Transcript Slide 1

NEUROSURGICAL SERVICES
now and for the future
New Zealand
South Island
Martin MacFarlane
Clinical Director
Department of Neurosurgery
Christchurch Hospital
Canterbury District Health Board
23rd August 2010
NEUROSURGERY (Neurological Surgery)
OPERATIVE and NON OPERATIVE management
WHAT TYPES OF CONDITIONS/OPERATIONS
DO NEUROSURGEONS TREAT/PERFORM
?
Surgery
Public
expectations
Healthcare
expectations
subspecialisation: better surgery: better outcomes: succession planning
Neurosurgery
Neurosurgery
for pain
Movement
disorders
Peripheral
nerves
Brain
tumours
Spinal surgery
Pituitary
tumours
Skull base
Epilepsy
Vascular Head &
craniotomies
spinal trauma
&
endovascular
Paediatric
neurosurgery
Tools, Equipment and Instrumentation
Shunt valve for hydrocephalus
Fibreoptic endoscope
Hudson brace, perforator
& conical burr
Sugita aneurysm clips & applicator
Coil for aneurysm
Image Imtensifier
Vessel stent
Stereotactic frame
Operating microscope
OT of the near future
Endoscopic tower
Neurosurgery in Christchurch – 1981/1982 to 2009/2010
Growth of a Specialist Service
Neurosurgical Inpatients
Neurosurgical Outpatients
1200
2500
1000
2000
800
1500
OP
1000
IP
400
500
0
1982/83
600
200
1987/88
1992/93
1998/99
2003/04
2008/09
0
1982/83 1986/87 1990/91 1995/96 1999/00 2003/04 2007/08
Neurosurgical Operations
700
600
500
400
Ops
300
200
100
0
1982/83
1987/88
1992/93
1998/99
2003/04
2008/09
NEUROSURGERY
and
NEUROSURGICAL UNITS
in New Zealand
Martin MacFarlane
Clinical Director
Department of Neurosurgery
Christchurch Hospital
21st August 2010
New Zealand
Neurosurgical Units
Auckland
•
Hamilton
(1945)
•
(2006)
3.3m
5 units for
4.327 m population
•
Wellington
(1965)
1.027m
•
Christchurch
(1981)
•
Dunedin
(1943)
Neurosurgical Services in New Zealand
North Island
• Auckland Neurosurgical Unit incl Starship
– 6 neurosurgeons
• Waikato Neurosurgical Unit
– 4 neurosurgeons
• Wellington Neurosurgical Unit
– 5 neurosurgeons (one currently partial clinical)
14 (15)
1 NS
Per
253,846
(220,000)
South Island
• Christchurch Neurosurgical Unit
– 4 neurosurgeons (+ one in sole pp)
• Dunedin
– O neurosurgeons – using sole locums
5 (6)
1 NS
per
205,400
(171,166)
Neurosurgical Services in New Zealand
South Island
• In the 1970s  changing population demographics in the South
Island
 continuing growth of Christchurch as the major
tertiary referral centre in the South Island
• 1979: Decision made by Dept/Ministry of Health to commision a
Neurosurgical Unit in Christchurch
(1st Review)
– The neurosurgical unit in Christchurch was established in August
1981 and was able to function as a fully-equiped independent
unit in April 1982
– The Minister of Health stated at that time that: “the Dunedin
Neurosurgical Unit would function on a week to week basis
with there to be no replacement of neurosurgeons as they retired”
– Christchurch Unit now has 4 neurosurgeons (747,000 people)
– Dunedin Unit has no permanent neurosurgeons – using locums
(280,000 people
Reviews of the provision of Neurosurgical Services
since 1979
2nd : 1988
“Hospital/Area Health Board
Service Planning Guidelines
Neurosurgery”
June 1988
Graham Martin, Martin MacFarlane, Owen Mooney (AHB), John Mills (OHB),
Liz Webb (Nursing, AHB), Dr Ray Dowden (PMO, DoH), Ray Collinge (DoH)
with input from Sam Bishara, Graeme MacDonald
• This was the first of two specific reviews of the requirements for/of a
Neurosurgical Unit in New Zealand and the provision of neurosurgical
services (population, staffing, bed numbers, affiliated surgical, medical, allied
health, support services, equipment, radiology etc).
• Basis for neurosurgeons was 1:300,000
• Minimum population to be served by a unit was 900,000 with 3 neurosurgeons
in a Unit
• Minimum of 8 adult beds per 300,000 - plus ICU beds, paediatric beds and
rehabilitation beds
• To ensure equitable access to neurosurgical services for the whole population
Reviews of the provision of Neurosurgical Services
since 1979
3rd : May 1995
“TERTIARY SERVICES
ISSUES PAPER
Neurosurgical Services”
p15:
Looked at ratios of neurosurgeons to population:
1:100,000 in US (Congress of Neurological Surgery)
1:400,000 in UK (SBNS)
1:250,000 previously in Australasia to
1:175,000 (Neurosurgical Society of Australasia)
p15:
“Neurosurgery cover should be available on a 24-hour basis due to the
semi-urgent nature of the surgical intervention and nonsurgical
consultation. Because of this, the recommended minimum number of
neurosurgeons per unit is three. Fewer than three neurosurgeons per
unit may reduce quality outcomes.
(It has been noted by the Core Services Committee that ‛centres that
currently meet quality criteria but have fewer than three neurosurgeons
per unit may be at serious risk of compromised quality if there are changes
of key staff, particularly neurosurgeons’)”
Reviews of the provision of Neurosurgical Services
since 1979
4th : Nov 1995
“Recommendations for the configuration of Tertiary Services
in New Zealand
A report from The Tertiary Services Committee
November 1995”
Re Neurosurgery:
• “The Tertiary Services Committee agreed with the recommendations from
professional bodies and clinical groups, both in NZ and overseas, that the
interests of the NZ patient would be best served by having three neurosurgical
centres, with a minimum of three neurosurgeons per centre, and with each
Neurosurgeon performing a minimum of 100 major neurosurgical
procedures a year.”
• “The Tertiary Services Committee’s preferred option is that RHAs purchase
neurosurgical services from three centres – in Auckland, Wellington
and one in the South Island”.
The neurosurgery workforce in Australia and New Zealand
1996
Discussion
“The NSA has attempted to maintain a balance between competency, accountability
and quality of life for the surgeon, and has nominated a surgeon to population ratio of
1:175,000. Notably, this figure is markedly different from the ratio in the US (1:61,000)
And from the whole world (1:230,000), but not dissimilar from that of the UK
(1:181,500. Additionally, this figure may need to be reconsidered over time as the
practice of neurosurgery and medicine in general changes”.
Reviews of the provision of Neurosurgical Services
since 1979
5th :1996/97
Tertiary Services
Neurosurgical Services
“Policy Guidelines
for
Regional Health Authorities
1996/97”
Current service
configuration
Four centres –
Auckland, Wellington,
Christchurch and Dunedin
Preferred option
Three centres –
Auckland, Wellington and
one in the South Island.
Affiliation of satellite units
possible if quality criteria
are met
Reviews of the provision of Neurosurgical Services
since 1979
6th : 1997
Discussion document for Neurosurgery Services,
South Island, New Zealand
7th
: 1998
Andrew Law and Nicholas Finnis, Neurosurgeons, Dunedin
1998
“Looking at operating statistics from 1996 and 1997 from Dunedin Hospital, there
are between 6 and 10 cases each year requiring urgent neurosurgical intervention.
Of these, less than half are from the Dunedin are, with surgical stabilisation already
performed in some cases in Invercargill by the general surgeons prior to transfer to
the (Dunedin) neurosurgical centre for definitive treatment. This does raise the issue
of excess morbidity in a few cases each year due to a change in service. …there is
likely to remain a few cases each year that need some form of life-saving surgical
intervention prior to transfer”
Considered positives and negatives for:
• Dual Site Service:
Dunedin 2 neurosurgeons, Christchurch 4 neurosurgeons
• Single Site Service: Christchurch 6 neurosurgeons with appropriate outreach and
professional and other linkages
Reviews of the provision of Neurosurgical Services
since 1979
8th: 2001
Safe Neurosurgery 2000
A Report from the
Society of British Neurological Surgeons
• Neurosurgical units should be situated within a multi-disciplinary Neurosciences
Centre and on a General Hospital site. Each unit must provide a full core neurosurgical service before any subspecialties are developed
• For maintenance of neurosurgical expertise and satisfactory training there must be
an adequate volume and diversity of work and sufficient population to generate this.
Whilst this must be reconciled with equity of access, a 1 million catchment
population should be the minimum
• All neurosurgical units must provide a full twenty-four hour consultant-led service
and be staffed accordingly, i.e. a minimum of 6 WTE consultant surgeons
increasing with populations of more than 1.5 million
• Thirty neurosurgical beds and four dedicated neurosurgical intensive therapy beds
per million population are needed to provide safe practice
• Every neurosurgical unit should have at least two fully resourced operating theatres;
those serving a population of more than 2 million need three
Reviews of the provision of Neurosurgical Services
since 1979
9th: 2009
February 2009 – meeting of all six SI DHB CEOs and others incl
clinicians from Dunedin, Christchurch, Spencer Beasley
and MoH personnel
June 2009: Prof Spencer Beasley  Draft Neurosurgical Service Plan
given to the SI DHBs
DHBs agreed:
• that there would be a single integrated Neurosurgical Service for the
South Island
• that a single interim clinical leader would be appointed to the
Service for 12 months to recommend future configuration of the
Service
• Dr Ian Brown appointed as clinical leader
Reviews of the provision of Neurosurgical Services
since 1979
10th: 2010
Neurosurgery for the South Island – the Present
Guidelines from the RACS
(Royal Australasian College
of Surgeons) and the
Neurosurgical Society of
Australasia:
747,000 with
4 neurosurgeons
= 1 to 186,750
and
1 in 4 on-call
• 1 neurosurgeon to 175,000
• 1 in 4 on-call roster (max)
• Minimum of 3 neurosurgeons
required for a neurosurgical unit
but note: 1 in 4 on-call
280,000 with
1 sole locum neurosurgeon
= 1 to 298,000
and 1 in 1 on-call
Neurosurgery for the South Island – the Future
1,027,000 population
•
•
•
•
•
•
One Service
One site: Christchurch
6+ neurosurgeons: 1 to 171,166
Appropriately resourced
Good & robust Outreach
Suitable transport links
• Neurosurgical services to
international standards for
the people of the SI
• Funding advantages for high
tech equipment and staff
• Will attract appropriately-trained
staff
• Allows for subspecialisation
• Allows for succession planning