Review of Radiotherapy Services Victoria

Recommendations

As a result of the analysis undertaken, ACIL has concluded that a highly prescriptive radiation oncology strategy would be a serious mistake, in that it would not provide the flexibility to respond effectively to new information as it emerges, it would diminish the role of both the private sector and competitive tendering processes to identify new opportunities and directions and it would almost certainly imply that the Victorian Government would need to accept a significantly higher proportion of the costs associated with providing the services and facilities needed to meet growing demand for radiation oncology services. This is likely to reduce the value of the services delivered and to constrain options for improving service delivery elsewhere in the health system.

In broad terms, ACIL has concluded in favour of, and recommends, a strategy which is designed to cater for, and encourage, increased demand for radiation oncology services. Key planks of this strategy should include:

Commitment to wider distribution of accessible (in terms of location and hours of operation) radiation oncology services, including consultation, treatment planning and treatment delivery (but not necessarily integrated within the one facility), to reduce consumer costs. This would occur across Melbourne and, subject to the successful undertaking of a proposed trial of a single machine facility outside of metropolitan Melbourne, in a number of rural locations.
A significantly changed role for the major tertiary centres, with them increasing their consultation and planning services relative to their treatment services; focusing their treatment services more heavily on patients in whom multidisciplinary disease management and/or technical aspects of radiotherapy are complex; and playing a crucial leadership role in respect of research, training and quality assurance across the system as a whole. Major regional facilities, such as Geelong, might also expand these non-treatment services, but not at the expense of delivering comprehensive treatment services. Given these changes, it is not considered appropriate to build treatment services on the Royal Melbourne campus, but there may be scope for this campus to deliver specialised hub services in conjunction with one of the major tertiary centres.
Increased emphasis on delivering balanced information to cancer patients and referrers on which to base decisions as to treatment regimen.
Strategies to address a likely major constraint on the ability to grow capacity rapidly - numbers of skilled personnel.
Development of an active policy of the Government seeking to engage both public and private service providers, actual or prospective, to ensure the cost effective delivery of the needed services.

This will commonly involve competitive processes and there are specific recommendations to ensure that the Government retains strategic options to underpin its negotiating position and to ensure gaps in service provision can be addressed cost effectively.
As a general proposition in relation to new service delivery, the primary role of Government should be one of complementing and influencing the decisions of private service providers, rather than of crowding them out - but this does not preclude commitment to public facilities which would detract from the commercial viability of private investments if this is the most cost effective way of ensuring adequate access to services for public patients.

A conservative approach to the initial roll-out of services to ensure adequate control of the risks associated with inadequate throughput or pressures on quality standards, but the use of monitoring and reassessment processes to allow adaptation to the additional information generated.

More specifically, the following recommendations are made:

Utilisation rates for planning purposes

1. That DHS accept radiotherapy utilisation rates of 50-55 per cent as reasonable for the purposes of 10-year planning, subject to monitoring the success of strategies to ensure an adequate supply of skilled professionals.

That it be accepted that these rates are unlikely to prove too low, in terms of appropriate medium term planning targets which take into account the range of social costs, but that resource constraints may prevent them from being achieved in this time period.

Balanced information

2. That DHS liaise with the various colleges to encourage the development of a strategy, possibly based around the release of both the final AHTAC report and this review, designed to improve the information available to both referrers and patients when addressing treatment choices - in order to encourage utilisation rates closer to the ‘socially optimal’ level.

Service delivery structures

3. That DHS endorse the progressive expansion of radiotherapy services using a broadly defined ‘hub and spoke’ configuration. New developments should complement existing local cancer services, in addition to forming part of a larger Statewide network based around major providers.

This will almost certainly involve multiple hubs and should not preclude the possibility that some hubs would consist of more than one campus or that some spokes could mature to the point where they begin to offer hub services, on their own or complementing those of their former hubs.
The precise nature of these hub services should be driven, principally, by the demand from the peripheral centres to satisfy appropriate quality standards - rather than being heavily prescribed. However, it is envisaged that a total hub will need to demonstrate the capability to manage all degrees of patient care, to have a complement of radiotherapy equipment for all but experimental treatments and, to have documented quality assurance and peer review programs in place and of a form suited to extension to peripheral facilities. It is likely also that most hubs would have active programs for registrar training and clinical research.

Refocusing of major tertiary centres

4. Underpinning this, the existing major tertiary centres (possibly including an expanded Geelong facility) should be encouraged to develop their capacities to compete for and deliver ‘hub services’ in the form of consultation and planning services running out to the spokes, probably incorporating clinics and increased use of telemedicine; delivery of quality, subspecialisation treatment services in respect of complex/rare conditions to patients referred from the spokes; quality assurance across the configuration; and leadership in R&D and training.

It should be recognised that most of these capabilities are already established and that there may well be steadily reducing demand for these providers to deliver more routine radiotherapy treatments, so the issue is more one of commitment and incentive than of significantly expanded aggregate resources, but their will be co-ordination, communication and service delivery costs to be covered.
Active competition to provide cost effective hub services is seen as desirable and feasible.
Reflecting the value and desirability of consumer and referrer choice, decisions as to the number and type of machines installed at the main campuses, and the extent to which they continue to provide less complex treatments which might reasonably be provided away from these centres, should be demand driven - ie, based on achieved throughput rather than imposed.

Priorities for regional metropolitan facilities

5. That, based on analysis of likely trends and numbers of accelerators already installed, short term priorities for increasing machine availability within Melbourne should be Metropolitan Western, followed by Metropolitan Southern and Metropolitan Eastern, although the demand for additional machines is likely to be strongest for Metropolitan Southern.

It is not expected that additional machines will be needed in inner Melbourne for some time (though there are needs for replacement, discussed below) and there is sufficient spare capacity for Metropolitan Northern at Austin Hospital to allow development there for it to be treated as a medium-term priority.
Given the nature of the development options in these three regions, it is feasible to look to expansion in capacity in all three regions simultaneously and this is recommended.

6.The Metropolitan Western catchment appears suited to supporting two machines, largely independently of the assumptions regarding leakage rates, but with a low leakage rate suggesting that it will approach capacity to support 3 machines over the next several years. Options for location essentially reduce to - Footscray, where there is an advanced proposal to install one machine into a 2-bunker design in the near future - and the Sunshine Hospital campus.

Given the very different socio-demographic profiles found across the region, a purely private facility at Footscray is unlikely to offer acceptable access for the region for all patients.
It is recommended that DHS recognise and secure Sunshine as a strategic option by including a 2-bunker facility in the design footprint, with a medium-term time horizon of 4 years for the first machine to be operational there, conditional on the outcome of the following processes.
It is further recommended that DHS enter into negotiations with EMROC and with other parties who express an interest, to secure cost effective access to radiotherapy services in the region for public patients. Options include a negotiated CSO arrangement for public services to be provided out of Footscray, a public facility to be installed at Sunshine or the location of a private facility, with a contract to deliver public services, on the Sunshine campus.
ACIL considers it likely, even given the recommended commitment to Sunshine as a strategic option, that one machine will be commissioned at Footscray and that the key issue will then be the location and management of the second machine in the medium term. This is sensibly approached through competitive negotiation, preferably commencing before the decision on Footscray is irreversibly taken and including options which do not involve its proceeding. Assuming one machine has been installed at Footscray, and a second bunker is in place, pure provider cost considerations would tend to favour expansion at Footscray but a range of other factors would need to be addressed in the negotiations. Low leakage rates and strong growth in demand may make a two machine facility at Sunshine attractive.
If development is to proceed at Sunshine, it should involve a strategic alliance with at least one supplier of hub services, and this should again be negotiated competitively.

7. In the short term, it is recommended that the needs of Metropolitan Southern be addressed through an expansion in facilities at Moorabin. Moorabin currently has 2 machines, and the analysis suggests that the catchment could support 4 to 5 machines in the medium term.

The priority should be to add one more machine at Moorabin but to do so in a manner which secures cost effective options for further expansion.
Recognising that adding a machine to Moorabin will require redevelopment of the site, consideration should be given, in considering redevelopment options, to scope for adding at least one further machine in the medium term. This might include longer term development of Moorabbin as a tertiary radiotherapy facility providing Brachytherapy and enhanced sub-specialisation, but this would need to be subject to satisfactory resolution of the issues associated with satisfactory provision of in-patient support services.
In the medium term, a fresh, additional site in Metropolitan Southern could be expected to further reduce access costs and to be consistent with projected demand. This option would probably be best addressed proactively by DHS in calling (once demand trends are apparent) for expressions of interest as to site and facilities, subject to the competitive pressures from other bidders and the option of expanding the facilities at Moorabin.

8. With the facilities at Ringwood and Box Hill, Metropolitan Eastern currently have two machines, while the projections suggest medium term demand for 4 to 5 machines. Short term expansion by one machine, with a view to adding one to two additional machines in the medium term, appears sensible and is recommended:

It is recommended that DHS secure an option for influencing at least the medium term development of services in this region by ensuring that, if the Knox hospital is to include comprehensive cancer care, provision be made in the footprint for the Knox for a two bunker facility.
It is further recommended that DHS enter into negotiations with the service providers at both Ringwood and Box Hill with a view to ensuring cost effective access to services by public patients. Options to be considered are essentially the same in form as have been specified for Metropolitan Western.
ACIL considers it likely that the short-term outcome of this will be the provision of an additional machine at Ringwood, which is likely to be cost effective in delivering one more machine, but a much wider set of options arises to deal with further growth in facilities in the medium term if two additional machines are needed.
ACIL considers that the Eastern suburbs would be overprovided if services were located at PMCI, Box Hill, Ringwood and Knox. Options could include the negotiated relocation of the Box Hill facility to Knox as part of a medium term expansion in the number of machines.

9. It is recommended that DHS give serious consideration to the proposal to expand Geelong to a three machine facility, with the inclusion of Brachytherapy.

This would provide a valuable expansion in the range of services available in this region and might underpin the medium-term development of Geelong as a tertiary facility with increased subspecialisation and as a useful provider of hub services, perhaps focusing principally on its wider region.
The short term viability of this strategy would, however, be dependent on (and should be a factor in) any decision on a suitable site for trialing a non-metropolitan single machine facility, as recommended below. It would make less sense if Ballarat were the chosen site.

Non-metropolitan

10. That DHS seek to reach agreement with the Commonwealth as to a set of quality assurance criteria to be met by a single machine unit in order that it qualify for Commonwealth funding during a period of evaluation of the long term role of single machine units; it is expected that the agreed criteria would incorporate the main criteria set out in Section 3.4 of the main body of this report.

11. Subject to this agreement, that DHS agree to facilitate actively one, and possibly two trials of such a facility as follows:

That DHS endorse the proposal to establish a single machine facility at Albury or Wodonga, recognising that such a unit is likely to grow to the two-machine size in the medium term. ACIL understands that the proposal may be modified to include two machines from the start by incorporating an older as a back-up unit; this would clearly constitute a more limited trial but is likely still to yield valuable insights given that the second machine would not normally be operating.

This facility could be part of a ‘hub and spoke’ arrangement with either a Melbourne or Sydney radiotherapy unit, depending on subsequent negotiations between Victoria, NSW, and the Commonwealth; in view of the unusual geography of the site, consideration could even be given to alternative models involving formal links to both Melbourne and Sydney facilities. In practice, the natural referral linkages will probably favour a relationship with one of the Melbourne hubs.

That DHS commit to a second trial of a single machine facility, at a site outside of metropolitan Melbourne which is unlikely in the foreseeable future to grow beyond single machine size, with the choice of a site for the trial to be based on:

Potential demand for the service;
Demonstrated links to local comprehensive cancer services and metropolitan radiotherapy services;
Demonstrated quality assurance program;
Overall cost and risk (to Government and the community as a whole), especially in the event that maintenance of a service of adequate quality proves difficult or costly;
Risk of adverse distributional impacts to existing services; and
Readiness to proceed.

That, based on these criteria, DHS identify LaTrobe, Bendigo and Ballarat as potential sites and enter into negotiations, based on the same criteria, to determine a preferred provider. Based on first principles, and specifically in the context of the trial of a strategy which is as yet unproven, ACIL considers that the LaTrobe option would probably provide the best outcome, based particularly on the implications for the aggregate reduction in community costs across the State, sensible management of the associated risks, and the potential strategic benefits from an expansion of Geelong along the lines indicated above. However, other factors, particularly readiness to proceed, could tilt the decision in favour of one of the other options.

Longer term monitoring and strategy

12. That no prescriptive decisions be taken regarding further facilities beyond those recommended here.

Instead, that DHS should commit to a process of constructive co-operation with prospective public and private sector participants to identify further prospects based on the principles set out above.
This process should reflect competition policy principles and should emphasis and encourage ‘smart solutions’ which better manage the trade-offs involved and which represent a cost effective means of improving access and both clinical and consumer outcomes.
This process may well involve a call for expressions of interest, following the initial results of the single machine unit trials, for additional facilities which will most cost effectively further advance the principles set out in this review.
ACIL expects the outcome of these processes to be progressively improved access to both consultation services and treatment facilities, with the majority of metropolitan developments taking the form of either further expansion of existing facilities or the establishment of new facilities with reasonable prospects for growing to at least 2-machine size.
The pattern in rural areas will be heavily dependent on the results of the single machine trials and the further development of other supportive technologies, such as telemedicine, and improved referrer and patient information.

13. That DHS set in train processes for monitoring both leakage rates and changes in demand for treatment delivery, with particular reference to inner Melbourne as a basis for deciding if there is need for a change in the number of machines located at the major tertiary centres.

As the other recommendations are implemented, there may be some contraction in demand sufficient to justify a reduction in the number of machines.
It is important that, until such a reduction arises, the critical mass of these institutions be retained so that their evolution as providers of hub services is not constrained - and to ensure adequate capability to deal with the growth in demand while these other changes are occurring.
It is recommended that there be a commitment to ensuring that these major tertiary centres have access to technologies of a high order, even to the point of consider transferring aging but functional machines from these centres to the other facilities, and replacing them with more modern equipment if technological developments which would be best assessed within the hub environment should warrant this. This should not, however, be used as a basis for locating inferior equipment, in the sense of being less suited to the services being delivered, in the peripheral centres.
In this context, it is recommended that a strategic approach be adopted to the replacement of equipment. The fact that there are machines needing replacement, and that there will be growth in the number of machines needed in Victoria over the next several years, means that the risk, to the health system as a whole, in replacing any machines approaching the end of their economic lives, even if there are questions as to the number of machines which will be needed at a particular site in the medium term, will involve relatively low risk to the system as a whole.
While ACIL does not see its brief as extending to a detailed replacement strategy for existing machines, we are aware of specific and pressing concerns with respect to the older machines at PMCI. In this context we note that it appears that at least three, and possibly more, dual energy machines at PMCI will be needed in the near future and for some time to come. In the short term, ACIL sees risks in not retaining (with appropriate replacement) the full 5 machines, given current demand levels and continuing demand growth, inevitable lags in introducing new facilities and the need to sustain and even build PMCI’s (and the Alfred’s) role as a supplier of high end hub services through subspecialisation, research, training and professional leadership. In the medium term if there is a decline in treatment demand in inner Melbourne, it will probably be felt most strongly at PMCI and justification for the reallocation of one or two machines seems likely, but not inevitable.

Securing skills

14. That DHS work with the relevant professional bodies and educational institutions to ensure that the implications, for future demand for radiotherapy professionals (including physicists), of the trends as developed in this report are fully understood and are communicated to students considering training options. Furthermore, consideration should be given to the appropriateness of developing more formal training arrangements for radiation physicists.

It is further recommended that, where sensible for managing risks to DHS and the Victorian community, DHS build into any contracts with new facilities a specific component of the quality plan for ensuring/managing - for the life of the contract - future access to suitably trained personnel; this might be done through on-site training, through a staff rotation arrangement with an established centre with a strong training function, through a budgeted willingness to meet the market in recruitment or through a range of other measures.
DHS should also monitor trends in availability in case there is a need to consider more explicit strategies to meet future needs. ACIL does not, however, recommend that DHS enter into explicit funding arrangements at this time.

Funding conflicts

15. That DHS note that the options available for cost effective progress in the treatment of cancer are seriously constrained by the conflicting incentives inherent in the present funding arrangements, both within Victoria and between the Commonwealth and Victoria.

While problems have been identified with specific payment schedules, most of these distortions are as a result of policies which are not specific to radiation oncology and which would be better addressed at a higher level.

It is likely that reducing these distortions could yield very considerable consumer benefits.

The analyses undertaken in this review have incorporated some adjustments for these distortions in examining questions of cost effectiveness.

16. That DHS note that, while it is not expected that implementation of these recommendations will entail significant increases in the total public sector cost per cancer patient treated, there are significant implications for the form of these costs and these will needed to be accommodated within any funding model.

There are likely to be significant reductions in VIPTAS funds requirements and in non-radiotherapy provider costs; expanded availability of private facilities may transfer some costs from public facilities to patients and their insurers.
There will be an increase in both the number of radiotherapy treatments and (probably) the average provider cost of delivery - representing a transfer of access costs from patients to providers.
Greater use of extended hours of operation will increase operating costs relative to capital costs at some facilities.
The provision of appropriate hub services is likely to require investments in information and communication systems and their on-going operation.

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