approaches don’t work here. They don’t provide us with any guidance about what to do in this situation and have limited application. So this has given the partnership reason to question the effectiveness of these traditional approaches and start to revisit the purpose of this committee and how they might tackle these things for the future in the state. While this is challenging, no doubt it is challenging, it also presents the partnership with some real opportunities to start to think about doing things in new and different ways and working together with centres between, say, A and B in new ways. New conversations, previously unexplored territory and solutions unanticipated are likely to eventuate by taking maybe a different sort of approach than one we might have otherwise have considered.

So, to recap, what have we achieved? Well, we’ve overcome the technical barriers, so we’ve overcome things like having unique patient identifier. We now have one for the 400,000 odd people with cancer in Queensland. We can track them within the system. The data is integrated in an e-Health solution which is accessible to a broad range of staff and clinicians across the state. We are able to support multi-disciplinary teams with tools and technology to enable them to more efficiently collect their information. They are able to feed it back into a repository so that they can also get that analysis and feedback in reporting starting to happen.

But the work of the partnership now becomes incredibly important. We do need the standardisation and the normalisation and we do need the tools and the basic functionality, but the partnership is a critical component now of the strategy for moving forward and starting to tackle these really difficult and challenging questions. The partnership has the ability to really maintain its flexibility in this challenging environment and take new approaches and tackle things in different ways, to meet that complexity of the unknowns that we are all facing. It is also able to create the space for new approaches, to bring people to the table to have those difficult conversations without that fear of retribution and try to understand how we can get that data to make a difference now.

So the next phase is an equivalent sized body of work, really, as the last six years and I guess for us, really, the challenge is probably now just beginning.

Thanks.

(applause)
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Norman Swan:

How much data scrubbing have you got to do to make sure that it’s clean coming in?

Ms Shoni Colquist:

Lots. Would you like a job? Enormous amounts.

Norman Swan:

I mean, in proportion to the resources you’re putting in, what percentage does ball park, would be on scrubbing?

Ms Shoni Colquist:

I think initially we spent an enormous amount of our time, we’re a very small team and it’s quite unusual for an activity of this size to be tackled by a group as small as us. So when we started this exercise there were four of us and where possible we’ve tried to automate things, so that we’re not having to continually go back and manually rectify things.

Norman Swan:

And rural patients, the quality of data are as good as metropolitan.

Ms Shoni Colquist:

It depends on what type of information we are talking about. So there’s variable quality, depending on the source. Clinicians in particular, and rightly so, have been very sceptical of some of the routine sources of data for a very long time. The admitted patient data collection which every state authority has an equivalent of, is one of them, but I think we were able to demonstrate that it was equally as good as, certainly what was written in the notes.

Norman Swan:

And are psychosocial factors fed into your data base. You didn’t mention that.

Ms Shoni Colquist:

I know, I didn’t mention that. Yes, we worked last year in particular, very closely with the cancer care co-ordinators across the state and there is now a psychosocial module attached to QOOL as well.

Norman Swan:

And what are you going to do about the private sector?

Ms Shoni Colquist:

Yeah, that’s a tricky one. David Currow was talking to me about this yesterday and he thought that maybe over a few bottles of red we could all get together in a room and start to share some of the data and just start to have some of those conversations.

Norman Swan:

But it’s almost one in two patients in Queensland, isn’t it.

Ms Shoni Colquist:

It is, and there’s an awful lot of movement in Queensland, maybe more so than in other states, between those two sectors. Many, many, many patients that we now see just from the systems we access, they are appearing in 10 or 11 of those 30 systems, so patient populations are very mobile and they do flow between the two systems. It’s a tricky one. I’d be interested to hear form other people how they think we might tackle that.

Question (Michael):

I’m a great fan of QOOL, I think it’s a fantastic tool and we use it in all our MDT”s in the public sector and the private sector in Toowoomba and in Cairns, so I think it’s achievable.

Norman Swan:

So you’ve got through the Queensland Health firewall, have you? Don’t tell them.

Question (Michael):

Exactly. That’s right, that’s a story in itself. And although I’m a great fan, I just wanted to heed some caution with all of the data and how we interpret with it. I’ll give an example and I hope Shoni doesn’t mind. When we’re looking at all the waiting time issues and we had the College guidelines in terms of what was an acceptable time for delay, we thought this would be really neat to look at this in regard to our lung cancer patients because we had a huge repository of data over about five years, or six years. We had all the dates of diagnosis, the start of radiation treatment and I thought this is going to be a very powerful tool to link increasing waiting times with poor outcome. And what we found was a highly statistically significant result and the shorter the waiting time, the poorer the patients did in terms of survival.

Norman Swan:

Adjusted for stage?

Question (Michael):

It was highly statistically significant and the reason is, as you’re onto it already, is that patients with short palliative courses start earlier than those who require complex treatment with negotiating with the medical oncologists wait six weeks longer. So we get fantastic data but you’ve gotta interpret it very carefully.

Norman Swan:

Thank you, yes.

Question (Michael Penniment):

Yeah, Michael Penniment, I’m from South Australia and I want to stress that because your presentation ...

Norman Swan:

You don’t have a chip on your shoulder do you?

Question (Michael Penniment):

No there’s a reason for it and also I’m from the Territory, as I said yesterday. Fabulous presentation, tremendous work, I wanted to say that. I’d still be sitting down and not asking a question if this wasn't - this is not the first time that I’ve seen a quality initiative where somebody has presented from Queensland and it’s fantastic, and there’s a question about what about complete buy in from the private sector. It’s probably not a question for you, maybe more for government or patient advocates – it’s not the first time I’ve heard this, and as I say I’m from South Australia and I’m just wondering what we do.

Norman Swan:

Lobby for conditional Medicare payments.

Ms Shoni Colquist:

Just to comment on that, I think that with our new look quality assurance committee, known as the partnership, and two of those members are here today, Liz Kenny and Roger Allison, both been recently appointed to that. One of the challenges they are going to have is how they can negotiate their way, if I can be bold enough to say that on their behalf, is through exactly that. Because it’s vital that we get that involvement from the private sector. Particularly when many of the issues, and the illustration I showed you with the bars across the page, also represented private facilities. We aren’t just talking about Queensland Health and the public facilities there, that’s the whole kit and caboodle in the state. So how do we share those messages and get some traction.

Norman Swan:

John ....

Question (John Stubbs):

John Stubbs, Cancer Voices Australia. Thanks Shoni. Just looking at the bigger picture and we've spoken to clinicians and patients in Queensland, they are very happy with the data you are getting out, but in terms of the patient electronic health record, have you spoken with NeHTA and DoHA on this, have they looked at your system and are they able to take the good or the bad or the indifferent from that?

Ms Shoni Colquist:

They are very welcome to have a look at it. It was certainly built with that in mind and so, when we set out.

Question:

So it’s NeHTA compliant?

Ms Shoni Colquist:

Yes, it’s NeHTA compliant, and our external access to the site specifically took into account primary care and patients so that if and when we were ready to extend it into those environments, it was able to do so.

Norman Swan:

Which is another point, which is the spreadability of this through other jurisdictions. I mean, is this a bespoke system, which is going to require the same development all over again, or is it to some extent transferable?

Ms Shoni Colquist:

Yeah, absolutely transferable. Really, there’s no magic here, just a whole lot of sheer hard work to get the thing up and running and we’ve had many discussions over the years with other jurisdictions around the country about just that. I think the biggest barrier, not from our perspective but from theirs is, well the one that's always put on the table is privacy legislation.

Norman Swan:

These privacy fascists have gotta get off the bike.

Question (Ian Roos):

Yes, look, my question has been partially answered. But from a patient perspective we sit and we see Queensland doing this fantastic work. We have representatives sitting on the Victorian clinical data set committee, we hear about what’s happening in Western Australia. We’re one nation. When are we going to get over .l..

Norman Swan:

Sorry, which planet are you on Ian?

Question (Ian):

No, the point is, when can we start getting a national approach to these sort of things, because that’s what we as patients want. Jurisdictions are outdated as far as we’re concern and when we cross a state border we shouldn’t have to change the systems, we should have easy access to this sort of stuff going into another jurisdiction. So when can we start having a national approach, rather than a jurisdictional approach.

Norman Swan:

Which requires the people in this room to organise and lobby. Roger?

Question (Roger Allison):

I just want to add my congratulations to what Shoni has done. One of the secrets is getting investment, to answer Ian’s question and the investment has been in the MDT co-ordinators actually doing the work and that’s the hard work. But it is popular and were I not here this morning, I’d be in a neurosurgical MDT, which is hard enough to get neurosurgeons to do anything, but they have been very keen and it’s working well. I think with regard to getting the private sector on board – I think all you can do is show the data and I think people like to see data, they like to see their own data, they like to have comparisons de-identified but I think that’s the way to show what you’re selling. This is the newest version of what’s been happening in Queensland since 50 years ago. In days gone by the Queensland Radium Institute used to have to supply an annual report to Parliament and it was tabled and woe betide us if we didn’t get the report in on time. So maybe some sort of legislative poking might be good in answer to Ian’s question.

Norman Swan:

Thank you very much. Thank you Shoni, that was great.

(applause)

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