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

Changing Models of Care to meet Future Cancer Workforce Challenges - Associate Professor Rosemary Knight

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Principal Adviser, Population Health Division, Department of Health and Ageing

Introduction by Norman Swan

So workforce is everything, as Shane's focus was. It was a major undercurrent to Michael's presentation and to talk about innovation and workforce and what models we might follow is Rosemary Knight, who is principal adviser in the Population Health Division in DoHA and advises the government on cancer and chronic diseases. Please welcome Rosemary Knight.

Assoc. Prof. Rosemary Knight

Thanks very much. And to follow the next Cadel Evans, basically I’m going to go completely differently and have a low tech option and I’m just going to talk to you without any Powerpoint, without any Twitter and without any Facebook. And this is carefully organised by the organisers, I have to let you know.

So the first thing I’d like to do is say how absolutely delighted I am to be here. It’s really great to have a follow up to last year’s session and to say it’s a bit of a luxury, in a senior executive position, to be able to have two days to do what I like best, that is mixing with the cancer community. On that note, I’d just like to say that my colleague, who’s in the same position, Brian Richards, gives his apologies for today. He is actually multi-tasking today and yesterday, between this meeting and chairing Health Pact in Brisbane, so just to let you know that.

I would like to begin by acknowledging the Indigenous people, the traditional people and owners of this land, on whose land we meet today and in particular to recognise the substantial ongoing contribution that they make to the work of the Department of Health and Ageing.

And I want to talk to you today about changing models of care to meet future cancer workforce challenges and I want to recap on some of the themes that we’ve heard at this conference, on some of the challenges of cancer, some of which are very familiar with you, but to actually put it into context. One of the things that our overseas visitors to the Department are always impressed with is two things: one is our expected longevity in Australia and the very naturally good public health type features that we have in terms of clean water, good housing and good opportunities. So, as David Currow said yesterday, cancer’s associated highest risk factor is age and so we do have a burgeoning ageing population, and most of you will have seen the kind of coffin analogy of the changing distribution of population. What that means is that by the time we meet 85, one in two men and one in three women are likely to have experienced cancer. That’s a real challenge for us when you look at the increasing cancer incidence, which is probably around 30% for a decade but one of the features that I’d like to bring to your attention is that if we’re going to manage the challenging load of cancer, one of the things we have to do is keep the pedal on prevention and we’re doing extremely well in tobacco and you will have seen the latest results from AIHW last year, where we are now down to about 15.5%, which is world class. Frankly, we’ve got huge obesity rising rates and if you talk to Ian Olver, for example, people in the Cancer Council, people who are involved with prevention, they say that they think this is going to be the next big one we have to watch. So that’s going to be really important for us, along with some of the increasing data on alcohol.

Something which really strikes us on a continual basis in the Department is the increasing complexity of cancer treatment. I think that all of you in this room are very familiar with that, but at a government level and indeed at a financial level, that is a continuing challenge for us, in terms of access to new drugs, to new therapies, to new treatments, often advancing so fast scientifically that we don’t have time to evaluate them and consider them and indeed when we do we’ve got to look at the enormous cost that its placing, in terms of pressure on our health care system. That’s going to increase and in particular, with access to new targeted therapies and genomics, which is definitely something we are looking at very seriously at the moment.

So one of the other things which I think has not really been talked about at this workshop, but it’s certainly something we are looking at very carefully, is the increasing co-morbidities. If you look at some of the recent data on links with diabetes, for example and cancer, I mean increasingly I think what we are going to see among our cancer patients is many more co-morbidities and that means a different sort of treatment modality and it means not just multidisciplinary teams and integrated care within cancer, but indeed across other elements of the health care and caring professions. I think that one of the most dominant themes, and I really enjoyed Cathy’s talk this morning about increasing survivorship and follow up care, we know that there is about 3% of Australians currently at the moment currently living with cancer, but what David Currow didn’t tell you yesterday, or didn’t show the overall figures that came from the Lancet, is that Australia is now leading on that project, where we have over 60% survival overall for all cancers and five year relative survival and what that means is that we’re going to have a huge number of people who are either living with cancer, or free from cancer or indeed, possibly from what we’ve heard from that just extraordinarily inspirational talk last night – the challenges of dealing with cancer even when you are free from recurrence and will it come back or not.

So I think that survivorship and follow up care is really something that we really haven’t dealt with and it has huge workforce implications.

One of the other features that I want to bring to your attention is just a personal view, but I think we do white middle class medicine in this country, but we don’t do so well when it comes to Aboriginal and Torres Strait Islander people, in particular. We also don’t do that well when it comes to different migrant groups. We have a huge influx of new migrant groups who have long term tobacco exposure, that’s really going to change the profile of the cancer wards, I’d suggest to you, in the next couple of decades, and indeed with different profiles in the population I’m not at all confident that when you look across all of the diversity of Australia, that we reach all of those people. And particularly because we tend to report averages in our data. I guess that’s another thing, and I guess a lot of us have really enjoyed networking and talking with each other at this conference and workshop about some of the data challenges and one of the major challenges that I think we have in Australia, in relation to cancer, is I think we have fantastic cancer registries and they tell us a lot about incidence and mortality, but we know practically nothing from the time of diagnosis through to time of death, in relation to the cancer treatment journey. You know, I’m one of the people in the Department who often has to fill out the forms that come from OECD, that come from some of the US sites that we look at, at WHO, and in terms of what can you tell us about cancer waiting times at a national level, what can you tell us about treatment outcomes, you know stage by survival for different groups.

We’ve got a pretty good gauge on breasts, thanks to 20 years investment in that. We have really good pockets of data – Roger Allison just showed me some lovely data from Queensland that they’ve got there. We heard about the really nice data that’s coming from the Buckland Centre yesterday and we’ve got enthusiasts, I’d suggest to you, who do data capture, from diagnosis through to treatment in their own centres and in particular around audit, and again we’ve heard about the Darwin situation. But we don’t yet have a comprehensive way of recording, auditing and monitoring at a national level, what happens from diagnosis to survival, or indeed to mortality. And that’s a bit of a challenge to us at a national level, because of course the data is collected, monitored and indeed paid for at a state level. So we have the issue around federation and what it is that we need, how we need to approach that is an ongoing task and I have to say that it’s not cost neutral.

So, where does that leave us in terms of the workforce? Because that’s been a major theme and I have to say that when we wrote the principles for the regional cancer centres and when we provided advice to government about what would be a sustainable, viable proposition for regional cancer centres and how we would assess these applications to provide advice to government, one of the things that we were focused on was workforce. Indeed, because it’s been bricks and mortar that the government has supported through integrated cancer centres and regional cancer centres, at a Commonwealth national level, we didn’t have the opportunity, wasn’t part of the policy platform that the government provided to us in terms of providing for workforce, but all of us who were involved in this work were extremely conscious of the fact that we didn’t want to be building white elephants. We wanted to make sure that what we had was sustainable, viable propositions.

What that means was a very, very strong focus on commitment by each of the jurisdictions to the workforce requirements for each regional cancer centre and indeed that’s part of the contractual obligations that have been signed up for. I don’t think anybody who works at my level and on a national basis, is naive about the fact that even though we may well have those contractual obligations, to actually provide the sustainable workforce for cancer into the future, to future-proof our regional cancer centres and indeed, might I say, also our metropolitan centres, some of whom have more challenging issues than the regional areas. I think we shouldn’t forget that this has been a regional program, but it was Michael Barton who taught me that often in western Sydney it’s worse than being in Dubbo, or something of that sort. So I think that the big issues in workforce is not only do we face difficulties in recruitment and retention, but the major issue in workforce is the long lead time. And I haven’t actually heard at this conference any sort of discussion about the fact is that what that means is that we have to plan for the future in a way that is quite cognisant of the fact that we won’t actually be producing some of these graduates for at least five to six years. And I know that some of the universities are looking at some ways of fast tracking that, but I don’t actually think we’ve nailed that yet and particularly in cancer, when we have such a rapidly changing field, it’s quite difficult for us to plan for a workforce that is still going to be fit for purpose when they become graduates.

So, the major issue in workforce, I think, is as we’ve just heard is about recruitment and retention and indeed engaging people and making sure they still want to be part of this party. But let’s just turn to workforce for a moment and say, what are some of the challenges we face in this? Well, I’ve been working with a group that’s been taking forward a COAG initiative that I'll tell you about, where we started to look for some of the definitions of what’s a cancer team. And in fact it doesn’t really exist. There are varying definitions, inconsistent across the nation and it depends on what you mean by the cancer team. Do you mean the cancer team that’s about the kind of, what we typically refer to as the treatment team, in terms of the multi-disciplinary care team that might deal with initial cancer presentation, first cancer presentation and planning of treatment? Or do you mean the team that’s going to care for the patient when he or she is back in the local community, or is that the same team, or is there an overlapping part of that team?

The National Breast and Ovarian Cancer Centre throughout its lifetime has done some absolutely first class work on definitions of multi-disciplinary care. Also looking at legal obligations, that’s been a big issue for health professionals in terms of what are their legal responsibilities of working in a team. For a while, that really derailed us, I think, in terms of promoting and supporting multi-disciplinary team care, but we don't have agreed definitions of what constitutes a cancer team. I have to say, even listening to the presentations at this workshop, I am amazed at the number of times surgeons aren’t involved or mentioned as part of the multi-disciplinary team. Although I recognise cancer’s trajectory, such that the patient is often referred from work up in primary care through to a surgeon, then the referral into acute care services in terms of radiation therapy and medical oncology, nonetheless, talk to the patients and they will tell you that this is about the same journey and that this is about the same integrated cancer care.

One of the major challenges in Australia, in terms of the workforce, is about the integration of private and public and I think in cancer we are rather fortunate because we have a very collaborative community, it’s one of the reasons I love working in cancer, I think there are very lovely people who work very effectively with very few issues across the different teams and it just comes unstuck very rarely.
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Nonetheless, the nexus between private and public is not one that we’ve reached some sort of satisfactory agreement on, even though we’ve heard some excellent examples of best practice care in a couple of sites. So this is a big issue for us because not only do we not have good definitions or consistency about what is cancer team care, nonetheless the definitions and the work in this area doesn’t take account of the new techniques which are emerging, new legislation, some of the policy changes and I think we’re still very much back at the drawing board in terms of definitions of workforce and what’s happened in this arena.

One of the other issues that I think is a bit of a major problem, in cancer, in relation to workforce, is the professional silos and barriers to team care and although I think there is a lot of intrinsic goodwill among cancer health professionals in terms of trying to integrate the cancer patient journey, nonetheless, if you talk – I mean I go back to my first experience of running cancer advisory groups more than a decade ago for government and the patient advocates, the cancer advocates, and I think that’s a great term by the way, who told us right then that they didn’t have an integrated journey.

I still hear today from our cancer advocates that that’s the most important thing that people who experience cancer and people who are affected by cancer, that’s what they miss most, is the lack of co-ordination and the lack of integration and the lack of planning. Jim Bishop says, well, it’s a bit like turning up at the airport and not even knowing where you’re going today. Forget about the analogy with safety and quality with aircraft travel, you don’t even know where your ticket is. So I think there are issues about roles, and role delineation and integration of care and I think there are some major challenges that we still have to face.

I haven’t even touched on allied health professionals and I can't tell you the number of times I see cancer teams and the radiologist isn’t on it, or the pathologist isn’t on it and although it’s definitely horses for courses, according to different tumour sites and different patients, nonetheless, I think we’re not really going to make much progress in this country in terms of cancer workforce needs, unless we’re absolutely clear about what is we need for whom, and when and how.

So let’s then turn to workforce shortages and what the key issues are. Well, I think there is still a debate about the absolute numbers that are required to provide effective, high quality, safe cancer care in this country. Although most people in this room would say no, there’s definitely a shortage, we’re not so sure. When you actually look at the issue around scope of practice, when you look at role delineation, when you look at some of the work around that people do both in rural and regional areas and in some of the metro centres, it may well be that we’re not using our workforce in the smartest way. There may well be an absolute shortage – I’m not denying that – I’m just saying that it’s more complex than that.

If you think about workforce, there’s only three ways that you can improve your workforce. One is by growing your own, in terms of universities, the other is by importing workforce from elsewhere, overseas and so on and the third is by role redesign. It’s just a personal view, but I think that if you look at the long lead time in terms of growing the workforce, if you look at the scarcity of resources, the competition for the resources and I see this all the time in cancer nurses, every time we get a head up by particular groups to provide cancer tumour nurses for particular streams, everybody in the acute care sector, our colleagues in Aboriginal and Torres Strait Islander land, our colleagues in primary care say – "Well, hang on a minute, where are those nurses going to come from?" This is about role substitution. We’ve got a finite number of nurses and when you’re robbing Peter to pay Paul, please consider the implications.

Now there is obviously some strengths and weaknesses to those arguments but I would suggest that there may well be one general pool and when we talk about increasing cancer workforce, what are we doing to the rest of the healthcare system? So the Commonwealth has taken some national leadership in relation to some of these issues and the first thing I’d like to talk to you about in terms of some proposed solutions, or some issues to address this, is that the Health Workforce Australia, which has recently been set up, its first major initiative that has been agreed by the Board is to look at cancer workforce on its program.

To profile the current cancer workforce, to identify future requirements and develop innovative shared models of care to address workforce pressures. That’s fantastic for cancer because we’ve never had a comprehensive look at it before. I think we’ve got pretty good data in radiation oncology, in terms of what we do and thanks to much of the work post-Baume. I remember actually chairing the first ROGIC meeting and the fact that I thought we’d never get anywhere in relation to radiation oncology, and look where we are now. We’ve got some fantastic data, some fantastic initiatives and a lot of really great work. Our knowledge and understanding of the medical oncology workforce is frankly quite poor and we don't even know what’s happening in relation to surgery and that’s before we look at some of the allied health professionals.

It’s definitely the case that a lot of the jurisdictions have got really good cancer plans, many of the specific jurisdictions have got workforce plans to address pressures in their state or area and we also have craft groups that are addressing those particular issues, but we don’t have it on a national basis and we don't have a comprehensive, integrated approach. We’re looking to Health Workforce Australia to help and support us, in relation to getting a much better handle on even a profile of the gaps and what we don’t know, as well as some of the really good work that’s been done in this area.
The other really important initiative that I’d like to alert you to is that COAG – Council of Australian Governments said in April 2010 – agreed that much more could be done to ensure consistency in cancer diagnosis and treatment. And they charged Victoria and the Commonwealth together to jointly lead a group, with the support of a national cancer expert reference group, to consider the issues about the most effective cancer diagnosis, treatment and referral protocols to be developed with expert clinical input.

About this time last year, we convened a National Cancer Expert Reference Group which was jointly chaired by Jim Bishop and Bob Thomas, with input from jurisdictions. We asked jurisdictions to please provide their most senior bureaucrat, together with their most senior clinical leader and with some of the smaller places, it was the same person, but to make sure we had input we invited representation from COSA, from Cancer Voices. Australia has a very proud record, I have to say, of having consumer involvement and whenever we get people through the Department they are really quite amazed at how much we do that, but we definitely do have it cemented in, together with input from the Cancer Council and we’ve met a number of times to consider what be some ways forward. It’s premature and inappropriate for me to discuss those deliberations, because of course they will need to go through AHMAC, the Health Ministers Advisory Council, together with through Health Ministers Committee, to go to COAG. But I have to say that the discussion, which might be useful to reflect upon, really revolved about two or three things. One was about the inefficiencies in the current system and I have to say again that hearing from our cancer advocates and talking to the clinicians, what was really was apparent was that we’re not making the best use of a cancer workforce that we’ve got. So for example in the diagnostic work up before patients get to see their surgeons, they tell us the story that they’ve often had the same x-rays, the same diagnostics, work up time and time again, the lack of co-ordinated care means that they front up for appointments, the person on the wrong day or wrong place and yes it’s definitely the case that we have hiccups in our system and actually I think we get it right more often in cancer than in other areas.

Nonetheless, I think there are two important features that result from that. One of the things I’ve learnt in cancer is that the cancer patient journey is often as important to the patient, their carers and families, as is the outcome. We really interfere with optimal quality of life when we have unco-ordinated and non-integrated cancer care. That’s really important.

There’s also a financial out of pocket cost and I think we’ve seen some interesting data today on private and public type features, but I would ask you to recall the fact that one of the important things that our cancer advocates tell us on a regular basis, is horrendous financial costs that they face when they have cancer and how it affects them. That’s a really important thing and if we could improve the efficiency and we think that one of the things we think, and this is a sort of collective wisdom of the people we’ve been liaising with – and I have to say a lot of the members of that committee are in this room and I thank them for their very valuable insights and very hard work, one of the things we think needs to happen is better pathways for cancer care. So one of the things that we have talked about and Cancer Australia has done some really excellent work through their CanNET program is to try and get what is the most efficient optimal, referral based protocols and agreed pathways of care.

I think it’s one of the things that the cancer advocates would have been talking about for a long time. Not only will that yield better quality of life and better integrated care, but frankly it’s going to deal with some of the inefficiencies in the system which we know are there.

Something else we think is really important is about cancer service capability. When we thought about, constructed and designed the regional cancer centres, we were absolutely clear about the fact that not every regional cancer centre should be treating every cancer patient in their area for every tumour site, for every stage. We know that best practice cancer care, as Bruce Mann was talking about yesterday for pancreatic care, is to get that patient as quickly as possible into a tertiary teaching hospital where you’ve got a strong volume outcome relationship. I have to say the UK data shows that volume outcome relationships are really important. So capability of cancer services – Victoria has done some excellent work in this area, in terms of looking at what it is that the service needs to be able to provide, rather than what the individual needs to provide and one of the things that Bob Thomas always says to me is “You know, I can do an oesophagectomy, Rosemary, pretty much where you need me to, but I wouldn’t, because the issue is do I have the cancer service capability, do I have around me the support staff and the equipment and the facilities and what I need to be able to deliver high quality, safe, effective care”.

And that’s about the service rather than the individual. So I’d suggest that one of the things we need to do, one of the challenges for role redesign, is to stop thinking about individuals so much and start thinking about the cancer service and the capability of the cancer service and what is it that that service can do. There is definitely some regional centres which might be able to do rectal cancer and there are other regional services that frankly don’t have the case load, don’t have the experienced clinicians and don't have the capability and needs to be triaged with an integrated network service. So we think that one of the important things is about integrated network cancer services. It could be a hub and spoke model, it could be a network model, it could be something that’s a linked model and we’ve heard lots of good examples of that. But we need to think a bit in a slightly more clever way about the capability of the cancer services. I guess one of the other things that we think is going to be really important in relation to future proofing optimal cancer care, is about the systematic application about evidence-based treatment and that’s about teams and that’s about making sure that we’ve got some checks and balances, but frankly that’s a personal view. But one of the best things I think about a multi-disciplinary team is that it protects the patient from the weakest link, and I think that’s one of the things we don't often say, but it’s true.

So it has to be profession led, a lot of these changes. We in government can’t tell clinicians, nor should we be telling people about what it is that you can and can’t do. You know yourselves what you’re capable of, you know what is best practice care and it has to have the patient at the centre. So it’s still true that the national service improvement framework that we designed so long ago has the patient at the centre of care and I think if we keep that focus in mind, then we’re likely to be able to provide the safest, highest quality best practice care and we’ll be able to continue the excellent record that we have in cancer.

Thank you.

(applause)

Norman Swan:

Given that Rosemary’s on the panel, we’ll have ample time for conversation later, so I might just leave it for now, because we have to finish so that we can rejoin the two rooms. Could you please join me in thanking our excellent speakers. A very energetic session, enjoy coffee and we’ll be back in here at 3.25.

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