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Aust. J. Rural Health (2015) 23, 32–39
Special Issue – Rural Cancer Original Research Improving regional and rural cancer services in Western Australia Violet Platt, RN, BSc (Hons), MNurs, Kathleen O’Connor, BSc AssDipMedLabTech, and Rhonda Coleman, MRTT Western Australia Cancer and Palliative Care Network, Perth, Western Australia, Australia
Abstract Objective: This paper examines health reform which has been designed to improve cancer services across Western Australia. Setting: Western Australia is a large state divided into nine regions each with differing demographics. The diversity of the state and the distribution of the population over a large area of land create significant challenge in ensuring equality in service delivery. Design: A comparison was conducted looking at cancer services in Western Australia pre-2005 and service delivery in 2014. A review of the partnership initiatives and programs provides a clear discussion on the need for coordination of care between service providers. Main Outcome: The approach undertaken in Western Australia has seen an increase in the delivery of cancer services closer to the patient’s home as well as greater involvement of primary care professionals in cancer care. This work has resulted in demonstrated improvements in patient care and support. Conclusion: Services for cancer patients need to be accessible closer to home with distance being an appreciable barrier to treatment access.A statewide approach needs to be developed to ensure all people have equitable access to service delivery. KEY WORDS: cancer, Western Australia.
remote,
rural,
service,
Introduction This paper will discuss some of the health reforms which have been undertaken to improve rural and regional cancer services in Western Australia (WA).
Correspondence: Ms Violet Platt, Western Australia Cancer and Palliative Care Network, 189 Royal Street, East Perth, Western Australia, 6004, Australia. Email: violet.platt@ health.wa.gov.au Accepted for publication 4 December 2014. © 2015 National Rural Health Alliance Inc.
WA is a vast state occupying one third of Australia and covering over 2.5 million square kilometres. The population is relatively low at 2.6 million people1 with 1.9 million of these located in Perth metropolitan region.1 Of the WA population, 91 898 (3.6%) are Aboriginal.2 WA Health Services are divided over nine regions including two metropolitan regions, shown in Figure 1. Each region has a different demographic in terms of population numbers, Aboriginal population mix, ethnic backgrounds and numbers and types of cancer diagnosed. Travel for rural and regional cancer patients can be multimodal, challenging, expensive, time consuming and arduous.
Cancer incidence in Western Australia Cancer incidence has steadily increased in recent years and is projected to continue on the upward trajectory for years to come, recent analysis indicates an annual average change of 5% (the highest of all Australian states and territories).3 Figure 2 provides an overview of current cancer incidence and projections for WA. In 2011, there were 11 939 new diagnosis of cancer across the state.4 While the incidence of cancer has risen, so too has the prevalence, as more people than ever before continue to survive their initial cancer diagnosis. Relative survival rates for cancer have increased in recent years, between the periods 1982 and 1987 and 2006 and 2010, 5-year relative survival increased from 46.9% to 66.1%.5
Cancer services in rural Western Australia pre-2005 Prior to 2005, there was not a workforce dedicated to cancer care based in rural WA. There were very limited services provided to some locations by visiting public and private oncologists. These outreach services were developed based on the individual clinicians preferences. A COSA (Clinical Oncology Society of Australia) report doi: 10.1111/ajr.12171
33
IMPROVING CANCER SERVICES
What is already known on this subject: • There is increasing need to ensure that cancer services are delivered as close to home as possible. • The significant burden of travel to large centres for cancer treatment may be a barrier to some people having treatment. • This paper illustrates how to take an equitable approach to system-wide service delivery in a jurisdiction with a relatively small population spread over incredibly large distances.
in 2006 identified that there were six qualified chemotherapy nurses working rurally at that time, therefore 32% of the workforce who were delivering chemotherapy in the rural setting were appropriately qualified.6 Non-government organisations (NGOs) such as Cancer Council WA and Leukaemia Foundation were providing much of the Perth-based accommodation for rural patients.
Western Australia Cancer and Palliative Care Network In 2005, Western Australia Cancer and Palliative Care Network (WACPCN) was the first official clinical network to be established in Western Australia developed after the release of The Cancer Framework (2005).7 As a network, there is an embedded culture of working in partnership with the value basis that a collective will achieve so much more than an individual. This means that partnerships are vital to all WACPCN developments whether they be with community groups and services, for example, Solaris Care for complementary care or Cancer Council WA for support in their local community. The strong links to other related disciplines such as palliative care teams and private providers results in a coordinated service to patients across the state. Educational institutions and universities, research providers and service planners are linked to the clinical teams. As a facilitator of strategic change, WACPCN brings together key elements and people in order to develop and enhance appropriate high-quality services for cancer patients throughout WA. WACPCN has been the facilitator of strategic cancer and palliative care direction across the state. The current Cancer Plan 2012–20178 underpins the statewide direction of quality improvement in cancer care © 2015 National Rural Health Alliance Inc.
What this study adds: • This paper outlines the approach undertaken by Western Australia to improve the availability and service delivery of cancer services in rural and remote populations. • It highlights that the geographic location of a person with cancer can impact the treatment options they source with travel to larger centres a potential barrier. • Networking of services and population-based initiatives provide opportunities to deliver the care needed for people living in rural and remote areas.
in WA, with a clear patient-centric focus (Fig. 3). Following its development, the Cancer Plan initiatives were prioritised in partnership with a wide range of stakeholders. WACPCN facilitates strategic change following Kotter’s 8-Step Process for Leading Change9 as outlined in Figure 4. • Steps 1–3 – were initiated by the Department of Health WA with the formation of the Cancer Framework Taskforce in 2005 and consolidated with the formation and ongoing work of WACPCN. • Steps 4–8 – have been led by WACPCN in collaboration with key stakeholders. Each development has been underpinned by research and evaluation and supported by champions in the clinical, policy and administrative fields.
Cultural change and strategic approaches Strategic approaches that have underpinned this cultural change began with the WA Cancer Framework7 which identified 48 initiatives to improve cancer services within WA. This included the development of tumour-specific collaborative, which brought together clinicians across WA with an interest in a specific tumour group, irrespective of the discipline, location or sector in which they worked. The collaborative group provided a mechanism to shape strategic direction for the specific tumour group issues and has been formalised into the development of tumour-specific models of care, which provide strategic direction in terms of service provision, funding and research. An overarching Model of Cancer Care for WA10 articulates the key principles of cancer care delivery in WA and provides the basis for all the tumour-specific models.
34
V. PLATT ET AL.
FIGURE 1: WA Health Service regions. (( ) regional hospital; ( ) local hospital; ( ) multi-purpose service; ( ) nursing post; ( ) Aboriginal community or silver chain facility; ( ) coloured lines denote grouped relationships)
© 2015 National Rural Health Alliance Inc.
35
IMPROVING CANCER SERVICES
New Cancer Cases by Region WA Cancer Registry March 2012 (actual 2001-2010 projected 2011-2026) 20,000 18,000 16,000
Cancer Incidence
14,000
se
crea
% in
99.8
12,000 10,000 8,000 6,000 4,000
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
0
2001
2,000
Region by Year
FIGURE 2:
Overview of current cancer incidence and projections for WA. (( ) Metro; ( ) Country)
multidisciplinary team engagement. Figure 5 below depicts the three main treatment settings for cancer patients in WA and demonstrates that patients can easily move between each level of care and change direction according to individual need. To achieve the desired Model of Care for Cancer, a cultural change was required; before 2005, cancer care in WA was mostly delivered in Perth and in silos of practice.
National partnerships
FIGURE 3: Key stakeholders for Western Australian Cancer and Palliative Care Network.
The WA Model of Care for Cancer10 proposes a strategic statewide linking of all public cancer services in order to improve the care delivered to cancer patients in WA. This linkage is supported by clear referral pathways, evidence-based treatment guidelines and strong © 2015 National Rural Health Alliance Inc.
WACPCN led the development of Cancer Services Networks National Program in WA (CanNET WA), a Cancer Australia-funded program intended to link regional and metropolitan cancer services into comprehensive cancer networks, several facets of this program are discussed elsewhere in this paper. This program of work provided the foundations of the rural cancer services strategic processes from a planning, educational and clinical service delivery perspective. Consumers were a key part of this development and particularly shaped the communication and multidisciplinary team components of this program. CanNET also fostered the development of strong national networking relationships across the states and territories which has led to considerable collaborations.
36
V. PLATT ET AL.
FIGURE 4: Kotter’s 8-Step Process for Leading Change (2012).9
8 steps to transforming your Organisation
Encouraging and Enabling the whole organisation Creating a climate for change
Implementing and Sustaining change
7
8
6 5 4
3 2 1
Establishing a sense of urgency
FIGURE 5:
Forming a powerful guiding coalition
Creating a vision
Communicating the vision
Empowering others to act on the vision
Planning for and creating short term wins
Consolidating Institutionalising improvements new approaches and producing still more change
Levels of care available to Western Australia cancer patients.
© 2015 National Rural Health Alliance Inc.
37
IMPROVING CANCER SERVICES
Education
Aboriginal specific program
Underpinning cultural change and new policy direction is education of the health care workforce and the community at large. WACPCN has led a variety of education activities to disseminate evidence-based best practice among health professionals and empower community members on cancer issues.
Another educational partnership with Cancer Council WA is the Aboriginal cancer education program. It has been well evaluated and enhanced on an annual basis and provides information across the entire cancer care continuum – from prevention and early detection, through the treatment journey, to survivorship and palliative care – to Aboriginal Health Workers (AHWs) from regional WA. This program uses a suite of Aboriginal specific resources developed to support health professionals when communicating with Aboriginal community members. The program has evolved from a Perth-based week-long program to include regional sessions to reach more AHWs and facilitate access to educational opportunities in regional WA.
Rural road shows Since 2007, WACPCN have supported rural road shows. These educational and strategic events are tumour specific and involve taking up to five members of the clinical multidisciplinary team (including the Cancer Nurse Coordinator) to a rural site. The team delivers a full education program to regional health care professionals including hospital staff, primary care, Aboriginal health services staff, NGOs, community groups, patients and carers. These programs, directed by regional requirements, have been well received and evaluated. The benefit is twofold, in that rural education is provided and metropolitan teams gain an understanding of what is and isn’t available in regional WA. Downtime during these events is usually utilised for the development of relationships, which facilitate pathways of communication between rural and metropolitan services.
Canar Mentoring (CaMen) CaMen Program was a federally funded rural education program which provided financial support and a personalised education program for individual rural health professionals with an interest in cancer. Practitioners would spend a week in Perth following a personalised timetable of cancer-related activities with specialist oncology providers. Despite finishing in 2009, the longevity of the benefits of this program continues with many rural practitioners continually recognising this opportunity as instrumental in the development of the cancer knowledge and partnerships that they value today.
Partnerships Partnerships in rural education are very important. Cancer Council WA has been a vital component of the rural road shows and the delivery of WA Clinical Oncology Group activities, providing specialist education in oncology utilising funding from WACPCN. The rural program is informed by health professional requests and supports strategic cancer service delivery developments. It provides an important neutral forum, which brings together all areas across the care continuum and public and private health care. © 2015 National Rural Health Alliance Inc.
Clinical Training and Evaluation Centre WACPCN established a funding partnership with the Clinical Training and Evaluation Centre (CTEC), based at UWA, to ensure the continuation of gastroenterology training courses for clinical staff – both doctors and nurses – to support skill enhancement and encourage workforce retention. These important courses underpin the provision of high-quality colonoscopy services in WA, which are of particular importance as the National Bowel Cancer Screening Program (NBCSP) expands to a full cohort (50–74 year olds, screened biennially) by 2020.
Communication Rural multidisciplinary teams Rural multidisciplinary teams (MDTs) have been in development since the initial CanNET program (2007) for most regions, this involves the facilitation of a rural MDT with videoconference links to members of specialist oncology teams in Perth. There are many challenges in the development of these processes included technological links, limited availability of clinicians (including radiology and pathology) and process issues, such as documentation of meeting outcomes. A positive outcome of this work has led to improved pathways of care and communication between metropolitan and rural clinicians and the introduction of formal agreed pathways. For one region, this included an increase in referrals of prostate cancer patients for radiotherapy by 30%. An enhanced relationship with PathWest Laboratory (statewide public service) to support rural MDTs has also resulted. WACPCN has utilised opportunities for these developments by working in partnership not only in a state-based approach, but also nationally in partnership with Cancer Australia and NBOCC (National Breast and Ovarian Cancer Centre), dovetailing with their MDT
38
development approaches. More information relating to the National CanNET program is available on Cancer Australia’s website www.canceraustralia.gov.au.
Telehealth As with other states in Australia, telehealth is an important communication approach which is supported across the state. It facilitates individual patient consultations, multidisciplinary meetings, educational events, strategic meetings and virtual visiting for rural patients who are in Perth for several weeks receiving treatment. Telehealth is widely used particularly to support the rural health workforce, enabling care for cancer patients closer to home.
Regional cancer strategic meetings WACPCN introduced the concept of regional meetings to specifically address cancer and palliative care issues to each of the seven non-metropolitan WA regions during the CanNET program. These meetings have been sustained and developed further in the regions with cancer diagnoses of more than 100 per year, due to the commitment and value expressed by local stakeholders. These meetings bring together, clinicians, funders, planners, executives and consumers within the region in a forum where both future direction and current local issues are addressed in a constructive and collaborative approach. WACPCN executive are key members of these meetings and bring the strategic direction from a state and national level to the regional discussions. This enables the development of services within the local context and the bigger picture strategic direction.
V. PLATT ET AL.
Nurse Coordinators (2006) who use specialist cancer nursing knowledge to facilitate seamless cancer journeys for patients with complex cancer needs. This includes direct patient management and indirect patient support through education, research and strategic change projects to facilitate the development of coordination and collaboration skills across the whole WA system. This service has been evaluated and proven to be highly beneficial to patients, carers and members of the multidisciplinary team across WA.11
WA Psycho Oncology Service Commenced in (2007) as an initiative to provide clinical psychology treatments and support to patients and their families. As there were already clinical psychology services for breast cancer patients, WA Psycho Oncology Service (WAPOS) focused on the needs of patients with other cancers. WAPOS developed as part of a wider focus on meeting the psycho-social needs of all patients with cancer. WA Health is working towards meetings the National Psychosocial Guidelines (2003). Inpatient and outpatient consultations are provided, these consultations are currently only available in Perth; however, they are available via telephone to regional/rural patients. As resources permit, the service will expand to more locations. An important part of WAPOS work is the education of health care teams in assessing and referring patients to appropriate psycho-social supports in the community. MDTs can access the expertise of the WAPOS team to learn strategies to deal with individual situations.
Web-based information
National Bowel Cancer Screening Program
WACPCN has developed a website to provide evidencebased information, resources and credible links for health professionals and consumers related to our work (http://www.healthnetworks.health.wa.gov.au/ cancer/home/). As part of the National Gynaecological Workforce Project for Cancer Australia, WACPCN developed a website for the WA Gynaecologic Cancer Service based at King Edward Memorial Hospital for Women (http://www.kemh.health.wa.gov.au/services/ Gynaecologic_Cancer_Service/index.htm). WACPCN promotes the use of the cancer page on the MyHospitals website giving patients across the state the ability to see what cancer services are available close to their home.
The WACPCN has overseen the NBCSP’s implementation in WA since commencement in 2007, collaborating with the Australian Government and engaging nongovernment agencies, in particular Cancer Council WA. Due to the logistic challenges inherent to WA, the rollout of the NBCSP was staggered across regional areas to enable educational road shows targeting health professionals to raise awareness of screening and clarify referral pathways for participants with positive screening results. Support of regional activities continues, with the current development of a promotion campaign in the Kimberley and Pilbara regions to coincide with their condensed invitation period which limits kit exposure to extreme heat.
Direct clinical influence Cancer nurse coordinators Examples of direct patient support by WACPCN include the introduction of a statewide service of Cancer
Visiting medical teams WACPCN has supported the development of rural outreach services in medical oncology, radiation oncology and surgical oncology in order to facilitate care closer to © 2015 National Rural Health Alliance Inc.
39
IMPROVING CANCER SERVICES
home where it is safe to do so. This support has ranged from strategic service planning to financial support, travel support, education, research and video conferencing equipment. This activity built upon early developments by a few pioneering medical oncologists who had provided outreach support as a lone practitioner. The success of this initiative has now led to a situation of overburdened clinics, requiring further reassessment of the supports offered across the system. Assessments of this mode of care delivery are monitored and developed from a regional perspective now, and particular attention is paid to regional medical governance in this mode of care delivery where there are no resident oncologists. The WA Government committed additional medical specialists in the tertiary facility to do this regional outreach. The Medical Services Outreach Assistance Program in WA was used for some of the oncology outreach; however, there were insufficient funds to enable this to be tumour specific or to be provided as often as needed to meet the needs of most tumour streams in regions. The WACPCN was able to assist by providing travel costs to continue to build these regional links.
Service delivery in 2014 The clinical services innovations as discussed above are now integral to the WA Model of Care for Cancer. Services are increasingly considered for care closer to home where possible, in line with the strategic direction set for WA. There are 25 models of care related to cancer either completed or in development. These models provide an evidence-based strategic approach to cancer care delivery in WA. WACPCN continues to maintain the overarching strategic view of cancer service delivery particularly important with the opening of new facilities in public, private and public/private partnership facilities across WA. Support in the consideration of service and pathway changes associated with new facilities and the introduction of activity-based funding are at the hub of all current activity for WACPCN. As are the important considerations to workforce challenges which face all health services including oncology across Australia.
Conclusion It is possible to say that the approaches to cancer care delivery in Western Australia are truly networked. The WA Cancer and Palliative Care Network has been instrumental in engaging a wide range of health professionals from primary care through specialist led care to end-of-life care, and this multidisciplinary team effort has resulted in improved patient care and support. © 2015 National Rural Health Alliance Inc.
WA with its sparely populated numerous small towns will never be able to have treatment services in all regions in WA; however, we have demonstrated that with a range of initiatives we can improve the outcomes that matter to patients – access to cancer experts, early diagnosis, information on treatment options, coordination of services during their treatment, psycho-social support as needed, early return to ‘normal’ daily routine after treatment with a rapid access re-entry into the cancer care system in the event of any disease progression or treatment complications. The challenges ahead relate primarily to the sustainability of these patient support initiatives that reduce the hospital activity and empower the patient to remain well within their community knowing they have access to a specialised team of cancer health professionals if they need them during their survivorship journey.
References 1 Australian Bureau of Statistics. Australian Demographic Statistics, March, 2014. 2014. [Cited 15/01/15]. Available from URL: http://www.abs.gov.au 2 Australian Bureau of Statistics. Estimates and Projections, Aboriginal and Torres Strait Islander Australians, 2001 to 2026. Canberra: Australian Bureau of Statistics, 2014. 3 Australian Institute of Health and Welfare. Radiation Oncology Areas of Need: Cancer Incidence Projections 2014–2024. Canberra: AIHW, 2014. Cancer series no. 85. Cat. no. CAN 82. 4 Threlfall TJ, Thompson JR. Cancer Incidence and Mortality in Western Australia, 2012. Department of Health, Western Australia, Perth. Statistical Number 99, 2014. 5 Australian Institute of Health and Welfare. Cancer Survival and Prevalence in Australia: Period Estimates from 1982 to 2010. Canberra: AIHW, 2012. Cancer Series no. 69. Cat. no. CAN65. 6 Clinical Oncological Society of Australia. Mapping Rural and Regional Oncology Services in Australia. 2006. [Cited 15/01/15]. Available from URL: https://www.cosa.org.au 7 WA Department of Health. Cancer Services Framework. 2005. [Cited 15/01/15]. Available from URL: http:// www.uwa.edu.au/__data/assets/pdf_file/0006/439845/ 279720CancerFramework20800.pdf 8 WA Cancer and Palliative Care Network. WA Cancer Plan 2012–2017. 2011. [Cited 15/01/15]. Available from URL: http://www.healthnetworks.health.wa.gov.au/ cancer/docs/12196_WA_Cancer_PLAN.pdf 9 Kotter JP. Leading Change. Harvard: Harvard Business Review Press, 2012. 10 WA Department of Health. Model of Care for Cancer, 2008. 11 WA Department of Health. Evaluation of the Western Australian Cancer Nurse Coordinator Role. 2011. [Cited 15/01/15]. Available from URL: http://www.healthnet works.health.wa.gov.au/cancer/docs/CANCER_REPORT _aug2011.pdf
Aust. J. Rural Health (2015) 23, 32–39
Special Issue – Rural Cancer Original Research Improving regional and rural cancer services in Western Australia Violet Platt, RN, BSc (Hons), MNurs, Kathleen O’Connor, BSc AssDipMedLabTech, and Rhonda Coleman, MRTT Western Australia Cancer and Palliative Care Network, Perth, Western Australia, Australia
Abstract Objective: This paper examines health reform which has been designed to improve cancer services across Western Australia. Setting: Western Australia is a large state divided into nine regions each with differing demographics. The diversity of the state and the distribution of the population over a large area of land create significant challenge in ensuring equality in service delivery. Design: A comparison was conducted looking at cancer services in Western Australia pre-2005 and service delivery in 2014. A review of the partnership initiatives and programs provides a clear discussion on the need for coordination of care between service providers. Main Outcome: The approach undertaken in Western Australia has seen an increase in the delivery of cancer services closer to the patient’s home as well as greater involvement of primary care professionals in cancer care. This work has resulted in demonstrated improvements in patient care and support. Conclusion: Services for cancer patients need to be accessible closer to home with distance being an appreciable barrier to treatment access.A statewide approach needs to be developed to ensure all people have equitable access to service delivery. KEY WORDS: cancer, Western Australia.
remote,
rural,
service,
Introduction This paper will discuss some of the health reforms which have been undertaken to improve rural and regional cancer services in Western Australia (WA).
Correspondence: Ms Violet Platt, Western Australia Cancer and Palliative Care Network, 189 Royal Street, East Perth, Western Australia, 6004, Australia. Email: violet.platt@ health.wa.gov.au Accepted for publication 4 December 2014. © 2015 National Rural Health Alliance Inc.
WA is a vast state occupying one third of Australia and covering over 2.5 million square kilometres. The population is relatively low at 2.6 million people1 with 1.9 million of these located in Perth metropolitan region.1 Of the WA population, 91 898 (3.6%) are Aboriginal.2 WA Health Services are divided over nine regions including two metropolitan regions, shown in Figure 1. Each region has a different demographic in terms of population numbers, Aboriginal population mix, ethnic backgrounds and numbers and types of cancer diagnosed. Travel for rural and regional cancer patients can be multimodal, challenging, expensive, time consuming and arduous.
Cancer incidence in Western Australia Cancer incidence has steadily increased in recent years and is projected to continue on the upward trajectory for years to come, recent analysis indicates an annual average change of 5% (the highest of all Australian states and territories).3 Figure 2 provides an overview of current cancer incidence and projections for WA. In 2011, there were 11 939 new diagnosis of cancer across the state.4 While the incidence of cancer has risen, so too has the prevalence, as more people than ever before continue to survive their initial cancer diagnosis. Relative survival rates for cancer have increased in recent years, between the periods 1982 and 1987 and 2006 and 2010, 5-year relative survival increased from 46.9% to 66.1%.5
Cancer services in rural Western Australia pre-2005 Prior to 2005, there was not a workforce dedicated to cancer care based in rural WA. There were very limited services provided to some locations by visiting public and private oncologists. These outreach services were developed based on the individual clinicians preferences. A COSA (Clinical Oncology Society of Australia) report doi: 10.1111/ajr.12171
33
IMPROVING CANCER SERVICES
What is already known on this subject: • There is increasing need to ensure that cancer services are delivered as close to home as possible. • The significant burden of travel to large centres for cancer treatment may be a barrier to some people having treatment. • This paper illustrates how to take an equitable approach to system-wide service delivery in a jurisdiction with a relatively small population spread over incredibly large distances.
in 2006 identified that there were six qualified chemotherapy nurses working rurally at that time, therefore 32% of the workforce who were delivering chemotherapy in the rural setting were appropriately qualified.6 Non-government organisations (NGOs) such as Cancer Council WA and Leukaemia Foundation were providing much of the Perth-based accommodation for rural patients.
Western Australia Cancer and Palliative Care Network In 2005, Western Australia Cancer and Palliative Care Network (WACPCN) was the first official clinical network to be established in Western Australia developed after the release of The Cancer Framework (2005).7 As a network, there is an embedded culture of working in partnership with the value basis that a collective will achieve so much more than an individual. This means that partnerships are vital to all WACPCN developments whether they be with community groups and services, for example, Solaris Care for complementary care or Cancer Council WA for support in their local community. The strong links to other related disciplines such as palliative care teams and private providers results in a coordinated service to patients across the state. Educational institutions and universities, research providers and service planners are linked to the clinical teams. As a facilitator of strategic change, WACPCN brings together key elements and people in order to develop and enhance appropriate high-quality services for cancer patients throughout WA. WACPCN has been the facilitator of strategic cancer and palliative care direction across the state. The current Cancer Plan 2012–20178 underpins the statewide direction of quality improvement in cancer care © 2015 National Rural Health Alliance Inc.
What this study adds: • This paper outlines the approach undertaken by Western Australia to improve the availability and service delivery of cancer services in rural and remote populations. • It highlights that the geographic location of a person with cancer can impact the treatment options they source with travel to larger centres a potential barrier. • Networking of services and population-based initiatives provide opportunities to deliver the care needed for people living in rural and remote areas.
in WA, with a clear patient-centric focus (Fig. 3). Following its development, the Cancer Plan initiatives were prioritised in partnership with a wide range of stakeholders. WACPCN facilitates strategic change following Kotter’s 8-Step Process for Leading Change9 as outlined in Figure 4. • Steps 1–3 – were initiated by the Department of Health WA with the formation of the Cancer Framework Taskforce in 2005 and consolidated with the formation and ongoing work of WACPCN. • Steps 4–8 – have been led by WACPCN in collaboration with key stakeholders. Each development has been underpinned by research and evaluation and supported by champions in the clinical, policy and administrative fields.
Cultural change and strategic approaches Strategic approaches that have underpinned this cultural change began with the WA Cancer Framework7 which identified 48 initiatives to improve cancer services within WA. This included the development of tumour-specific collaborative, which brought together clinicians across WA with an interest in a specific tumour group, irrespective of the discipline, location or sector in which they worked. The collaborative group provided a mechanism to shape strategic direction for the specific tumour group issues and has been formalised into the development of tumour-specific models of care, which provide strategic direction in terms of service provision, funding and research. An overarching Model of Cancer Care for WA10 articulates the key principles of cancer care delivery in WA and provides the basis for all the tumour-specific models.
34
V. PLATT ET AL.
FIGURE 1: WA Health Service regions. (( ) regional hospital; ( ) local hospital; ( ) multi-purpose service; ( ) nursing post; ( ) Aboriginal community or silver chain facility; ( ) coloured lines denote grouped relationships)
© 2015 National Rural Health Alliance Inc.
35
IMPROVING CANCER SERVICES
New Cancer Cases by Region WA Cancer Registry March 2012 (actual 2001-2010 projected 2011-2026) 20,000 18,000 16,000
Cancer Incidence
14,000
se
crea
% in
99.8
12,000 10,000 8,000 6,000 4,000
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
0
2001
2,000
Region by Year
FIGURE 2:
Overview of current cancer incidence and projections for WA. (( ) Metro; ( ) Country)
multidisciplinary team engagement. Figure 5 below depicts the three main treatment settings for cancer patients in WA and demonstrates that patients can easily move between each level of care and change direction according to individual need. To achieve the desired Model of Care for Cancer, a cultural change was required; before 2005, cancer care in WA was mostly delivered in Perth and in silos of practice.
National partnerships
FIGURE 3: Key stakeholders for Western Australian Cancer and Palliative Care Network.
The WA Model of Care for Cancer10 proposes a strategic statewide linking of all public cancer services in order to improve the care delivered to cancer patients in WA. This linkage is supported by clear referral pathways, evidence-based treatment guidelines and strong © 2015 National Rural Health Alliance Inc.
WACPCN led the development of Cancer Services Networks National Program in WA (CanNET WA), a Cancer Australia-funded program intended to link regional and metropolitan cancer services into comprehensive cancer networks, several facets of this program are discussed elsewhere in this paper. This program of work provided the foundations of the rural cancer services strategic processes from a planning, educational and clinical service delivery perspective. Consumers were a key part of this development and particularly shaped the communication and multidisciplinary team components of this program. CanNET also fostered the development of strong national networking relationships across the states and territories which has led to considerable collaborations.
36
V. PLATT ET AL.
FIGURE 4: Kotter’s 8-Step Process for Leading Change (2012).9
8 steps to transforming your Organisation
Encouraging and Enabling the whole organisation Creating a climate for change
Implementing and Sustaining change
7
8
6 5 4
3 2 1
Establishing a sense of urgency
FIGURE 5:
Forming a powerful guiding coalition
Creating a vision
Communicating the vision
Empowering others to act on the vision
Planning for and creating short term wins
Consolidating Institutionalising improvements new approaches and producing still more change
Levels of care available to Western Australia cancer patients.
© 2015 National Rural Health Alliance Inc.
37
IMPROVING CANCER SERVICES
Education
Aboriginal specific program
Underpinning cultural change and new policy direction is education of the health care workforce and the community at large. WACPCN has led a variety of education activities to disseminate evidence-based best practice among health professionals and empower community members on cancer issues.
Another educational partnership with Cancer Council WA is the Aboriginal cancer education program. It has been well evaluated and enhanced on an annual basis and provides information across the entire cancer care continuum – from prevention and early detection, through the treatment journey, to survivorship and palliative care – to Aboriginal Health Workers (AHWs) from regional WA. This program uses a suite of Aboriginal specific resources developed to support health professionals when communicating with Aboriginal community members. The program has evolved from a Perth-based week-long program to include regional sessions to reach more AHWs and facilitate access to educational opportunities in regional WA.
Rural road shows Since 2007, WACPCN have supported rural road shows. These educational and strategic events are tumour specific and involve taking up to five members of the clinical multidisciplinary team (including the Cancer Nurse Coordinator) to a rural site. The team delivers a full education program to regional health care professionals including hospital staff, primary care, Aboriginal health services staff, NGOs, community groups, patients and carers. These programs, directed by regional requirements, have been well received and evaluated. The benefit is twofold, in that rural education is provided and metropolitan teams gain an understanding of what is and isn’t available in regional WA. Downtime during these events is usually utilised for the development of relationships, which facilitate pathways of communication between rural and metropolitan services.
Canar Mentoring (CaMen) CaMen Program was a federally funded rural education program which provided financial support and a personalised education program for individual rural health professionals with an interest in cancer. Practitioners would spend a week in Perth following a personalised timetable of cancer-related activities with specialist oncology providers. Despite finishing in 2009, the longevity of the benefits of this program continues with many rural practitioners continually recognising this opportunity as instrumental in the development of the cancer knowledge and partnerships that they value today.
Partnerships Partnerships in rural education are very important. Cancer Council WA has been a vital component of the rural road shows and the delivery of WA Clinical Oncology Group activities, providing specialist education in oncology utilising funding from WACPCN. The rural program is informed by health professional requests and supports strategic cancer service delivery developments. It provides an important neutral forum, which brings together all areas across the care continuum and public and private health care. © 2015 National Rural Health Alliance Inc.
Clinical Training and Evaluation Centre WACPCN established a funding partnership with the Clinical Training and Evaluation Centre (CTEC), based at UWA, to ensure the continuation of gastroenterology training courses for clinical staff – both doctors and nurses – to support skill enhancement and encourage workforce retention. These important courses underpin the provision of high-quality colonoscopy services in WA, which are of particular importance as the National Bowel Cancer Screening Program (NBCSP) expands to a full cohort (50–74 year olds, screened biennially) by 2020.
Communication Rural multidisciplinary teams Rural multidisciplinary teams (MDTs) have been in development since the initial CanNET program (2007) for most regions, this involves the facilitation of a rural MDT with videoconference links to members of specialist oncology teams in Perth. There are many challenges in the development of these processes included technological links, limited availability of clinicians (including radiology and pathology) and process issues, such as documentation of meeting outcomes. A positive outcome of this work has led to improved pathways of care and communication between metropolitan and rural clinicians and the introduction of formal agreed pathways. For one region, this included an increase in referrals of prostate cancer patients for radiotherapy by 30%. An enhanced relationship with PathWest Laboratory (statewide public service) to support rural MDTs has also resulted. WACPCN has utilised opportunities for these developments by working in partnership not only in a state-based approach, but also nationally in partnership with Cancer Australia and NBOCC (National Breast and Ovarian Cancer Centre), dovetailing with their MDT
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development approaches. More information relating to the National CanNET program is available on Cancer Australia’s website www.canceraustralia.gov.au.
Telehealth As with other states in Australia, telehealth is an important communication approach which is supported across the state. It facilitates individual patient consultations, multidisciplinary meetings, educational events, strategic meetings and virtual visiting for rural patients who are in Perth for several weeks receiving treatment. Telehealth is widely used particularly to support the rural health workforce, enabling care for cancer patients closer to home.
Regional cancer strategic meetings WACPCN introduced the concept of regional meetings to specifically address cancer and palliative care issues to each of the seven non-metropolitan WA regions during the CanNET program. These meetings have been sustained and developed further in the regions with cancer diagnoses of more than 100 per year, due to the commitment and value expressed by local stakeholders. These meetings bring together, clinicians, funders, planners, executives and consumers within the region in a forum where both future direction and current local issues are addressed in a constructive and collaborative approach. WACPCN executive are key members of these meetings and bring the strategic direction from a state and national level to the regional discussions. This enables the development of services within the local context and the bigger picture strategic direction.
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Nurse Coordinators (2006) who use specialist cancer nursing knowledge to facilitate seamless cancer journeys for patients with complex cancer needs. This includes direct patient management and indirect patient support through education, research and strategic change projects to facilitate the development of coordination and collaboration skills across the whole WA system. This service has been evaluated and proven to be highly beneficial to patients, carers and members of the multidisciplinary team across WA.11
WA Psycho Oncology Service Commenced in (2007) as an initiative to provide clinical psychology treatments and support to patients and their families. As there were already clinical psychology services for breast cancer patients, WA Psycho Oncology Service (WAPOS) focused on the needs of patients with other cancers. WAPOS developed as part of a wider focus on meeting the psycho-social needs of all patients with cancer. WA Health is working towards meetings the National Psychosocial Guidelines (2003). Inpatient and outpatient consultations are provided, these consultations are currently only available in Perth; however, they are available via telephone to regional/rural patients. As resources permit, the service will expand to more locations. An important part of WAPOS work is the education of health care teams in assessing and referring patients to appropriate psycho-social supports in the community. MDTs can access the expertise of the WAPOS team to learn strategies to deal with individual situations.
Web-based information
National Bowel Cancer Screening Program
WACPCN has developed a website to provide evidencebased information, resources and credible links for health professionals and consumers related to our work (http://www.healthnetworks.health.wa.gov.au/ cancer/home/). As part of the National Gynaecological Workforce Project for Cancer Australia, WACPCN developed a website for the WA Gynaecologic Cancer Service based at King Edward Memorial Hospital for Women (http://www.kemh.health.wa.gov.au/services/ Gynaecologic_Cancer_Service/index.htm). WACPCN promotes the use of the cancer page on the MyHospitals website giving patients across the state the ability to see what cancer services are available close to their home.
The WACPCN has overseen the NBCSP’s implementation in WA since commencement in 2007, collaborating with the Australian Government and engaging nongovernment agencies, in particular Cancer Council WA. Due to the logistic challenges inherent to WA, the rollout of the NBCSP was staggered across regional areas to enable educational road shows targeting health professionals to raise awareness of screening and clarify referral pathways for participants with positive screening results. Support of regional activities continues, with the current development of a promotion campaign in the Kimberley and Pilbara regions to coincide with their condensed invitation period which limits kit exposure to extreme heat.
Direct clinical influence Cancer nurse coordinators Examples of direct patient support by WACPCN include the introduction of a statewide service of Cancer
Visiting medical teams WACPCN has supported the development of rural outreach services in medical oncology, radiation oncology and surgical oncology in order to facilitate care closer to © 2015 National Rural Health Alliance Inc.
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IMPROVING CANCER SERVICES
home where it is safe to do so. This support has ranged from strategic service planning to financial support, travel support, education, research and video conferencing equipment. This activity built upon early developments by a few pioneering medical oncologists who had provided outreach support as a lone practitioner. The success of this initiative has now led to a situation of overburdened clinics, requiring further reassessment of the supports offered across the system. Assessments of this mode of care delivery are monitored and developed from a regional perspective now, and particular attention is paid to regional medical governance in this mode of care delivery where there are no resident oncologists. The WA Government committed additional medical specialists in the tertiary facility to do this regional outreach. The Medical Services Outreach Assistance Program in WA was used for some of the oncology outreach; however, there were insufficient funds to enable this to be tumour specific or to be provided as often as needed to meet the needs of most tumour streams in regions. The WACPCN was able to assist by providing travel costs to continue to build these regional links.
Service delivery in 2014 The clinical services innovations as discussed above are now integral to the WA Model of Care for Cancer. Services are increasingly considered for care closer to home where possible, in line with the strategic direction set for WA. There are 25 models of care related to cancer either completed or in development. These models provide an evidence-based strategic approach to cancer care delivery in WA. WACPCN continues to maintain the overarching strategic view of cancer service delivery particularly important with the opening of new facilities in public, private and public/private partnership facilities across WA. Support in the consideration of service and pathway changes associated with new facilities and the introduction of activity-based funding are at the hub of all current activity for WACPCN. As are the important considerations to workforce challenges which face all health services including oncology across Australia.
Conclusion It is possible to say that the approaches to cancer care delivery in Western Australia are truly networked. The WA Cancer and Palliative Care Network has been instrumental in engaging a wide range of health professionals from primary care through specialist led care to end-of-life care, and this multidisciplinary team effort has resulted in improved patient care and support. © 2015 National Rural Health Alliance Inc.
WA with its sparely populated numerous small towns will never be able to have treatment services in all regions in WA; however, we have demonstrated that with a range of initiatives we can improve the outcomes that matter to patients – access to cancer experts, early diagnosis, information on treatment options, coordination of services during their treatment, psycho-social support as needed, early return to ‘normal’ daily routine after treatment with a rapid access re-entry into the cancer care system in the event of any disease progression or treatment complications. The challenges ahead relate primarily to the sustainability of these patient support initiatives that reduce the hospital activity and empower the patient to remain well within their community knowing they have access to a specialised team of cancer health professionals if they need them during their survivorship journey.
References 1 Australian Bureau of Statistics. Australian Demographic Statistics, March, 2014. 2014. [Cited 15/01/15]. Available from URL: http://www.abs.gov.au 2 Australian Bureau of Statistics. Estimates and Projections, Aboriginal and Torres Strait Islander Australians, 2001 to 2026. Canberra: Australian Bureau of Statistics, 2014. 3 Australian Institute of Health and Welfare. Radiation Oncology Areas of Need: Cancer Incidence Projections 2014–2024. Canberra: AIHW, 2014. Cancer series no. 85. Cat. no. CAN 82. 4 Threlfall TJ, Thompson JR. Cancer Incidence and Mortality in Western Australia, 2012. Department of Health, Western Australia, Perth. Statistical Number 99, 2014. 5 Australian Institute of Health and Welfare. Cancer Survival and Prevalence in Australia: Period Estimates from 1982 to 2010. Canberra: AIHW, 2012. Cancer Series no. 69. Cat. no. CAN65. 6 Clinical Oncological Society of Australia. Mapping Rural and Regional Oncology Services in Australia. 2006. [Cited 15/01/15]. Available from URL: https://www.cosa.org.au 7 WA Department of Health. Cancer Services Framework. 2005. [Cited 15/01/15]. Available from URL: http:// www.uwa.edu.au/__data/assets/pdf_file/0006/439845/ 279720CancerFramework20800.pdf 8 WA Cancer and Palliative Care Network. WA Cancer Plan 2012–2017. 2011. [Cited 15/01/15]. Available from URL: http://www.healthnetworks.health.wa.gov.au/ cancer/docs/12196_WA_Cancer_PLAN.pdf 9 Kotter JP. Leading Change. Harvard: Harvard Business Review Press, 2012. 10 WA Department of Health. Model of Care for Cancer, 2008. 11 WA Department of Health. Evaluation of the Western Australian Cancer Nurse Coordinator Role. 2011. [Cited 15/01/15]. Available from URL: http://www.healthnet works.health.wa.gov.au/cancer/docs/CANCER_REPORT _aug2011.pdf
