Radiotherapy: developing a world class service
Radiotherapy: developing a world class service
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» Radiotherapy: developing a world class service
Summary:
this based on the report provided by Rohit from 2007 dealing with the NHS. We shouldn't deal with the specifics, but there are some interesting discussion points there.
http://www.axrem.org.uk/radiotheraphy_papers/DH_Radiotheraphy_developing_first_class_service_NRAG.pdf
There is a general consensus among experts that the projected need for radiotherapy was significantly underestimated 15-20 years ago. There is a large gap (63%) between current activity levels and optimal treatment levels, if radiotherapy were to be given to all who might benefit. The position is set to worsen as cancer incidence increases with the ageing population.
What is happening in your jurisdiction?
Has health planning got your resource levels right? Why? Why not? How close to disaster are you?
The NRAG document was a expert committee report prepared in 2007 and submitted to the ministers in the parliament in 2008 or 2009 i think.
The report is a recommendation based on experience and data collected from 27 leading cancer institutes.
Currently health planning since 2008 has put all mandatory targets for all NHS hospitals.
And funding / payment is by results and achieving this target.
the higher the deviation, the more penalty you pay.
This has certainly helped the waiting times as the axe is always on the oncologist as at the end of every 6 months, there is a detailed discussion of all missed targets which the treating consultant is responsible for.
As per the radiotherapy resources, there has been a shift in power, with the Conservatives and Liberal democrats coming in power as labour has lost the elections, there is currently a fiscal deficit of £ 156 billion, and it seems unlikely that there will be more machines and more manpower installed.
In fact, the ministers have announced no renewal of jobs of retired consultants making the economic situation appear worse.
So currently its the economic disaster which appears high priority as opposed to radiotherapy services.
"the axe is always on the oncologist as at the end of every 6 months, there is a detailed discussion of all missed targets which the treating consultant is responsible for"
how does this happen?
how is the oncologist 'axed'?
how is the oncologist 'responsible' for all these things, especially when he has no financial control over the system's capabilities?
The referral is made by GPs to oncologists and they should see pts in 2 weeks time. After a diagnosis is made, they should initiate treatment by 31 days. In category 1 patients, this is always a problem to start CTRT ASAP and have planning done ASAP.
The oncologist have always traditionally been the chief personnel responsible for the overall mgt of cancer pts, despite the input from multidisciplinary members. Hence the mangement would always hold the oncologist responsible for effectively maintaining these targets, which are essentially national standards now which all oncologists should meet.
This clinical governance eventually benefits the patients. This is not a problem of financial control, its a matter of organistaion and prioritisation in a systematic fashion to ensure fair, sensible and uniform oncological treatment.
The important thing now is for clinical staff working with cancer patients to be able to identify and ensure that all patients who could benefit from radiotherapy have access to this treatment option and that they can be offered it in a timely manner. One way to ensure this happens is to set a specific waiting times target for the start of radiotherapy treatments for all cancer patients ….
Is the notion of a Waiting Times Target a useful concept?
What is the acceptable waiting time for cancer treatment?
List your departmental numbers: 1. waiting time for radical H&N RT; 2. radical prostate RT; 3. Number of RTs/machine
Is the notion of a Waiting Times Target a useful concept?
This is a difficult and controversial topic. For health care mangers and may man, its a good thing.
For an oncologist, its sort of a nuisance and overwork.
cancer waiting time is 2 weeks from time of referral to time seen by an oncologist.
the time from being seen by an oncologist to initiation of any cancer treatment is 31 days.
Roughly waiting time for Radical H & N RT is 10-14 days as this is Category 1.
For Radical RT prostate, waiting time is 1-3 months as this is category 2.
Most pts usually have neoadjuvant hormones — so booking and co-ordinating their treatment is not difficult.
I persistently remind our oncologists and trainees that Waiting Times are the result of reporting on what we are doing, it is not OUR aim. Certainly departmental organization should be organized on the ALARA principle at multiple levels, and wait times should be ALARA.
If waiting times are increasing, organization needs to be reviewed to try to improve throughput, if efficiency is maximal (how to do this is a whole topic itself) then additional resources are needed.
ICCC - 1. 7 days 2. 10 days 3. 26 RT/ 2 LA / 1000 NP/yr
there is a two and a half fold variation in the number of fractions that are provided per million population between cancer networks …….. NHS delivers around 1.5 million fractions annually … however, to achieve optimal treatment levels (as set out in the treatment pathways in the scenario planning report) … around 2.5 million fractions should be delivered each year.
Are we seeing a homogenizing of RTh approach?
Are there problems with this productivity approach to medical treatment? (will a manager come in and demand more fractions to meet national performance criteria?)
Making the best use of the resource we already have - NRAG believes that some increase in capacity could be achieved by using existing equipment to its full potential. It recommends that all radiotherapy departments should ensure that their linear accelerators (linacs) deliver at least 8,000 fractions per annum averaged across all linacs in the department
What is the fractions per annum for each of your linacs? [List the pairing e.g., LA1 - 7655, etc]
i. each linac delivers 4- 4.5 fractions (ie. patient treatments) on average per hour;
Enter one week of activity for each linac [LA1 - Mon 42Fx, Tue 38Fx, etc]
ii. linacs within radiotherapy departments work on average 9.2 hours per day with a minority running for an extended day (eg. 11.5 hours);
Enter the operating hours fr each linac [LA1 - Mon 7 hours]
iii. radiotherapy departments operate 239 days per year – a standard 5 day week, closing for only 3 bank holidays and ensuring that each linac is out of action during normal working hours for no more than 19 days for QA/servicing a year. In addition, departments undertake some palliative radiotherapy on Saturdays. [Availability of staff and the appropriate skills mix will be the rate limiting factor for many localities seeking to increase productivity in this way.]
How many days were worked last year? [days]
iv. radiotherapy departments have a service efficiency machine ie. an additional machine that would be in use 50-75% of the time providing capacity to deal, for example, with unexpected peaks in workload or linac breakdown without increasing waiting times for patients and minimising the need for cancellations/ rescheduling.
Do you have a "service efficiency machine" with 50% capacity? [Y/N]
v. in addition to having a service efficiency machine, radiotherapy departments progressively increase capacity so that they operate at 87% capacity
What was your capacity each day last week - assume 100% daily fractions = (8000Fx/yr)/(239day/yr) Fx/day? [LA1 - Mon 76% Tue 87% etc]
This calls for an audit at your department Andrew.
it will be a good exercise.
Perhaps you could ask one of you junior students to liase with the Radiotherapy superindent and perform this audit for the next month or two.
I believe I could have the numbers this afternoon!
Add: 27/5/2010 …. when I get some time! We have a reporting tool that gives all these numbers already
Do you believe radiotherapy treatment (amount of treatment, quality of treatment) in the UK would improve if Clinical Oncologists focused on being either Medical Oncologists or Radiation Oncologists?
I think certainly if a radiation oncologist - delivers radiotherapy
and medical oncologist - prescribes chemotherapy
This will be a very ideal scenario as both will be experts in their own fields and i m sure All would believe and agree thats the way forward as thats what all most of the members in this group do.. however you would find a few oncologists trying to explore beyond this cage and grab their hands on some chemotherapy not by compassion, but due to lack of medical oncologists in their setup or for financial interets.
However UK is quite unique, with the entity of the so called " Clinical Oncologists " who can do both and its their compassion here.
The reason this works well, is the infrastructure is quite robust here.
The radiotherapy departments are very strong with clinical dosimetrists, physicisits, radiographers or radiotherapy technologists
The oncologist does not simulate patients as we used to do in India.
Entire protocols are followed by radiographers, the oncologists simply signs plans. They work as a collective group and each one is designated work to co-ordinate treatments, arrange appointments etc.
They damn explain the side-effects and procedure of simulator and radiotherapy treatments to pts as well, however its the primary oncologits who usually consents patients.
the oncologist just draws the GTV, CTV and PTV. Rest are drawn by clinical dosimetrists.
the dose constraints are all known to physicists as within the protocols of class solutions.
They always give you an ideal plan. hardly would a oncologist ask for another plan.
When the sytem works so efficiently i doubt at times that would it make a difference if Clinical Oncologists gave up chemo, when the sytem is pretty robust.
They have pre- designated protocols, pre-designated dose constraints and class solutions for almost all tumour sites.
The health care professionals have made Clinical oncologists almost redundant.
IMRT & IGRT have not come out in a big way here yet. The technology is here, but the clinical need appears to be in doubt all the time.
The primary outcome is getting it right first, getting it across uniformly all over the UK with minimal waiting time.
Survival is the main primary end point after all.
Reducing side-effects and toxicity come later.
These guys would change practise overnight as soon as One good randomised trial shows that IMRT improves survival.
I can see H & N cancers, IMRT is emerging to be standard treatment, but rest of the cancers …. use it only if there is a clinical need.
Americans using IMRT for Breast in adjuvant fashion is a common joke here.
They feel there is no clinical need for it.
You can certainly treat anypatient with IMRT if you ve got the toys.
Is that a medical sausage factory you are describing? :)
I can't help but think that this efficiency results because the oncologist is too busy with chemotherapy.
As for reducing toxicity later, that is unlikely to happen, which oncologists in this system have the time to play and experiment with technique?
I agree about IMRT, it has two sites of large gain - pelvis and H&N. Although, we use IMRT as a partial boost to the breast to improve homogeneity because it is easier, quicker and more homogeneous than playing with wedges.
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