Acute Health Division
Department of Human Services
Victoria, Australia

 

Review of Radiotherapy Services
Victoria, Australia

Discussion Paper and Submission Guide

August 1997

A Review conducted for
the Victorian Department of Human Services

by

ACIL Economics and Policy Pty Ltd

Economics, Policy and Strategy Consultants

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Table of Contents

1. Introduction

2. Previous Reports and Recommendations

3 Demand for Cancer Services and Radiotherapy

4 Supply and Configuration of Radiotherapy Technology

5 Consumer Issues

6 Options for Radiotherapy Services

7 Consultation Process

8 Submission Guide

9 Key References

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1. Introduction

Objective of this Review

The Victorian Department of Human Services (DHS) has initiated this Review to provide the Government with an analysis of options for future development of Radiotherapy services. The Review will examine implications of these options to inform the Government's decisions in relation to radiotherapy services policy.

ACIL Economics Pty Ltd has been commissioned by the Victorian Department of Human Services (the Department) to undertake the Review. This document is the first to be released as part of the Review, culminating in a final report to the Department by January 1998. The release of this discussion paper coincides with a call for submissions to the Review. The paper provides background to the Review and an overview of some of the key issues raised by stakeholders.

The Review will produce a final report that outlines options for the development of Radiotherapy services in Victoria. The implications of these options will be explored to provide a framework for future decisions. The final report will provide a perspective on the costs and benefits of options for the provision of Radiotherapy services and the qualitative perspectives of stakeholders.

Government Policy Directions

Radiotherapy and cancer services are undergoing changes due to the rapidly changing nature of treatment protocols and technology. Other policy reforms in the organisation, financing and delivery of health services also affect these services. In such a rapidly changing environment, a review of services is timely, in order to monitor the development of cancer services in general and radiotherapy services in particular. The government is seeking a sustainable long-term strategy that fulfils its policy objectives.

The Victorian Minister for Health released a Plan for Metropolitan Health Care Services in October 1996 which set out the Government's policy directions for Hospital and health services. This incorporates:

• Locating services closer to where people live
• Shifting services from an institutional to a community based setting
• Improving access to specialised services
• Developing services to meet the growth in health needs of older people
• Providing services from efficient appropriately located facilities

The government's principles in planning for the delivery of these services is based on improving the health and well-being of all people through a focus on health needs, through effective and efficient services across the government and non-government sector. The Government recognises that health services rely on a range of professional teaching and research activities in addition to direct patient care. The Government also seeks to promote genuine arm's length capital investment decisions in radiotherapy services.

Consultation

The consultation process for this Review has been shaped through an Advisory Committee comprising key stakeholders and experts in the field. Consultation has also occurred more broadly involving staff from radiotherapy units, DHS staff, the Anti-Cancer Council of Victoria (ACCV) and others.

Submissions from interested individuals and organisations are now being sought. Submissions will be received until the end of September. Following the receipt and collation of submissions, ACIL will evaluate this information with input by the Review Advisory Committee, other stakeholders, key informants, and the DHS. Technical and clinical information will also be gathered. A workshop is planned to enable wider discussion and examination of key assumptions and potential strategies.

2. Previous Reports and Recommendations

AHTAC report, 1996

Recent work by the Australian Health Technology Advisory Committee (AHTAC) summarised the present knowledge of the key issues in the field of radiotherapy. The report ("Beam & Isotope Radiotherapy", December 1996) contained several key recommendations to improve radiotherapy services in Australia, including :

• radiation oncology be organised through networks of services that provide coordinated, comprehensive care in multimodal settings,
• efforts are made to decentralise services to enhance access for consumers.

Greater education of the health workforce in general is also thought to be necessary, because the full benefits of radiotherapy are not as widely known as they could be. Oncologists in general, and Radiation Oncologists in particular have a role in ensuring that information is widely available to assist referring practitioners in determining whether radiotherapy is an optimal course of treatment.

Victorian Reviews

The major reviews of radiotherapy services in Victoria include the Lovell Inquiry in 1985, and the Cancer (Radiotherapy) Services Strategic Plan in 1990.

The Lovell inquiry recommended the redevelopment of the Peter MacCallum Institute and the creation of a second principal centre in the South Eastern Melbourne Region, along with associated referral services. The inquiry highlighted the potential cost and access disadvantages for patients from non-metropolitan areas. The Lovell report also proposed guidelines for the equipment requirements for a radiation oncology department, which have subsequently been adopted by other studies and influenced the development of radiotherapy services in Victoria over recent years.

The 1990 strategic plan continued and updated the issues examined by the Lovell inquiry, and recommended an increase in the number of megavoltage machines to 19 by 1996. This would be achieved through two groups of services. Firstly, redevelopment of the Peter MacCallum Cancer Institute (PMCI), and a distribution of machines in association with the PMCI at Geelong and Heidelberg. A second service network would operate through the Alfred hospital and Monash University with machines also at Box Hill and Moorabbin.

Current Status

The recent plan for Metropolitan Health Care Services recommends that the PMCI and the William Buckland Radiotherapy Centre at the Alfred Hospital maintain current roles as coordinated statewide cancer service providers in conjunction within the Inner and Eastern Health Care network.

The current numbers and distribution of machines is in accordance with the 1990 strategic plan, however, the organisational arrangements have not resulted in PMCI having any direct association with either the Geelong or the Heidelberg units. The PMCI currently operates Box Hill and Moorabin as satellite centres, rather than the Alfred, as originally proposed in the 1990 plan.

3. Demand for Cancer Services and Radiotherapy

Cancer incidence

According to the recently released report by AHTAC, the incidence of cancer in Australia has increased from 3,440 per million in 1988 to 3,979 per million in 1995, representing an increase in incidence of around 2.1% per year. If this trend continues, then the incidence of cancer may be around 4,500 per million by 2001, and 5,000 per million by 2006. This increase is primarily due to the ageing of the population, and changes in the incidence of specific cancers as a result of changes in exposure to risk factors.

All areas of Victoria will be affected because of the ageing of the population. While the Victorian population is expected to grow by around 8.2% over the next ten years, the population of over 65's will increase by 12.3%.

Radiotherapy

The percentage of all patients in Australia with cancer who receive radiotherapy at some point in the management of their cancer ranged from less than 40% up to 47% in WA. The recent AHTAC report pointed to Australia's relatively dispersed population, compared to Europe and America, as a factor influencing the lower rate of referrals to radiotherapy and recommended a rate between 50 and 55% be used for planning purposes. However, while this figure is generally accepted, clear justification for a specific referral rate is lacking.

Radiotherapy services in Victoria are concentrated in Melbourne, and in the Inner East of Melbourne. Geelong operates a two machine unit that services the local catchment and a wide rural catchment. Despite this development, it is generally acknowledged that rural patients have significantly diminished access to radiotherapy services. Within Melbourne also, the population of the Western Network has no direct access to radiotherapy services, despite the Western Network having one of the highest rates of population growth.

4. Supply and Configuration of Radiotherapy Technology

In excess of 95% of all radiotherapy treatment is delivered by linear accelerators. Current technology allows linear accelerators to treat around 40 patients per day, for a typical nine hour day. However this figure is highly dependent on the types of treatment offered, and the standard operating hours of the unit. Units used for special treatment techniques such as multiple daily fractionation, whole body irradiation or convergent beam radiotherapy have lower overall throughput, as these procedures are more time consuming and consequently reduce total throughput.

The types of cases for which Radiotherapy is an appropriate therapy varies across all types of cancers. While it is somewhat simplistic to categorise these cases, broad groups could be thought of based on types of cancers and types of treatment normally needed, for example :

• Malignancies which are amenable to treatment using relatively standard techniques. Many of the more common cancers such as most prostate, breast and lung cancers fall into this category, and
• Rare malignancies, and those requiring complicated time consuming techniques, and/or high technology procedures, such as brachytherapy, paediatric cancers, head and neck cancers and many gynaecological cancers.

Radiotherapy may also be thought of as primarily palliative, involving relatively short courses, or curative, in which the tumour is normally irradiated on a daily basis over a period of around two to three weeks. Because of the diverse range of treatments which may apply, the AHTAC report describes measures of Radiotherapy unit activity or throughput in terms of patients treated and the number of attendances for treatment. More detailed measures of the number of fields are also used when determining resource utilisation and payment levels.

From this perspective, the difference in the resource requirement of palliative and curative treatments can be seen. Whilst the proportion of palliative to curative patients may be around 50 % (generally slightly less), palliative patients generally require less attendances, and fields. This then means that around 80% or more of the resources used in radiotherapy are for curative treatment.

Costs and configuration of Radiotherapy services

The major capital items to be considered for radiation oncology are linear accelerators themselves, up to $2m. However, the building infrastructure, and associated capital, plus supporting diagnostic, analytical and computer equipment add to the substantial up front capital costs of establishing radiotherapy services. Operating costs vary but are around $1.5 million per machine per year.

There are a range of opinions regarding the optimal size and structure of radiotherapy units. Many clinicians do not believe single machine units are viable and cost-efficient, however this view is not universally held. Two to four machine departments are often favoured in new developments. However, large units (5+ machines), with extensive research and teaching functions, plus a wide range of specialist and tertiary treatment modalities are also thought to maximise links with other treatment services and provide comprehensive care.

Some overseas studies have revealed differences in costs and treatment outcomes for units of different size and type, which indicate superior effectiveness, and outcomes from larger units. However the evidence may also be interpreted as indicating superior performance for units which have well established links to comprehensive cancer services (ie. Medical and surgical oncology) and teaching, research and continuing professional development facilities, rather than on the basis of size and throughput alone. Relatively larger units also have advantages in attaining and maintaining a high level of quality and effectiveness through their ability to attract staff, and the pivotal role they play in the treatment f complex cases.

Planning Guidelines

Guidelines proposed in 1989 by the Australian Health Ministers Advisory Council estimated that one machine is required for every 440 new cases. A more recent guideline published by the Commonwealth Department of Human Services and Health suggests 8,280 treatments per megavoltage machine per year based on a nine hour day. A unit's throughput capacity will depend on casemix and the provision of special treatment techniques.

The current average of 17 treatment sessions or increments per patient would enable each machine to treat around 480 patients per year. Given that around 15 to 20% of patients are re-treatments, this equates to around 400 new cases per year, only slightly less than the estimate from the late 1980's. The actual throughput of units is highly dependent on its hours of operation, and other constraints, such as the availability of staff, maintenance and technical support, and the rate at which patients are referred for treatment. It is also important to note that Radiotherapy remains a rapidly changing and developing therapeutic technique, requiring periodic assessment and review of operational and planning guidelines.

1990 Planning guidelines

The Department's 1990 strategic plan proposed a planning model to determine the number of machines required in Victoria. This took account of :

• Existing and planned centres, and the need for specialised principal centres to support specialist teaching and training, plus research.
• Current and project needs, with consideration of patient access
• Key recommendations of the Lovell and subsequent reports, for example, the Government policy of 1988 to redevelop PMCI,
• Agreement regarding two principal centres linked to Universities for Teaching and Research,
• The Commonwealth Department of Veteran's Affairs establishing services at Heidelberg
• Workforce, Education and Research Issues
• There is a common view that all units, but specifically major tertiary units have significant teaching and research functions, and require established links, interaction and other resource sharing with University Medical Schools and research institutions.
• Research activity has been criticised by some stakeholders as not sufficiently focussed on clinical trials to develop and refine more effective patient treatment protocols.
• Previous forecasts of demand, which will be re-assessed by this review, indicate additional Radiation Oncologists will be required to meet demand. Specialist training and Continuing Medical Education should therefore be an integral part of service development, requiring resources and commitments by employers, plus flexible approaches to research, study and professional commitments.
• Many stakeholders believe that all units, but specifically major tertiary units must also ensure that appropriate and effective links exist for training and orientation in Radiation Oncology for other relevant specialties, eg. Surgeons, Medical Oncologists.
• Other Professional training and education requirements are necessary for Radiation Therapists, Physicists, and Nursing and allied health staff.
• Specifically for Medical Physicists, there are concerns regarding the shortage of physicists entering the industry, resulting in some instances of relatively inexperienced people talking up senior physicist positions.
• Medical Physicists also lack a coordinated and agreed professional development path. Many senior physicists believe some form of vocational post graduate study is necessary, providing necessary education in health and life sciences, and in the requirements of physics in radiotherapy.

5. Consumer Issues

The 1996 AHTAC report identified a number of issues and concerns for consumers, many of which have been encountered in initial consultation for this Review. These include :

Access to services

• Comprehensive cancer services, including radiotherapy are not always available at a comprehensive level in outer urban, rural and regional communities. For these patients, the direct and indirect costs of travel and accommodation, plus absences from family and friends, can be significant. This is particularly the case for patients from remote rural locations, where multi-day overnight stays may be required to receive radiotherapy treatment.
• While consumers may have some alternatives available to them, either for curative or palliative services, radiotherapy is often a superior form of treatment. However, while reasonable geographic access is important to consumers, quality of treatment is also, and many consumers fear that small units may not have the same level of experienced clinicians and therapists.
• Other consumer based concerns relate to availability and accessibility of health services at times that suit the consumer. Currently, most radiotherapy units provide a nine hour per day. Other States, and Victoria in previous years, have operated extended shifts, which have been preferred as more convenient by many consumers.

Quality of life

• Cancer affects the quality of life of patients, and the families of patients, since they provide much of the personal care and support to the patient. Cancer patients are often very ill and their treatment prolonged. The families of cancer patients are also affected, since the illness is often prolonged, may relapse even after successful therapy, and frequently results in the eventual death of the patient.
• Of the cancer treatments available, radiotherapy, as opposed to surgery, or chemotherapy, involves less trauma, and fewer risks and side effects. It also enhances the effectiveness of other modalities of treatment. Affordable, accessible radiotherapy is of major benefit to cancer patients, and their families. The primary concern for most consumers, and their family and carers, is that the treatment be safe, effective and affordable.
• Safety requires that the treatment not place the patient at greater risk of illness. Unfortunately, delivering therapeutic procedures almost always involve some risk to the patient. This is the case with cancer treatment. Surgery always involves some risk during anaesthesia, while the side effects of other therapies, including chemotherapy and radiotherapy for cancer patients, can be uncomfortable, disfiguring, or debilitating. The knowledge that a cancer service is safe, or that risk is effectively managed is important for consumers.

Education and information

• Consumers have expressed a view that information regarding diagnosis, treatment, and prognosis is important, so that they can be fully informed when making decisions. The early involvement of the patient, and, where appropriate, their family can lead to more effective and long term treatment.
• Consumers value information regarding their illness, the types of therapy available for them, and the knowledge that a therapy will be effective in treating their illness. The effectiveness of radiotherapy is considered high amongst cancer therapies, and is usually enhanced when used, where indicated, with other modes of therapy, either as a primary or adjunctive therapy.

Rural and Regional Issues

• Service to rural and remote areas is affected by the need to maintain some degree of concentration of expertise and critical mass. This implies that services to rural and remote area must be on an outreach basis, imposing travel costs and clinical limitations.
• Services to rural and remote areas should include the development of skills in oncology diagnosis and case management for rural and remote primary health workers, including GPS, Primary Care Nurses, and where appropriate, Aboriginal Health Workers.
• Primary care services (eg. General Practitioners) should receive accurate and up to date advice regarding options for radiotherapy and referral networks.

Quality and Health Outcomes

• Health outcomes, and consumer perceptions of services suggest that radiotherapy should operate as part of an integrated cancer service to take advantages of benefits of multimodal therapy. This requires the capacity for combined clinics and sharing of clinical and support services.
• Radiotherapy operates through a highly skilled multi-disciplinary team. Clinical and professional staff should ensure the development of clinical pathways and protocols to reflect current best practice and local circumstances.
• New Technologies provide both incremental improvements and radical change in radiotherapy planning, treatment regimes, and anticipated outcomes. Units should have access to up to date technology, and develop networks at local, State, National and international level to monitor and assess new developments. However, access need not imply that such facilities and technology are available on-site, but through established affiliations and associations amongst Radiotherapy units.

6. Options for Radiotherapy Services

Options for future distribution of services

The distribution of linear accelerators is acknowledged to be concentrated in the inner east of Melbourne. An increase in the supply of machines appears justified, subject to more detailed analysis. However, amongst the suggestions for additional service capacity put forward to date, are:

• Establishment of new public services in the Metropolitan outer East, South, West, and rural areas, such as Ballarat, Bendigo, Traralgon and Albury-Wodonga.
• Reduction or redistribution of units from the Inner and Eastern Network
• Facilitate private sector developments either separately, or collocated with new or existing public units
• Review of hub and spoke arrangements for both hub and spoke centres, and
• Combinations of some or all of the above

Health Care Network Configuration

The establishment and subsequent changes to the structure of the Metropolitan Health Care Networks affects Radiotherapy services in that competing centres can be in the same network, yet satellite (or "spoke") services operate through different networks. A number of stakeholders have questioned whether :

• the current network arrangement is a limitation on the effectiveness of radiotherapy services,
• the "hub & spoke" model can work effectively within a network system, and even,
• a hub & spoke model is appropriate, and what format it should take.

Funding for Radiotherapy services

In the period since services were previously reviewed, Victorian hospitals have undergone a substantial budget cut, combined with a move to casemix based funding for inpatient services. Most recently, and relevant to this review,

• The casemix funding model will now include outpatient, or ambulatory cases. Radiotherapy services are primarily provided on an outpatient basis and will be funded through a price * volume arrangement. The compensation payments will be retained in 1997/98 and funding to radiotherapy units will not be affected. Further development is proposed leading to full implementation in 1998/99.
• The creation of the Metropolitan Health Care Networks (HCNs) has resulted in the two major tertiary services, the Peter MacCallum Institute, and the William Buckland Unit, at the Alfred hospital, coming under a single Network management.

The Victorian Department of Human Services and Health has recently completed a study of radiotherapy costs across all units in order to establish appropriate unit costs, which would form part of the overall throughput, or casemix based funding model. Because of concerns regarding the accuracy and appropriateness of the classification system, and the prices used, the model will not be implemented in full in 1997/98.

The budgets of each of the units will not be affected directly in 1997/98, as a final decision on the structure and implementation of the funding model will be taken later this financial year. The model is intended to eventually provide for a payment to each of the units based on throughput, measured through appropriately defined measures of the number of fields, dosimetry, simulation, and consultations.

The budget of each of the units is also adjusted according to a proportion of the revenue raised through charges against the Health Insurance Commission according to the Commonwealth Medicare Benefits Schedule (CMBS) fees. The major concern amongst radiotherapy units is the potential for units to be disadvantaged because of variation in their policies in respect of the disbursement of fees between clinicians and the facility. Some stakeholders think that the use of a fixed percentage (75%) does not reflect the different approaches used across radiotherapy units.

Management and Reporting Issues

Data Recording / Reporting requirements and the links to funding systems should be clear and well understood by service delivery units. Consistency and accuracy in data and other information collection is necessary for monitoring and evaluation. Confidentiality of patient information must be assured. The ultimate aim in establishing accurate and relevant information systems is to facilitate outcomes monitoring and ensure that treatment protocols are evidence based.

Role of the Private Sector

Complementary to the changing roles of health services within the public sector, will be the relationship and interaction between the public and private sector. Further developments may also lead to greater competition between public and private facilities for the provision of services to both public and private patients. The Department is examining a range of options for private sector involvement in health services that could see public patients treated in private facilities under contracts with the public system.

Options for service development could include direct capital investment by government, or mechanisms and incentives which encourage private sector input, which in turn has implications for the structure of contracts and other funding arrangements. The cost of options to the public sector should be clearly identified, and taken into account in determining the merits of various options. The role of the private sector as a source of capital, or alternative service provider is a key issue for this Review.

Contestability

The Government has a policy of encouraging more effective and efficient use of the private sector in provision of public services. This will imply that future radiotherapy services provide to public patients will be provided by both public and private facilities according to principles of contestability. The approach to capital funding is particularly relevant in this respect. The Government seeks to promote arm's length capital investment decisions in Radiotherapy services to ensure value for money through competitive bidding, proper allocation of risk, and enhanced flexibility.

7. Consultation Process

The Review will be publicised through advertisements placed in the Age and Regional newspapers on Saturday August 23. Letters will also be sent to Public Health services and Networks advising of the Review and requesting their input. Key stakeholders in the health sector, and experts in the field of radiotherapy will also be consulted, including the Royal Australasian College of Radiologists, the Australian Institute of Radiographers, the Australian College of Physical Scientists and Engineers in Medicine and other key informants.

Submissions will be received until September 30, after which time ACIL will evaluate progress in the Review in conjunction with the Advisory Committee and the DHS. Final consultation will occur through October and November, with the development of recommendations and a draft report planned for December. The final report of the Review will be presented to DHS prior to 31 January 1998.

8. Submission Guide

At this stage of the Review, ACIL is seeking input from all interested individuals and organisations in relation to the aims and objectives of the Review, and the major issues identified. Input is sought from the health sector, consumers and the community.

The framework set out below is suggested for written submissions to the Review, However, contributors should not feel obliged to comment on all issues. Contributors may also include any additional comments relevant to the Review. Submissions to the Review will be held in confidence, and not released without permission of the contributors.

Format for Submissions to the Review of Radiotherapy Services (Victoria)

• Name of individual or organisation
• Contact person(s)
• Your involvement with Radiotherapy, cancer or associated services
• Your specific interests in regards to Radiotherapy
• Specific comments against key factors and major issues raised in the Review, that is comments in relation to :
• Demand for Cancer Services and radiotherapy
• Supply and Configuration of radiotherapy Technology
• Consumer Issues
• Options for radiotherapy Services in Victoria

9. Key References

There have been a number of major reports and papers written regarding Radiotherapy over the past ten years. The reference lists contained within these reports also refer to numerous other reports and published literature that outlines the recent developments in radiotherapy, results of clinical trials and other research into the effectiveness and applications of radiotherapy.

Inquiries regarding the availability of these reports may be directed to the relevant organisation. ACIL and DHS have limited copies of these reports.

Department of Human Services, Victoria

Report of the Ministerial Committee to Review Cancer Services in Victoria (October 1985)

Cancer (Radiotherapy) Services Strategic Plan (Health Department Victoria, March 1990)

A Healthier Future - A Plan for Metropolitan Health Care Services, (Victorian Department of Health & Human Services, 1996)

Victoria - Public Hospitals : Policy and Funding Guidelines, 1997/98

Australian Health Technology Advisory Committee (AHTAC)

Report of the Working Party on Beam and Isotope Radiotherapy, (AHTAC: NHMRC, December 1996)

Anti-Cancer Council of Victoria

"Cancer in Victoria 1993" Canstat No. 22, August 1996

"Trends in Cancer Mortality, Australia 1910 - 1994" Canstat No. 24, January 1997

Other references

Morgan, G (1996) "Development of Radiation oncology Services in Australia", International Journal of Radiation Oncology, Biology and Physics, Vol 36, no.1: p 219 - 232

Langlands A & Morgan G (1993) "The problems Facing Radiation Oncology in the 1990's", Cancer Forum, 17: p 2 - 17