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

Building Innovation & Expertise in a Remote Location: The Allan Walker Experience - Associate Professor Michael Penniment

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Deputy Director of Radiation Oncology, Royal Adelaide Hospital & Visiting Radiation Oncologist, The Alan Walker Cancer Care Centre

Download powerpoint presentation by Associate Professor Michael Penniment (PDF 4441 KB)

Introduction by Norman Swan:

The theme in this section is capacity and innovation, and we're going to follow up on a presentation I think that happened last year about Darwin which I found fascinating and was a major change to providing radiation oncology services in Darwin and the support required and needed. The hub and spoke with Adelaide was a significant part of that enterprise and it's going to be fascinating to follow-up on that this year, and Michael Penniment is going to do that for us. He's the Senior Radiation Oncologist and the Deputy Director of Radiation Oncology at Royal Adelaide and he is a visiting radiation oncologist at the Alan Walker Cancer Care Centre in Darwin, which is fantastic that it's been called the Alan Walker Centre. I knew him well and one of the greatest paediatricians I ever worked with or knew. So after a really innovative clinician, not a cancer clinician, in Darwin. Therefore it to be named after him is really a very good thing.
Please welcome Michael.

Assoc. Prof. Michael Penniment:

Thank you. And thanks to Abel for inviting me. And also thanks to DOHA for really for this conference and also just having an interest in radiation oncology facilities and rolling out good centres.
As we’ve said, I’ll be probably saying a few things that have already been spoken about through the course of the conference but I think that’s hopefully just ‘cause they’re good messages that we do need to reinforce. In particular I’ve been asked to speak about building innovation and expertise in a remote location, the Alan Walker Experience and, sorry, that’s actually the Jimi Hendrix Experience. That’s the Alan Walker Experience, we opened in March, we actually opened clinical services in March 2010. The opening that happening there was in January 2010, as these sort of political things often occur before the actual patients get treated and Alan Walker, I think there’s an important message in terms of Alan Walker. As Norman said, he was a Paediatrician that, I think there’s one message that we can take from his work where he saw a problem which was the infant mortality of Indigenous children in the Northern Territory and it was a fairly discreet, obvious problem that he put a lot of work into trying to solve and he did that in some ways which have meaning for us as well.

There he is consulting with the local Boy Scout Troop, that's actually Brendan Nelson and the community people that he consulted with to try and work out some ways and I think the next slide, we’ve seen a lot of slides about is the service better because of X or Y and how many people here and whatever. The next slide really shows the effect of just one person working very hard with a group of people around him in terms of just infant mortality, you know, it doesn’t take - and you can be right up the back of the room and you can see the affects of ten years of hard work in terms of the drop in infant mortality in the Northern Territory and The Royal Darwin, and I think all this shows is that, you know, that if you know what the community needs, you know what the problem is, you can really focus on achieving something quite remarkable.

So, we, I won’t go all the way back to in details of what we talked about last year but in essence, we had an advantage that we had been servicing the Northern Territory community through Royal Adelaide. I’ve been doing clinics there since ’96 and The Royal Adelaide, my staff have been working with me. In particular Giam who’s our Service Operations Manager who’s with us, the two of us and the rest of the team have been trying to customise solutions for Northern Territory patients for a decade. But that’s not always going to be the case in the various communities that you’re rolling out centres and I think it’s very important to talk to the people that are providing whatever cancer service exists in the area that you’re going to put a Cancer centre.

The extra factor that we had, as well, which was important and I think it’ll be a reoccurring thing through my talk is importance of independent consultants and Michael Barton was a tremendous help. He was given the brief by the Northern Territory Government to do a comprehensive review of cancer services in the Northern Territory which did two things. One is that is actually crystallised a lot of the ultimate needs that a cancer centre would have to provide. It was an independent voice so it wasn’t sort of us preaching to the converted in terms of, "We want this, we want that. I want a couple of lin-accs with this". It was somebody independent saying, ‘This is what the Territory needs.’ He was also then important to when we were actually rolling the centre out, that he could continue to provide guidance in the Northern Territory Government which was independent of us so more often than not, it was just validating what we were saying in terms of the key messages, like there needed to be two linear accelerators, remoteness was such a problem, we had to put money and resources into things that would actually make sure that this Centre could operate independently although and also needed the hub and spoke that we’ll talk about.

And in terms of setting it up, one of the critical things which was unique to us, although I’m sure it will be a factor for others as well, is that we were given a political deadline that we really needed to roll the centre out, from the first announcement was going to happen through to three of the patients in less than 15 months. And so we set up a critical path analysis and all the usual sort of Gantt charts or whatever to look at what actually had to happen in that time.

And then we had other people that were, again, independent – Paul Tyrrell was one person I’d like to highlight who was the Chief Ministers Head Bureaucrat in the Northern Territory and have been used to rolling out multi billion dollar pipeline plans in the Northern Territory and initially Paul sort of, the actual fiscal size of our project, it seemed like it was something he was going to be able to sort of knock of in half time at the Territory Thunder match but he only had to talk with a couple of Physicists to start to understand that, okay, the actual amount of money that was being spent wasn’t so great but the complexity of the task in terms of commissioning machines, getting the staff to the Northern Territory, working out patient needs, working out distribution trains for patients and stakeholders actually was very complex. But again, he was an independent help to us to just to sort of consolidate what we were saying.

And this is some of the key people, Giam on the left and Scott Caruthers next to me. Scott came on board in terms of helping with really just setting up the whole service but in particular the clinical service and we’ve gone on to also still consult to the centre which you need to do in terms of supporting the existing staff and providing not only sub speciality expertise but also sort of collegial and peer review and just a sense that it actually is part of the hub and spoke.

The independent auditing, in the centre John Drew and next to me, Eva Bezak. Eva's Chief of Physics for Royal Adelaide. We knew that we, when we were hiring people, we had the person that we wanted who was in the UK, John Shakeshaft for our Chief Physicist but we knew that he wasn’t going to be in Australia when we wanted him. That was partly because of x-rays and all the immigration and whatever whatever and I certainly rang poor old Abel’s staff a number of times saying, “Any chance that we can get the visa people to ... we can build a centre in 15 months, what about a visa approval?” And anyway, so in the end, we didn’t win that one and so the Royal Adelaide was able to do all the commissioning for the machines but that in itself meant that then when John Shakeshaft came on board, the first machine was commissioned, he was able to commission the second machine and then go back to check the commissioning on the first and so, again, there was checking and cross checking what was done. We were able to schedule that in terms of when we were implementing IMRT on the first machine we were able to sort of move over to run on the second machine. So we had issues of, we had free capacity so that we had enough patients that were requiring one machine capacity and we could then schedule and work out how we were going to implement new technology and Michael Barton was also there too but he needs no introduction.

The expertise started at the building phase. You can see two of our key builders there, Therese Verma and Bob the Builder Abel. Abel was saying to Therese, “The Federal Government funding unfortunately means we can’t have a roof.” Therese is saying, “Have you been to Darwin in the wet season?” And Therese, I don’t think she’s with us here but, actually Abel was al-, it was always going to have a roof. And that’s the centre. Indeed in terms of the first sort of sign of excellence, the centre, it’s not a great photo but I’m happy to say that it won a number of building awards including Best Territory, Northern Territory Building in 2010. So things were done speedily and not expensively but were done to a quality framework right from the start.

But that’s just the building. This is the people and this slide highlights a couple of things. It highlights that even a small centre that’s essentially got two linear accelerators and chemotherapy, there are a lot of staff and this is really our core staff in terms of there’s no, none of our Breast Surgeons, this is the core Alan Walker Cancer Centre staff and the same thing, put a different way, highlights that we had to be fairly firm on what we wanted and what we needed right from the start.

The Northern Territory Government, the relationship that we had was such that the rollout and the capital provision was from the Federal Government but the Northern Territory Government knew that we wouldn’t have sufficient capacity for a full private provider to just come in and run the unit and so they had to underpin the running of the unit as they would in a public centre. So, they wanted us to manage the Core Radiation Oncology staff but they also were very fortunate that we’d done this a few times before and that when their stakeholders came to the Government separately and said that we want a provision of quite a lot of things including, I think, 60 beds of ward space, six Speech Pathologists etcetera, we were able to sort of link those two things together and say, “Well, you don’t need all of that however this is exactly what you do need.” And we were able to make sure that we had a very well rounded facility with really – we were able to do head and neck because we’ve engaged a dental service in a variety of innovative ways, you know, we do have Speech Pathology allied health in terms of Clinical Psychologists and other people that aren’t even on the list. But you’ve got to get this right before you actually start operations because as we all know, it’s really hard to sort of go to somebody and say, “Oh actually, we need to get a couple of X.” And so that’s certainly a lesson there.
A slide of chemotherapies just to highlight that we have talked a lot over the last day about radiotherapy facilities. If you really want a comprehensive Cancer Centre then you do need medical oncology. Getting medical oncology is the subject of another five talks but basically we’ve managed to do that.

We do have equipment. I really wanted to give an unscripted and unpaid advert to Elekta in terms of when we, again, we were very clear what we wanted. We wanted two linear accelerators but we knew that we were going to have to have some special things. We knew we needed an Engineer on the ground. We’re too far away, it’s not a two hour drive from Melbourne. It’s a four hour plane flight from Adelaide. We needed an Engineer on the ground. We needed IT, not only for all of our MDT’s and our patient services but for QA, for remote QA, for our chart rounds, for a variety of things and we also knew that the majority of the doctors that would be involved, external to the centre, would be rotating through Royal Adelaide and so on our wish list was that ideally we needed the same planning system, i.e. Pinnacle that we were using at the Royal Adelaide Hospital. We knew we were going to be rotating radiation therapy staff as well so if we could have a common platform that would be good. And we knew that we needed MOSAIQ sort of the enth degree, we needed to be paperless and we need to be able to access all of our planning and case note and other data really anywhere via a sort of Citrix based web solution. And I’m happy to say all those things, with very, very, very occasional little glitches, all worked very well.

That’s the linear accelerator.
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So, the basis is you’ve got to set up. And this is really just a snap shot. We wanted to set up a really sound strategy in terms of what was not negotiable and then customise and improve as we went along and this isn’t a complete list. Protocol development was important. We didn’t want it, on the one hand sort of inhibit territory specific work but we knew that the patients, that the staff will be rotating across the Darwin and the Adelaide groups and so we needed sort of common QA clinical and other ways of doing things. The only real brief that we were given when we were setting up the service was that it had to be obviously for all Territory patients and so there was no out of pocket charges, and that the technology was that we didn’t want a very standard centre. We wanted a centre that was basically, again in the theme of what we’ve been talking about, something that when you look at the graphs and you look at the small centres in regards to Head Start trial and other things, we didn’t want to be an outlier. We wanted to be right in there giving sort of state of the art treatment from day one. We had an implementation plan from IMRT and VMAT and we wanted the technology for that, we also wanted the staff and other resources to do it. And we wanted to be able to use our technology to drive all of our data gathering in terms of survival toxicity, special projects, Indigenous needs, looking at the outcome for our remote clinics, which centres should we be visiting, which centres perhaps would be too remote.

So, you know, we had access to technology for all the right reasons and also because we wanted to track staff that wanted to work in a centre that was able to do what they were used to doing in their major centres elsewhere.

And, I put these numbers up. The numbers that I’ll put are not so much for notation, it’s more that we also wanted a system where our key performance indicators were not something that we’d have four or five, whether they’d be meaningful or not, don’t know in five years' time we change them anyway. We wanted some really core things that we could follow long term. We wanted to be able to look at the dashboard of our centre across all parameters at any time so we can basically come up with the data on terms of basic data like consultations and treatment outcomes at sort of a couple of keystrokes. And we’re happy to say that, yes, we did treat more than 400 new patients in our first 12 months and that that was 20% above expected activity and also we came in under the expected budget for the, what the Territory had, we’d discussed.

Wait times. Wait times are completely really run by clinical need. My major, in fact my only frustration with the centre is that I’ll see somebody in the morning and sneak off to get something to eat and I’ll be already getting a call from the RT saying, you know, “When are you going to plan that patient because we want to start them tomorrow.” And, the only time I have to be really specific about things if I see somebody in Darwin and I don’t want them to start tomorrow or the next or even the next week, and then I’ll have to sort of discuss that. So I say that purely just to really piss a few people off in the room. There really isn’t a waiting time.

The Indigenous patients, we’ve treated 105 Indigenous patients and one of the key things there, and this is something that we are just in the process of looking at, we’re about to release our data from Royal Adelaide with our treatment of Indigenous patients in the five years prior to starting the centre and over that period we had 186 patients treated with radiotherapy of which 183 completed the entire course of radiotherapy as scheduled. And certainly the message that I’m talking with my Indigenous committee colleagues down in Adelaide, they think that’s a fantastic message that we’re going to get out because 183 of 186 and I certainly didn’t give them a single fraction when they were really radical head and neck. They were being offered very standard treatment with only the slightest modifications if they insisted and so they, when we discussed the treatment, they engaged in it and they followed it through. The compliance rate, and compliance isn’t quite the right word, but the sort of flow through and treatment rate in the Territory, at this stage, smaller number's 85%. We expected it to be less, I mean the advantage we did have in Adelaide was if you have to bring somebody down on a plane and you’re putting them up and you have to sign a piece of paper to send them back on the plane, there’s a bit of control there. Whereas a lot of patients from Darwin, not a lot, it’s only a couple from Darwin obviously haven’t stayed for whatever reasons but it generally suggests that, you know, if we’re giving a personalised message that we’ve customised and we’ve tailored to the patient, then really there shouldn’t be any great difference.

And this slide just sort of suggests, again, that we can come up with some good data fairly quickly in terms of the Indigenous patients, obviously there’s a weighting towards head and neck and lung and there’s a reasonable number of breast and palliative patients whereas obviously the little spike in the curve for prostate is the non-Indigenous patients.

So, these things have come out before. The advantage of small centres, I mean, our advantage is that we are flexible and we can adapt rapidly. As I said, we were really crystal clear about things that we do. I was speaking to someone at lunch about things that we set up in written agreements with the Royal Adelaide and with the Territory Government, the things that the Royal Adelaide was going to provide and they’re obvious things like paediatric treatment, stereotactic brachytherapy but also the provision of staff rotation, the tele medicine links, QA, physics, all those things which were basically before the centre just in the mates agreement that we had, then they were all written down and like Mike said, the legals took a fair while but there’s agreement there that the Royal Adelaide provides certain things. The Royal Adelaide didn’t want to have a fiscal management role because, in essence, they’re the South Australian Government but they certainly, they had to have a clinical and an overseeing hub and spoke role, which they do.

But because of where we sit, we are in a position where we can take on patient need and staff recommendations sort of very quickly. One of the things that was, has again been mentioned was I was concerned that we hadn’t really fully rolled out telehealth initiatives with patients and we looked to, and we had one of our fellows in Royal Adelaide who was between, was about to be between jobs, and I thought it would be fantastic if he was able to go up to the Darwin Centre, finish off a number of protocols and a number of trial proposals and also help us to roll out the telehealth across 17 small centres across the Northern Territory. And took that to the Financial Operation Managers at the NT Health. Giam and I had a chat with a few ideas on a piece of paper and it was, in essence, how much does it cost, when do you want to start it. I said ideally it would be nice if we got him up next week and I think it actually took 10 days but, you know, it was, it’s great to have a relationship that we can get movement on quickly.

So, that’s just saying the same thing. The Health Minister, Dr Silver on the right, I think’s heard Health Minister Kon Vatskalis talk before, but we’re lapping it because, you know, we want a good relationship.

Celebrate the uniqueness. You know, we’re rolling out an Indigenous DVD which shows the patient journey in Dec-, sorry, September.

The isolation, I’ve already mentioned. There was no discussion, we had to do those things. We’ve engaged in clinical trial and the clinical trial and the community foundation is the other thing that Michael mentioned. We’ve started a community foundation. It started because a patient that was from East Timor had a locally advanced nasopharyngeal cancer with metastatic disease, we were able to treat him with the help of a number of the NT community. Businesses rallied around and got him over. We got a fantastic palliative response and the foundation really arose from that. There was businesses that really wanted to pitch in.

And probably one of the final, the final word, really, is auditing. As I’ve mentioned before, we want to really embrace the ability to set ourselves up in comparison with other centres. Trials, we all know the data there. We know that that’s a good way of putting yourself in a multi centre trial, shows how you’re doing with other centres. Independent expert review, prior to the thing starting, all the way through and (inaudible), all of those things are basically ways to benchmark yourself and you’ve got to embrace them.

Rotation of staff is another way. We have the rotations to the Royal Adelaide so people see how we do things up in the Darwin Centre. We’re bringing a lot of messages back. Finally I think it’s the Darwin Centre that’s got Royal Adelaide really moving on IMRT and so it’s positive both ways.

Accommodation - there’s a 60 bed accommodation facility which is more than we need but, again, the Territory had the facility that they were willing to kit out and that makes us future safe.
Future. The other things we’re doing, training allied health workers in the left of the screens are RT staff. They’re going to Gove, Nhulunbuy, a few centres and training the Aboriginal Health Workers.
And Dry July. Obviously a unique thing with the Territory, if you can get the Territorians off the grog for a month. That was $20,000 to kick start the foundation so there’s a good thing there.

And, again, the community provided a bus and the local Mitsubishi guy, he’s the head of the Golf Club and he said he’ll service it as well, just by asking.

And I think, sorry in conclusion, to find the core needs, plan and work with the people you’re going to have to work with. Fight to get what the patients want and if you do all that before you start. Embrace any opportunity to audit and just the broader ones, just to close one, I think we are a unique cancer treatment. We’re capital intensive, we’re team focused. I don’t know what the local area health, local network health whatever it is, effect will have but we’ve just got to, there’s a lot of providers that are providing to regions and we need to use these opportunities to link in and work out ways that we can service a population in a sort of a seamless way as possible.

Thank you.

(applause)

Norman Swan:

Guys we heard yesterday, you could have zero waiting times on yours but if the patient's journey up to there is pretty crap, you're dealing with a real problem. What role do you see yourself playing in improving the system around you so that in fact the stuff that happens before is much better, which could have a (inaudible)?

Assoc. Prof. Michael Penniment:

Yeah. There’s all sorts of aspects to that and one is that there’s so many small focuses of population that we would like to do, we weren’t seeing people from Alice Springs, we knew that was part of the roll out, that we weren’t doing clinics there. They were all coming down to Adelaide. We knew that we had to start a clinic in Alice Springs and of course once we did that, we were giving, we engaged that community and them coming up to Darwin. But smaller centres; Gove, Nhulunbuy, whatever, there’s really not enough critical mass to send a team to do a traditional radiation oncology clinic.

Norman Swan:

But that’s not what I’m talking about …I’m talking about non radiation oncology here, I’m talking about prompt diagnosis, prompt referral, any of them so the stage of diagnosis comes down, working with Aboriginal, you know, community controlled services, that sort of thing. What, given that you are sort of like the jewel in the crown, you also, presumably, should have a role in improving the whole system around you.

Assoc. Prof. Michael Penniment:

Yeah. We’ve been invited, again, probably it’s fortunate when you’re in a small centre, we’ve been invited to participate on the Northern Territory Cancer Plan and also to a number of the candidate things which are getting into the community and so we also, the colorectal screening program, we engaged in that. Which is not really our core area of expertise but it is a way of going out with other health professionals and getting the message about radiation out in the community. So, all of our staff and again the advantage of the small staff is it’s our RT staff, it’s our registrars, when they come on board, it’s our radiation oncologists, they’re all able to do those community things. And the video which is coming.

Norman Swan:

True. Well presumably it’s in your interest to be doing more curative radio therapy than palliative?

Assoc. Prof. Michael Penniment:

Yeah, yeah.

Norman Swan:

Any questions or comments for Michael? It sounds like a great centre. Anything bad to tell us? You know, we love bad news.

Assoc. Prof. Michael Penniment:

Well clinical trials is still a problem and we, and that was the one bit that we never solved, we never asked and wanted a data, we knew we wanted a Data Manager but we were told we’d get one from the Uni and dah dah dah and that’s a classic, you get told, ‘Don’t worry, we’ll sort that out.’ Won’t get sorted out.

Norman Swan:

Right and what’s going to happen with that?

Assoc. Prof. Michael Penniment:

We were part of the, we, it’s a long story but we …

Norman Swan:

Are you part of the South Australian program?

Assoc. Prof. Michael Penniment:

No, there’s a number of aspects. I mean we were part of the Cancer Australia roll \out but that got inhibited in a number of ways which I don’t think’s specifically Cancer Australia. I think it’s the bureaucracy of ethics committees and the Royal Darwin as well and, but I think there is also an issue that the trials that we did have funded have been pulled because there’s uncertainty about the trials. You know, we’re looking to do the way that everybody else does it, if we can get an industry trial then we’ll be able to get some core funding to be able to support ... a bit, Michael with the foundation that …
(Inaudible comment made from audience member - no microphone)

Assoc. Prof. Michael Penniment:

Yeah, yeah.

Norman Swan:

Michael, thank you. Oh sorry, yes?

Unidentified Male:

(Inaudible comment made from audience member - no microphone) .... you lift up the phone and then you talk to someone today and a month later you ring up and they’re not there any more so it’s a lot of issues. It is not all rosy like we say it is because it’s as a state, the Cancer Initiative Cancer plan has been set up and it will be launched in October. Also addressing the other aspects of patient needs is the Cancer Foundation which is the Alan Walker Cancer Care Foundation which hopefully will be formalised in a month or two. It looks at all the aspects that the Eastern states takes for granted like nutritional supplements, like patient costs of travelling and all the sort of things are taken for granted in the Eastern states have to be looked at an entry level in the Northern Territory. So we have set up the foundation for that purpose as well other than including East Timor but there is a lot of work to be done in the Territory, if we are behind the eight ball when we started. I think Michael Barton’s utilisation rate in 2000 was 22% for RT which is very low. I think currently, I don’t have specific numbers but it’s roughly in the mid 30’s. So hopefully we can reach the mid 40’s and there will be an aim we want to reach but we will never reach the Eastern states' statistics.)

Thanks very much and thank you Michael.

(applause)
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