On Tuesday 26^th February, a delegation of senior management and clinicians from the South East met with Prof. Donal Hollywood, Chairman, and members of the National Expert Review Group on Radiotherapy.  The delegation members included: Mr. John Cooney CEO, Dr. Paula Calvert Consultant Oncologist, Mr. Peter Finnegan Regional Manager, Dr. Fred Jackson Consultant Haematologist, Mr. John Magner Deputy CEO and Dr. Orlaith O’Reilly Director of Public Health.

The delegation put forward a submission (attached) based on need, equity, quality, patient focus and value for money on the need to establish a radiotherapy department as part of the development of a comprehensive cancer treatment service in the South East. The submission will form part of the final considerations of the Review Group.The delegation made a strong call for the development of radiotherapy services in Waterford Regional Hospital. The submission highlighted the fact that approximately 20% of cancer patients in Ireland receive radiotherapy whereas best medical practice suggests that this should be 60% for most cancers.  This is at a time when there is a sufficient population within the South Eastern region to sustain a local radiotherapy facility as modelled on the best available evidence from a recent report, highlighting the inequality in current service provision. Furthermore, 75% of breast cancer patients should receive radiotherapy, but in the South East only 48% receive it.  It is also recognised that it is often difficult to persuade patients to undertake the onerous journey to distant radiotherapy sites for five days a week over a five week period because of the inherent hardship and fatigue for the patient, also by the resultant difficulties in families generated by the recurring absence of a wife/mother/father or child needing to be accompanied.

Mr. John Cooney, Chief Executive Officer said, “Currently 625 new patients from the SEHB are seen at radiotherapy clinics per year, of whom approximately 300-400 are referred mainly to St. Luke’s Hospital, Dublin for radiotherapy. This is expected to reach 1800 per year by 2015. There is a waiting list at St. Luke’s of approximately eight weeks with an additional two weeks waiting for a clinic appointment. For patients with breast cancer for example, radiotherapy is delivered over five to six weeks for up to ten minutes per day on a five-day basis.  This treatment has to be taken by daily travel to the radiotherapy centre or by staying near the centre for five to six weeks.  This is at a time when patients are at their most vulnerable and need their family/friends around them. This is why a radiotherapy service is essential for the South East and it can be delivered in Waterford at little extra cost to the exchequer but with huge advantages to the sick. We await the outcome of the Expert Review Group’s deliberations with great anticipation.”

Key Issues

The Case for Radiotherapy Services in the South Eastern Health Board

1. The South Eastern Health Board’s population is growing and now exceeds 400,000. We are the third most populated Health Region in the country. By 2015, the time scale being planned for, it is expected to approach 500,000 people thus justifying a 4 Linear Accelerator Radiotherapy Unit in Waterford. Other national authorities considering the development of radiotherapy services, most recently the Dutch, have concluded at a population between 400,000 and 500,000 warrant the development of a local radiotherapy service.

2. The Board has to recognise the unique and special vulnerability of cancer patients requiring radiotherapy because of the stressful nature of their illness, their vulnerability, the presence of distressing side effects as treatment accumulates and especially the need, presently, for daily journeys over long distances for periods of up to seven weeks in duration.
3. Any service model other than local deployment of radiotherapy treatment would be inhumane and would undermine the recent aspirations to a quality driven service based on people centredness and fair access as set down in the recent National Health Strategy – “Quality and Fairness”.
4. The Eastern Regional Health Authority has difficulties arising from the volume of patients from other Regions seeking service in Dublin at a time when acute care services in the city are under extreme pressure of demand from their own population.
5. The Board believes that a 4 Linear Accelerator Unit in Waterford Regional Hospital will be as economically used in Waterford as in Dublin; that they will cost the same to purchase and house and that it is only in relation to ancillary space that limited economies might arise from a central model. Against any such economy must be put the cheaper cost of land and building costs in Waterford compared to Dublin. Similarly, the local operating costs of staff, etc. will be offset by avoiding travel costs for 1,800 patients per annum travelling to Dublin for an average of about 20 trips each.
6. The South Eastern Health Board’s strategic policy is to achieve self-sufficiency for all services appropriate to front line local delivery. A local radiotherapy service is essential for the delivery of high quality self-sufficient cancer services.

The Case for Radiotherapy Services in the South Eastern Health Board – a statement by Mr. John A. Cooney, CEO South Eastern Health Board to the National Expert Review Group on radiotherapy on Tuesday February 26th

1. The South Eastern Health Board’s population is growing and now exceeds 400,000.  We are the third most populated Health Region in the country.  By 2015, the time scale being planned for, it is expected to approach 500,000 people thus justifying a 4 Linear Accelerator Radiotherapy Unit in Waterford.

2. Cancer care is considered to be an essential local service, affecting large numbers of patients.  Demand for such care is growing rapidly as its incidence rises.  The Board has responded by developing Waterford Regional Hospital as a major cancer centre.  Other Hospitals in the Region have joined with the Regional Hospital in support of a centre of excellence for breast cancer in Waterford Regional Hospital and the community as a whole have strongly supported the acquisition of CAT Scanners and an MRI Scanner recently as part of the drive towards creating the ongoing capacity needed to conveniently support cancer and other services locally.  Consultant strength has been increased to lead this policy of local service delivery and a wide range of regional specialties, including cancer-related specialties, now exist in Waterford Regional Hospital to support the cancer service.
3. The South Eastern Health Board’s strategic policy is to achieve self-sufficiency for all services appropriate to front line local delivery.
4. While supporting this general policy of self-sufficiency and the avoidance of travelling to external sites for service, the Board still participates in various tertiary arrangements with major hospitals in Dublin and Cork because the travel impact is very low on the individual patient involving a few trips over an extended period of time. However, the Board has to recognise the unique and special vulnerability of cancer patients requiring radiotherapy because of the stressful nature of their illness, their vulnerability, the presence of distressing side effects as treatment accumulates and especially the need, presently, for daily journeys over long distances for periods of up to seven weeks in duration.
5. In addition, the resultant social and financial costs and inconvenience to patients and their families from such extended travel can constitute an additional serious burden in a society where so many people live on modest incomes or where families are dependent on the presence of a wife worker, etc. to keep the family viable.
6. Accordingly, the South Eastern Health Board believe very strongly that any service model other than local deployment of radiotherapy treatment would be inhumane and would undermine the recent aspirations to a quality driven service based on people centredness and fair access as set down in the recent National Health Strategy – “Quality and Fairness”.
7. Indeed, the Board has had representations from patients that the travel requirement forced on patients up to now to the distant existing service dissuaded or prevented many patients from seeking their optimal treatment. Given the changed public expectations now about standards of service and the State’s recent acceptance of those standards, their acceptance of such travel hardship and delays is not expected to continue. It would be wrong, therefore if the Irish State, now seeking to provide a sufficiency of resources for Radiotherapy, were to institutionalise and perpetuate such an unfair and difficult service model on the people of the South East. This need to minimise the amount of travel involved for patients has been widely accepted and adopted abroad.  The South Eastern Health Board therefore considers that a more considerate and humane solution is required which will minimise the travel factor for patients.
8. To these considerations must be added the Eastern Regional Health Authority’s difficulties arising from the volume of patients from other Regions seeking service in Dublin at a time when acute care services in the city are under extreme pressure of demand from their own population.
9. It would be ironic if, now that the South Eastern Health Board is seeking to minimise this, a solution should be put forward to the Radiotherapy issue which would further compound congestion in Dublin/Cork by seeking to cause a flow of up to 30,000 journeys per annum from this Region, for no tangible additional patient benefit beyond that attainable at Waterford, if they had this service there.  Neither is a fragmentation of staff in two centres a comfortable or efficient environment for staff in either centre and it can lead to practical difficulties for all members of the divided team in their attempts to liaise, consult and co-ordinate their contributions to the patient’s care.
10. The Board is also concerned that the exclusion of one of the three major cancer treatment modalities could undermine the image of its own Waterford based service amongst an increasingly demanding public and that it will tend to cause staff to avoid the service here and to impede staff retention. This would undermine cancer services generally leading to possible crisis of care and a renewal of reliance on a congested Dublin and Cork health care system.
11. In relation to accountability and the need for value for money, the Board believes that a 4 Linear Accelerator Unit in Waterford Regional Hospital will be as economically used in Waterford as in Dublin; that they will cost the same to purchase and house and that it is only in relation to ancillary space that limited economies might arise from a central model. Against any such economy must be put the cheaper cost of land and building costs in Waterford compared to Dublin.  Similarly, the local operating costs of staff, etc. will be offset by avoiding travel costs for 1,800 patients per annum travelling to Dublin for an average of about 20 trips each.
12. The net differences in economic cost will therefore be small and could not be deemed to warrant the concentration in Dublin/Cork of this service at such a cost of patient inconvenience and hardship.  In any event, the people of the Region will, in our view, support a locally based service financially if needed to make up any small diseconomy that may arise. There will, therefore, be no additional costs to the Exchequer.
13. On behalf of the Board, we therefore earnestly request you to recognise the seriousness of purpose shown in the South Eastern Health Board to date in mobilising its resources and community contributions behind a quality driven cancer service, by recommending that this final modality of Radiotherapy be added to our capability, thus resulting in an efficient and effective complete service to our population.

I therefore request that full consideration be given to the issues raised in our presentation and I am enclosing a written copy for your attention.

John Cooney
Chief Executive Officer
South Eastern Health Board
26^th February 2002

The need for a Radiotherapy Unit in the SEHB – the SEHB proposal to the National Working Group on Radiotherapy Services – 26^th February, 2001.

Introduction

The National Health Strategy “Quality and Fairness” identifies the four principles of the Health Service, these are; Equity, Quality, People-Centredness and Accountability. With regard to the application of these principles for the development of radiotherapy services, it is essential that services be developed which give equity of access to the people in the regions. Services should be developed with appropriate quality assurance standards. This will be achieved by national co-ordination involving protocol development and audit standards, together with continuing professional development. Services should be developed in a people centred way, i.e. peoples choice on how services are arranged should be respected wherever possible. Services should be developed in an accountable way i.e. they should be planned based on the research evidence available, and provide value for money.

Inequity

The current provision of radiotherapy services is inadequate to meet the need of cancer patients. In addition, there is evidence of inequity of service provision; a smaller proportion of cancer patients from the South Eastern Health Board, and other regions receive less radiotherapy than residents of the ERHA and Southern Health Board regions. Currently, radiotherapy facilities are only available in the ERHA and Southern Health Board regions. In addition, patients from the South Eastern Health Board and other regions experience longer delays in accessing radiotherapy services than residents of the ERHA and Southern Health Board.  There is currently a large under capacity within the radiotherapy service provision in Ireland; approximately 20% of cancer patients receive radiotherapy whereas international best practice would suggest that this should be 60% of cancer patients. In some cancers, where local services are well developed, for example in the case of breast cancer in the South Eastern Health Board, a higher proportion, 48%, of breast cancer patients receive radiotherapy. However, best practice would suggest that this should be up to 75%. It has proved extremely difficult to persuade additional patients to undertake the onerous repeated journies to distant radiotherapy sites, over periods of six weeks as a result individuals have chosen not to avail of this service.

The South Eastern Health Board consists of the counties of; Wexford, Carlow, Kilkenny, South Tipperary and Waterford.  The population of the region is concentrated in the Southern part. The South Eastern Health Board commissioned Trinity College9 Dublin, to undertake a study of travelling times to major hospital centres for residents of the South Eastern Health Board.  These travelling times do not take account of traffic congestion, which is obviously a factor in travelling to Dublin or Cork at the times where patients would need to commute.  International reports recommend that travelling times for services should be under 60 minutes;  0% of the population of the South Eastern Health Board region were within 60 minutes travelling time of St. James Hospital, St. Vincent’s Hospital or St. Luke’s Hospital, 1% was within the 60 minutes travelling time of Cork University Hospital and 63% were within 60 minutes travelling time of Waterford Regional Hospital.  All residents of the South Eastern Health Board were within 90 minutes of travelling to Waterford Regional Hospital.  Patients requiring radiotherapy usually have to receive treatment for approximately 5 minutes per day, 5 days a week for 5/6 weeks depending on the particular cancer involved.  This treatment either has to be undertaken by daily commuting to the centre or by staying at a remote centre for 4/5 days a week for 5/6 weeks.  This is at a time where patients are at their most vulnerable and need their family supports around them.

Accountability – Evidence Based Planning

There is no consistent evidence in the medical research literature linking the outcome of radiotherapy with the structure of the delivery of services. The Patterns of Care Study in the US showed that smaller stand alone centres had less quality assurance than larger hospital based centres. The PCS studies emphasise that “it is not established that this finding has any impact on outcome”. Most of these centres had only one linear accelerator and did not function in an organised care system. This is quite different to that proposed in the South East, where a 4 unit facility would be fully integrated within a teaching hospital and linked to other national centres.

Neither is there one model of treatment which is universally considered applicable or successful, hence there are many different models existing in all Western countries.

It has not been possible to state the minimum size of radiotherapy facility below which quality falls. The UK Calman Hine report states that “It is not possible or appropriate to attempt to define a specification of an optimum radiotherapy facility”.

The National Swedish Board of Health and Welfare Guidelines recommend radiotherapy at the 8 regional hospitals in the country.

The most authoritative report on the subject is the recently published report from the Netherlands “Actualisation Commission, Radiotherapy: our care 2000”. This report recommends that an “average or model” radiotherapy facility should consist of 4 Linear accelerators, this would cater for 1800 radiotherapy treatments per year i.e the volume which the population of the SEHB will generate in the coming years.

Radiotherapy Requirements

It is expected that there will be at least a 40% increase in cancer cases in Ireland within the next 15 years.  This is mostly a function of ageing population. Almost 1 in 5 people will require radiotherapy in their lifetime, this plan will determine the comprehensiveness of cancer services for a generation.

As previously stated, radiotherapy is currently only provided to approximately 20% of cancer patients in Ireland whereas best practice would suggest that this should be 60%. Taking these new standards into account, algorithms for radiotherapy requirements have been developed by both the UK and Dutch Health Authorities. These standards based on research evidence should supersede the previous standard proposed in the National Cancer Strategy of 1996 which was based on expert opinion, which suggested a population base of 650,000. The application of the Dutch or UK algorithms to the South Eastern Health Board indicate that currently there is a radiotherapy requirement for the population of the region of 3 linear accelerators, this would increase to 4 linear accelerators for the year 2015. This development is the model or average facility proposed in the Dutch report.

It is accepted that the current service does not have adequate capacity and that pre-operative radiotherapy and palliative radiotherapy are underdeveloped.  In addition, it is recognised that accessing radiotherapy for elderly people and providing the necessary psychological supports at this vulnerable time have proven difficult in the current scenario. It is accepted that radiotherapy treatment should be integrated in a multi-disciplinary way with other treatment modalities for cancer patients.  Therefore, the provision of radiotherapy to patients at the centre that they will be attending for their medical oncology, surgery or palliative care services, is highly desirable.

Regional Cancer Services in the South Eastern Health Board

The South Eastern Health Board currently has well developed cancer services, centred at Waterford Regional Hospital, which provides multi-disciplinary care to all residents of the region, on an in-patient basis, an out-patient basis and day patient basis.  The  multi-disciplinary facilities and skills available at the Regional Cancer Centre include;  2 Medical Oncologists, 2 Haematologists, a Palliative Care Physician, the Regional Breast Cancer Unit, General Surgery, Gynaecological Oncology, General Medicine, Regional Cardiology, Regional Pathology, Regional ENT and Ophthalmic Surgery, Regional Orthopaedic Surgery, Plastic Surgery is being developed, Rehabilitation Services, Intensive Care, Full Laboratory Service including 4 Histopathologists and 2 Micro-biologists, a full Imaging Service including MRI, CT, Ultrasound and Nuclear Medicine facilities. 

The Cancer Services provide multi-disciplinary clinics, clinical pathological meeting and continuing professional development. Regular out-patient and day-patient services are delivered at sector hospitals. Specific links to Tertiary Centres have been developed, for example, to St. James hospital for malignant haematology, liver surgery links to St. Vincent’s hospital and paediatric oncology links to Our Lady’s Hospital, Crumlin, as an integrated supra-regional centre does not currently exist. In addition, Waterford Regional Hospital is an RCSI teaching hospital and has an excellent record for clinical trial participation.The hospital is recognised for undergraduate and higher specialist training. In addition, there is a structured transport service within the South Eastern Region to Waterford Regional Hospital. 

These are the necessary criteria for the development of a Regional Radiotherapy Department.

Quality

It is intended that a strong quality assurance structure will be put in place for radiotherapy. It is envisaged that national co-ordination for protocol development and audit will be established, WRH will participate in implementing these standards. It is also envisaged that all radiotherapy centres will be networked, WRH will link with other centres and participate in Continuing Professional Development for all disciplines. A 4 unit linear accelerator facility is large enough to support site specific specialisation and to cater for any necessary downtime. It is envisaged that rare tumours will be referred to the South Dublin centre. As previously mentioned, WRH has an excellent track record in clinical trial participation and academic training. The South East has proven an attractive location for staff, and the region is not experiencing the recruitment difficulties experienced currently in some of the larger centres, it is envisaged that this trend will continue. 

Patient Centred

The current service for radiotherapy assessment, delivered at a limited number of local clinics has proven inadequate in a number of ways.  In particular, it has proved extremely difficult to integrate the treatment assessment from the visiting Radiation Oncologist with the rest of the multi-disciplinary team who are based at Waterford Regional. Average attendance rates at clinics vary between 50 and 80 patients, and delays for patients in assessment, referral for treatment planning and receipt of therapy, have proven unacceptable for patients.  The centralised treatment service has resulted in inefficient use of time and resources for many members of the multi-disciplinary team, including the Radiation Oncologist who wastes valuable time in commuting to distant centres.

The impact on patients of the centralised service is significant. As stated, patients must either commute daily for 5/7 consecutive weeks or stay at a distant location for 5 days a week. This leaves them isolated from social and family supports at a crucial time in their illness. It results in unnecessary suffering and lack of public confidence in the service. From the cancer service point of view, it results in a disjointed and frequently unco-ordinated service, which gives rise to unnecessary delays. In some cancers, it has given rise to a low referral for radiotherapy; for example, very few lung cancer patients are referred for radiotherapy, pre-operative radiotherapy is an established standard of care and rectal cancer and is available for patients diagnosed in Dublin hospitals, however, no patients from the South Eastern Health Board hospitals are treated in this way because of delays and logistical difficulties.  In the case of emergency radiotherapy, this service is made available but often requires daily commuting to Dublin because of unavailability of beds in the centre.  This is particularly difficult for people experiencing metastatic bone pain who are not in a condition to travel.

Accountability – Value for Money

The Dutch report emphasises that radiotherapy is a very cost-effective treatment for cancer, as its use frequently minimises the need for expensive in-patient and medical oncology treatments. This report emphasises that whereas capital outlay may be significant initially, there are considerable savings in the longer term.

It is accepted that the revenue costs for a 4 linear accelerator facility would have marginally higher revenue costs than a larger facility, however, this revenue cost is more than offset by the savings which accrue in reduced travel costs to the Health Services. To provide 1800 treatments, an individual would make an average of 20 trips to the Radiotherapy Centre, i.e. 36,000 trips from the region per annum. If the centre was in Cork/Dublin, 25% of patients would to Cork @ €80 per trip and 75% to Dublin @ €100 per trip.This mounts to €3,420,000 per annum. If the centre was in Waterford, 8000 trips would be local @ €20 per trip and 28,000 from the region @ €50 per trip. This amounts to €1,560,000 per annum.  Overnight stay costs are not any less expensive. The revenue saving would be €1,860,000m per annum.

In addition to this, the personal costs of having to travel long distances for an extended period of time are considerable. Patients usually require the spouse to travel with them, this necessitates the spouse taking time off work and possibly incurring child care expenses. This in addition to the hardship involved, are strong reasons why people often opt not to avail radiotherapy treatments.

It is accepted that the initial capital costs of 4 linear accelerator facility would have higher unit cost than a larger facility. However, it must be recognised that this is a once off investment. The Capital cost of a 4 unit facility and a 10 unit facility was estimated using the Q Cost method. The unit cost for an LA in the 4 unit model was €5,486,000 compared to the unit cost of €4,488,000 in a 10 unit facility. Hence the marginal cost of the 4 unit facility is €3,992,000. This does not allow for the more expensive site costs or building costs in Dublin or Cork, so that the net cost concerned would reduce further.

Given the strength of support for the development of a centre within the South East and the offers of financial support that have already been received, it is likely that the local region would be effective in raising funds to contribute to these excess capital costs.  There is a very active cancer foundation within the South East which has considerable assets and has pledged support for the radiotherapy development, it has been also shown that local fund raising in the South East have been very effective in purchasing capital equipment in the past. 

Conclusion

Therefore, it is proposed that 4 linear accelerator facility should be developed at Waterford Regional Hospital to serve the South Eastern Health Board region. This would be networked to all other facilities in the country and linked to the South Dublin centre for referral of rare cancers. Quality Assurance and continuing professional development standards would be met by building on existing well established structures, the adoption of the nationally developed protocols and audit systems and linkage to the South Dublin centre is necessary. There is a sufficient population within the South Eastern region to sustain a radiotherapy facility as modelled on the best available evidence from the recent Dutch report. A local facility for radiotherapy would ensure equity for the people of the South East and avoid the severe hardships currently experienced. The revenue funding of the facility would provide value for money, as unnecessary travel costs would be eliminated, the initial capital outlay would be ameliorated by local contributions.