0 Tasmania’s Health Plan Clinical Services Plan May 2007 Department of Health and Human Services Table of Contents 1. Preamble 4 2. Introduction and background 6 Clinical Services Plan Project Working Group 6 Community and clinical consultations 6 Workshops 7 Issues Paper 7 3. Governance, planning and policy framework 8 3.1 Governance 8 3.1.1 Department of Health and Human Services 8 3.1.2 Acute Health Services Group 8 3.2 Planning and policy framework 9 3.3 Reform strategies and strategic priorities 9 4. Profile of Tasmania 10 4.1 Geographic profile 10 4.2 Population 11 4.2.1 Current population 11 4.2.2 Projected Population – Tasmania 12 4.2.3 Projected Population – Region 12 4.2.4 Current and projected age profile 14 4.2.5 Cultural diversity 15 4.2.6 Indigenous population 16 4.3 Social and health status indicators 16 4.3.1 Socio-economic status 16 4.3.2 Health status indicators 17 4.3.3 Morbidity 18 4.3.4 Mortality 20 5. Current services, activities and issues 23 5.1 Current facilities and services 23 5.1.1 Major acute public hospital services 23 5.1.2 Ambulance and Retrieval Services 26 5.1.3 Rural hospitals 26 5.1.4 Private acute hospitals 26 5.1.5 Residential aged care services 27 5.2 Activity profile 28 5.2.1 Inpatient services 29 5.3 Service profiles for public hospitals 33 5.3.1 Adult public hospital medical services 33 5.3.2 Adult public hospital surgical services 34 5.3.3 Critical care public hospital services 36 5.3.4 Public hospital emergency medicine 36 5.3.5 Women’s and children’s public hospital services 37 5.3.6 Cancer services 41 5.3.7 Clinical Support Services 44 Clinical Services Plan 5.4 Workforce 47 5.4.1 Workforce profile 47 5.4.2 Nursing and allied health 48 5.4.3 Medical workforce 49 5.5 Other support services 49 5.5.1 Transport and retrieval services 49 5.5.2 Teaching and research 51 5.5.3 Accommodation 53 6. Assessment of future health care demand 54 6.1 Projected demand for acute inpatient services 55 6.2 Projected flows analysis 59 6.3 Projected demand for emergency department services 62 6.4 Projected outpatient activity 64 6.5 Ambulatory care sensitive conditions 66 7. A sustainable acute health system for the future 67 7.1 Designing the system 68 7.1.1 Key principles 68 7.1.2 Capability framework for local, regional, single site and state-wide services 69 7.1.3 Clinical networks 71 7.1.4 Integration with the primary health system 74 7.2 Implementing the System 79 7.2.1 Assessment of strategies and plan for the south 79 7.2.2 Assessment of strategies and plan for the North 83 7.2.3 A New Strategy for the North West 85 8. State-wide; single service and network strategies 100 8.1 State-wide and single site services 100 8.2 Specific service strategy issues 103 8.2.1 Bariatric surgery 103 8.2.2 Bone Marrow Transplantation 103 8.2.3 Cardiac electrophysiology 106 8.2.4 Cardiothoracic surgery 108 8.2.5 Complex upper gastrointestinal including hepatobiliary surgery 108 8.2.6 Cystic Fibrosis (adult and paediatric) 109 8.2.7 Endocrinology and diabetology 110 8.2.8 Medical imaging services 110 8.2.9 Pain management services 111 8.2.10 Pathology services 111 8.2.11 Pharmacy services 111 8.2.12 Positron Emission Tomography 112 8.2.13 Radiation oncology services 113 8.2.14 Renal dialysis services 115 8.2.15 Vascular surgery 115 Clinical Services Plan 8.3 Key service areas 117 8.3.1 Adult medical services 117 8.3.2 Cardiology services 121 8.3.3 Renal medicine and renal dialysis services 124 8.3.4 Endocrinology 127 8.3.5 Respiratory medicine 130 8.3.6 Neurology services 132 8.3.7 Surgical services 133 8.3.8 Women’s and Children’s Services 137 8.3.9 Critical care services 146 8.3.10 Cancer services 148 8.4 Interface with other services 153 8.4.1 Aged Care/GEM 153 8.4.2 Rehabilitation services 154 8.4.3 Palliative care services 156 8.4.4 Mental health services 156 8.4.5 Drug and alcohol services 157 8.4.6 Private sector interface 158 9. Enablers for services strategies 159 9.1 Workforce 159 9.2 Teaching and research interface 162 9.3 Transport and retrieval services 163 9.4 Accommodation 163 9.5 Information and communication technology 164 10. Bibliography 166 11. Tables 170 12. Figures 174 13. Abbreviations 175 14. Glossary of Terms 177 15. Appendices 178 Clinical Services Plan 1. Preamble The Tasmanian Department of Health and Human Services has developed a strategic plan for the health system in Tasmania – Tasmania’s Health Plan. Tasmania’s Health Plan is an overarching document that sets the future direction for a high quality, sustainable, responsive, and integrated health system to meet the future needs of the Tasmanian community. Tasmania’s Health Plan includes two major service components: • the Clinical Services Plan (this document); and • the Primary Health Services Plan. The Clinical Services Plan provides more detailed information on the clinical and acute aspects of Tasmania’s Health Plan. The key feature and objective of the Clinical Services Plan is sustainability. The current Tasmanian hospital system is becoming unsustainable in the face of the following pressures: • increasing demand for health services, well above rate of population growth, due to an ageing population and increase in chronic disease; • ageing workforce and inability to attract/retain sufficient clinicians to meet expected demand while providing safe and effective services; • coupled with: o The costs of health services rising well above the rate of CPI and as a proportion of the total Tasmanian public budget; and o Inability to meet current demand, let alone the expected future demand for health services within the available budget. To provide a safe, effective and affordable system, we must change the way we configure and deliver our health services. This will require new responses to ensure access is equitable across the State. The key changes are: • Introduction of a Service Capability Framework that meets the sustainability objective by requiring that, where services cannot be delivered safely, effectively and affordably (ie at an acceptable cost), access is facilitated through service coordination, transport assistance and other appropriate patient support. • Establishment of clinical networks under the guidance of a revamped clinical advisory committee and continuing review of the optimum arrangements for state-wide health services, including bone marrow transplantation and vascular surgery. • Re-orientation of the major acute hospitals to provide a more targeted range of services and the introduction of clear acute care service levels: local, regional, single site and state-wide, to improve community health outcomes and address sustainability, access, safety and efficiency levels. Clinical Services Plan • Confirmation of the Royal Hobart Hospital (RHH) as the principal tertiary referral hospital for Tasmania and a major teaching and research hospital linked to the University of Tasmania. • Confirmation of the role of the Launceston General Hospital (LGH) in providing a comprehensive range of acute hospital services to its own community and on a regional referral basis to people from the West and North West of the State. Launceston will continue to provide several tertiary-level services and continue in its role as a teaching hospital of the University of Tasmania, supporting significant research activity. • Revision of roles of the Burnie and Mersey campuses of the North West Regional Hospital (NWRH), to improve community health outcomes and access to services. • Introduction of an integrated care service model that combines both primary and acute health services and where acute services are provided in higher service levels to reflect the complexity of care delivered. • Enhancement of Ambulance and patient transport services to ensure accessibility. Clinical Services Plan 2. Introduction and background Key points • This Clinical Services Plan defines the roles, services, and strategic directions for Tasmania’s three major public acute hospitals – the RHH, LGH, and NWRH, Burnie and Mersey campuses. • The Department of Health and Human Services initiated the Clinical Services Plan to set strategic directions for acute health services and to position Tasmania’s health system to provide safe, high quality, efficient, sustainable clinical services in response to emerging trends in health and health care. • The Clinical Services Plan has a planning horizon to 2021. The Department of Health and Human Services will review this Plan during that time to respond to changes in demographics, technology, service practices and other areas of change. • The Department of Health and Human Services managed a comprehensive consultation process to develop the Plan and conducted community and clinical consultations across Tasmania over a period of six months. The planning process identified the key challenges and opportunities facing Tasmania’s health system, developed different strategies for service delivery, and identified the preferred service strategies for clinical services in Tasmania. Clinical Services Plan Project Working Group The Clinical Services Plan Project Working Group guided the development of the plan. Membership of the Project Working Group included the Deputy Secretary from both the Acute and Community Health Groups, the CEO of each major acute public hospital and the Tasmanian Ambulance Service, and project consultants. Community and clinical consultations The clinical services planning team conducted community and clinical consultations across Tasmania with community groups, community leaders, clinicians, professional associations, key stakeholder groups associated with teaching, research, and transport, the private sector, and non-government organisations. This process: • Informed stakeholders of the purpose of the Clinical Services Plan and methodology for its development. • Identified key service issues that should be considered in developing the plan. • Informed the development of an Issues Paper. • Sought stakeholder input on the outcomes of the data modelling. • Developed strategies for clinical service delivery in partnership with the community and clinicians. • Identified the preferred strategic directions for Tasmania’s health system. Clinical Services Plan Workshops Workshops were held at strategic points in the planning program. Workshops included broad representation from the Department of Health and Human Services, managers and clinicians from the major acute public hospitals, and key stakeholder representatives. Issues Paper The Department of Health and Human Services released an Issues Paper for public comment in February 2007. Its purpose was to: • Raise awareness of the planning process. • Identify the challenges and opportunities facing Tasmania’s acute public hospitals, and the health system generally. • Identify the key issues to be addressed in developing the plan. • Seek input on proposed service principles, and models for service delivery. There were 168 responses to the Issues Paper: 38 from the South; 34 from the North; 75 from the North West and 21 from state-wide groups; 72 consumers/consumer groups and 96 individuals/groups directly involved in the provision of services provided responses. The Issues Paper sought input on a range of issues, and posed six targeted questions: • Question 1 Please comment on the principles proposed as a basis for the Clinical Services Plan. Are they comprehensive and appropriate? Do they define an appropriate balance between access to health care services and service safety, effectiveness and efficiency? Should any additional principles be considered? • Question 2 Please comment on the models for local, regional, and state-wide services and the general service design principles. Are they comprehensive and appropriate? • Question 3 Which services should be designated as local, regional and state-wide services? Why? • Question 4 What factors may inhibit implementation of these models and principles? • Question 5 Are there new clinical services other than PET and cardiac electrophysiology that should be considered for introduction to Tasmania? • Question 6 Please comment on the service planning principles proposed for the hospitals, in particular the Burnie and Mersey campuses of the NWRH. What would be the practical implications of implementing them? Which critical functional relationships need to be taken into account? Respondents to the Issues Paper generally supported the principles outlined in the Issues Paper and the models for service delivery, and recognised the need to reconfigure services across Tasmania’s major acute public hospitals to support service quality, safety, effectiveness, efficiency and sustainability. Appendix H contains a detailed summary of responses to the Issues Paper. Clinical Services Plan 3. Governance, planning and policy framework Key points • The Department of Health and Human Services reformed its governance framework in 2006 with the implementation of the fit Program and consolidated its management structure into four business groups: Acute Health Services; Community Health Services; Human Services; and Shared Services. • The Acute Health Services Group is responsible for the delivery of hospital and ambulance services to the Tasmanian community through responsible management of the RHH, LGH, NWRH (Burnie and Mersey campuses), Tasmanian Ambulance Service, and Forensic Medical Services. • A CEO/Director manages each of the above services within a policy framework established by the Department of Health and Human Services. • Recent reviews include the Richardson Report (2004) which made 34 recommendations for the operation of Tasmania’s public and private tertiary hospital sector, and the Cameron Report (2004) which proposed a number of options for service delivery in the North West. 3.1 Governance 3.1.1 Department of Health and Human Services The Department of Health and Human Services reformed its governance framework in 2006 with the implementation of the fit Program. This program focused on: • establishing a clear and shared purpose and direction for the agency; • achieving better integration of services; • implementing effective ways to plan for, measure and improve performance; • becoming more solutions-oriented and decision-focused; • improving communication; • improving management and leadership; • strengthening staff capacity; and • reforming the organisational arrangements. 3.1.2 Acute Health Services Group The Acute Health Services Group is responsible for the delivery of high quality, efficient patient- focused hospital and ambulance services to the Tasmanian community through responsible management of the RHH, LGH, NWRH (Burnie and Mersey campuses), Tasmanian Ambulance Service, and Forensic Medical Services. Each of the above services is managed by a Chief Executive Officer/Director reporting to the Deputy Secretary, Acute Health Services. Clinical Services Plan 3.2 Planning and policy framework A range of Department of Health and Human Services planning and policy documents shapes the delivery of acute health services in Tasmania. These strategic goals and enabling strategies that informed the development of this Plan include: • Department of Health and Human Services Corporate Plan 2003-2006; • Strengthening the Prevention and Management of Chronic Conditions, Policy Framework, 2005; • Mental Health Services Strategic Plan 2006; • Aboriginal Health and Wellbeing Strategic Plan; • (Draft) Rehabilitation Services Plan; • (Draft) Strategic Framework for State-wide Cancer Services; and • Tasmania’s Diabetes Action Plan. 3.3 Reform strategies and strategic priorities In recent years, the Department of Health and Human Services has undertaken or commissioned several reviews relevant to this plan including The Tasmanian Hospital System: Reforms for the 21st Century (the ‘Richardson Report’). Richardson Report The Richardson Report outlined 34 recommendations for the operation of Tasmania’s public and private tertiary hospital sector addressing the following issues: • reducing waiting times for elective surgery. • accommodating increasing demands for renal dialysis, endocrinology, medical oncology and haematology. • minimising the numbers of acute care beds being utilised by patients eligible for aged care placement. • maximising the use of limited, high cost technology, equipment and services. • more effectively recruiting, using and retaining the hospital workforce. • further developing the capacity of the hospital sector to provide clinical education and training at undergraduate, postgraduate and specialist levels. • ensuring that effective cooperative arrangements are in place to deal with the demand for hospital services in the case of major emergencies. The Tasmanian Government responded to the Richardson Report with the following strategies: • the First Better Hospitals Package (2004) which committed $75 million over five years for the recruitment of additional staff, equipment purchases, the provision of specialist state-wide services and the establishment of an aged-acute care transition unit; and • the Second Better Hospitals Package (2005-06) which committed $8.8 million to additional medical and support staffing. The Clinical Services Plan further develops the service system design concepts introduced in Richardson’s Report, particularly concepts relating to the sustainability of the Tasmanian health system that have not yet been implemented systematically (including service system issues in the North West). Clinical Services Plan 4. Profile of Tasmania Key points • Tasmania’s geography, topography and dispersed population pose challenges to the delivery of acute services. • There are 29 local government areas (LGAs) in Tasmania. For planning and policy purposes, these LGAs form three regions across Tasmania – the South, North and North West. • The major population centres in Tasmania are Hobart (South), Launceston (North) and Burnie and Devonport (North West). • The Tasmanian estimated resident population at June 2006 was 488,948 persons. The population increased by 3.7% between 2000 (471,409) and 2006. • Tasmania (with South Australia) has the oldest population in Australia, with a median age of 39 years. • The Tasmanian population will remain relatively stable between 2006 and 2021, with growth in the South (1.4%) and North (2%) and a decrease in the North West (-7.5%). • Tasmania has one of the fastest ageing populations in Australia and over the next fifteen years, the Tasmanian population will age significantly. By 2021, there will be 28,236 more people aged 70 years and above. The proportion of the population aged 70 years and above will increase from 10.6% in 2006 to 16.6% in 2021. Ageing is associated with increasing prevalence of chronic disease and a greater need for health and community care services. • Socio-economic indexes show that the Tasmanian population is generally poorer, less well educated, and more disadvantaged than the general Australian population. • Tasmanians life expectancy (76.7 years males, 81.8 years female) is lower than that of Australia (78.1 years male, 83 years female). • In 2004-05 Tasmanians had higher rates of smoking, obesity and chronic disease, but were at less risk of alcohol-related harm, and had a higher childhood immunisation rate than Australia (2006). The prevalence of chronic disease in Tasmania is above the national average • Digestive system diseases were the leading cause of hospitalisations between 2000 and 2004, accounting for 71,142 separations (10.4% of total separations). • Circulatory system disease and neoplasm were the leading causes of death in Tasmania in 2004, accounting for 64% of all deaths. 4.1 Geographic profile Tasmania is located approximately 240 km off the south-eastern corner of mainland Australia, with Melbourne the closest major city on the Australian mainland. Tasmania covers 68,331 square kilometres and at its maximum is approximately 315 km from West coast to East coast and 286 km from North to South. National parks and/or world heritage wilderness areas cover one third of Tasmania, with the majority of these areas in the South West of the State. There are 29 LGAs in Tasmania. For Department of Health and Human Services planning and policy purposes, these LGAs form three catchment populations, the South, North and North West. 10 Clinical Services Plan South North North West Brighton, Central Highlands, Break O’Day, Dorset, Flinders, Burnie, Central Coast, Circular Clarence, Derwent Valley, George Town, Launceston, Head, Devonport, Kentish, Glamorgan/Spring Bay, Meander Valley, Northern King Island, Latrobe, Waratah/ Glenorchy, Hobart, Huon Valley, Midlands, West Tamar Wynyard, West Coast Kingborough, Sorell, Southern Midlands, Tasman Figure 1: Catchment areas North West North South The major population centres in Tasmania are Hobart in the South, Launceston in the North, and Burnie and Devonport in the North West. The distances between these population centres are approximately 180 km (Hobart to Launceston); 278 km (Hobart to Devonport); 332 km (Hobart to Burnie); 98 km (Launceston to Devonport); 152 km (Launceston to Burnie); and 54 km (Devonport to Burnie). Tasmania has major road networks between Hobart and Launceston, and Launceston and Devonport and Burnie in the North West. Many areas of Tasmania are not well served by major road networks. This influences resident flow patterns to access health services. 4.2 Population 4.2.1 Current population The Tasmanian estimated resident population at June 2006 was 488,948 persons. – 49.4% were male and 50.6% female The Tasmanian estimated resident population increased from 471,409 to 488,948 between 2000 and 2006. This is a total population increase of 3.7% over the period, or a compound annual increase of 0.6%. This growth is the second lowest in Australia, the lowest being South Australia which experienced a 3.3% increase, or a compound annual increase of 0.5%. Australian Bureau of Statistics, Australian Demographic Statistics, catalogue no. 3101.0 . Clinical Services Plan 11 Table 1: Estimated resident population, Sex, Tasmania, June 2006 Sex 0-14 yrs 15-44 yrs 45-69 yrs 70-84 yrs 85 yrs + Total Males 49,437 94,665 75,531 19,042 2,684 241,359 Females 46,881 95,316 76,673 22,806 5,913 247,589 Persons 96,318 189,981 152,204 41,848 8,597 488,948 % Males 51.3% 49.8% 49.6% 45.5% 31.2% 49.4% % Females 48.7% 50.2% 50.4% 54.5% 68.8% 50.6% Source: ABS catalogue number 3201.0, June 2006 South Australia and Tasmania had the oldest population of all states and territories at June 2006, with a median age of 39 years. This was 2.1 years above the median age for Australia (36.9 years). Compared with Australia, the Tasmanian age profile at June 2006 shows a lower proportion of persons aged 15-44 years, and a higher proportion of persons aged 45-69 years, 70-84 years, and 85 years and above. Table 2: Estimated resident population, Age, Tasmania and Australia, June 2006 State / Territory 0-14 yrs 15-44 yrs 45-69 yrs 70-84 yrs 85+ yrs Total Tasmania 19.7% 38.9% 31.1% 8.6% 1.8% 100.0% Australia 19.3% 42.6% 28.7% 7.8% 1.6% 100.0% Source: ABS Catalogue no. 3201.0, June 2006. 4.2.2 Projected Population – Tasmania Tasmania’s population will increase by 3.2% between 2006 and 2021. Table 3: Analysis of projected resident population, Tasmania, 2006 to 2021 Sex 2006 2011 2016 2021 Change (%) Males 241,039 244,520 247,133 248,536 3.1% Females 247,376 250,851 253,607 255,422 3.3% Total 488,415 495,371 500,740 503,958 3.2% Source: ABS, Population Projections Australia, 2004-2101, Catalogue no. 3222.0. Note: Table 3 will not equal Table 1 as information is based on a different data series. 4.2.3 Projected Population – Region The projected population change varies across catchment populations. The population will increase in the South and the North, but will decrease in the North West. Table 4: Projected population by planning region, 2006 to 2021 Change Change Planning zone 2006 2011 2016 2021 2006-2021 (no.) 2006-2021 (%) South 235,330 237,447 238,554 238,692 + 3,362 + 1.4% North 135,404 136,852 137,747 138,096 + 2,692 + 2.0% North West 105,759 103,759 101,087 97,798 -7,961 -7.5% Tasmania 476,493 478,058 477,388 474,586 -1,907 -0.4% Note: This table will not equal Table 1 or Table 3 as information is sourced from a different data series. Source: ABS, Projected Resident Population on 2001 statistical local area (SLA). 12 Clinical Services Plan Figure 2 shows the projected populations by LGA in 2006 and 2021, and therefore, the change in population over this period. Figure 2: Projected resident population by LGA, 2006 and 2021 Break O’Day 2006 Brighton 2021 Burnie Central Coast Central Highlands Circular Head Clarence Derwent Valley Devonport Dorset Flinders Island George Town Glamorgan/Spring Bay Glenorchy Hobart Huon Valley Kentish King Island Kingborough Latrobe Launceston Meander Valley Northern Midlands Sorell Southern Midlands Tasman Waratah/Wynyard West Coast West Tamar 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 Number of population Source: ABS, Projected Resident Population on 2001 statistical local area (SLA). Clinical Services Plan 13 4.2.4 Current and projected age profile Table 5 shows the projected age profile (number of persons) of the Tasmanian population and each catchment population in 2006 and 2021. Appendix B shows additional detailed information on current and projected age profiles for Tasmania. The population will age significantly between 2006 and 2021. Key points are: • A decrease in population aged 0-44 years, attributable to a drop in fertility rates and the emigration of younger adults to the Australian mainland. The rate of decrease is greatest in the North West. • An increase in the middle age-range (45-69 years) in the South and North, but a stable population in the North West. • An increase in the number of older people. Table 5: Current and projected population, population by age group, Tasmania and regions, 2006 and 2021 State / Region Year 0-14 yrs 15-44 yrs 45-69 yrs 70-84 yrs 85 yrs + Total Tasmania 2006 92,874 184,561 148,375 42,004 8,679 476,493 2021 75,505 161,851 158,311 64,963 13,956 474,586 Change (no.) -17,369 -22,710 9,936 22,959 5,277 -1,907 Change (%) -18.7% -12.3% 6.7% 54.7% 60.8% -0.4% South 2006 44,786 92,951 73,189 20,133 4,271 235,330 2021 37,759 83,594 79,159 31,462 6,718 238,692 Change (no.) -7,027 -9,357 5,970 11,329 2,447 3,362 Change (%) -15.7% -10.1% 8.2% 56.3% 57.3% 1.4% North 2006 26,330 52,316 42,139 12,053 2,566 135,404 2021 21,672 47,190 46,112 19,008 4,114 138,096 Change (no.) -4,658 -5,126 3,973 6,955 1,548 2,692 Change (%) -17.7% -9.8% 9.4% 57.7% 60.3% 2.0% North West 2006 21,758 39,294 33,047 9,818 1,842 105,759 2021 16,074 31,067 33,040 14,493 3,124 97,798 Change (no.) -5,684 -8,227 -7 4,675 1,282 -7,961 Change (%) -26.1% -20.9% 0.0% 47.6% 69.6% -7.5% Note: This table will not equal Table 1 or Table 3 as information is sourced from a different data series. Source: ABS, Projected Resident Population on 2001 statistical local area (SLA). In addition to the increase in the number of older people in the population, there will also be a structural change in the population make up. Table 6 shows the projected age profile (proportion of persons) of the Tasmanian population and for each catchment population in 2006 and 2021. Key points are: • a decrease in the proportion of the population aged 0-14 years from 19.5% to 15.9%; • a decrease in the proportion of the population aged 15-44 years from 38.7% to 34.1%; and • an increase in the proportion of the population aged 70 years and above from 10.6% to 16.6%. 14 Clinical Services Plan Table 6: Current and projected population, proportion of population by age Group, Tasmania and regions, 2006 to 2021 Catchment Year 0-14 yrs 15-44 yrs 45-69 yrs 70-84 yrs 85 yrs + Total Tasmania 2006 19.5% 38.7% 31.1% 8.8% 1.8% 100% 2021 15.9% 34.1% 33.4% 13.7% 2.9% 100% Change (% points) -3.6% -4.6% 2.2% 4.9% 1.1% South 2006 19.0% 39.5% 31.1% 8.6% 1.8% 100% 2021 15.8% 35.0% 33.2% 13.2% 2.8% 100% Change (% points) -3.2% -4.5% 2.1% 4.6% 1.0% North 2006 19.4% 38.6% 31.1% 8.9% 1.9% 100% 2021 15.7% 34.2% 33.4% 13.8% 3.0% 100% Change (% points) -3.8% -4.5% 2.3% 4.9% 1.1% North West 2006 20.6% 37.2% 31.2% 9.3% 1.7% 100% 2021 16.4% 31.8% 33.8% 14.8% 3.2% 100% Change (% points) -4.1% -5.4% 2.5% 5.5% 1.5% Source: ABS, Projected Resident Population on 2001 statistical local area (SLA). Figure 3: Projected change (%) in resident population 2006 and 2021 30,000 22,959 20,000 9,936 10,000 5,277 0 Number of people -10,000 -20,000 -17,369 -22,710 -30,000 0-14 yrs 15-44 yrs 45-69 yrs 70-84 yrs 85 yrs + Age Source: ABS, Projected Resident Population on 2001 statistical local area (SLA). 4.2.5 Cultural diversity At the 2001 Australian Bureau of Statistics (ABS) census, the majority of people in Tasmania were Australian born (84.9%). Tasmania recorded the highest proportion of people born in Australia, above the Australian proportion of 72.6%. Clinical Services Plan 15 The largest overseas born groups comprised people born in the United Kingdom (4.7% or 21,306 people), New Zealand (0.8% or 3,590 people), the Netherlands (0.5% or 2,483 people), Germany (0.4% or 1,908 people), and Italy (0.2% or 1,127 people). Tasmania also recorded the highest proportion of people who speak only English at home (92.6%), above the Australian proportion of 80%. 4.2.6 Indigenous population The Indigenous population of Tasmania was 15,773 persons in 2001, and represents 3.5% of the total Tasmanian population. This is the second highest proportion of any state or territory (second only to the Northern Territory) and is above the proportion of the Indigenous population across Australia at 2.2%. The majority of the Indigenous population is located in the South (47.9%). The main Indigenous populations are located in Launceston, Glenorchy, Clarence, Huon Valley, Flinders and Cape Barren Islands and the Central Coast. Table 7: Number and proportion of indigenous population, region, Tasmania, 2001 Region Number of Indigenous Population % of Total Indigenous Population South 7,559 47.9% North 3,165 20.1% North West 5,035 31.9% Other 14 0.1% Total 15,773 100.0% Source: ABS, Census of Population and Housing 2001. 4.3 Social and health status indicators 4.3.1 Socio-economic status The ABS produces the Socio-Economic Indexes for Areas (SEIFA), which provides a method for determining the level of social and economic wellbeing of Australian communities. The Index of Disadvantage is based on several factors such as income, educational attainment, and unemployment. The index has a baseline of 1,000. A score above 1,000 indicates an area of socio- economic advantage, and a score below 1,000 indicates an area of disadvantage. The level of deviation from 1,000 indicates the level of advantage or disadvantage. Tasmania (969.7) has a greater level of disadvantage than most Australian states and territories. Detailed indicators of socio-economic status are at Appendix B. ABS, Census of Population and Housing 2001. 16 Clinical Services Plan Economic index of disadvantage, State and Territory, 2001 State / Territory Disadvantage Australian Capital Territory 1078.7 Victoria 1014.6 Western Australia 1003.6 New South Wales 1000.5 South Australia 995.2 Queensland 991.5 Tasmania 969.7 Northern Territory 952.3 Source: ABS, Census of Population and Housing: Socio-Economic Indexes for Areas (SEIFA) 2001, Catalogue no. 2033.6.55.001. Figure 4 shows the Index of Disadvantage by LGA in 2001. Of the 29 LGAs in Tasmania, only seven score average or above average in socio-economic status. Figure 4: Socio-economic index of disadvantage, Tasmanian LGAs, 2001 1,200 1,200 1,000 1,000 800 800 600 600 400 400 200 200 0 0 Sorell Burnie Dorset Kentish Tasman Hobart Latrobe Brighton Clarence Glenorchy King Island Devonport Launceston Huon Valley Huon West Tamar West West Coast West Kingborough Break O’Day George Town George Circular Head Flinders Island Central Coast Meander Valley Meander Derwent Valley Derwent Central Highlands Waratah/Wynyard Southern Midlands Northern Midlands Glamorgan/Spring Bay 4.3.2 Health status indicators There are multiple indicators of health status in a community. Collectively, these provide a useful profile of a community’s health status. Life expectancy In 2002-2004 the life expectancy at birth of Tasmanian males was 76.7 years, and Tasmanian females 81.8 years. This is below the Australian average, and is second only to the Northern Territory. Clinical Services Plan 17 Table 9: Life expectancy at birth by sex and state and territory, 2002-2004 State / Territory Males Females Australian Capital Territory 79.7 83.9 Western Australia 78.6 83.3 Victoria 78.5 83.3 New South Wales 78.0 83.3 South Australia 78.0 83.1 Queensland 77.8 82.9 Tasmania 76.7 81.8 Northern Territory 72.3 78.0 Australia 78.1 83.0 Source: AIHW, Australia’s Health 2006. 4.3.3 Morbidity Morbidity refers to the incidence or prevalence of disease in a community. Table 10 provides statistics for several health risk factors for the Tasmanian and Australian population. Compared with the national average, Tasmania has: • a higher proportion of the population over 18 years who smoke; • a higher proportion of the population who are obese; • a lower proportion of the population at risk of alcohol related harm; and • a vaccination rate above the national average. Table 10: Health risk factors, Tasmania and Australia, various years Risk factor Indicator Tasmania Australia Vaccination % – Children 12-15 months 94.0 91.2 % – Children 24-27 months 94.5 92.4 % – Children 72-75 months 89.3 88.0 Smoking % of 18 years + who are current daily/ 24.5 23.2 occasional smokers Nutrition % of 18 years + eating < five serves 79.4 85.7 vegetables % of 18 years+ eating < two serves fruit 46.3 46 Alcohol consumption % of 18 years + at risk of long-term alcohol 11.4 13.5 related harm Physical activity % of 18 years+ classified as sedentary 34.1 34.0 Overweight / Obesity (BMI) % of 18 years+ classified as overweight 31.8 32.7 % of 18 years+ classified as obese 17.1 16.6 Source: ABS, National Health Survey, 2004-05: Australian Childhood Immunisation Register, statistics at 31 December 2006. 18 Clinical Services Plan The estimated percentage of the Tasmanian and Australian population with a long-term condition (conditions which have lasted or are expected to last six months or more) is shown in Table 11. This information should be interpreted with caution as results are self-reported and not adjusted for jurisdictional age structure. Older people have a greater need for health services and their needs are more likely to be related to chronic diseases. The total proportion of the Tasmanian population with a long-term health condition in 2004-05 was above the national average (79% compared with 76.7%), and Tasmania had a higher proportion of several long-term health conditions. Table 11: Morbidity and disease prevalence, percentage of population, Tasmania and Australia, 2004-05 Condition Tasmania Australia Neoplasms 2% 2% Endocrine, nutritional and metabolic diseases 12% 12% Mental and behavioural disorders 12% 11% Diseases of the nervous system 9% 8% Diseases of the eye and adnexa 52% 52% Diseases of the circulatory system 22% 18% Diseases of the respiratory system 20% 29% Diseases of the digestive system 9% 7% Diseases of the musculoskeletal system and connective tissue 36% 31% Diseases of the genitor-urinary system 4% 3% Total with long-term condition 79% 77% Source: ABS, National Health Survey, 2004-05. Table 12 shows the major causes of hospitalisation in Tasmania between 2000 and 2004. The leading cause of hospitalisation was digestive diseases (eg abdominal pain, hernia procedures) which accounted for 10.4% of total hospitalisations. Combined, these leading causes of hospitalisation accounted for 56.6% of total hospitalisations. Table 12: Leading causes of hospitalisation in Tasmania, 2000 to 2004 Hospitalisation cause Number Percentage Digestive diseases 71,142 10.4% Circulatory diseases 51,509 7.5% Cancer 50,541 7.4% Injury and poisoning conditions 44,435 6.5% Pregnancy complications 43,641 6.4% Mental disorders 40,614 5.9% Genitourinary diseases 39,320 5.7% Respiratory diseases 30,980 4.5% Endocrine and nutritional conditions 15,087 2.2% Hospitalisations (all causes) 684,626 Source: Primary Health Services Plan, LGA Profiles Clinical Services Plan 19 Ambulatory care sensitive conditions Ambulatory care sensitive conditions, also referred to as potentially avoidable hospitalisations, represent hospital activity that is avoidable if timely and adequate non-hospital care, such as specialist outpatient services and GP and primary care, is provided. Table 13 shows the separation rate per 1,000 population (age-standardised to enable comparison across different populations), and the standardised separation rate ratio for selected chronic conditions. The only condition in which Tasmania has a higher separation rate per 1,000 population is for diabetes complications. This data should be interpreted with caution. Table 13: Separation rate per 1,000 population for ambulatory care sensitive conditions, chronic conditions, Tasmania and Australia, 2004-05 Chronic condition Tasmania Australia(c) SSRR (Tasmania) Angina 1.78 2.03 0.88 Asthma 1.00 1.89 0.53 Chronic obstructive pulmonary disease 2.52 2.67 0.94 Congestive cardiac failure 1.60 1.94 0.82 Diabetes complications 10.72 9.77 1.10 Hypertension 0.22 0.29 0.76 Rheumatic heart disease 0.06 0.11 0.54 Total chronic conditions 17.99 18.71 0.96 Note: Separation rate per 1,000 was age standardised Source: AIHW, Australian Hospital Statistics 2004-05 4.3.4 Mortality Mortality refers to the frequency of death in a community. The standardised mortality rate (the number of deaths per 1,000 standard population) in Tasmania and Australia decreased between 2000 and 2005. The Tasmanian rate is the highest in Australia across all years, and in 2005 was 6.9 deaths per 1,000 population compared with six deaths per 1,000 population for Australia. This means that Tasmanians, taking into account as far as possible demographic differences, die at a higher rate than the general Australian population. Table 14: Standardised mortality rate, Tasmania and Australia, 2000 to 2005 Sex 2000 2001 2002 2003 2004 2005 Tasmania Males 9.3 9.2 9.4 9.1 8.9 8.2 Females 6.0 6.3 6.2 6.0 5.7 5.7 Persons 7.5 7.6 7.6 7.4 7.1 6.9 Australia Males 8.5 8.2 8.2 7.9 7.7 7.3 Females 5.5 5.4 5.5 5.2 5.1 4.9 Persons 6.8 6.6 6.7 6.4 6.3 6.0 Notes: Age-standardised to the total Australian population as at 30 June 2001. Source: ABS, Deaths, Australia, 2005 20 Clinical Services Plan Infant mortality The infant mortality rate represents the number of deaths per 1,000 live births in a population. The infant mortality rate in Tasmania and Australia decreased between 2000 and 2005. The rate of decrease was significantly higher in Tasmania. In 2005, Tasmania had the lowest infant mortality rate of any Australian state or territory. Table 15: Infant mortality rate (per 1,000 live births), Tasmania and Australia, 2000-2005 2000 2001 2002 2003 2004 2005 Tasmania 5.8 6.2 6.2 7.0 3.6 3.5 Australia 5.2 5.3 5.0 4.8 4.7 5.0 Source: ABS, Deaths, Australia, 2005 Leading causes of mortality The leading causes of mortality in Tasmania in 2004 were diseases of the circulatory system and neoplasms which, combined, accounted for 64% of all deaths. Table 16: Leading causes of mortality in Tasmania, 2004 Cause of death Males Females Total % of total Diseases of the circulatory system 621 672 1,293 33.2% Neoplasms 673 524 1,197 30.8% Diseases of the respiratory system 169 148 317 8.1% External causes of morbidity and mortality 178 99 277 7.1% Endocrine, nutritional and metabolic disease 91 95 186 4.8% Other causes of death* 57 67 124 3.2% Diseases of the nervous system 86 80 166 4.3% Diseases of the digestive system 53 47 100 2.6% Mental and behavioural disorders 39 61 100 2.6% Diseases of the genitourinary system 40 49 89 2.3% Diseases of the musculoskeletal systems 11 32 43 1.1% Total deaths 2,018 1,874 3,892 100% *Notes: includes certain infectious and parasitic disease; diseases of the blood and blood forming organs and certain disorders involving the immune system; diseases of the skin and subcutaneous tissue; pregnancy, childbirth and the puerperium; certain conditions originating in the perinatal period; congenital malformations, deformations and chromosomal abnormalities; and symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified. Source: ABS, Causes of Death, Australia, 2004, Catalogue no. 3303.0. Table 17 shows the age standardised mortality rates per 100,000 population for selected causes of death for Tasmania in 2004. Age-standardisation enables comparisons of mortality across different populations, as the differences in population age structure are taken into account as far as possible (a population with an older age profile might expect to have a higher rate of mortality). Tasmania has a higher death rate for a number of causes, notably malignant neoplasms, diabetes mellitus, nervous system diseases, accidents, and intentional self harm (the age-standardised suicide rate in Tasmania between 2000 and 2004 was 14.7 per 100,000 population, above the Australian average of 11.6 per 100,000 population). Clinical Services Plan 21 Table 17: Age-standardised death rates, selected causes of death, Tasmania and Australia, 2004 Cause of death Tasmania Australia Malignant neoplasms 213.9 180.7 Diabetes mellitus 25.9 17 Mental and behavioural disorders 17.6 15.9 Diseases – nervous system 30.1 21.5 Diseases – circulatory system 232 223 Diseases – respiratory system 56.9 54.7 Diseases – digestive system 18.1 21.5 Accidents 33.9 25.3 Intentional self harm 18.7 10.4 Source: ABS, Causes of Death Australia, 2004, Catalogue no. 3303.0. 22 Clinical Services Plan 5. Current services, activities and issues Key points • Tasmania has three major acute public hospitals – the RHH, LGH, and NWRH (Burnie and Mersey campuses). • Tasmania has a network of rural hospitals and multipurpose services that support the major acute public hospitals. • The Tasmanian Ambulance Service has a network of 47 stations for road ambulance services plus a rotary and fixed wing capacity. There is a wide distribution of paramedic level services across major population centres and larger rural centres and strategic locations, plus 23 smaller rural stations that have wholly volunteer services. • Healthscope, Tasmania and Calvary Health Care, Tasmania are the major providers of private acute services in Tasmania. • There were 541 GPs working in Tasmania in 2006, or a full-time equivalent (FTE) rate of 357.3. The FTE rate was highest in the South, and lowest in the North West. • In 2004-05, Tasmania had 107.8 residential and community aged care places per 1,000 population aged 70 years and above). The number of places per 1,000 population aged 70 years and above is highest in the South, and decreases in the North and North West. 5.1 Current facilities and services The current public acute services within Tasmania include: • major acute public hospitals – the RHH, LGH, and NWRH (Burnie and Mersey campuses); and • a network of rural hospitals and multipurpose services. There is also a major public subacute facility (the Repatriation Hospital) located in Hobart and a major service precinct (St John’s Park) located at New Town. 5.1.1 Major acute public hospital services Royal Hobart Hospital The RHH is the principal referral hospital for Tasmania and a major teaching and research hospital with linkages to the University of Tasmania. The RHH provides services primarily at role delineation levels 5 and 6 in medicine, surgery, critical care, aged care, rehabilitation, mental health, obstetrics and paediatrics. The RHH is the state-wide provider of several services including cardiothoracic surgery, neurosurgery, high risk obstetric services, neonatal and paediatric intensive care, hyperbaric medicine, complex paediatric surgery, gynaecological oncology and extensive burns. Role delineation is a process that determines what support services, staff profile, minimum safety standards and other requirements are provided to ensure that clinical services are provided safely and appropriately supported. Clinical Services Plan 23 The RHH operates from a maximum base of 550 beds, including 460 acute overnight and 90 day beds. The RHH also has a contract with the private sector for the provision of public ophthalmology services, and a partnership with the Hobart Private Hospital for some patient care and support services. Table 18: Royal Hobart Hospital activity, 2000-01 to 2005-06 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 Change (%) Overnight 19,764 20,032 19,885 19,843 20,874 19,953 1% separations Same day 23,499 30,735 31,705 33,556 32,744 33,450 42% separations Total separations 43,263 50,767 51,590 53,399 53,618 53,403 23% % same day 54.30% 60.50% 61.50% 62.80% 61.10% 62.60% 8.3% points Beddays 145,026 157,522 163,133 166,019 166,503 172,316 19% ALOS - total 3.4 3.1 3.2 3.1 3.1 3.2 -0.2 days ALOS - overnight 6.1 6.3 6.6 6.7 6.4 7.0 0.9 days ED presentations 34,285 36,484 35,743 36,085 37,922 39,275 15% OOS* - - - - 98,418 109,143 n/a *Note: Outpatient data is for the calendar year eg 2004-05 equals 2005, and 2005-06 equals 2006. Source: Greg Hardes & Associates Launceston General Hospital The LGH is the major referral hospital for the North of Tasmania and a major teaching and research hospital with linkages to the University of Tasmania. The LGH provides services primarily at role delineation levels 4 and 5 in medicine, surgery, critical care, aged care, rehabilitation, mental health, obstetrics and paediatrics. The LGH is also the state-wide provider of brachytherapy. The LGH operates from a maximum base of 339 beds, including 283 acute overnight and 56 day beds). The LGH also has several contracts with the private sector for the provision of public services, including ophthalmology and nuclear medicine services. Table 19: Launceston General Hospital activity, 2000-01 to 2005-06 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 Change (%) Overnight 13,128 13,591 13,179 13,743 14,147 13,721 5% separations Same day 14,153 15,088 16,700 22,323 23,488 19,821 40% separations Total separations 27,281 28,679 29,879 36,066 37,635 38,418 41% % same day 51.90% 52.60% 55.90% 61.90% 62.40% 64% 12 % points Beddays 106,668 105,790 105,990 112,433 107,688 113,265 6% ALOS - total 3.9 3.7 3.5 3.1 2.9 2.9 -1 day ALOS - 7.0 6.7 6.8 6.6 6.0 6.5 -1.1 days overnight ED presentations 27,242 28,205 27,599 27,873 30,939 32,050 18% OOS* - - - - 51,962 58,072 n/a *Note: Outpatient data is for the calendar year eg 2004-05 equals 2005, and 2005-06 equals 2006. Source: Greg Hardes & Associates 24 Clinical Services Plan North West Regional Hospital (Burnie and Mersey Campus) The NWRH operates under a “one hospital-two campus” model, with campuses at Burnie and Mersey (approximately 60 km apart) operating under a single executive management structure. The NWRH is the major referral hospital for the North West of Tasmania, and is a teaching and research hospital with linkages to the University of Tasmania. The Rural Clinical School of the University of Tasmania is located at the Burnie campus. The NWRH provides services primarily at role delineation levels 3 and 4 in medicine, surgery, critical care, obstetrics, paediatrics, mental health, drug and alcohol and aged care and rehabilitation. The NWRH Burnie operates from a maximum base of 157 beds including 142 acute overnight and 15 day beds. The NWRH Mersey operates from a maximum base of 115 beds including 95 acute overnight and 20 day beds. The NWRH has several contracts with the private sector for the provision of public services. Major contracted services in the North West include maternity services, ophthalmology services, and diagnostic pathology and imaging services, which are provided at the North West Private Hospital. Pathology and imaging are also provided at the Mersey campus. Table 20: North West Regional Hospital activity, 2000-01 to 2005-06 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 Change NWRH Burnie Overnight separations 5,695 5,538 5,571 5,106 5,112 5,396 -5% Same day separations 2,534 2,352 2,088 2,505 2,464 2,717 7% Total separations 8,229 7,890 7,659 7,611 7,576 8,113 -1% % same day separations 30.80% 29.80% 27.30% 32.90% 32.50% 33.50% 2% Beddays 34256 34378 33303 34103 35330 36,573 7% ALOS – total 4.2 4.4 4.3 4.5 4.7 4.5 0.3 days ALOS – overnight 5.6 5.8 5.6 6.2 6.4 6.3 0.7 days ED presentations 19,184 19,450 19,693 20,394 22,054 23,155 21% OOS* - - - - 41,113 46,434 n/a NWRH - Mersey Overnight separations 3,775 4,813 na Same day separations 2,018 2,458 na Total separations 5,793 7,271 na % same day separations 34.80% 33.80% na Beddays 22960 28,504 na ALOS – total 4 3.9 na ALOS – overnight 5.5 5.4 na ED presentations na na na na na 22,044 na OOS* - - - - 41,113 46,434 n/a North West Public Contract Total separations 8,862 8,555 8,916 8,446 1,912 -78% Beddays 26,657 26,266 29,064 27,466 5,966 -78% Note 1: The Mersey campus came back on line as a public facility in December 2004. The first full year of data for the Mersey campus as a public facility in 2004-05 and there is a resulting decrease in services provided through the NW private contract. Note 2: Outpatient data shows the total for both campuses as data was not available at the individual campus level. Data is for calendar year eg 2004-05 equals 2005, and 2005-06 equals 2006. Source: Greg Hardes & Associates. Clinical Services Plan 25 5.1.2 Ambulance and Retrieval Services Ambulance Services The Tasmanian Ambulance Service (TAS) provides emergency ambulance care and a non-emergency patient transport services, coordinated from a communication centre in the South. The TAS has a network of 47 stations for road ambulance services plus a rotary and fixed wing transport capacity. Paramedics are supported by 450 volunteer officers who work alongside paramedics in 14 locations, as well as from 23 wholly volunteer stations. Table 21: Number and type of ambulance station by region, 2006 Region Two person Double Branch Volunteer Hospital Total salaried crews branch stations stations based 24/7 stations stations South 3 2 3 13 0 21 North 1 0 5 5 1 12 North West 4 0 4 5 1 14 Total 8 2 12 23 2 47 Source: Tasmanian Ambulance Service Tasmanian Ambulance Service resources increased by 32% between 2001-02 and 2005-06. Further detail on Tasmanian Ambulance Services is in Section 4.7. Medical retrieval services Tasmanian medical retrieval services provide emergency support to rural and remote health practitioners and their patients and manages the care and transfer of the most critical patients between hospital facilities in Tasmania and interstate to access higher level care. The adult medical retrieval service operates with the use of a fixed-wing aircraft based at Launceston which is managed under a commercial agreement with the Royal Flying Doctor Service. The service is coordinated from the LGH and staffed on a rotational basis by the LGH and RHH. The neonatal and paediatric retrieval service operates with the use of an air ambulance. The service operates from, and is staffed by, the RHH. The helicopter used by the Tasmanian Ambulance Service, is based in Hobart and managed under contract by the Department of Police and Public Safety and its primary role is search and rescue. 5.1.3 Rural hospitals Tasmania has a network of ten rural hospitals and five multipurpose services which deliver a broad range of services. These are described in detail in the Primary Health Services Plan. 5.1.4 Private acute hospitals Healthscope Tasmania Healthscope Tasmania operates two hospital campuses – the Hobart Private Hospital and St Helen’s Private Hospital. The Hobart Private Hospital is co-located with the RHH, and provides a range of medical and surgical services and a 24-hour department of emergency medicine. St Helen’s Private Hospital, located in Hobart, is a 37-bed hospital which includes a dedicated 31-bed acute psychiatric inpatient unit. 26 Clinical Services Plan Calvary Health Care Tasmania Calvary Health Care Tasmania comprises five campuses - Lenah Valley, St John’s (South Hobart), the outpatient rehabilitation service (New Town), St Luke’s (Launceston) and the St Vincent’s Hospital (Launceston). Lenah Valley provides a comprehensive range of acute hospital services including accident and emergency, obstetrics, critical care, neurosurgery, cardiology, and acute medical and day surgery. St John’s provides inpatient rehabilitation, palliative care, ophthalmology, short-stay and day surgery, plastic surgery, and general medicine. New Town provides outpatient rehabilitation services including physiotherapy, speech therapy, hydrotherapy, and occupational therapy. St Luke’s provides general medical and surgical services, day surgery, post-natal services, chemotherapy and palliative care. St Vincent’s Hospital provides general surgical and medical services, including a sleep studies unit. Healthe Care Australia Pty Ltd The North West Private Hospital (70 beds) is co-located with the NWRH (Burnie campus), and provides services in general surgery, orthopaedic surgery, general medicine, ophthalmology, gynaecology, and obstetrics. The hospital is privately owned and is operated by Healthe Care Australia Pty Ltd. Other Acute Private Hospitals Hobart Clinic (Rokeby) is a 27-bed inpatient hospital providing assessment and treatment for a wide range of psychiatric and mental health disorders. Philip Oakden House Hospice is a six-bed private hospital which specialises in palliative care for both private and public patients. 5.1.5 Residential aged care services The Australian Department of Health and Ageing (DoHA) manages residential and community aged care programs and subsidises the cost of each person in a residential care setting. The supply of residential aged care beds and aged care services generally is a key influence on the management of hospital demand. The Residential Aged Care Program is allocated in proportion to the number of people aged 70 years or older. Community Aged Care Packages (CACPs), and Extended Care in the Home (EACH) packages, also funded by the DoHA, provide an integrated package of services which aim to support people to stay at home rather than enter residential care. There were 4,353 residential aged care places (RACP), 925 CACPs, 55 EACH packages, and 15 EACH dementia packages in Tasmania at June 2006. Table 22: Aged care places, ACAT region, 2006 ACAT region High RAC Low RAC Total RACS CACPs EACH EACH Total Dementia South 1,055 1,124 2,179 453 32 0 2,664 North 673 552 1,225 259 23 10 1,517 North West 490 459 949 213 0 5 1,167 Total 2,218 2,135 4,353 925 55 15 5,348 Source: DoHA, Aged Care Stock take of Places, 2006 Clinical Services Plan 27 At June 2006, Tasmania had 87.8 RACP, 18.7 CACPs, 1.1 EACH packages per 1,000 population aged 70 years and above. This is above the majority of states and territories (second only to South Australia), but is below the current DoHA benchmark of 88 RACPs and 20 community aged care places. The number of residential and community care places per 1,000 population aged 70 years and above is highest in the South, and decreases in the North and North West. Table 23: Residential aged care places, CACPs, and EACH packages per 1,000 persons aged 70 years and over, Tasmanian ACAT region, 30 June 2006 High level Low level Total EACH ACAT region CACPs EACH Total RAC RAC RACS Dementia South 43.9 46.8 90.7 18.9 1.3 0 110.9 North 47.6 39.1 86.7 18.3 1.6 0.7 107.4 North West 42.8 40.1 82.9 18.6 0 0.4 101.9 Total 44.7 43.1 87.8 18.7 1.1 0.3 107.8 Source: DoHA, Aged Care Stock take of Places, 2006 5.2 Activity profile The following section gives an overview of the utilisation of acute health services by Tasmanian residents over the past five years. This is a system-wide analysis, and includes public and private activity as well as Tasmanian and interstate hospitals. Key attributes of the Tasmanian hospital system are: • The major acute public hospitals each service their local community. Residents mainly access services within their geographic region. There are referrals for specialised services to the RHH and LGH and interstate. • There is a high level of self sufficiency in the provision of public hospital services in Tasmania. Only a small proportion of Tasmanians access public hospital services outside the State. • Public hospital usage is increasing. Between 2000-01 and 2004-05 total public hospital usage by Tasmanian residents increased by 20.2% for separations and 7.8% for beddays. The key driver of this change was a major growth in day only separations of 38.3%, with overnight separations increasing by 3.5%. • Private hospital separations are increasing. Between 2000-01 and 2004-05 private hospital separations increased by 4.1%, however private hospital beddays decreased by 4.9%, with the main driver being a growth in day only separations of 15.1%. • The average length of stay for the public hospital system is decreasing. Between 2000-01 and 2004-05, the average length of stay in Tasmania’s public hospitals decreased from 3.9 days to 3.5 days, due mainly to an increase in the proportion of day-only separations from 48.1% to 55.3% of total separations. The overnight average length of stay was stable during this period. • Tasmania’s public hospitals generally have a longer average length of stay than public hospitals in other states (based on a comparison of public hospital separations for each specialty in 2004-05 with the average length of stay of four other states in Australia). 28 Clinical Services Plan 5.2.1 Inpatient services The following set of tables show trends in the utilisation of public and private inpatient services (separations and beddays) by Tasmanian residents (including both Tasmanian hospitals and interstate hospitals). Information is provided at a system level, and for a number of service areas, including adult medical, adult surgical, paediatrics, and obstetrics, based on grouping of service related groups. Table 24 shows resident utilisation of acute inpatient services between 2000-01 and 2004-05. Total separations increased in the public and private sector with a higher rate of growth in the public sector, and higher growth in day only separations. The proportion of separations provided in the public sector increased from 62% in 2000-01 to 66% in 2004-05. Table 24: Resident utilisation of acute services, sector, 2000-01 and 2004-05 Separations Beddays Change (%) Sector Stay type 2000-01 2004-05 2000-01 2004-05 Separations Beddays Public Day only 45,717 63,213 45,717 63,213 38.3% 38.3% Overnight+ 49,398 51,128 324,898 336,357 3.5% 3.5% Total public 95,115 114,341 370,615 399,570 20.2% 7.8% Private Day only 29,383 33,826 29,383 33,826 15.1% 15.1% Overnight+ 27,901 25,799 161,517 147,700 -7.5% -8.6% Total private 57,284 59,625 190,900 181,526 4.1% -4.9% Total Day only 75,100 97,039 75,100 97,039 29.2% 29.2% Overnight+ 77,299 76,927 486,415 484,057 -0.5% -0.5% Total 152,399 173,966 561,515 581,096 14.2% 3.5% Source: Greg Hardes & Associates Tasmanian resident separations increased across all age groups between 2000-01 and 2004-05. The greatest increase in separations over this period was the population aged 45-69 years, and there was also strong growth in the age groups 70-84 years and 85 years and above. Table 25: Resident utilisation of acute services, age group, 2000-01 to 2004-05 Separations Beddays Change (%) Age 2000-01 2004-05 2000-01 2004-05 Separations Beddays 0-14 15,502 15,677 48,630 48,677 1.1% 0.1% 15-44 46,423 48,537 129,143 128,532 4.6% -0.5% 45-69 50,865 64,628 156,240 175,583 27.1% 12.4% 70-84 33,508 37,944 174,965 170,315 13.2% -2.7% 85+ 6,101 7,180 52,537 57,989 17.7% 10.4% Total 152,399 173,966 561,515 581,096 14.2% 3.5% Source: Greg Hardes & Associates Service related group(s) is a term used to categorise admitted patient episodes into groups representing clinical divisions of hospital activity. Clinical Services Plan 29 Figure 5 below shows resident utilisation of acute services by age group as a proportion of total services in 2004-05 and their respective population share at June 2005. The population aged 70 years and above accounted for approximately 10% of the total population. However, this group accounted for approximately 26% of total separations and 39% of beddays. Figure 5: Resident utilisation of acute services by age group as a proportion of total services, 2004-05 50% 39% 40% 37% 31% 30% 29% 30% 28% 22% 22% 20% 20% Proportion of total 10% 10% 9% 8% 9% 4% 2% 0% 0-14 yrs 15-44 yrs 45-69 yrs 70-84 yrs 85 yrs + Age population separations beddays Source: Greg Hardes & Associates; ABS ERP at June 2005, Catalogue no. 3201.0. Adult medical services Table 26 shows Tasmanian resident utilisation of acute adult medical services by sector and stay type in 2000-01 and 2004-05. This includes the service related groups of cardiology, interventional cardiology, dermatology, endocrinology, gastroenterology, diagnostic gastro-intestinal endoscopy, haematology, immunology and infections, medical oncology, chemotherapy and radiotherapy, neurology, renal medicine, renal dialysis, respiratory medicine, rheumatology, and non-subspecialty medicine. Adult medical separations increased by 28% between 2000-01 and 2004-05. The proportion of adult medical separations delivered in the public sector increased from 72% in 2000-01 to 76% in 2004-05. Table 26: Resident utilisation, adult medical services, 2000-01 and 2004-05 Separations Beddays Change (%) Sector Stay type 2000-01 2004-05 2000-01 2004-05 Separations Beddays Public Day only 28,134 43,320 28,134 43,320 54.0% 54.0% Overnight+ 16,594 17,607 109,904 115,323 6.1% 4.9% Total public 44,728 60,927 138,038 158,643 36.2% 14.9% Private Day only 9,315 11,869 9,315 11,869 27.4% 27.4% Overnight+ 8,485 7,382 54,793 45,130 -13.0% -17.6% Total private 17,800 19,251 64,108 56,999 8.2% -11.1% Total Day only 37,449 55,189 37,449 55,189 47.4% 47.4% Overnight+ 25,079 24,989 164,697 160,453 -0.4% -2.6% Total 62,528 80,178 202,146 215,642 28.2% 6.7% Note: Excludes 0-14 year olds. Source: Greg Hardes & Associates 30 Clinical Services Plan Adult surgical services Table 27 shows Tasmanian resident utilisation of acute adult surgical services by sector and stay type in 2000-01 and 2004-05. This includes the following surgeries: breast, cardiothoracic, colorectal, upper gastro-intestinal, head and neck, neurosurgery, dentistry, ear, nose and throat, gynaecology, orthopaedics, ophthalmology, plastic and reconstructive, urology, vascular, non-subspecialty, transplantation, extensive burns, and tracheostomy. Adult surgical separations increased by 2.8% between 2000-01 and 2004-05, with an increase in day only separations and a decrease in overnight separations. The proportion of adult surgical separations delivered in the public sector remained stable in 2000-01 and 2004-05. Table 27: Resident utilisation, adult surgical services, 2000-01 and 2004-05 Separations Beddays Change (%) Sector Stay type 2000-01 2004-05 2000-01 2004-05 Separations Beddays Public Day only 12,447 13,820 12447 13820 11.0% 11.0% Overnight+ 13,706 12,875 83537 79358 -6.1% -5.0% Total public 26,153 26,695 95984 93178 2.1% -2.9% Private Day only 15,781 17,042 15781 17042 8.0% 8.0% Overnight+ 13,642 13,373 69833 60804 -2.0% -12.9% Total private 29,423 30,415 85614 77846 3.4% -9.1% Total Day only 28,228 30,862 28228 30862 9.3% 9.3% Overnight+ 27,348 26,248 153370 140162 -4.0% -8.6% Total 55,576 57,110 181598 171024 2.8% -5.8% Note: Excludes 0-14 year olds Source: Greg Hardes & Associates Paediatric services Table 28 shows Tasmanian resident utilisation of paediatric (0-14 years) acute services by sector and stay type in 2000-01 and 2004-05. This includes all separations for persons aged 0-14 years however excludes neonates. Paediatric separations decreased in the public and private sector between 2000-01 and 2004-05. Paediatric inpatient services are primarily delivered in the public sector. Table 28: Resident utilisation, paediatric services, 2000-01 and 2004-05 Separations Beddays Change (%) Sector Stay type 2000-01 2004-05 2000-01 2004-05 Separations Beddays Public Day only 3,124 3,192 3,124 3,192 2.2% 2.2% Overnight+ 4,354 4,253 13,451 13,018 -2.3% -3.2% Total public 7,478 7,445 16,575 16,210 -0.4% -2.2% Private Day only 1,443 1,574 1,443 1,574 9.1% 9.1% Overnight+ 763 550 1,636 1,616 -27.9% -1.2% Total private 2,206 2,124 3,079 3,190 -3.7% 3.6% Total Day only 4,567 4,766 4,567 4,766 4.4% 4.4% Overnight+ 5,117 4,803 15,087 14,634 -6.1% -3.0% Total 9,684 9,569 19,654 19,400 -1.2% -1.3% Note: Excludes neonates. Source: Greg Hardes & Associates Clinical Services Plan 31 Obstetric services Public sector obstetric separations increased between 2000-01 and 2004-05, however beddays decreased. Private sector obstetric separations decreased significantly over this period. The proportion of obstetric services delivered in the public sector increased from 67.5% in 2000-01 to 77.9% in 2004-05. Table 29: Resident utilisation, obstetric services, 2000-01 and 2004-05 Separations Beddays Change (%) Sector Stay type 2000-01 2004-05 2000-01 2004-05 Separations Beddays Public Day only 685 1,228 685 1,228 79.3% 79.3% Overnight+ 5,180 5,356 20,319 17,639 3.4% -13.2% Total public 5,865 6,584 21,004 18,867 12.3% -10.2% Private Day only 343 79 343 79 -77.0% -77.0% Overnight+ 2,476 1,792 11,389 8,609 -27.6% -24.4% Total private 2,819 1,871 11,732 8,688 -33.6% -25.9% Total Day only 1,028 1,307 1,028 1,307 27.1% 27.1% Overnight+ 7,656 7,148 31,708 26,248 -6.6% -17.2% Total 8,684 8,455 32,736 27,555 -2.6% -15.8% Source: Greg Hardes & Associates Table 30 shows Tasmanian resident births by sector and stay type in 2000-01 and 2004-05. Public sector births increased between 2000-01 and 2004-05, and yet beddays decreased. The number of private sector births decreased significantly over this period. The proportion of births delivered in the public sector increased from 70.3% in 2000-01 to 77.9% in 2004-05. The proportion of caesarean sections increased from 21.1% to 24.2% in the public sector, and from 25.6% to 32.5% in the private sector between 2000-01 and 2004-05. Table 30: Resident utilisation, separations for births, 2000-01 to 2004-05 Separations Beddays Change (%) Sector Stay type 2000-01 2004-05 2000-01 2004-05 Separations Beddays Public Day only 176 160 176 160 -9.1% -9.1% Overnight+ 3,969 4,198 17,032 15,218 5.8% -10.7% Total public 4,145 4,358 17,208 15,378 5.1% -10.6% Private Day only 19 2 19 2 -89.5% -89.5% Overnight+ 1,729 1,233 8,393 6,331 -28.7% -24.6% Total private 1,748 1,235 8,412 6,333 -29.3% -24.7% Total Day only 195 162 195 162 -16.9% -16.9% Overnight+ 5,698 5,431 25,425 21,549 -4.7% -15.2% Total 5,893 5,593 25,620 21,711 -5.1% -15.3% Source: Greg Hardes & Associates. 32 Clinical Services Plan 5.3 Service profiles for public hospitals This section provides a profile of current service delivery models and activity across the major acute public hospitals and publicly contracted services delivered in the private sector. Further detailed profiles are provided in Appendix C. 5.3.1 Adult public hospital medical services Adult medical services include the service-related groups of cardiology, interventional cardiology, dermatology, endocrinology, gastroenterology, diagnostic GI endoscopy, haematology, immunology and infections, medical oncology, chemotherapy and radiotherapy, neurology, renal medicine, renal dialysis, respiratory medicine, rheumatology, and non-subspecialty medicine. Several medical services are also discussed under the profile of cancer services. Royal Hobart Hospital The RHH provides a comprehensive range of medical services and provides outreach services to the LGH for infectious diseases. The RHH is also the state-wide provider of hyperbaric medicine. Launceston General Hospital The LGH provides a comprehensive range of medical services and provides outreach services to the NWRH for clinical haematology, renal medicine, and respiratory medicine. North West Regional Hospital The NWRH (Burnie and Mersey campuses) provides a limited range of medical services. The LGH provides haematology and respiratory medicine outreach services to the NWRH, and dermatology outreach services are provided from interstate. Activity Activity for medical service related groups increased by 37.9% for separations and 15.3% for beddays between 2000-01 and 2004-05. There were increases in all service related groups with the exceptions of dermatology, endocrinology, and diagnostic GI endoscopy. Clinical Services Plan 33 Table 31: Adult medical services, major acute public hospitals and public contracts, 2000-01 and 2004-05 Service related Separations Beddays Change (%) group 2000-01 2004-05 2000-01 2004-05 Separations Beddays Cardiology 3,883 4,047 16,095 13,562 4.2% -15.7% Interventional 1,400 1,908 4,721 5,107 36.3% 8.2% cardiology Dermatology 545 426 1,108 988 -21.8% -10.8% Endocrinology 1,916 1,650 5,487 5,236 -13.9% -4.6% Gastroenterology 1,137 1,680 4,351 4,663 47.8% 7.2% Diagnostic GI 5,912 5,292 9,464 8,917 -10.5% -5.8% endoscopy Haematology 1,911 3,302 4,167 6,344 72.8% 52.2% Immunology & 788 1,287 4,185 5,624 63.3% 34.4% infections Medical oncology 1,269 1,490 7,119 6,866 17.4% -3.6% Chemotherapy and 1,532 6,121 1,537 6,121 299.5% 298.2% radiotherapy Neurology 2,229 3,014 13,456 15,926 35.2% 18.4% Renal medicine 485 738 2,153 2,565 52.2% 19.1% Renal dialysis 12,763 17,948 12,763 17,969 40.6% 40.8% Respiratory 2,705 2,867 15,606 16,630 6.0% 6.6% medicine Rheumatology 729 1,185 1,903 2,630 62.6% 38.2% Non subspecialty 2,555 4,617 10,570 13,063 80.7% 23.6% medicine Total 41,759 57,572 114,685 132,211 37.9% 15.3% Note: Excludes 0-14 year olds. Source: Greg Hardes & Associates 5.3.2 Adult public hospital surgical services A comprehensive range of adult surgical services is provided in Tasmania, and the State’s major acute public hospitals have referral processes in place with interstate hospitals for particular surgical procedures, including specialised paediatric surgery and organ transplantation. Surgical services include breast surgery, cardiothoracic surgery, colorectal surgery, upper gastro- intestinal surgery, head and neck surgery, neurosurgery, dentistry, ear nose and throat surgery, orthopaedics, ophthalmology, plastic and reconstructive surgery, urology, vascular surgery, non- subspecialty surgery, transplantation, extensive burns, tracheostomy, and gynaecology. Royal Hobart Hospital The RHH provides a comprehensive range of adult surgical services and is the state-wide provider of cardiothoracic surgery, complex neurosurgery, complex paediatric surgery, and extensive burns. 34 Clinical Services Plan Launceston General Hospital The LGH provides a comprehensive range of adult surgical services and is the state-wide provider of hepatobiliary surgery (surgery of the liver and pancreas). The LGH has contractual arrangements in place with the private sector for public ophthalmology services. North West Regional Hospital The NWRH (Burnie and Mersey campuses) provides a limited range of adult surgical services in general gynaecological, orthopaedic, urology and vascular surgery (Mersey campus only). The NWRH also has a contract with a private provider to provide public ophthalmology services. Activity Total activity for surgical service related groups increased by 2.1% for separations and decreased by 3.9% for beddays. Ophthalmology separations increased at the highest rate between 2000-01 and 2004-05, and there was also significant growth in the number of non-subspecialty surgery separations. There were notable decreases in the number of separations for gynaecology, ear, nose and throat, vascular, and cardiothoracic surgery. Table 32: Adult surgical services, major acute public hospitals and public contracts, 2000-01 and 2004-05 Separations Beddays Change (%) Service related group 2000-01 2004-05 2000-01 2004-05 Separations Beddays Breast surgery 416 375 843 750 -9.9% -11.0% Cardiothoracic surgery 501 409 4,474 4,163 -18.4% -7.0% Colorectal surgery 800 840 5,139 4,692 5.0% -8.7% Upper gastro-intestinal 1,152 1,330 5,048 4,744 15.5% -6.0% surgery Head & neck surgery 235 226 595 529 -3.8% -11.1% Neurosurgery 458 514 3,471 4,368 12.2% 25.8% Dentistry 824 720 1,035 871 -12.6% -15.8% Ear, nose & throat 667 479 1,173 798 -28.2% -32.0% Orthopaedics 5,106 5,856 23,354 22,554 14.7% -3.4% Ophthalmology 1,312 2,046 1,560 2,347 55.9% 50.4% Plastic and reconstructive 1,604 1,704 4,592 4,141 6.2% -9.8% surgery Urology 2,062 2,193 5,324 5,469 6.4% 2.7% Vascular surgery 1,598 1,195 6,341 5,248 -25.2% -17.2% Non-subspecialty surgery 3,663 4,636 12,901 14,515 26.6% 12.5% Transplantation 0 0 0 0 na na Extensive burns 40 47 408 497 17.5% 21.8% Tracheostomy 162 186 5,167 5,142 14.8% -0.5% Gynaecology 4,585 2,963 8,180 5,327 -35.4% -34.9% Total 25,185 25,719 89,605 86,155 2.1% -3.9% Note: Excludes 0-14 year olds Source: Greg Hardes & Associates Clinical Services Plan 35 5.3.3 Critical care public hospital services Critical care services are often the patients’ first point of contact with the hospital system. Critical care services are divided into two areas; intensive care services and emergency medicine services. Intensive care services Intensive care services deal with the provision of higher levels of observation and medical care to patients who are in a critical or unstable condition. Intensive care services are available at each of the major acute public hospitals in Tasmania. The availability of intensive care services determines the type of medical and surgical services at each hospital site. The ANZICS review of intensive care services which provided data for 2002-03 showed that across Australia there were 9.3 available beds per 100,000 population and 6.1 ventilator beds per 100,000 population (6.4 available beds per 100,000 population and 4.3 ventilator beds per 100,000 population in the public sector, and 2.9 available beds per 100,000 population and 1.8 ventilator beds per 100,000 population in the private sector). Tasmania had 6.5 available beds per 100,000 population and 5.2 ventilator beds per 100,000 population in the public sector. Royal Hobart Hospital The RHH provides a nine-bed intensive care unit and five-bed high dependency unit. The RHH also provides a three-bed cardiothoracic intensive care unit, which is a state-wide service and supports the RHH to undertake cardiothoracic surgery. Launceston General Hospital The LGH provides a combined intensive care and coronary care unit of 11 beds, which is generally managed as five beds for intensive care, five beds for coronary care, and one isolation room as required. North West Regional Hospital The NWRH Burnie campus provides an eight-bed intensive care unit for intensive care, coronary care, and high dependency care patients. The unit also has telemetry monitoring of a number of medical beds. The NWRH Mersey campus has a four-bed (currently only two beds are operating) ward for intensive care, coronary care, and high dependency patients. 5.3.4 Public hospital emergency medicine Emergency medicine services deal with the management of acute and urgent aspects of illness and injury affecting patients. Emergency medicine services are available at each of the major acute public hospitals in Tasmania. Each hospital uses the Australasian Triage Scale for assessing patients in emergency department presentations. Royal Hobart Hospital The RHH provides a 24-hour, seven-day-a-week Emergency Department (ED). The ED was rebuilt in 2007 and includes 41 treatment spaces/resuscitation bays, an assessment and planning unit and a 10- bed short stay observation unit. ANZICS, Review of Intensive Care Resources and Activity 2002-03. Private sector figures were derived from several tables in the ANZICS report, as there were errata in the summary table. See tables 12, 13 and 14 of the report. 36 Clinical Services Plan Launceston General Hospital The LGH provides a 24-hour, seven-day-a-week ED. The ED includes 18 treatment spaces and two resuscitation bays. The Department of Health and Human Services has committed funding to expand the size of the ED at the LGH. North West Regional Hospital The NWRH Burnie provides a 24-hour, seven-days-a-week ED. The ED includes ten treatment spaces and two resuscitation bays. The NWRH Mersey provides a 24-hour, seven-day-a-week ED. The ED includes seven treatment spaces and one resuscitation bay. Activity ED presentations increased by 17% (excluding Mersey) between 2000-01 and 2005-06. Percentage growth in emergency department presentations was greatest at the NWRH Burnie. There is a higher proportion of ATS category 4 and 5 presentations to the NWRH Burnie and Mersey campuses. Table 33: Emergency department presentations, major acute public hospitals, 2000-01 and 2005-06 Hospital 2000-01 2005-06 Change (%) RHH 34,285 39,275 15% LGH 27,242 32,050 18% NWRH Burnie 19,184 23,155 21% NWRH Mersey na 22,044 na Source: Greg Hardes & Associates 5.3.5 Women’s and children’s public hospital services Obstetrics Obstetrics is a combined medical and surgical specialty which deals with the care of women during pregnancy, childbirth, and the recovery period following childbirth. A variety of obstetric models are used in Tasmania’s major acute public hospitals, including obstetrician- led care, GP–obstetrician shared care, and midwifery care. Royal Hobart Hospital The RHH provides a comprehensive range of obstetric services including ante-natal, birthing, and post–natal care. The RHH is the state-wide provider for high-risk obstetric care, with protocols in place to receive patients from across the State. Launceston General Hospital The LGH provides a comprehensive range of obstetric services including ante-natal, low- and medium-risk birthing, and post-natal care. The LGH has protocols in place for the transfer of high-risk pregnancies to RHH. North West Regional Hospital The NWRH Mersey provides a range of obstetric services including low to medium risk birthing. Obstetric services are provided through a public contract with the North West Private Hospital at Burnie. Protocols are in place for the transfer of high risk pregnancies to the RHH. Clinical Services Plan 37 Activity Total obstetric separations increased by 14.3% between 2000-01 and 2004-05. The number of obstetric separations at the RHH and LGH was stable over this period, with the major growth in the NW public contract. Table 34: Obstetric services, major acute public hospitals and public contracts, 2000-01 and 2004-05 Separations Beddays Change (%) Place of treatment 2000-01 2004-05 2000-01 2004-05 Separations Beddays Royal Hobart 2,642 2,684 8,003 7,959 1.6% -0.5% Launceston General 2,112 2,097 9,552 5,889 -0.7% -38.3% NWRH Burnie 39 26 109 53 -33.3% -51.4% NW Public Contract 770 1,014 2,563 2,610 31.7% 1.8% NWRH Mersey 0 543 0 1,735 na na Total 5,568 6,364 20,240 18,246 14.3% -9.9% Note: Total includes South Public Contract of five obstetric separations and 13 beddays in 2000-01. Excludes 0-14 year olds. Source: Greg Hardes & Associates There were 4,288 births at Tasmania’s major acute public hospitals and provided through public contracts in 2004-05, an increase of 6.8% from 2000-01. The number of births declined at the RHH and was stable at the LGH. The number of births provided through the North West public contract increased by 15%. The proportion of births by caesarean section increased from 21.8% in 2000-01 to 24.5% in 2004-05. Table 35: Births, major acute public hospitals and public contracts, 2000-01 and 2004-05 Enhanced service related Separations Change (%) Place of treatment group 2000-01 2004-05 Separations Royal Hobart Vaginal delivery 1,532 1,377 -10.1% Caesarean delivery 436 424 -2.8% Total 1,968 1,801 -8.5% Launceston General Vaginal delivery 1,219 1,123 -7.9% Caesarean delivery 302 390 29.1% Total 1,521 1,513 -0.5% NWRH Burnie Vaginal delivery 2 2 0.0% Total 2 2 0.0% NW Public Contract Vaginal delivery 384 464 20.8% Caesarean delivery 135 132 -2.2% Total 519 596 14.8% NWRH Mersey Vaginal delivery 0 275 na Caesarean delivery 0 101 na Total 0 376 na Total Vaginal delivery 3,140 3,241 3.2% Caesarean delivery 875 1,047 19.7% Total 4,015 4,288 6.8% Note: Total includes South Public Contract of five obstetric separations in 2000-01. Excludes 0-14 year olds. Source: Greg Hardes & Associates 38 Clinical Services Plan Neonatology Neonatology is a medical specialty which deals with the care and treatment of newborn infants. Neonatal services are coordinated across Tasmania. Guidelines for levels of care are developed in consultation with all major acute public hospitals. Royal Hobart Hospital The RHH is the State referral hospital for neonatal intensive care, and is the only level 3 neonatal nursery in Tasmania. RHH core services include a 16-bed neonatal intensive care and special care nursery unit. The RHH is developing a combined 10-bed neonatal and paediatric intensive care unit. Launceston General Hospital The LGH provides neonatal care to low- and medium-risk babies (generally > 32 weeks), and has a level 2 neonatal nursery. Protocols are in place for the transfer of high-risk pregnancies and babies requiring specialised care to the RHH. North West Regional Hospital The NWRH provides neonatal care to low-risk babies (generally > 34 weeks) from the Mersey campus and through public contract with the North West Private Hospital at Burnie. Protocols are in place for the transfer of high-risk pregnancies and babies requiring specialised care to the RHH. Paediatrics Paediatrics is the medical specialty that covers treatment of infants and children. Paediatric patients are generally those up to 14 years of age (excluding neonates). Tasmania provides a comprehensive range of paediatric surgical and medical services, with more complex services generally referred to the RHH. A number of paediatric services, including complex paediatric neurosurgery and cardiac surgery, are referred to the Royal Children’s Hospital in Melbourne. Royal Hobart Hospital The RHH provides a comprehensive range of paediatric surgical and medical services and has a dedicated 25-bed paediatric unit. The RHH is the state-wide provider of complex paediatric surgery and of paediatric oncology, and has the only paediatric surgeon in Tasmania. Launceston General Hospital The LGH provides a comprehensive range of paediatric surgical and medical services and has a dedicated 28-bed paediatric unit. Paediatric services provided at the LGH are generally of a lower complexity than the RHH, because the LGH does not have a paediatric intensive care unit. Paediatric surgical services are delivered by general surgeons. The LGH has protocols in place for the referral of complex paediatric cases to the RHH. North West Regional Hospital The NWRH Burnie and Mersey provide general paediatric surgery and medical services. The Burnie campus has a designated 10-bed paediatric unit. The Mersey campus has four beds allocated specifically for paediatric patients in a specialised women’s and children’s unit. The NWRH has protocols in place for the referral of complex paediatric cases to the RHH. Activity Paediatric separations at the RHH and LGH increased between 2000-01 and 2004-05, but decreased at NWRH Burnie. Clinical Services Plan 39 Table 36: Paediatric services, major acute public hospitals and public contracts, 2000-01 and 2004-05 Place of treatment Separations Beddays Change (%) 2000-01 2004-05 2000-01 2004-05 Separations Beddays Royal Hobart 3,410 3,696 7,183 7,505 8.4% 4.5% Launceston General 2,015 2,100 4,646 4,705 4.2% 1.3% NWRH Burnie 936 657 1,691 1,175 -29.8% -30.5% NW Public Contract 549 16 932 22 -97.1% -97.6% NWRH Mersey 0 440 0 723 na na Total 6,925 6,920 14,468 14,142 -0.1% -2.3% Note: Total includes a small number of paediatric separations and beddays provided in the South public contract and the North public contract. Source: Greg Hardes & Associates Gynaecology Gynaecology is the branch of medicine which deals with the treatment of disease of the female reproductive system. Royal Hobart Hospital The RHH provides a comprehensive range of gynaecological services, and is the state-wide provider of gynaecological oncology. Launceston General Hospital The LGH provides a comprehensive range of gynaecological services. North West Regional Hospital The NWRH (Burnie and Mersey) provides a range of gynaecological services. Activity The number of gynaecology separations and beddays decreased for all major acute public hospitals between 2000-01 and 2004-05. Table 37: Gynaecology separations and beddays, major acute public hospitals and public contracts, 2000-01 and 2004-05 Place of treatment Separations Beddays Change (%) 2000-01 2004-05 2000-01 2004-05 Separations Beddays RHH 1,545 1,150 3,017 2,343 -25.6% -22.3% LGH 1,227 863 2,152 1,486 -29.7% -30.9% NWRH Burnie 718 609 1,291 1,002 -15.2% -22.4% NW public contract 831 3 1,449 5 -99.6% -99.7% NWRH Mersey 0 264 0 417 na na Total 4,585 2,963 8,180 5,327 -35.4% -34.9% Note: Total for 2000-01 includes 264 separations and 271 beddays provided under the South public contract; and 74 separations and beddays provided in 2004-05 in the North public contract. Excludes 0-14 year olds. Source: Greg Hardes & Associates 40 Clinical Services Plan 5.3.6 Cancer services Tasmania’s public acute hospitals provide a comprehensive range of cancer services, with more specialised services, such as radiation oncology, bone marrow transplantation, and gynaecological oncology concentrated at the RHH and the LGH. Medical oncology Medical oncology is devoted to the investigation, diagnosis and management of people with malignant diseases including prevention and palliative medicine. A major treatment modality of medical oncology is chemotherapy. Royal Hobart Hospital The RHH provides a comprehensive range of medical oncology consulting and treatment services. Chemotherapy services are delivered from a 12-chair inpatient oncology unit. Launceston General Hospital The LGH provides a comprehensive range of medical oncology consulting and treatment services. Chemotherapy services are delivered from a 12-chair inpatient oncology unit. The LGH also provides visiting specialist medical oncology services to the NWRH. North West Regional Hospital Specialist medical oncology consulting services are provided to the NWRH from the LGH. Chemotherapy services are delivered from an eight-chair oncology unit at the Burnie campus, and a five-chair oncology unit at the Mersey. Activity Medical oncology separations increased by 68% at the LGH and 7% at the RHH between 2000-01 and 2004-05. Table 38: Adult medical oncology separations and beddays, major public acute hospitals and public contracts, 2000-01 and 2004-05 Place of treatment Separations Beddays Change (%) 2000-01 2004-05 2000-01 2004-05 Separations Beddays RHH 855 914 3,568 3,278 7% -8% LGH 256 430 2,571 2,263 68% -12% NWRH Burnie 78 72 533 713 -8% 34% NW public contract 77 0 444 0 -100% -100% NWRH Mersey 0 74 0 612 na na Total 1,269 1,490 7,119 6,866 17% -4% Notes: Total includes 3 separations in 2000-01 provided through the South public contract. Excludes 0-14 year olds Source: Greg Hardes & Associates Chemotherapy Chemotherapy separations increased at the RHH, LGH, and NWRH Burnie between 2001-02 and 2004-05. The most significant growth in separations was at the RHH. Clinical Services Plan 41 Table 39: Adult chemotherapy separations and beddays, major public acute hospitals and public contracts, 2001-02 and 2004-05 Place of treatment Separations Beddays Change (%) 2001-02 2004-05 2001-02 2004-05 Separations Beddays RHH 2,804 3,913 2,804 3,913 40% 40% LGH 1,882 2,161 1,882 2,161 15% 15% NWRH Burnie 1,084 1,305 1,084 1,305 20% 20% NW Public Contract 239 0 239 0 -100% -100% NWRH Mersey 0 269 0 269 na na Total 6,009 7,648 6,009 7,648 27% 27% Notes: Base year data is for 2001-02. Source: Greg Hardes & Associates; LGH Holman Clinic; NWRH Burnie and Mersey Brachytherapy Brachytherapy is an advanced treatment for several types of cancer. The treatment involves the insertion of radiation applicators within a cavity of the body, such as the bronchus, vagina, cervix or uterus that is in or around the tumour. This provides a dose of radiation to the cancerous tumour while limiting the radiation exposure to the surrounding healthy tissue. Brachytherapy can be delivered at either a low- or high-dose rate, which generally refers to the length of time the radiation is delivered in a treatment episode. Low dose is generally delivered over 2-3 days, and high dose in a period of minutes. Service profile The Holman Clinic at the LGH is the state-wide provider of public brachytherapy services in Tasmania, providing high dose brachytherapy. Brachytherapy is also provided privately at the Hobart Private Hospital. Activity The number of brachytherapy treatments at the LGH increased by 75.4% between 2000 and 2006. This is a compound increase of approximately 10% per annum. Table 40: Number of brachytherapy treatments, LGH, 2000 to 2006 2000 2001 2002 2003 2004 2005 2006 Change (%) 264 223 226 245 453 362 463 75.4% Source: Grant Smith, Increasing Demand for Radiation Oncology Services in Tasmania 2005-06 to 2009-10. Haematology Haematology is the branch of medicine concerned with blood and blood disorders. This includes malignant disorders such as leukaemia and lymphoma. Royal Hobart Hospital The RHH provide a comprehensive range of haematological oncology and non-oncology services. Launceston General Hospital The RHH provide a comprehensive range of haematological oncology and non-oncology services. 42 Clinical Services Plan North West Regional Hospital The NWRH Burnie and Mersey provide limited haematology services. Visiting clinical haematology services are provided to the NWRH Burnie from the LGH. Activity Haematology separations increased significantly between 2000-01 and 2004-05. The number of separations at the LGH increased significantly over this period. Table 41: Adult haematology separations and beddays, major public acute hospitals and public contracts, 2000-01 and 2004-05 Place of treatment Separations Beddays Change (%) 2000-01 2004-05 2000-01 2004-05 Separations Beddays Royal Hobart 1,473 1,941 2,346 3,085 32% 32% Launceston General 204 1,177 1,130 2,523 477% 123% NWRH Burnie 63 90 285 419 43% 47% NW Public Contract 171 0 406 0 -100% -100% NWRH Mersey 0 94 0 317 na na Total 1,911 3,302 4,167 6,344 73% 52% Note: Total includes 171 separations and 406 beddays in 2000-01 provided in the North West public contract. Excludes 0-14 year olds. Source: Greg Hardes & Associates Bone Marrow Transplantation Bone marrow transplantation (BMT) involves the infusion of blood stem cells into a patient, usually for patients with cancer or platelet disorders. There are two types of BMT dependent upon the source of the blood stem cells. Allogeneic BMT uses blood stem cells from a donor who is an identical, or near identical, tissue type match. Autologous BMT uses the patient’s own blood stem cells that have been previously collected (harvested) and preserved (known as cryopreservation). Allogeneic BMT for Tasmanian residents is provided at the Royal Melbourne Hospital. Royal Hobart Hospital The RHH provides stem cell harvesting and is the state-wide provider of autologous BMT. Launceston General Hospital The LGH provides stem cell harvesting only, with protocols in place for the transfer of stem cells to the RHH for cryopreservation prior to BMT. Activity The RHH provides approximately 35 autologous BMT per annum. The Royal Melbourne Hospital provides approximately five allogeneic BMT for Tasmanian residents per annum. Radiation oncology Radiation oncology is the treatment of cancer using therapeutic radiation, and is also referred to as radiation therapy and radiotherapy. Radiation therapy services are delivered from the Holman Clinic at the RHH and LGH. The LGH provides services to residents of the North West. Each clinic operates two linear accelerators, a low energy linear accelerator and a dual-energy linear accelerator. Clinical Services Plan 43 Activity Radiation oncology service utilisation increased 28.5% between 2000 and 2006. The growth rate was consistent across the North and South. Table 42: Linear accelerator attendances, RHH and LGH, 2000 to 2006 Treatment 2000 2003 2006 Change (%) Low Energy (RHH) 5,011 4,948 7,506 49.8% Dual Energy (RHH) 8,504 9,335 9,846 15.8% Low Energy (LGH) 6,650 7,279 8,181 23.0% Dual Energy (LGH) 6,978 8,273 9,343 33.9% Total 27,143 29,835 34,876 28.5% Source: Grant Smith 2006, Increasing Demand for Radiation Oncology Services in Tasmania 2005-06 to 2009-10. Surgical oncology Surgical oncology is the treatment of cancer using surgery and usually involves the removal of cancerous tumours and tissues. Service profile Surgical oncology services are provided from the RHH, LGH and NWRH (Burnie and Mersey campuses). A comprehensive range of complex surgical oncology services are provided from the RHH and LGH, with lower complexity services provided at the NWRH. 5.3.7 Clinical support services Allied health Allied health services covers a range of professionals, who are generally concerned with the assessment, treatment planning and independence type activities. Royal Hobart Hospital The RHH provides a comprehensive range of inpatient and outpatient allied health services including audiology, dietetics, occupational therapy, optometry, orthoptics, orthotics, physiotherapy, podiatry, psychology, social work and speech pathology. Launceston General Hospital The LGH provides a comprehensive range of inpatient and outpatient allied health services including audiology, chaplaincy, dietetics, neuro-psychology, occupational therapy, orthoptics, physiotherapy, podiatry, psychology, social work and speech pathology. North West Regional Hospital The NWRH provides a broad range of inpatient and outpatient allied health services including audiology, dietetics, occupational therapy, orthotics, physiotherapy, podiatry, social work and speech pathology. Activity There were 24,164 allied clinical outpatient occasions of service provided in 2006. The majority of these services (62%) were delivered at the RHH. 44 Clinical Services Plan Table 43: Allied clinical outpatient occasions of service, 2005 and 2006 Place of treatment 2005 2006 Change (%) Royal Hobart 11,258 14,952 33% Launceston General 5,927 7,172 21% North West Regional 1,619 2,040 26% Total 18,804 24,164 29% Source: Greg Hardes & Associates Medical imaging Medical imaging is used to create medical images of the structure of the body, and is used in the diagnosis and management of patients. It includes modalities such as x-ray, ultrasound, mammography scans, MRI, CT and PET scanning. A comprehensive range of medical imaging services are provided in Tasmania, with the majority delivered by the private sector. PET scanning is not provided in Tasmania; patients are referred to Melbourne or Sydney for services. Current services In the South, medical imaging services, apart from a private plain x-ray service in Hobart, are provided by one private radiology practice. Nuclear Medicine services are provided by the RHH although medical staff are sub-contracted from the private provider. One company provides private radiology services to the North and Nuclear Medicine services are provided by a private contractor. A private plain x-ray service is also available in the North. In the North West radiology services are provided by a visiting radiologist in-hours and out-of-hours reporting of x-rays and ultrasound is privately sub-contracted. MRI and nuclear medicine services are contracted to the private sector. MRI services There are three MRI scanners in Tasmania: two in the private sector (at Launceston and Hobart) and a public scanner at the RHH. RHH has recently purchased a new MRI, which has caused an increase in throughput because of the more advanced technology it provides. Mammography BreastScreen Tasmania provides a free mammography screening service, which includes follow up of screen-detected abnormalities involving breast ultrasound, fine-needle aspiration and/or biopsy of suspicious lesions. The southern BreastScreen unit has a digital mammography unit with stereotactic capability. Private imaging companies provide all diagnostic mammography services in the South, North and North West. Hospital radiology services in the North West are provided by the private sector on a contractual basis. Therefore access to public diagnostic mammography services is a problem for Tasmania. Ultrasound services Ultrasound services are provided by each of the major acute hospitals with an outreach service to the West Coast as part of the NWRH contract with the private provider on site at Burnie. Clinical Services Plan 45 Problems with ultrasound services in Tasmania include, workforce recruitment and retention, and resources available to provide enhanced capacity for ultrasound, particularly because there has been a recent shift in the delivery of obstetric ultrasound from the private sector to the public sector in the South. Reporting of films Private sector contractual arrangements limit after-hours reporting of films and after-hours CT scans. Royal Hobart Hospital The RHH provides 24 hour x-ray services, CT scanning, fluoroscopy services, ultrasound services, MRI services, nuclear medicine services (provided by doctors contracted from the private sector), and angiography services. The RHH is also the sole provider of nuchal translucency (NT) services in Tasmania. Launceston General Hospital The LGH provides 24-hour x-ray services, CT scanning, fluoroscopy services, ultrasound services, and angiography services (including an emergency angiography service to the North West). The LGH contracts MRI and nuclear medicine services from the private sector. North West Regional Hospital The NWRH provides 24-hour X-Ray services (delivered by a visiting radiologist between 9 am–5 pm and out-of-hours reporting of x-rays sub-contracted to Regional Imaging Tasmania), and ultrasound services. MRI and nuclear medicine services are contracted to the private sector. Pathology Pathology is a medical science that studies the cause, nature, and effect of disease on the body, and assists in the diagnosis of disease by testing samples of tissue, including blood. Royal Hobart Hospital The RHH provides a comprehensive range of inpatient and outpatient pathology services. The state- wide forensic pathology service is located at the RHH. However, the RHH does not manage the forensic pathology service. Launceston General Hospital The LGH provides a comprehensive range of inpatient and outpatient pathology services, and also provides outreach services to the NWRH. North West Regional Hospital The NWRH (Burnie and Mersey campuses) contracts pathology services to the private sector. Pharmacy Pharmacy deals with the compounding of medical substances and dispensing of medications. Royal Hobart Hospital The RHH pharmacy service also provides services to the Hobart Private Hospital. Launceston General Hospital The LGH pharmacy service provides a wide range of pharmacy services including those to surrounding rural hospitals. There is also a small satellite clinic in the Holman Clinic at the LGH for the preparation and management of chemotherapy and related patient medication. North West Regional Hospital The NWRH provides pharmacy services from both the Burnie and Mersey campuses, and to satellite sites, such as Smithton and King Island. 46 Clinical Services Plan 5.4 Workforce 5.4.1 Workforce profile A profile of the clinical workforce at each of Tasmania’s major acute public hospitals is provided below. Royal Hobart Hospital The RHH had 1,573.6 FTE clinical staff in the first quarter of 2007. Approximately 22% of clinical staff were medical, 61% nursing, and 17% allied health. Table 44: Clinical workforce overview, RHH, 2007 Specialty Actual FTE Medical 223.6 Surgical 117.3 Total Medical 340.8 Registered nurses 880.3 Enrolled nurses 81.0 Total Nursing 961.3 Allied Health 271.5 Total 1573.6 Source: RHH. Launceston General Hospital The LGH had 841.45 FTE clinical staff in the first quarter of 2007. Approximately 17% of clinical staff were medical, 67% nursing, and 16% allied health. Table 45: Clinical workforce overview, LGH, 2007 Specialty Actual Medical 87.13 Surgical 16.49 RMO / Intern 40.5 Total Medical 144.12 Registered nurses 527.5 Enrolled nurses 36.64 Total Nursing 564.14 Allied health 133.19 Total 841.45 Source: LGH executive. North West Regional Hospital The NWRH Burnie had 290.5 FTE clinical staff in the first quarter of 2007. Approximately 16% of clinical staff were medical, 71% nursing, and 12% allied health. Clinical Services Plan 47 Table 46: Clinical workforce overview, NWRH Burnie, 2007 Specialty Actual Medical 24.1 Surgical 8.9 RMO / Intern 14.5 Total Medical 47.5 Registered nurses 184.0 Enrolled nurses 22.9 Total Nursing 206.9 Allied health 36.1 Total 290.5 Source: NWRH executive. The NWRH Mersey had 222.84 FTE clinical staff in the first quarter of 2007. Approximately 16% of clinical staff were medical, 79% nursing, and 5% allied health. Table 47: Clinical workforce overview, NWRH Mersey, 2007 Specialty Actual Medical 19.94 Surgical 7.31 RMO 8.78 Total Medical 36.03 Registered nurses 153.55 Enrolled nurses 22.26 Total Nursing 175.81 Allied health 11 Total 222.84 Source: NWRH executive. 5.4.2 Nursing and allied health There are considerable challenges facing the nursing and allied health workforces in Tasmania’s health system, for example: • The nursing workforce is ageing. • Although Tasmania has 2% of the national population and 2% of the national allied health workforce, suggesting that the State is not facing an overall disadvantage, distribution within the State is uneven. Outer regional and remote regions of Tasmania have 36% of the population but only 24% of the allied health workforce. Some professional groups such as orthotics and prosthetics are based entirely in the larger population centres. • The allied health workforce in Tasmania grew by 5% between 1996 and 2001,while the very small professions such as orthoptics, orthotics and audiology showed significant decline. In addition, there are current acute shortages in some key allied health professions including nutrition, dietetics, exercise physiology and speech pathology. 48 Clinical Services Plan 5.4.3 Medical workforce The Australian Medical Workforce Advisory Committee (AMWAC) has developed population-based benchmarks for medical and surgical specialists, which have been compared with Tasmania’s existing specialist numbers. This comparison does not seek to analyse future workforce needs and in particular takes no account of demographic trends or succession planning issues. Rather, it presents a current snapshot of specialist supply across the health system, encompassing private practice, as well as the public and private hospital workforces. When the Tasmanian specialist medical workforce is compared with AMWAC’s national benchmarks, Tasmania meets or exceeds the benchmarks in 21 of the 35 specialties considered. In seven specialties, Tasmania does not meet benchmarks and in another seven specialties no benchmarks have been established. AMWAC population benchmarks indicate that Tasmania is supplied adequately with specialists in anaesthesia, critical care medicine, emergency medicine, general surgery, geriatric medicine, neurosurgery, obstetrics and gynaecology, orthopaedic surgery, paediatric surgery, pathology, psychiatry, radiation oncology, radiology, rehabilitation medicine, respiratory medicine, urology and vascular surgery. In ear, nose and throat (ENT) surgery, gastroenterology, medical and haematological oncology and ophthalmology there will be an adequate supply of specialists, according to AMWAC benchmarks, if the vacancies that were identified at the time the benchmarking exercise was undertaken are filled. AMWAC population benchmarks indicate that cardiologists, dermatologists, neurologists and paediatricians are in relatively short supply and that shortages also exist in palliative medicine, cardiothoracic surgery and renal medicine. 5.5 Other support services 5.5.1 Transport and retrieval services The key elements of patient transport and retrieval services in Tasmania are: • Tasmanian Ambulance Service, which provides emergency ambulance care and a non-emergency patient transport service. • Tasmanian adult medical retrieval service. • Tasmanian paediatric/neonatal medical retrieval service. • Patient “stretcher” transport services. • Patient Transport Assistance Scheme. • Community Transport Services. Patient transport and retrieval services are coordinated through the Tasmanian Ambulance Service. Tasmanian Ambulance Service Tasmanian Ambulance Services are coordinated from a communication centre in the South with a network of 47 stations for road ambulance services and a rotary and fixed wing hangar capacity. Stations operate as a hub and spoke model around each of the major acute public hospitals. The number of Tasmanian ambulance services increased by 20% over the past three years, from 51,324 to 61,715 services with highest growth in the North West. Clinical Services Plan 49 Figure 6: Ambulance services by region of residence, 2003-04 to 2005-06 70,000 60,000 61,715 50,000 55,879 51,324 40,000 30,787 28,505 30,000 26,074 16,482 20,000 14,547 15,032 Number of services 10,000 14,446 10,703 12,342 0 2003-04 2004-05 2005-06 Year South North North West Total Source: Department of Health and Human Services scorecard reporting The increasing use of ambulance services over the past three years has been highest in the urgent (34%) and emergency (17%) categories. Figure 7: Ambulance services by urgency category 2003-04 to 2005-06 70,000 60,000 61,774 56,066 50,000 51,430 40,000 31,487 29,144 30,000 26,918 17,032 19,370 20,000 14,505 10,000 10,917 Number of ambulance servicesNumber of ambulance 10,007 9,890 0 2003-04 2004-05 2005-06 Year Emergency Urgent Non-urgent Total Source: Department of Health and Human Services scorecard reporting Medical retrieval services The Tasmanian medical retrieval service provides emergency support to rural and remote health practitioners and their patients. In 2005 there were 133 retrievals, with the majority by air transport (99 cases) or road transport (30 cases). 50 Clinical Services Plan Patient transport services Patient transport services coordinate the non-emergency transport of patients. The service is coordinated at a regional level. Table 48: Number of patient transport services, 2001-02 to 2005-06 Region 2001-02 2002-03 2003-04 2004-05 2005-06 South 1,537 2,067 1,800 1,376 1,364 North 3,202 3,332 3,333 3,683 3,371 North West 1,370 1,534 1,419 1,694 1,700 Total 6,109 6,933 6,552 6,753 6,435 Source: Department of Health and Human Services Patient Travel Assistance Scheme The Department of Health and Human Services operates the Patient Travel Assistance Scheme (PTAS) which helps to ensure equity of access for Tasmanian residents to specialist medical services. The scheme is targeted at Tasmanians who have to travel long distances (intrastate or interstate) to access specialised medical services, and face high travel costs in accessing these services. The Department of Health and Human Services contributes to the cost of patients and their carer for travel and accommodation. The number of PTAS services increased in all regions. The greatest volume of services in 2005-06 was for residents of the North West, which accounted for 55% of total PTAS services. Table 49: Number of PTAS services, 2001-02 to 2005-06 Region 2002-03 2003-04 2004-05 2005-06 South 853 981 1,111 1,253 North 1,537 1,425 1,455 2,085 North West 3,721 3,930 3,954 4,151 Total 6,111 6,336 6,520 7,489 Note: 2005-06 is skewed upward due to a delay in processing in 2004-05. Source: Department of Health and Human Services scorecard reporting (updated 23 April 2007) Community Transport Service The Community Transport Service provides assistance and advice to individuals and organisations in the community to help meet their transport needs and access a range of services and community facilities. 5.5.2 Teaching and research Each of the major acute public hospitals support teaching and research and have linkages with the University of Tasmania. There are multidisciplinary clinical schools located at Hobart, Launceston, and Burnie. The rural clinical school at Burnie aims to prepare students for rural practice through clinical education and training in a variety of rural and remote settings. The University of Tasmania The University of Tasmania is the sole university in Tasmania. The University is committed to the delivery of clinical education, training, and health research in all regions of Tasmania. Clinical Services Plan 51 The Faculty of Health Science provides clinical education and training for health professionals (and is the fastest growing faculty in the University). The University offers the following health courses: Bachelors Biomedical science; Exercise science; Health science; Health science and teaching; Health science/Medical radiation science; Medical research; Medical science; Medicine and Surgery; Nursing; Pharmacy Honours Biomedical science; Health science; Medical research; Medical science; Medicine and Surgery; Nursing; Pharmacy Associate Degree Paramedic studies Graduate Certificate E-Health (health informatics); Nursing Graduate Diploma/postgraduate Pathology; E-Health (health informatics); Medical laboratory sciences; Diploma Midwifery; Nursing; Pharmaceutical science Masters Clinical midwifery; Nursing; Pharmaceutical science The University of Tasmania delivers a number of these courses through partnership arrangements with interstate universities, including dental training, radiography training and paramedic science. New courses have been approved in Exercise Science, Environmental Health, and are planned for Dentistry, Health Services Management, Health Leadership and Innovation, Clinical Education, and Public Health. The development of a Physiotherapy course and Dietetics course is also under consideration. The University of Tasmania and the Department of Health and Human Services The University of Tasmania and the Department of Health and Human Services have formed a strategic partnership through the “Partners in Health” agreement. This agreement commits the organisations to work together to develop the health workforce in Tasmania, and contribute to the health and wellbeing of the Tasmanian population through education, training and research. The Department of Health and Human Services is working with the University to review the partnership in 2007. Menzies Research Institute The Menzies Research Institute is a biomedical research institute, owned by the University of Tasmania. The Institute conducts epidemiological and population health research. The Menzies Research Institute also runs the Tasmanian State Cancer Registry, which is responsible for the recording and reporting of cancers in Tasmania. Clifford Craig Research Foundation The Clifford Craig Research Foundation is based at the LGH, and is a major medical research facility. The Royal Hobart Hospital Research Foundation The RHH Research Foundation is an independent, private organisation established to promote and fund medical, healthcare and scientific research in Tasmania. Menzies Research Institute website (available at http://www.menzies.utas.edu.au/aboutus.html) 52 Clinical Services Plan 5.5.3 Accommodation The accommodation needs of staff, patients, and the patient’s family or carer, are important considerations in the delivery of health services. This is particularly the case for patients (and their family/carer) travelling long distances to access services. The Department of Health and Human Services provides financial assistance to patients, and their family or carer, to contribute to the cost of transport and accommodation. This is provided through the Department of Health and Human Services Patient Travel Assistance Scheme (PTAS). Patients travelling interstate to access services generally use accommodation options provided by the treating hospital. Each of the major acute public hospitals provides accommodation services to patients (and their family/ carer) and staff. Royal Hobart Hospital • The RHH provides accommodation services through the Ronald McDonald House (Hobart) for families of expectant mothers, babies, children and adolescents, requiring medical treatment as either hospital inpatients or outpatients. • The RHH has arrangements with a number of local providers for discounted accommodation for patients. • The RHH leases staff accommodation commercially on an as-required basis to meet employment contract provisions. In particular, the RHH provides accommodation for medical appointees for the first three months of their appointment, locum staff, and registrars on rotation through national training programs. Launceston General Hospital • The LGH has arrangements with a number of local providers for discounted accommodation for patients. • Staff accommodation is available at several properties in Launceston managed by the LGH. In particular, the LGH provides accommodation for new medical staff and selected other staff for short periods to enable transition into the area. North West Regional Hospital • The NWRH Burnie campus has several hospital units available for patients on site, and has arrangements with a number of local providers for discounted accommodation. Clinical Services Plan 53 6. Assessment of future health care demand Key Points • Demand for health services is increasing rapidly, driven by community ageing and a high prevalence of chronic disease. • The Tasmanian community has higher rates of preventable disease than communities in almost all other Australian States and Territories. These diseases are causing significant morbidity and mortality for individuals, which influences the use of hospitals and hospital services and is creating an unsustainable cost burden on the Tasmanian community. • Tasmania has unique characteristics (a small, dispersed population, a finite number of clinical staff due to recruitment and retention difficulties and limited resources) that affect demand for health services. These characteristics pose significant challenges for the delivery of clinical health services. • The Clinical Services Plan analyses current and future demand for health services. Projections of acute inpatient activity, emergency department presentations, and outpatient occasions of service have been developed using the Hardes data set. This is a local data set for Tasmania, developed in response to local data issues. • The Hardes model provides a status quo projection to 2021-22 based on the previous five-years of activity and changing population demographics. The model enables different adjustments to be applied to the projections. • Adjustments were made to the status quo projection for average length of stay, relative utilisation of services, population projections, and projected births and maternity and neonatal activity due to recent trends in fertility rates. • The Tasmanian public acute system will need to manage significant projected growth in demand for inpatient services. Resident demand for public acute services will increase by 55% for separations and 42% for beddays between 2004-05 and 2021-22. There will be significant growth across all regions. • Resident demand for private acute services will increase by 41% for separations and 39% for beddays between 2004-05 and 2021-22. • Two-thirds of separations are projected to take place in the public sector in 2021-22, a greater share than in 2004-05. • The proportion of day-only separations will increase from 56% in 2004-05 to 63% in 2021-22. • Resident demand for public emergency department presentations will increase by 32% between 2005-06 and 2021-22. There will be growth in resident demand across all regions. • Outpatient occasions of services will grow, but the level of growth is still the subject of review and analysis. Hardes and Associates prepared projections of inpatient separations and beddays using a model tested in a number of States and Territories across Australia. 54 Clinical Services Plan Tasmania together with the rest of Australia and other developed countries, faces challenges because of increasing demand for hospital services. The rate of increase in demand and the level of demand is affected by a number of factors. • Rates of chronic disease: the effect of increasing chronicity due to increased longevity and the fact that most illness is expensive in the last years of life, have implications for the cost and organisation of services. • Ageing of the population: almost all Tasmania’s population growth will occur in the older age groups, with the population aged 65 years and above increasing by approximately 41,500 (58%). The number of people aged 14 years and under will decrease by approximately 10,000 (or 11%). • Older people have a greater need for health services and their needs are more likely to be related to chronic diseases. The effect of increasing chronicity due to increased longevity and the “compression of morbidity” phenomenon both have implications for the cost and organisation of services. • Tasmania’s health system will need to provide more health and community services, which are coordinated, and focused around the patient’s needs, to meet the demands of an ageing population. • Tasmania’s rate of smoking and other health risk factors is above the national average. • Tasmania has a level of disadvantage greater than all but one Australian State or Territory. Low socio-economic status is associated with greater health risks and poorer health. • People have more information about health care than they did a decade ago and their expectations of the public health care system are increasing. • There has been an “explosion” in diagnostic treatment and information technology in the health care system, changing outcomes for patients, improving the longevity of the Australian community and driving organisational change in the health care system. Technology has increased demand for health care as well as providing considerable patient benefit. • New diagnostic and monitoring technologies and new pharmaceuticals are becoming available to improve the quality of care for people with serious illnesses and disabilities. 6.1 Projected demand for acute inpatient services Hardes and Associates prepared projections of inpatient separations and beddays for a range of key descriptors, including service grouping, place of residence, place of treatment, age group, and stay type. The Hardes model provides a status quo projection of the previous five years’ activity to 2021-22 based on changing population demographics. The model enables different assumptions to be applied to the data underpinning the projections, for example varying relative utilisation of services, average length of stay, or population adjustments. Several adjustments were made to the Hardes projections based on advice of clinicians and a review of the status quo projections. These adjustments have been incorporated in the activity projection modelling presented in this section. A summary of the adjustments is provided in Table 50, and further detail is in Appendix E. Compression of morbidity is an expression used to describe the hypothesis that illness in old age will be compressed into a shorter time span, due to healthier lifestyles or medical advances. Clinical Services Plan 55 Table 50: Summary of adjustments to projections of acute inpatient demand Adjustment Description Result Population ABS 2001 census projections Increased acute activity, as adjusted up to estimated the 2006 estimated resident resident population 2006 and population indicates increased the percentage change by population size and varying age age at state level applied to group distribution than 2001 subsequent years data projected to 2006 Relative Utilisation Rate (acute) Relative utilisation rate of Increased activity for these selected acute service-related service-related groups groups increased based on benchmark to four-state comparison and allowing for public/private sector provision Average Length of Stay (acute) Average length of stay Reduced average length of stay decreased for selected acute for these service-related groups service-related groups based on access to benchmark data for peer hospitals Average Length of Stay (sub- Average length of stay Reduced average length of stay acute) decreased for selected subacute for these service-related groups service-related groups No. of births and associated Births adjusted based on recent Significant change in projected maternity and neonatal activity fertility rates applied to regional births, maternity and neonatal level data on births activity Ambulatory care sensitive Separations were identified for No adjustment in baseline conditions flow reversal out of the hospital projections, separate discussion below There are many factors which affect the provision of acute services that cannot be incorporated into the projection model, but could have a significant impact on the provision of acute services in the future. Factors such as: • the introduction of new technology; • changes to government policy; and • a cure or new treatment for a specific condition. Projected resident demand for acute services Resident demand for separations is projected to increase by 50% between 2004-05 and 2021-22, with higher growth in the public sector, and a significantly higher growth in day-only separations.1010 The proportion of separations in the public sector is projected to increase from 65.7% in 2004-05 to 67.7% in 2021-22. Resident demand for beddays is projected to increase by 39% between 2004-05 and 2021‑22. The proportion of beddays in the public sector is projected to increase from 68.8% in 2004-05 to 70% in 2021-22. This lower projected growth in beddays is due to the application of benchmark average length of stay which result in a more efficient acute care system. The total proportion of day-only separations will increase from 56% in 2004-05 to 63% in 2021-22. 10 It should be noted that the longer the projection time frame (in this case to 2011-22), the greater the degree of uncertainty and therefore the need for regular review. 56 Clinical Services Plan Table 51: Projected resident demand, separations and beddays, sector, 2004-05 and 2021-22 Sector Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays Public Day Only 63,213 113,293 63,213 113,293 79% 79% Overnight+ 51,128 63,545 336,357 452,133 24% 34% Total public 114,341 176,838 399,570 565,426 55% 42% Private Day Only 33,826 50,769 33,826 50,769 50% 50% Overnight+ 25,799 33,409 147,700 192,128 29% 30% Total private 59,625 84,178 181,526 242,897 41% 34% Total Day Only 97,039 164,063 97,039 164,063 69% 69% Overnight+ 76,927 96,953 484,057 644,261 26% 33% Total 173,966 261,016 581,096 808,323 50% 39% Source: Greg Hardes & Associates Projected resident demand for acute services is to increase across all regions. There is differential change in the public and private service mix across regions. South Resident demand will increase by 53% in the public sector and 39% in the private sector. Approximately 59% of separations will be undertaken in the public sector in 2021-22. Table 52: Projected resident demand, South, 2004-05 and 2021-22 Sector Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays Public Day Only 31,684 54,706 31,684 54,706 73% 73% Overnight+ 21,365 26,483 147,042 197,087 24% 34% Total public 53,049 81,189 178,726 251,793 53% 41% Private Day Only 22,576 33,040 22,576 33,040 46% 46% Overnight+ 17,738 22,926 108,856 140,072 29% 29% Total private 40,314 55,965 131,432 173,112 39% 32% Total Day Only 54,260 87,745 54,260 87,745 62% 62% Overnight+ 39,103 49,409 255,898 337,160 26% 32% Total 93,363 137,154 310,158 424,905 47% 37% Source: Greg Hardes & Associates Clinical Services Plan 57 North Resident demand will increase by 60% in the public sector and 44% in the private sector. Approximately 75% of separations will be undertaken in the public sector in 2021-22. Table 53: Projected resident demand, North, 2004-05 and 2021-22 Sector Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays Public Day Only 19,206 35,522 19,206 35,522 85% 85% Overnight+ 15,920 20,588 107,196 146,555 29% 37% Total public 35,126 56,110 126,402 182,077 60% 44% Private Day Only 7,812 11,828 7,812 11,828 51% 51% Overnight+ 5,245 7,003 26,087 35,853 34% 37% Total private 13,057 18,832 33,899 47,681 44% 41% Total Day Only 27,018 47,350 27,018 47,350 75% 75% Overnight+ 21,165 27,591 133,283 182,407 30% 37% Total 48,183 74,942 160,301 229,758 56% 43% Source: Greg Hardes & Associates North West Resident demand will increase by 60% in the public sector and 44% in the private sector. Approximately 81% of separations will be undertaken in the public sector in 2021-22. Table 54: Projected resident demand, North West, 2004-05 and 2021-22 Sector Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays Public Day Only 12,323 23,066 12,323 23,066 87% 87% Overnight+ 13,843 16,473 82,119 108,491 19% 32% Total 26,166 39,539 94,442 131,556 51% 39% Private Day Only 3,438 5,901 3,438 5,901 72% 72% Overnight+ 2,816 3,480 12,757 16,203 24% 27% Total private 6,254 9,381 16,195 22,104 50% 36% Total Day Only 15,761 28,967 15,761 28,967 84% 84% Overnight+ 16,659 19,953 94,876 124,694 20% 31% Total 32,420 48,920 110,637 153,660 51% 39% Source: Greg Hardes & Associates 58 Clinical Services Plan 6.2 Projected flows analysis South Current and projected South resident demand flow patterns are shown in Figure 8. South resident demand will continue to be met primarily by the RHH and private acute hospitals, with an increase in South resident flows to the RHH. Figure 8: South resident demand, place of treatment, 2004-05 and 2021-22 2004-05 Private 47.6% RHH 48.9% NWRH Mersey 0% Other NW public 0% Interstate public 0.7% Other public 2.0% NWRH Burnie 0.1% LGH 0.5% Projected 2021-22 Private 47.6% RHH 49.6% NWRH Mersey 0% Other NW public 0% Interstate public 0.7% Other public 2.2% NWRH Burnie 0.1% LGH 0.6% Note: Excludes renal dialysis and qualified and unqualified neonates. Source: Greg Hardes & Associates Clinical Services Plan 59 North Current and projected North resident demand flow patterns are shown in Figure 9. North resident demand will continue to be met primarily by the LGH, with an increase in North resident flows to the LGH. Figure 9: North resident demand, place of treatment, 2004-05 and 2021-22 2004-05 Other public 6.6% RHH 3.7% LGH 56.8% Private 31.4% Other NW public 0% NWRH Burnie 0.3% Interstate public 0.8% NWRH Mersey 0.4% Projected 2021-22 Other public 6.5% RHH 4.0% LGH 58.2% Private 29.8% Other NW public 0% NWRH Burnie 0.3% Interstate public 0.7% NWRH Mersey 0.4% Note: Excludes renal dialysis and qualified and unqualified neonates Source: Greg Hardes & Associates 60 Clinical Services Plan North West Current and projected North West resident demand flow patterns are shown in Figure 10. North West resident demand will continue to be met primarily by the NWRH Burnie and Mersey campuses. However, North West resident flows will increase to the RHH and in particular the LGH. Figure 10: North West resident demand, place of treatment, 2004-05 and 2021-22 2004-05 LGH 11.5% NWRH Burnie 31.7% Other public 0.2% RHH 6.5% NWRH Mersey 19.2% Private 23.5% Other NW public 6.1% Interstate public 1.4% Projected 2021-22 LGH 15.1% NWRH Burnie 27.5% Other public 0.2% RHH 7.2% NWRH Mersey 19.6% Private 23.6% Other NW public 5.2% Interstate public 1.5% Note: Excludes renal dialysis and qualified and unqualified neonates. Source: Greg Hardes & Associates Clinical Services Plan 61 6.3 Projected demand for emergency department services Projections of emergency department presentations were prepared by Hardes and Associates based on Department of Health and Human Services methodology for classifying activity according to service-related groups. The following information provides projected resident demand for emergency department presentations. Projected resident demand Resident demand for public emergency department presentations will increase by 32% between\ 2005-06 and 2021-22. Figure 11: State-wide projected resident demand for emergency department presentations, 2005-06 to 2021-22 160,000 140,000 149,828 120,000 139,288 128,354 100,000 113,112 80,000 60,000 40,000 20,000 Number of presentations 0 2005-06 20011-12 2016-17 2021-22 Year Source: Greg Hardes & Associates Resident demand for public emergency department presentations will increase in all regions between 2005-06 and 2021-22, with highest growth in the South. Figure 12: Regional projected resident demand for emergency department presentations, 2005-06 to 2021-22 60,000 56,490 50,811 48,196 50,000 44,648 50,110 51,699 45,099 40,000 41,640 37,730 38,366 30,000 35,059 30,734 20,000 Number of presentations 10,000 0 2005-06 20011-12 2016-17 2021-22 Year North South North West Source: Greg Hardes & Associates Resident demand for public emergency department presentations will increase in all age groups between 2005-06 and 2021-22. Projected growth is highest in the age groups 70-84 years and 85 years and above, with lower growth in the age group 0-14 years. This is driven by Tasmania’s changing population demographics. 62 Clinical Services Plan There will be a differential change in projected resident demand for public emergency department presentations by age group, with a decrease in the proportion of presentations for 0-14 year olds, and an increase in the proportion of presentations for people aged 70 years and above. Figure 13: Current and projected emergency department presentations by age group, 2005-06 and 2021-22 2004-05 15-44yrs 44.5% 0-14yrs 19.5% 45-69yrs 22.3% 85+yrs 3.3% 70-84yrs 10.4% 2021-22 15-44yrs 39.4% 0-14yrs 17.2% 45-69yrs 23.1% 85+yrs 4.8% 70-84yrs 15.5% Source: Greg Hardes & Associates Resident demand for the projected volume of public emergency department presentations by service- related group is highest for orthopaedics, injuries, gastrointestinal tract, general medicine, and cardiac conditions. Resident demand for public emergency department presentations will increase most significantly (50% or more between 2005-06 and 2021-22) for the service-related groups of genito-urinary, endocrinology, cardiology, neurology, immunology, psychiatry, and general medicine. Clinical Services Plan 63 Figure 14: Projected emergency department presentations, service related groups, 2005-06 and 2021-22 20,000 18,000 17,693 16,090 16,000 14,813 14,305 14,000 13,003 12,608 12,422 12,000 11,899 10,000 9,342 8,908 8,268 7,540 8,000 7,447 6,638 6,204 6,075 5,913 6,000 5,474 4,773 4,348 Number of presentations 3,656 3,807 4,029 4,000 3,401 3,007 2,777 2,802 2,515 2,087 2,000 1,846 1,064 609 0 GIT Major Neuro WACS Injuries Cardiac Surgery Psychiatry HeadNeck Respiratory Immunology Endocinology Orthopaedics ED SRG Genito-Urinary General Medicine Drug and Alcohol Drug and 2005-06 2021-22 Note: Excludes DOA, Did Not Wait, Not Recorded, No Diagnosis. Source: Greg Hardes & Associates 6.4 Projected outpatient activity Two models were used to project outpatient occasions of service. The first model is projected on base year (2006) data and accounts for changes to population demographics. The second model is based on historic service trends (2005 and 2006) and accounts for changes to population demographics. Data is provided for both models, but is not reliable as a basis for service planning until more detailed analysis is undertaken of the trends and detailed service strategies developed for the management of non-inpatients across a range of settings. No adjustments have been made in this data set for fertility rates and birthing numbers associated with the inpatient data modelling. Model one: Projections based on changing population demographics Resident demand for outpatient occasions of service will increase in all regions, with highest growth in the North. Table 55: Projected outpatient occasions of service, region, 2006 to 2021 Region 2006 2011 2016 2021 Change (%) North 54,938 58,194 60,363 62,674 14.1% South 107,201 109,728 112,966 116,588 8.8% North West 51,175 54,809 55,111 55,230 7.9% Total 213,314 222,730 228,439 234,492 9.9% Note: This data set is not comparable to other Department of Health and Human Services reporting of outpatient services. Source: Greg Hardes & Associates 64 Clinical Services Plan Resident demand for outpatient occasions of service will increase for allied clinical, medical, and surgical. Table 56: Projected outpatient occasions of service, tier, 2006 to 2021 Tier 2006 2011 2016 2021 Change (%) Allied Clinical 24,138 25,411 26,278 27,256 13% Dental 77 66 65 63 -18% Medical 65,036 69,239 72,688 76,065 17% ObsGynae 40,951 42,364 41,290 40,179 -2% Other 44 49 48 48 8% Paediatric 8,888 8,339 7,936 7,656 -14% Surgical 74,180 77,262 80,134 83,225 12% Total 213,314 222,730 228,439 234,492 10% Note: This data set is not comparable to other Department of Health and Human Services reporting of outpatient services. Total includes tier of “other” and “dental”, Number for these tiers was small. Source: Greg Hardes & Associates Model two: Projections based on historic service trends and changing population demographics Resident demand for outpatient occasions of service is projected to increase in all regions between 2006 and 2021, with highest growth in the North. Table 57: Projected outpatient occasions of service, region, 2006 to 2021 Region 2006 2011 2016 2021 Change (%) North 54,938 83,969 112,947 141,737 158% South 107,201 157,132 207,010 256,597 139% North West 51,175 71,888 91,003 108,090 111% Total 213,314 312,989 410,960 506,424 137% Note: This data set is not comparable to other Department of Health and Human Services reporting of outpatient services. Source: Greg Hardes & Associates Resident demand for outpatient occasions of service is projected to increase for all tiers, with highest growth projected for allied clinical. Table 58: Projected outpatient occasions of service, tier, 2006 to 2021 Tier 2006 2011 2016 2021 Change (%) Allied Clinical 24,138 40,615 56,835 72,270 199% Medical 65,036 90,844 116,021 139,152 114% ObsGynae 40,951 56,066 69,832 82,238 101% Paediatric 8,888 13,954 18,405 22,524 153% Surgical 74,180 111,300 149,573 189,867 156% Total 213,314 312,989 410,960 506,424 137% Note: This data set is not comparable to other Department of Health and Human Services reporting of outpatient services. Total includes tier of “other” and “dental”. Numbers for these areas was small. Source: Greg Hardes & Associates Clinical Services Plan 65 These projections assume a constant model of service delivery and funding. Projections will change with a change in policy such as: • The extent to which services are shifted from an inpatient to a non-inpatient setting. • The extent to which services are resourced in non-inpatient settings. • The availability of workforce with the appropriate skills base to deliver the services. • The funding and other arrangements regarding the delivery of some of these services in a private setting, given the ability of an increasing range of allied health and other practitioners to charge for services through Medicare. 6.5 Ambulatory care sensitive conditions There has been a significant body of work undertaken regarding the number of patients currently managed in inpatient settings who could be managed in non-inpatient settings with appropriate services and resources in place. It was therefore decided to estimate the number of patients who are currently managed in inpatient settings within the major acute hospitals who fall in this category. Royal Hobart Hospital An analysis of activity at the RHH in 2004-05 indicated that there were nearly 4,000 separations and 13,500 beddays attributable to patients who could be managed in non-inpatient settings. This is a significant proportion of inpatient activity, attributable to some 38 inpatient beds. The majority of this overnight care is provided in medical inpatient units. Launceston General Hospital An analysis of activity at the LGH in 2004-05 showed that there were nearly 2,300 separations and 10,300 beddays attributable to patients who could be managed in non-inpatient settings. This is a significant proportion of inpatient activity, attributable to some 30 inpatient beds (more than one ward). The majority of this overnight care is provided in medical inpatient units. North West Regional Hospital An analysis of activity at the NWRH (Burnie and Mersey campuses) in 2004-05 indicated that there were nearly 1,400 separations and 6,500 beddays attributable to patients who could be managed in non-inpatient settings. This is a significant proportion of inpatient activity, attributable to some 20 inpatient beds. The majority of this overnight care is provided in medical inpatient units. 66 Clinical Services Plan 7. A sustainable acute health system for the future Key points The Plan proposes several key changes to the way hospital and health services are organised in Tasmania. The Plan proposes a configuration of acute hospital services based on a defined service capability framework comprising: • designation of clinical services according to their geographic and clinical roles and responsibilities; • adoption of principles for the future development of single site and state-wide services; • the development of clinical networks, overseen by a Clinical Advisory Council, to facilitate service integration, monitoring and development; • a best practice process for credentialing and defining the scope of practice for all senior medical staff; and • clarification of the roles and responsibilities of each of the acute hospitals. The service capability framework has four levels: state-wide, single site, regional referral and local services. Each of the three major acute hospitals will have a specific role under the service capability framework. A four-tiered service model has been applied that provides a structural mechanism to integrate primary and acute health services and a mix of health services to local communities. This Plan proposes the development of new integrated care centres11, in the South (in or adjacent to the RHH and stand-alone on the Eastern Shore and in Kingborough); and in the North (sited close to the LGH). 11 Integrated Care Centres are facilities that: • are designed and managed specifically to accommodate a range of health services that provide efficient, integrated care regardless of who funds, owns or provides each element of the services a client accesses; • operate under a philosophy which is less interventional and oriented towards care in the community rather than institutional care; and • provide greater certainty of access for clients because they focus on non-emergency services including a broad range of non- admitted primary, secondary and tertiary services, short-stay elective services and specialised sub-acute services. Clinical Services Plan 67 7.1 Designing the system The challenges facing the Tasmanian health and hospital system outlined in the previous chapters require the careful design of a health care service that will deliver quality sustainable health care at an affordable cost. In summary, Tasmania has: • a small and dispersed population; • comparatively poor health status associated with low socioeconomic status in areas of the state; • low patient numbers for particular procedures or services, creating a risk of poor quality care; • insufficient workload to support a professional workforce of the size necessary to provide high quality services – if services are provided under these circumstances they are likely to be unreliable and to place patients at risk; • some services dependent on costly technology, which can only be provided at a limited number of sites; and • a limited resource base because of its small population and capacity to attract revenue (unlike larger states or states with significant mineral resources and/or bigger populations). 7.1.1 Key principles Given these challenges the Department of Health and Human services has adopted the following principles to guide service design. Tasmania’s health services will be: • accessible as close as possible to where people live, providing services can be delivered safely, effectively and at an acceptable cost; • appropriate to community needs; • client and family focused; • integrated, through effective service coordination and partnerships between providers; and • designed for sustainability. When services cannot be delivered safely, effectively and at an acceptable cost locally, access will be facilitated through service coordination, transport assistance and other appropriate support.12 The design of services in this Plan is based on the following premises: • public resources for health services will will always be limited; • responsible budgetary management requires government to make transparent and evidence- based decisions on priorities; • both Government and the community aim to achieve the best possible value for public expenditure, so that the greatest community benefit can be achieved; and 12 The Department of Health and Human Services has adopted the following definitions to support these principles: Accessible – ensuring care is available when (at the time) and where (in the location) people need it Safe – minimising risks, so that patients are safe from unintended harm Effective – providing care that results in a good outcome Efficient – using available health care resource wisely Appropriate – providing the “right” care at the “right’”time, including health promotion and integrated community-based and hospital-based services Patient and family focused – designed to meet the needs of patients and their families/carers, respectful of patients as individuals and enabling them to access information and be engaged as active participants in their own care 68 Clinical Services Plan • some services, because of their remoteness or special local factors, inevitably will cost more than equivalent services delivered in other locations. Responsible planning, however, requires that an assessment is made of whether significant additional costs incurred to provide services in particular settings are justified by a corresponding health benefit. This plan has two broad components: • a capability framework that defines the roles of the hospitals, including principles for state-wide and single services and a network governance structure to manage the delivery of services; and • and a structural mechanism to integrate the hospital services with primary care. 7.1.2 Capability framework for local, regional, single site and state-wide services The service capability framework provides a way for clinical services to be categorised according to whether they are provided locally to a hospital’s immediate referral population or whether they are provided to a broader referral population. If services are to be provided locally in all three hospital referral regions (South, North and North West) they must attract adequate patient volume to sustain quality service delivery, have no special equipment requirements or critical relationships with other services and be capable of sustainable staffing in multiple sites. Some of these services are provided on an outreach basis in community settings – for example, the obstetric service of the NWRH provides outreach pregnancy care to communities on the West Coast. For the purposes of this Plan these services are described as local acute hospital services. Some services, because of workforce, service volume, cost or equipment constraints can only be delivered sustainably from two sites in the State, one in the North and one in the South. In the North, the catchments for these services generally extend to the North West. Some elements of these services may be provided on an outreach basis to the North West, either on an inpatient or non- admitted patient basis. For example, renal services are provided by the LGH to a referral population comprising the whole of the North and North West and some service elements (eg renal dialysis) are provided on an outreach basis in Burnie. For the purposes of this Plan these services are described as regional acute hospital referral services. Finally because of workforce, service volume, cost or equipment constraints or because they are critically dependent on other single-site services, some services must be managed from a single site in Tasmania. Again, some elements of these services may be provided on an outreach basis in distributed locations, either on an inpatient or non-admitted patient basis. These services may be: • specific specialised clinical components of larger clinical services – for example, cancer services are provided at both the LGH and the RHH, but brachytherapy, which is a subspecialty cancer treatment, is provided only at the LGH; and paediatric surgical procedures are provided in all centres, but subspecialist complex paediatric surgery is provided by a single specialist based in Hobart and offers some outreach services; or • stand-alone specialist services providing comprehensive care – for example, cardiothoracic surgery, which is provided only by the RHH. For the purposes of this Plan, these services are described as: • single site services – where a service is based at a single site and may provide outreach services but has no formal state-wide responsibility or accountability for distributed service development; and • state-wide services – when a single-site service is designated as such and has a significant state- wide coordinating role, a responsibility to accept all emergency referrals and formal responsibility and accountability to the system as well as to its host hospital for its performance. Clinical Services Plan 69 The characteristics of each type of service are described in Table 59. Table 59: Service capability framework for acute hospital services Regional Referral Characteristic Local Service Single Site Service State-wide Service Service Clinical Based at host site Based at host site Based at LGH Based at LGH or Governance – NWRH, LGH, – LGH. May be or RHH. May be RHH. Responsible Responsibility RHH networked clinically networked to and accountable to to equivalent RHH complementary host site and whole units for quality local units or of state for clinical and professional specialist interstate performance. May support units for quality be networked to and professional interstate units support for quality and professional support Management Based at and Based at and Based at and Based at LGH or responsible and responsible and responsible and RHH. Responsible accountable to host accountable to host accountable to host and accountable site – NWRH, LGH, site – LGH site – LGH or RHH to host site for RHH operations and to whole of state for clinical performance Throughput Sufficient to support Sufficient to Specialised Comprehensive throughput for support throughput service. Sufficient service at all levels at least three for at least three throughput to of complexity. practitioners at each practitioners at support throughput Sufficient host site if frequent both LGH, RHH for at least three throughput to out-of-hours recall if frequent out-of- practitioners support throughput hours recall at single site if for at least three frequent out- practitioners at of-hours recall single site if frequent unless special out-of-hours recall arrangements apply unless special arrangements apply Outreach May provide May provide May provide Generally will outreach in outreach from LGH outreach from host provide outreach community settings to community or site to community from host site to inpatient settings in or inpatient settings community or the North West across the State inpatient settings across the State Complexity Less complex More complex than High complexity High complexity services although local services low-volume low-volume services role delineation may services vary across sites Workforce At least At least At least At least three medical three medical three medical three medical practitioners at each practitioners at practitioners at practitioners at of NWRH, LGH, each of LGH, RHH either LGH or either LGH or RHH RHH if frequent if frequent out-of- RHH if frequent to support state- out-of-hours recall hours recall out-of-hours recall wide role Other clinicians as Other clinicians as Other clinicians as Other clinicians as required to support required to support required to support required to support a quality service a quality service a quality service a quality service Support Not dependent on May be dependent May be dependent May be dependent Services high cost technology on expensive but on very high cost on very high cost or other highly not very high cost technology technology specialised services technology 70 Clinical Services Plan Roles and responsibilities of the acute hospitals The service capability framework includes designation of the roles and responsibilities of each acute hospital as follows: • the RHH is the major tertiary referral hospital for the State, and most single site and state- wide services should continue to be provided by it because of its capital city location, level of infrastructure, associated services and access to important non-health organizations; • the LGH is the major referral hospital for the North and North West of the State, providing a comprehensive range of acute hospital services and a significant number of single site services at a tertiary level; and • the NWRH provides local acute hospital services to the communities of the North West and West of the State. Principles for single site and state-wide service development The following principles will apply for the sustainable development of single site and state-wide services: • single site and state-wide services will not be designed or developed around the needs of individual clinicians, individual regions or individual hospitals – a system-wide, population-needs, evidence-based approach will be taken for the establishment of these services; • critical clinical interdependencies will be taken into account when planning the location of single site and state-wide services; • funding for supporting infrastructure for single site and state-wide services (eg to enable the provision of outreach services) will be provided as appropriate through funding streams independent of normal hospital budgets; • single site services will be required to participate in the usual quality and accountability processes that apply at their host hospital; • state-wide services will be accountable to their host hospital but also will be required to account for their performance on a state-wide basis, addressing issues such as accessibility and outcomes of care; • most single site and state-wide services will continue to be located at the RHH because it is the main tertiary teaching hospital in Tasmania and has the necessary infrastructure to provide more complex services and necessary associated support services that aid in quality service provision and attraction and retention of professional staff for those types of service. • where a single site or state-wide service does not depend on critical internal or external relationships that are more achievable at the RHH, the service may be located at the LGH. Tasmania’s acute hospital services have been categorised according to this service capability framework. Specific service strategies are discussed in Chapter 8. 7.1.3 Clinical networks Clinical networks have been developed in a number of Australian states and internationally, to improve the collaboration, integration and coordination of services across organisational and professional boundaries. Their functions may include information exchange, development of referral protocols and procedures, establishment of clinical guidelines, coordination of scarce resources, evaluation of performance, professional development, support and leadership and service development. Clinical Services Plan 71 Multidisciplinary clinical networks will be established in Tasmania when services would benefit because: • there are small numbers of clinicians based at different sites and/or operating under different management structures who would benefit from coordinated peer review and support processes; • there is a need to coordinate and plan for the efficient management of scarce system-wide resources; • services are complex, pose high clinical risk and/or are costly and would benefit from state-wide clinical guidelines, referral protocols and monitoring of quality; and/or • there are opportunities to improve service integration within and/or across sectors. Clinical networks will be advisory to the Department of Health and Human Services and to service providers. Clinical network leaders will be selected on merit and interest. Efforts will be made to ensure that there is equitable representation in leadership positions from each area of the State. Clinical networks will span the primary, secondary and tertiary sectors and advise on diverse issues including policy, planning, governance, training of health professionals and service quality. It is proposed to establish the following clinical networks: • adult medical services; • adult surgical services; • aged care and rehabilitation; • cancer services; • cardiology/cardiac surgery; • diabetes and chronic disease; • emergency, critical care services and trauma services; • renal medicine; and • women’s and children’s services incorporating maternal and perinatal services and paediatric medicine and surgery. Clinical networks will only be necessary in medical imaging and pathology if state-wide services are not established. If state-wide services are established, service coordination will occur through a single administrative structure. Clinical Advisory Council A new multidisciplinary Clinical Advisory Council will be convened, comprising clinicians from the primary and acute health service systems. The Clinical Advisory Council will lead and coordinate the clinical networks and will be the principal vehicle for clinical advice to the Department of Health and Human Services about the structure and performance of the service system as a whole. Ensuring effective credentialing and defining the scope of clinical practice As technology advances and the risks associated with health care delivery are better understood, greater attention is being paid to ensuring that: • the qualifications and experience of health care professionals who offer clinical services are reviewed thoroughly, an assessment is made of their competence and their performance is monitored over time; • there is sufficient patient volume and appropriate equipment and staffing to support quality services at each site from which they are offered; and 72 Clinical Services Plan • new services and elements of services are developed in a planned and systematic manner, avoiding the development or expansion of services in one part of the system that may affect the cost, quality or sustainability of services in other parts of the system. This Plan will ensure that only well-designed, sustainable services are offered to the community. Effective processes will be implemented to ensure the initial and ongoing qualifications, experience, competence and performance of health care practitioners and the capability of the service system to support the services are delivered. Credentialing refers to the formal process used to verify the qualifications, experience, professional standing and other relevant professional attributes of health care professionals for the purpose of forming a view about their competence, performance and professional suitability to provide high quality health services within specific organizational environments. Defining the scope of clinical practice follows on from credentialing and involves delineating the extent of an individual health professional’s clinical practice in a particular organization, based on the individual’s credentials, competence, performance and professional suitability and the needs and capability of the organisation to support the requested scope of clinical practice. There is a National Standard for Credentialing and Defining the Scope of Clinical Practice13 (the National Standard) which has been endorsed by Australian Health Ministers and will be implemented in Tasmania, initially in relation to senior medical practitioners, but in future in relation to other clinicians whose clinical decisions are not supervised directly and whose practice generates significant clinical risk. The Department of Health and Human Services will investigate, through the new clinical network structures, the adoption of a centralised credentialing process. An effective and consistent credentialing system is an important administrative practice that ensures all Tasmanian hospital clinicians are subject to the same efficient and robust processes. The process for defining the scope of clinical practice will be local to each of the three hospitals, because an appropriate scope of practice depends on both the clinician’s competence and performance and the hospital’s needs and capability. Each hospital will have a committee that is responsible for advising on the appropriate scope of practice for each senior medical practitioner. The committee will be constituted and should operate in compliance with the National Standard. The National Standard also defines a process for the introduction of new clinical services, procedures or other interventions. These are services, procedures or interventions that may be but are not necessarily new to the health system overall, and yet are being introduced into an organizational setting for the first time. They may, but will not necessarily be, expensive, innovative or costly. They will, however, require more than incremental change in the way in which health services are delivered within a specific organisational setting. There is an urgent need for a robust and transparent process for the introduction of new clinical services, procedures or other interventions into Tasmania’s hospitals. The process must take account of a number of issues, including: • whether it is safe to introduce the service in the setting and manner proposed; • the costs that will be incurred by introducing the service; and • the impact on the quality and cost of existing services. 13 Available at http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/A0E19BFE6489F6E1CA2571C70008A86A/$File/ credentl.pdf Clinical Services Plan 73 These are not issues that can be decided at a single hospital level – the system as a whole has a legitimate interest. There should be a single process introduced for the State, consistent with the National Standard, to ensure that new clinical services, procedures or other interventions are introduced in a planned and systematic manner over time, avoiding harm to existing services and ensuring ongoing quality of care. 7.1.4 Integration with the primary health system One of the key principles articulated in the plan is the integration of acute services with community- based services. The overarching Health Plan provides the model for this service integration, and therefore comments strategically and organisationally on how these changes can take place. The purpose of this section is to document the specific planning issues and service strategies that address this principle in the context of a Clinical Services Plan. The services strategies previously articulated, in particular the development of the integrated care centre model will enable the concept of a “third space” in health care in Tasmania to be developed. This will allow for the integration of service delivery, supported by an organisational framework. Under the proposed model for integrated care centres, only the fourth tier requires direct support from an acute hospital. Additional definitions of the interrelationships of the services managed across the acute care and primary health interface are as follows: • Acute hospital facilities should be reserved for situations where intensive nursing and medical care is required on a 24-hour basis. • Facilities and services need to exist to maximise recovery potential after an acute health episode. However, they do not need to be located in an acute setting. These services can include inpatient and community-based rehabilitation and restorative services, outreach medical and nursing specialist clinics, hospital-in-the-home services, transitional care services and other ambulatory care services. • Linkages and partnerships with community services for patient/client education, information, prevention and self-management purposes. Those developing these policies and strategies for building the interface need to consider: • new service delivery models with other government agencies and non-government organisations; • models and mechanisms for sharing and rotating of staff; • appropriate financial allocation; • skills development/workforce capacity; • development of a shared culture; and • services built around local health needs and community views. The strategy for the management of chronic diseases requires the development of coordinated multidisciplinary care teams and new roles in order to reduce the number of avoidable hospital admissions and improve hospital utilisation and overall health outcomes. It is essential that local services are adequately resourced to support state-wide initiatives to address these health issues. This will require the allocation of local staff involved in the day-to-day care of patients with chronic conditions supported by specialised teams (often located in the major acute hospitals) and with innovative use of communications and other types of technology. 74 Clinical Services Plan This model would also benefit from a collaborative interdisciplinary approach to the management of specific conditions, which were designated as state-wide services in Section 7.1.3. Integrated care services There is a significant body of evidence to support the recognition that the traditional configuration of services is no longer providing the most appropriate model for many local communities and has generated options for a new contemporary approach. Changes in demographic trends and health needs are resulting in the development of specialised service models, in which not all acute inpatient care is provided at one site. Instead, a range of specialised services are delivered consistent with the community’s health needs. Major growth areas include the shift from overnight care to day surgery (often delivered in a discrete setting for booked elective surgery), and aged care and rehabilitation services. The former has been enabled by advances in technology and anaesthetics, and the latter is necessitated by the ageing of the population. There are increasing workforce constraints in all areas of the health workforce due to a lack of local supply of staff. Increasing costs associated with using locum and agency staff require consolidation of acute health services across fewer locations when such staff are available, and referral to other service centres when adequate staffing cannot be maintained. The workforce is being redesigned to respond to these shortages. Complementary service roles are also being developed whereby higher acuity services are delivered at fewer sites, supported by correspondingly lower acuity services at other sites, in order to ensure provision of services that are safe and meet quality benchmarks. Traditionally, the settings in which health care is delivered have been determined largely by their sources of funding. State-funded health services have been provided mainly through state-owned facilities that often have been established in relative isolation from Commonwealth- or privately-funded health care providers such as GPs, private hospitals, private community nursing services and private allied health services. There has been increasing recognition of the urgent need to integrate services so that wasteful gaps and duplication are minimised and clients’ access is coordinated, unimpeded by funding or organisational boundaries The traditional model for a local service has been based on an acute general hospital which delivers a range of services, subject to population size and workforce availability as follows: • acute medical & surgical services for Type 1 specialisation (general medicine, general surgery, cardiology, dermatology, endocrinology, gastroenterology, geriatric medicine, neurology, renal medicine, rheumatology, paediatrics, respiratory medicine, ENT surgery, obstetrics & gynaecology, ophthalmology, orthopaedics, urology)14 • ICU/CCU/HDU & ED services dependent on demand • aged care and rehabilitation services • mental health services • cancer services (cancer units) • ambulatory care services including chemotherapy, renal dialysis, chronic disease management services, specialist outpatient clinics, allied health day therapy, clinical measurement services, strategy for community health and primary health services 14 Department of Health WA, Clinical Services Consultation 2005: Clinical Services Framework Definitions, 2005. Clinical Services Plan 75 Ambulatory care service models have been developed based on the concept of integrated care. There is a well-defined set of acute and chronic medical conditions that do not require a hospital stay exclusively, and can be managed by a combination of hospital or centre-based consultations and home visits by nurses and allied health staff, while still being under the care of a hospital doctor or General Practitioner. Many medical investigations and treatments can be safely delivered in a home or community setting, including blood tests, wound dressings, oxygen therapy, rehabilitation and administration of medications such as antibiotics and chemotherapy. The Department of Health and Human Services has categorised these and similar ambulatory and non-inpatient services into a four-tiered service structure, taking account of: • population trends and community need; • distance from other services; and • sustainability including considerations such as cost and workforce availability. The four tiers are set out below: Tier 4 sites are part of the acute care services model and are not normally provided under the primary health services model. Tier 4 sites provide health care on a same-day basis, requiring inpatient back-up in order to be safely and effectively delivered. Tier 4 sites generally would be planned in metropolitan or large regional areas. Services at this tier may include radiotherapy, day surgery and procedures involving a high degree of clinical risk (for example, stents, angiograms or some laparoscopic surgical procedures). Most outpatient services that are required immediately pre- and post-admission would also be provided at tier 4 sites. Tier 3 sites provide extended primary health services with significant outreach across the network and a stronger representation of acute services. In addition to Tier 1 and Tier 2 services, Tier 3 services provide some or all of the following according to community need: • specialised palliative care; • hospital in the home (contracted with acute hospitals); • inpatient and outpatient rehabilitation; • aged care assessment and inpatient care services, including transition programs; • alcohol and drug services; • oral health services; • visiting specialist mental health care; • dietetics; • specialist diabetes education; • continence service; • medical oncology; • satellite renal dialysis services; and • more extensive health promotion and prevention programs. 76 Clinical Services Plan Tier 2 sites operate rural inpatient services in addition to their community health services. Tier 2 services may include: • Subacute inpatient services in a rural setting, eg step down from acute health services including: o rural non-specialist obstetrics for normal (low-risk) patients; o minor surgery for low-risk patients; o low- and high-care residential aged care; o inpatient palliative care; o overnight respite and care waiting placement for older persons; o minor surgical procedures under local anaesthetic in a procedure room; and o slow stream rehabilitation. • Ambulatory care services such as renal dialysis satellite services, chemotherapy services. • Specialist outpatient clinics, including ante- and post-natal classes and clinics. Tier 1 services can also be provided at all Tier 2 sites. Tier 1 sites provide core community health services in a local community. They reflect the increasing emphasis on community-based and home-based care and the provision of these services through an integrated team approach. Tier 1 services are described in detail in the Primary Health Services Plan, but will provide a range of services from among the following: • primary prevention and community development; • general practice, either in the facility or available to the local community from a separate location; • in-home and centre-based community care; • clinic based community nursing and domiciliary nursing services; specialist community nursing eg cancer nurses; • chronic disease management such as general diabetes education; health coaching and advice concerning healthy lifestyle; • allied health services; • other services such as primary mental health or alcohol and drug services; youth health services; women’s health; post-natal care and limited ante-natal services; centre-based respite; child and family health services; • capacity to treat minor injury; blood diagnostic and collecting services; and • referral to other more specialised services. Clinical Services Plan 77 This model will be applied to existing services as follows Tier 4 (new sites) – an integrated care centre will be developed in Hobart (within or adjacent to the RHH) and in Launceston close to the LGH. Tier 3 (new sites) – integrated care centres providing a range of short stay and ambulatory acute and primary care services will be developed in the Clarence/Sorell area and in Kingborough (potentially on existing sites). Tier 3 – Extended primary health sites with significant outreach across the network and incorporating over time a stronger representation of acute services: Burnie (Parkside); Devonport; Glenorchy; Kingston (upgraded over time from its current Tier 1 status); Clarence; and Hobart (Repatriation Centre). Tier 2 – Rural sites that provide both Tier 1 level services and inpatient services: Beaconsfield; Campbell Town; Deloraine; Dover; (Esperance MPC); Flinders Is; Franklin (Eldercare); George Town; King Is; New Norfolk; Nubeena (Tasman MPS); Oatlands; Queenstown; Scottsdale; Smithton; St Helens; and Swansea (May Shaw Nursing Centre). Tier 1 – Core Primary Health: Bridgewater; Bruny Is; Burnie (Jones St); Cape Barren Island; Cygnet; Huonville; Kings Meadows; Ouse; Ravenswood; Risdon Vale; Rokeby; Rosebery; Sorell; Strahan; Swansea; Triabunna; Ulverstone; Westbury; Wynyard; and Zeehan. Note: The delivery of services from the St Mary’s and Longford sites require further investigation and consultation with the communities before a firm direction can be established. Integrating models of care in emergency departments New models of care are coming to light in emergency medicine aimed at improving access to emergency services, improving patient care in the emergency department (including providing a more appropriate physical setting), reducing the need for admission to hospital, and reducing the acuity of patients and resulting length of stay in hospital on admission. Models such as the following will be considered for progressive adoption across the major hospitals: Emergency Short Stay Unit These units are attached to emergency departments and are designed for patients who are likely to be discharged within 24 hours and generally have a length of stay of four to 24 hours. Patients in the short stay unit generally receive intensive assessment and treatment under the guidance of an emergency department physician. Patients who might be managed within a short stay unit include those requiring diagnostic testing to determine the nature and seriousness of their condition, or a short course of treatment to resolve their condition. Medical Assessment and Planning Unit Medical Assessment and Planning Units are designed to provide observation, care and treatment to medical inpatients prior to transfer to an appropriate ward or hospital discharge. Patients in these units are generally admitted from the emergency department, and are managed by medical physicians with collaborative multidisciplinary input for up to 48 hours to facilitate intensive treatment and to streamline care planning. Patients requiring specialist services are not managed in these units. Day Treatment Centres Day treatment centres or medical procedure units are designated facilities for day-treatment patients who do not require an inpatient bed or emergency department treatment space. Patients who are managed in a day treatment centre generally require low complexity services such as intravenous infusions. 78 Clinical Services Plan Fast Track Fast tracking of patients in emergency departments enables more timely treatment for people with less serious illnesses or injuries. The model has been shown to reduce waiting times for people with less serious conditions (who might otherwise have long waiting times because patients with higher urgency are prioritised for treatment) and also reduce bottlenecks in the waiting rooms. The process sooner identifies patients who are lower complexity triage categories, requiring less complex care and unlikely to require hospital admission. Patients are referred to a designated fast-track area of the emergency department to await treatment from doctors and nurses who are allocated to that area. Low complexity patients include sprains, strains, plaster checks, simple wounds and fractures. Psychiatric Emergency Care Centre (PECC) PECC units provide rapid assessment, observation, short-term care and discharge planning for patients presenting to emergency departments for mental health conditions. PECC units provide a more discrete, safer environment for mental health patients treated within emergency departments. PECC units generally provide care for up to 48 hours. Co-located GP Clinics Co-located GP clinics have been trialled throughout Australia and have been shown to reduce waiting times for people with less serious illnesses and conditions, reduce bottlenecks in waiting areas, and free up emergency medicine specialists to manage higher acuity presentations. 7.2 Implementing the system 7.2.1 Assessment of strategies and plan for the south The analysis of demographic trends in the South region, including the city of Hobart, showed major LGAs where there will be significant growth in inpatient demand for services. These are shown in the graph below. Figure 15: Current and projected resident demand by LGA, South region, 2004-05 to 2021-22 (inpatient separations, excludes renal dialysis & neonates) Central Highlands Southern Midlands Huon Valley Kingborough Hobart Glenorchy Derwent Valley Brighton Clarence Sorell Tasman Glamorgan/Spring Bay 0 5,000 10,000 15,000 20,000 25,000 30,000 2004-05 2021-22 Source: Greg Hardes & Associates The significant number of renal dialysis separations for each patient (156 per year per patient), distort the data and therefore these separations have been removed to show patterns of utilisation more clearly. All neonate activity is also excluded in this data analysis, as varying coding rules were applied which resulted in inconsistent data. Clinical Services Plan 79 Residents of Hobart LGA will account for the highest resident demand in this area both in 2004-05 and in 20021-22. Clarence residents will have the second highest level of inpatient demand by 2021-22, followed by residents of Glenorchy. Kingborough residents show the highest rate of projected growth in resident demand, with a 76.9% projected growth followed by Huon Valley with a 74.2% growth. These therefore represent areas within the city of Hobart and surrounding areas where local service models including integrated care models could be developed. As a result of this analysis, it was decided to create catchment areas for the South as follows: Eastern Shore of Hobart & surrounding areas Glamorgan Spring Bay; Tasman; Sorell; Clarence; Brighton Southern Midlands: Central Highlands; Derwent Valley; Remainder of Hobart & surrounding areas Glenorchy; Hobart; Kingborough; Huon Valley An analysis was conducted of facility requirements for an integrated care centre on the Eastern Shore of Hobart in the Clarence/Sorell areas, and one in the South of Hobart located in Kingston servicing residents of the Kingborough and Huon Valley areas. The redevelopment of the RHH offers a major opportunity to incorporate new models of care in an inpatient setting, as well as test the feasibility of the model of integrated care centres for Hobart and surrounding areas. The range of service strategies considered for the South therefore included: • full integration of all overnight and ambulatory care services in one setting; • full integration of all acute overnight and ambulatory care services in one setting; with subacute services strategically located elsewhere; and • integration of essential overnight and ambulatory care services in one setting with a series of integrated care centres in strategic locations in Hobart based on population growth centres. Based on the strategic direction of this Plan and the services principles adopted, it was agreed to support the third strategy as it best met the service principles of the Plan. The following tables provide the facility requirements for two approaches: • Projected inpatient facility requirements based on continuing the status quo delivery of services. • Projected inpatient requirements based on the development of two integrated care centres in other locations throughout Hobart, and a major integrated care function in the RHH. Table 60: Projected inpatient activity, separations and beddays, RHH base case, 2004-05 to 2021-22 Stay type Year Change 2004-05 20011-12 2016-17 2021-22 Nos % Separations Day Only 32,701 43,092 49,777 56,619 23918 73% Overnight+ 19,997 22,209 23,339 24,631 4634 23% Total 52,698 65,301 73,116 81,251 28553 54% Beddays Day Only 32,701 43,092 49,777 56,619 23918 73% Overnight+ 131,152 147,964 161,324 177,012 45860 35% Total 163,853 191,057 211,101 233,631 69778 43% Notes: method of estimating facility requirements included in Appendix E. Excludes unqualified neonates. No adjustment for Ambulatory Care Sensitive Conditions managed in other settings. Source: Hardes data. 80 Clinical Services Plan Table 60 shows that there will be a major growth in inpatient demand for the RHH, with inpatient activity projected to grow from 52,698 separations to 81,251 separations by 2021-22. This is a 54% growth in inpatient demand, although there is much higher growth projected in day only separations (73%) compared to overnight separations (23%). Major projected growth areas for overnight services include renal dialysis and renal medicine, neurosurgery, rehabilitation, non acute care, and drug and alcohol services (90% or greater). There is major growth projected in chemotherapy, medical oncology, haematology demand and renal dialysis chairs. These activity projections have not been adjusted for any management of patients with ambulatory care-sensitive conditions, in other settings. Table 61 shows the projected inpatient demand for RHH with the development of two integrated care centres in other parts of Hobart. The estimated inpatient demand is lower than for the baseline estimate, with a projected growth at the main facility of 23% for separations and 20% for beddays. The services to be provided at the main RHH location would be based on the development of a Tier 4 function integrated with other services. Table 61: Projected inpatient activity, separations and beddays, RHH adjusted for development of two integrated care centres, 2004-05 to 2021-22 Stay type Year Change 2004-05 20011-12 2016-17 2021-22 Nos % Separations Day Only 32,701 33,857 36,432 41,325 8624 26% Overnight+ 19,997 21,883 22,630 23,669 3672 18% Total 52,698 55,740 59,062 64,994 12296 23% Beddays Day Only 32,701 33,857 36,432 41,325 8624 26% Overnight+ 131,152 140,315 144,923 155,239 24087 18% Total 163,853 174,172 181,355 196,564 32711 20% Notes: method of estimating facility requirements included in Appendix E. No adjustment for Ambulatory Care Sensitive Conditions managed in other settings Source: Hardes data. The projected inpatient demand for each of the integrated care centres is shown in the tables below. This service configuration allows for the development of Tier 4 integrated care centre services as part of the redeveloped Hobart hospital. Table 62 shows activity in the major integrated care centre proposed for the Clarence/Sorell area. Services at this site could be targeted for 2011-12. This centre would be the larger of the two proposed centres for Hobart, and would be a Tier 3 centre providing two theatres for same-day surgery, renal dialysis satellite services as well as chemotherapy chairs. The centre would also provide a range of overnight and ambulatory rehabilitation and non-acute services. There would also be a significant range of other services provided at the site consistent with a Tier 3 service as previously defined. Clinical Services Plan 81 Table 62: Estimated inpatient activity, 2004-05 to 2021-22, Eastern Shore Integrated Care Centre in Hobart Stay type Year Change 2011-12 - 2021-22 2004-05 20011-12 2016-17 2021-22 No. % Separations Day Only 0 9,236 10,609 12,086 2851 31% Overnight+ 0 326 447 593 267 82% Total 0 9,561 11,056 12,679 3117 33% Beddays Day Only 0 9,236 10,609 12,086 2851 31% Overnight+ 0 7,649 10,392 13,433 5784 76% Total 0 16,885 21,001 25,519 8634 51% Note:s method of estimating facility requirements included in Appendix E. No adjustment for Ambulatory Care Sensitive Conditions managed in other settings. In addition, a smaller integrated care centre will be developed to service the community of Kingborough and Huon Valley, with possible commencement of services in 2016-17, as population growth and ageing results in a sufficient volume of services to support the centre’s acute ambulatory services. This centre will be developed as a Tier 3 service in the longer term. Table 63: Estimated inpatient activity, 2004-05 to 2021-22, Kingborough Integrated Care Centre Stay type Year Change 2016-17 - 2021-22 2004-05 20011-12 2016-17 2021-22 No. % Separations Day Only 0 0 2,736 3,208 472 17% Overnight+ 0 0 262 370 108 41% Total 0 0 2,998 3,578 580 19% Beddays Day Only 0 0 2,736 3,208 472 17% Overnight+ 0 0 6,009 8,340 2331 39% Total 0 0 8,745 11,548 2803 32% Note:s method of estimating facility requirements included in Appendix E. No adjustment for Ambulatory Care Sensitive Conditions managed in other settings. This service strategy consolidates the main acute inpatient services at the redeveloped Royal Hobart site and develops services in local communities where there is sufficient volume due to local inpatient demand. There is a significant range of other services which could also be provided at these centres. The specific scope of these services will be developed in consultation with local service providers and local communities noting that the centres are designed to provide a combination of acute and primary care. 82 Clinical Services Plan 7.2.2 Assessment of strategies and plan for the North Launceston General Hospital, incorporating new models of care, will be the regional referral hospital for the North. The major growth in inpatient demand for residents in the North region will be in the city of Launceston itself. These projected trends are shown in the graph below. Figure 16: Current and projected resident demand by LGA, North region, 2004-05 and 2021-22 (excludes renal dialysis and neonates) Meander Valley Northern Midlands West Tamar Launceston George Town Break O’Day Dorset Flinders 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 2004-05 2021-22 The proposed strategy for the North is to: • Develop the LGH to accommodate role changes to the NWRH. • Develop an integrated care centre in the city of Launceston. Based on the advice of clinicians in the North West, the strategy assumes that, following changes to the role of the Mersey campus of the NWRH, one third of adult medical and surgical overnight services, and paediatric services will flow to LGH. The tables below show projected inpatient demand based on these service strategies. Table 64: Projected inpatient activity, LGH, 2004-05 to 2021-22, baseline estimates Stay type Year Change 2004-05 2008-09 20011-12 2016-17 2021-22 Nos % Separations Day Only 24,244 24,894 27,601 32,774 38,171 13927 57% Overnight+ 13,058 14,655 16,153 17,202 18,362 5304 41% Total 37,302 39,549 43,754 49,976 56,533 19231 52% Beddays Day Only 24,244 24,894 27,601 32,774 38,171 13927 57% Overnight+ 80,574 90,362 99,957 110,120 121,945 41371 51% Total 104,818 115,255 127,558 142,893 160,116 55298 53% Note: Method of estimating facility requirements included in Appendix E excludes unqualified neonates, and includes resident demand for renal dialysis services from 2008-09; there is no adjustment for Ambulatory Care Sensitive Conditions managed in other settings. Clinical Services Plan 83 Under the baseline estimates, should the LGH continue to provide the range and quantity of existing services projected over time, the inpatient demand is projected to grow by 52% for separations and 53% for beddays, with higher projected growth in same-day activity. Under the new model of service delivery, inpatient demand will grow by 20% for separations and 9% for beddays. In addition, some 50% of same-day surgery for patients currently attending LGH will be delivered at the Mersey campus, in its comprehensive same-day surgical service. Patients west of Launceston will also attend Mersey campus for rehabilitation services. Table 65: Projected inpatient activity, LGH with Launceston Integrated Care Centre and enhanced referral role for North and North West, 2004-05 to 2021-22 Stay type Year Change 2004-05 2008-09 20011-12 2016-17 2021-22 Nos % Separations Day Only 24,244 21,730 21,912 25,010 28,125 3881 16% Overnight+ 13,058 14,452 15,208 15,847 16,491 3433 26% Total 37,302 36,181 37,120 40,857 44,616 7314 20% Beddays Day Only 24,244 21,730 21,912 25,010 28,125 3881 16% Overnight+ 80,574 87,888 81,338 81,747 85,939 5365 7% Total 104,818 109,618 103,250 106,757 114,064 9246 9% Note: Method of estimating facility requirements included in Appendix excludes unqualified neonates, and includes resident demand for renal dialysis services from 2008-09. Note: No adjustment for Ambulatory Care Sensitive Conditions managed in other settings. Table 66 shows that the demand would justify the development of a Tier 4 integrated care centre by 2016-17. The centre would deliver renal dialysis; overnight rehabilitation services and non acute services including services under the transition program. Overnight services would commence from 2011-12 Table 66: Projected inpatient activity, Launceston Integrated Care Centre, 2004-05 to 2021-22 Stay type Year Change 2011-12 to 2021-22 2004-05 2008-09 20011-12 2016-17 2021-22 Nos % Separations Day Only 0 0 2434 4075 5956 3521 145% Overnight+ 0 0 641 966 1,546 905 141% Total 0 0 3,075 5,041 7,502 4427 144% Beddays Day Only 0 0 2434 4075 5956 3521 145% Overnight+ 0 0 13,456 20,438 33,382 19926 148% Total 0 0 15,890 24,513 39,338 23448 148% Notes: Method of estimating facility requirements included in Appendix E, No adjustment for Ambulatory Care Sensitive Conditions managed in other settings. 84 Clinical Services Plan 7.2.3 A new strategy for the North West Key points The North West had the highest proportion of older people in the State in 2006. There are also significant areas of socio-economic disadvantage in this area, often associated with poorer health outcomes. Both facts indicate that demand for health services will continue to grow. This makes decisions about the sustainability of health services in the North West all the more critical. The configuration of services across the two campuses of NWRH – at Burnie and the Mersey campus at Latrobe – has been the subject of much attention and robust debate for a number of years. This came to a head with the return in 2004 of the Mersey facility to public ownership,; its future role was among the most keenly considered topics during the consultation on the development of this Plan. The planning process has paid considerable attemtion to the value to local communities of the services provided at each campus, and the well-known ans long-standing difficulties experienced in providing a sustainable service over both campuses. Present service patterns reflect a number of past policy, planning and operational decisions. By contrast, in this Plan, decisions about the future have been based on the overall health needs of the population of the North West region, coupled with careful consideration of well-integrated health service design, rather than on current patterns of service delivery. Continuing efforts to duplicate services across both campuses have created major problems of sustainability, and have compromised the quality of health care for the whole community. Considerable growth in demand for inpatient and outpatient care will need to be accommodated, and current service design problems must be and have been addressed. Addressing these problems has necessitated a change of role for both campuses, with each complementing the other. This will allow the NWRH, in conjunction with primary health services, to provide a comprehensive service to the entire community. High acuity inpatient, intensive care and emergency services will be consolidated on the Burnie campus. The Mersey campus will refocus on high-volume medical and surgical day-only services, including: chemotherapy and renal dialysis; lower risk booked day surgery (general surgery, orthopaedic and gastroenterology); low-risk maternity and paediatric services; specialist aged care and rehabilitation; together with a full range of non-inpatient consulting services. There will be an emergency care centre at the Mersey open 24 hours each day; and the theatre recovery area will be capable of providing resuscitation support. This will allow procedural and obstetric patients to be supported appropriately in the event of an emergency and requiring transfer from the campus. Ambulance and paramedic support will be enhanced to ensure that emergency transport is available at all times for residents of the Mersey catchment area, so that they can be taken quickly and safely to appropriate emergency services at either Burnie or Launceston. An opportunity will be provided for the existing vascular surgical service to relocate to the LGH. Clinical Services Plan 85 Current facility and service profile Both the Burnie and Mersey campuses are important elements of the North West Regional Health Service, rather than stand-alone hospitals. Together with community-based health services in the North West region, they provide a comprehensive health service that meets the needs of the population of the North West as a whole. Each has endeavoured to provide a full range of services to their communities, although the Burnie campus has a higher throughput and currently provides a broader range of acute and other services. The Burnie campus is a relatively modern and well-presented facility that is owned privately and leased to the Government. The services at the Burnie campus were developed based on a highly integrated service model between the public hospital and the co-located North West Private Hospital. The private hospital provides obstetrics services for both public and private patients and has the only facilities for delivery suites and obstetrics services at the site. The University of Tasmania’s Rural Clinical School also is co-located with the public campus and the private hospital on the Burnie site. The Mersey campus was operated for some years as a separate private hospital until the government resumed ownership and operational responsibility in 2004-05. It is much older than the Burnie campus and is in modest repair. Efficiency issues The cost of acute care services in the North West is higher than for the other two major acute hospitals due to a number of factors including the cost of recruitment of clinical staff to the services, and the inefficiencies created by two hospitals in close proximity, each providing similar services to the same population. Hospital utilisation data and catchment profile The patterns for place of treatment for residents of the North West are more complex than for other regions of the State. Total resident demand Some 77% of residents of the North West utilise public hospital services, and 23% utilise private hospital services. The Burnie campus of the NWRH provides 33% of all separations (including a contract for provision of obstetrics and ophthalmology by the local private hospital). The Mersey campus provides 19% of all separations. Public hospital resident demand The region is currently 74% self-sufficient for public hospital services – 41% of separations are provided at the Burnie site (both public and public contract), 25% at the Mersey campus and 8% at other rural hospitals in the North West. As noted above, there are comparatively large outflows to both Launceston (15%) and Hobart (9%). Overall, the region’s level of self-sufficiency is lower than targets set in other states for locally provided services in regional settings (eg 85% self sufficiency for public hospital inpatient services, Victoria). Demographics and patterns of service delivery Analysis of the flow of patients to the two campuses indicates that there are two sub-catchment populations in the region. The Local Government Areas (LGAs) that form the sub-catchment populations for each campus are depicted in Table 67. 86 Clinical Services Plan Table 67: LGAs for the North West of Tasmania Burnie sub-catchment Mersey sub-catchment Burnie Devonport Circular Head Kentish King Island Latrobe Waratah/Wynyard 50% of Central Coast West Coast 50% of Central Coast 77% of hospital separations for residents of the North West are from public hospitals (including private sector provision of public services) and 23% are from private hospitals (not including private sector provision of public services). Features of the local catchments The Burnie sub-catchment is the larger of the two local catchments, accounting for 57.4% of total inpatient resident demand. Burnie catchment 15,252 separations, 57.4% of NW King Island, Circular Head, Waratah/ resident demand Wynyard, Burnie, West Coast, 50% of Central Coast Devonport catchment 11,333 separations, 42.6% of NW Devonport, Kentish, Latrobe, 50% of resident demand Central Coast Figure 17 below shows that, of the public hospital separations provided for North West residents, 41% are provided at the Burnie campus, 25% are provided at the Mersey campus, 8% are provided at small rural hospitals and 26% are provided elsewhere. Figure 17: North West public hospital resident demand by place of treatment, 2004-05 (ex. renal dialysis & unqual. neonates, n=20,342) NWRH Burnie 41% LGH 15% RHH 9% NWRH Mersey 25% Interstate public 2% Other NW public 8% Other public 0% Source: Greg Hardes & Associates. Clinical Services Plan 87 There is some crossover between the sub-catchment populations of the North West. Five per cent of public hospital inpatient separations for residents of the Burnie sub-catchment currently occur at the Mersey campus, whereas 19% of public hospital inpatient separations for residents of the Mersey catchment currently at the Burnie campus. Residents of the Mersey sub-catchment have been utilising services in several locations, including Burnie and LGH, at a significant rate. If the current service configuration between the two campuses were to continue, the Burnie campus would continue to be the main provider, followed by the private sector, then the Mersey campus and the LGH (see Figure 18 below). Figure 18: Current and projected North West resident demand by place of treatment 2004-05 and 2021-22 Private 9,371 6,242 607 Interstate Public 364 91 Other Public TAS 53 2,072 Other NW Public 1,613 7,800 NWRH Mersey 5,111 10,948 NWRH Burnie 8,416 6,023 LGH 3,054 2,861 RHH 1,731 0 2,000 4,000 6,000 8,000 10,000 12,000 Number of separations 2004-05 2021-22 Source: Greg Hardes & Associates. As noted above, past policy, planning and operational decisions have had a very significant influence on the current configuration of services between the two campuses. Current activity and service capabilities on each of the campuses are not necessarily indicative of what could be achieved with an integrated service plan for the NWRH. For that reason, decisions about the future roles and responsibilities of the two campuses have been based on an analysis of the needs of residents of the catchment population of the North West and the capability of the NWRH as a whole, rather than on the current distribution of services between the campuses, or their relative activity levels. This is important because it allows planning for the health needs of the entire population of the North West, and takes into account the capacity of all accessible facilities, including the LGH for those residing at the eastern end of the North West region, to provide services equitably. 88 Clinical Services Plan Ensuring sustainable service design The new service design for the NWRH is based on the following principles, strongly supported by stakeholders during the development of this Plan: • Each campus should retain a vibrant and cohesive range of sustainable services which may differ in their orientation but not their importance to or influence on the health and wellbeing of the community. • Patient transport services should facilitate reasonable access to both campuses for the entire community. • Where a service cannot be provided safely, effectively and at an acceptable cost on both campuses of the NWRH, it should be provided on one campus only. • The distribution of services between the campuses needs to take account of important functional relationships (eg stroke/rehabilitation; emergency medicine/ICU). The concept of sustainability is central to this Plan. Factors that determine sustainability are: • sufficient patient volume to support and maintain the competence of health care professionals; • a staffing infrastructure that can withstand temporary shortages without excessive cost or operational burden; • quality equipment and facilities; • appropriate access to necessary clinical and non-clinical support services; • costs that are reasonable in the context of competing demands for resources; and • transparent and predictable funding allocations. Current service issues of concern Clinicians and other key stakeholders have raised significant issues of concern about duplication of services across both campuses. These factors, presented below, support the case for change of acute health service configuration in the North West. The current provision of a similar range of acute services across both campuses is unsustainable due to: • a lack of clinicians to cover on-call rosters at the two sites; • the high cost of services provision; • a large reliance on overseas trained doctors, with inadequate support and supervision, particularly at the Mersey campus; • a lack of suitably trained nursing and other staff to provide the full range of acute care services at the two sites; • lack of adequate facilities particularly at the Mersey campus; • worsening workforce issues with the pending retirement of key clinicians and lack of succession planning strategies; • compromising of capacity to achieve accreditation of training posts due to low volumes of activity at both sites; • increasing outflows to LGH in particular as local residents in the North West by-pass the Mersey campus (see Figure 19 below); and • difficulty sustaining volumes needed to meet minimum accepted standards for safe practice. Clinical Services Plan 89 Figure 19: Number of presentations to LGH by NW LGA residents 250 200 150 100 50 0 Number of presentations Burnie Kentish Latrobe King Island Devonport West Coast West Circular Head Central Coast Waratah Wynyard Waratah 2001-02 admitted 2005-06 admitted 2001-02 not admitted 2005-06 not admitted These issues are nothing new. The residents who use the services and the clinical and other staff who work in the facilities have known all too well and for too long about these problems. At present, each campus of the NWRH attempts to provide services to a referral base of approximately 50,000 people. The NWRH has not been able to achieve service sustainability across both campuses. There is an inappropriate dependence on locum staffing, creating high levels of clinical risk. The cost of service delivery in the North West is excessive, resulting in lost resources for the residents of the North West as well as for the health system as a whole. These ongoing sustainability problems at the NWRH are a direct consequence of poorly designed services and, in particular, of attempts to provide key volume-dependent services across two campuses when only a single integrated acute service is sustainable for the population of 100,000. The impact of these issues on the cost and quality of care is likely to worsen in the future as workforce shortages become more acute and demand increases. It is imperative that the structural deficiencies are addressed. The following framework has been employed for decision-making about sustainable service development in the North West: • if it is not possible to design a sustainable service for a population of 50,000, but it is possible to design a sustainable service for a population of 100,000, then the service should be provided on one campus only; and • if it is not possible to provide a sustainable service for a population of 100,000, then the service should not be established in the North West, but should be provided on a regional referral or state-wide basis with outreach services as appropriate. 90 Clinical Services Plan Reasons for the decision to reconfigure acute services The facilities at the Mersey campus do not support an adequate standard of care delivery for some acute services currently provided there; nor does the workforce provide the cover and skills-base required. The clinical risk of maintaining services with inadequate staffing levels, and the increasing inefficiencies this creates, cannot continue. The existing situation exposes the Mersey community to the risk of sub- standard health services. There are several major reasons for deciding to consolidate major acute services on the Burnie campus, and for Mersey to focus on non-acute and lower-risk services: • the Burnie campus is well located to provide access to residents in the West and far North West of the state who would otherwise be unable to access emergency and critical care services readily; • the Mersey campus is within a clinically safe distance for emergency transport of patients to other acute facilities, including Burnie and Launceston, as required; • the Burnie campus is a newer facility and has a range of services on-site consistent with the proposed role; • the Burnie campus is co-located with the University of Tasmania Rural Clinical School and therefore offers opportunities for development of rural education and training models; • the Burnie campus was developed on an integrated public/private sector model and the services provision is the subject of current contractual arrangements; • the Mersey campus has previously provided a rehabilitation service and has some of the necessary infrastructure to provide these services again (although the facility needs and will receive refurbishment for provision of best practice services); and • a hydrotherapy pool for rehabilitation services is conveniently located across the road from the Mersey campus (with appropriate transport to be provided). Intensive care services in the North West Intensive care services are highly demanding of human resources and require significant laboratory, radiology and technical medical support. Sustainable specialist intensive care services require a population base of at least 100,000 people. The current intensive care service of the NWRH is attempting to service a population base of approximately 100,000 people from two discrete campuses. Each unit is smaller than optimal and there have been ongoing difficulties staffing intensive care services on the two campuses. Previous reviews have recommended that, to ensure sustainability, the intensive care service for the NWRH should be consolidated into one campus. The Burnie campus has an eight-bed unit for intensive care, coronary care and high-dependency patients. The unit also has telemetry monitoring for a number of medical beds. The Mersey campus has a four-bed unit for intensive care, coronary care and high-dependency patients (currently only two beds are operating). Neither unit has an optimal caseload. At present, neither has continuous in-house registrar staffing, an important requirement for the safe delivery of intensive care services. It is not viable to provide high-quality intensive care services in two separate locations, each serving a population base of 50,000 people; nor is it feasible to provide a single service split over two sites. Clinical Services Plan 91 The community will continue to miss the substantial opportunities for more effective service and better use of resources if the intensive care service is not consolidated into a single large, active and well-resourced unit. The only sustainable option is to provide a single intensive care service on one site, servicing the regional population of approximately 100,000 people. Consolidation of intensive care services into one campus is thus essential. It will enable the unit to be better equipped, will ensure sufficient patient throughput to support a viable specialist and registrar roster appropriate to the level of care being provided, and will assist the service to withstand short- term fluctuations in staffing. Of the two intensive care units, Burnie’s has a higher admission rate than Mersey’s. Minimum Standards for Intensive Care Units specify that an intensive care unit providing services of the complexity of those currently provided by the NWRH should have more than 200 mechanically ventilated patients per annum.15 In 2005-06 the average acuity of the 586 patients admitted to Mersey was low, with only 46 patients requiring mechanical ventilation, and 204 patients discharged directly from ICU. On this basis, and because it is proposed that a range of related high acuity services will be co-located there, it has been decided that the intensive care service will be based at Burnie. The protocols for patient assessment and transfer will be developed across the site and in conjunction with the Tasmanian Ambulance Service. Emergency medicine in the North West As with intensive care services, there has been significant difficulty staffing emergency medicine services in their current configuration across two campuses. As a consequence these services, particularly those on the Mersey campus, have been extremely unreliable. Analysis of recent trends in emergency presentations and projected activity to 2021-22 for the North West suggest that: • predicted growth in emergency presentations to North West hospitals is relatively low; • a high proportion of patients attending both the Mersey and Burnie campuses have low acuity conditions (69% of Burnie presentations and 74% of Mersey presentations are triage categories 4 and 5); and • an increasing number of residents of the North West bypass the NWRH and present to LGH for emergency care (see Figure 20), particularly those from Devonport and the Central Coast. This trend has continued since the Mersey returned to the government. An analysis based on the following criteria showed that 36% of cases at Mersey and 32% of cases at Burnie could be managed in a GP service: • low urgency and low acuity; • diagnosis that is not Emergency Department specific; • presentation during normal work hours; and • cases referred by a GP were not counted as cases that could be managed by a GP. 15 http://www.jficm.anzca.edu.au/pdfdocs/ic1_2003.pdf. 92 Clinical Services Plan Figure 20: Annual DEM LGH attendances excluding residents in the North by origin 2,000 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 2000 2001 2002 2003 2004 2005 2006 2007 North West South Interstate International Source: DHHS data collection. It is necessary to consolidate scarce specialist Emergency Medicine resources in the North West to ensure a sustainable service for the population of the whole region. The management of all Emergency Department presentations on one campus would result in over 37,000 presentations per annum by 2021-22, a standard number of presentations for one fully functioning emergency service in a rural area. Because of the critical interrelationships between intensive care and Emergency Medicine, the Emergency Department should be located on the same site as the Intensive Care Service. For the reasons discussed, that site is the Burnie campus. Obstetric services in the North West There is a projected decline in births to North West residents in public hospitals from 1,035 to 803 births by 2021-22. Births at Burnie (including the North West public contract with the North West Private Hospital) are projected to decrease from 593 to 431 in that time; births at Mersey are projected to decrease from 344 to 296 over the same period. Residents in the Mersey sub-catchment currently use the Mersey campus for only 60% of births. The remaining births occur at a number of other sites, including the North West Private Hospital (29%), at the LGH (5%) and at the RHH (3%). Previous reviews of obstetric services in the North West have recommended a range of strategies, including: • provision of low-risk birthing at the Mersey campus and low- to medium-risk birthing at the Burnie campus; • all birthing at Burnie with inpatient pregnancy and post-delivery care provided at both campuses; or • all inpatient maternity services provided by the Burnie campus. Clinical Services Plan 93 Under all options, non-admitted pregnancy and postnatal care could be provided at both campuses. Low-risk birthing services can be provided safely in facilities with lower levels of staffing infrastructure. Their success depends on staff training and competence and implementation of protocols for patient eligibility, management and transfer. It is thus feasible to continue to provide pregnancy and post-natal care (both inpatient and non- admitted) and low-risk birthing services on both campuses of the NWRH, even in the absence of an on-site intensive care service. By contrast, medium-risk birthing services depend for their safety on the availability of teams of skilled health care professionals including anaesthetists, specialist obstetricians and paediatricians and registrars, as well as on sophisticated infrastructure including operating theatres and intensive care/high dependency units. It is clear that the proposed consolidation of intensive care and associated services at one site will necessitate a corresponding consolidation of medium-risk birthing services at the same site. For these reasons, medium-risk birthing will continue at Burnie, while Mersey will focus on providing a local, low-risk maternity service (with obstetrician supervision), with related pre- and post-natal care services. Other medical and surgical services in the North West The proposed consolidation of intensive care services into one site necessitates a corresponding consolidation of higher acuity medical, surgical and trauma services, which may require intensive care support, at the same site. The service configuration across the two campuses of the NWRH is thus based on: • consolidation on a single campus of all high acuity services which depend for their sustainability on a referral population of 100,000 people; • the other campus must provide a viable mix of complementary services; and • in aggregate the two campuses must provide a comprehensive range of services for the population of the North West. There has been detailed consideration of which campus is most appropriate for provision of higher acuity services. The Burnie campus has been selected for the reasons discussed above. Services to be provided from each campus are detailed in Table 68 (right). 94 Clinical Services Plan Table 68: Services to be provided from the Burnie and Mersey campuses of the North West Regional Hospital Burnie campus Mersey campus Intensive Care Recovery suite Specialist aged care (admitted and non admitted), Inpatient acute medical subacute, rehabilitation and transition care Inpatient acute surgical 23-hour acute elective surgical Low- and medium-risk obstetrics Low-risk obstetrics Ante-natal and post-natal care (admitted and non- Ante-natal and post-natal care (admitted and non- admitted) admitted low-risk) Inpatient paediatrics Short-stay paediatrics (12 hours) Emergency medicine Emergency care centre 24 hours, 7 days a week Satellite renal dialysis (Parkside) Satellite renal dialysis (new service) Day chemotherapy Day chemotherapy Specialty and subspecialty consulting Specialty and subspecialty consulting Role of the Burnie campus • Provision of inpatient acute care services at the Burnie campus for care services in the longer term (general medicine, general surgery, cardiology, dermatology, endocrinology, gastroenterology, geriatric medicine, neurology, renal medicine, rheumatology, paediatrics, respiratory medicine, ENT surgery, low- and medium-risk obstetrics, gynaecology, ophthalmology, orthopaedics, urology). • Enhance medical inpatient services in general medicine, endocrinology, gastroenterology, renal medicine, neurology, respiratory medicine, geriatric medicine in the short to medium term either on-site or with outreach services from LGH. • Outreach services for rheumatology and dermatology from LGH. • Renal dialysis satellite service at Parkside supported by LGH. • Consolidation of ICU services for the North West. • A full Emergency Department service. • Provision of a Tier 2 integrated care centre for the Burnie catchment increasing to a Tier 3 service over time. Clinical Services Plan 95 Table 69 below shows that there will be a high level of growth at the Burnie campus while consolidation of major acute services is occurring. Table 69: Estimated inpatient activity, 2004-05 to 2021-22, Burnie Campus Stay type Year Change 2004-05 2008-09 2011-12 2016-17 2021-22 Nos % Separations Day Only 4,960 6,400 7,513 8,643 9,647 4688 95% Overnight+ 5,909 7,945 8,788 9,195 9,604 3695 63% Total 10,869 14,345 16,301 17,838 19,251 8383 77% Beddays Day Only 5,287 6,972 7,970 9,147 10,196 4909 93% Overnight+ 38,375 54,315 57,739 62,460 67,592 29217 76% Total 43,662 61,287 65,709 71,606 77,788 34126 78% Note 1: Method of estimating facility requirements included in Appendix E; excludes unqualified neonates, includes resident demand for renal dialysis from 2004-05. Note 2: No adjustment made for Ambulatory Care Sensitive Conditions managed in other settings. Role of the Mersey campus As already noted, the Mersey campus is within clinical distance requirements for safe transport of emergency patients to other sites as required. The role change for Burnie provides an opportunity for the Mersey campus to refocus and concentrate on lower risk and subacute services. Consistent with government’s commitment to develop each campus to provide a meaningful mix and volume of complementary services on each site, the Mersey campus will focus on providing a range of services that are relevant to, and valued by, the community. Some services provided at the Mersey campus will be whole-of-region services for residents from throughout the North West. In addition, it is expected that some residents of the LGH catchment, particularly those residing closer to Latrobe, will choose to access elective services at the Mersey campus because they will not be competing with emergency services for theatre access. Services provided from the Mersey campus will also include specialist aged care and rehabilitation services, low-acuity maternity and paediatric services, and high-volume medical and surgical day-only services (including general surgical, orthopaedic and gastroenterology procedures for patients requiring hospital admissions of up to 23 hours). The theatre recovery suite will be capable of providing resuscitation support so that procedural and obstetric patients can be supported appropriately in the event of an emergency requiring transfer from the Mersey campus. There will be a short stay observation area for low-acuity paediatric patients – paediatric patients requiring admission will be transferred to the Burnie campus or other hospitals as appropriate. Day-only services will include renal dialysis and chemotherapy; a full range of non-inpatient consulting services will be provided and there will be an 24-hour emergency care centre. Emergency services at Mersey An emergency care centre will operate from the Mersey campus 24 hours each day with a GP- and CMO-supported low-acuity emergency service. Any triage Category 1 and 2 and complex Category 3 who present to the Mersey emergency care centre will be assessed, stabilised and transferred to Burnie or LGH. Short-term observation services only will be available in the emergency care centre. 96 Clinical Services Plan All triage Category 1 and 2 and complex Category 3 requiring theatre services (eg compound fractures) will be triaged by ambulance paramedics and taken to the Emergency Department at Burnie campus or LGH. There will be no arrangement for theatre usage for emergencies and any patients needing theatre services will be transferred. There will be rostered GP services and the option of CMO-rostered support from Burnie. This will be supported by a triage nurse and associated support services. There will be an on-call arrangement for medical support (with a capacity to attend within 10 minutes) for all overnight services at the hospital to cover cases of patients in the rehabilitation and transition care service who become medically unstable. This cover will not however be provided for people presenting to the emergency care centre. Although there are no definitive Australian standards for time to travel to intensive care, there is a widely accepted concept of an acceptable period of one hour. Access time to either the Burnie campus or the LGH will remain within acceptable limits. Table 70 shows the estimated projected emergency service presentations with service strategies in the North and North West. Note that this analysis does not take account of possible changed flows due to implementation of new models of care such as integrated care centres and co-located GP clinics. Table 70: Projected emergency service presentations, by place of treatment, 2004-05 to 2021-22 Place of treatment 2005-06 2011-12 2016-17 2021-22 LGH 35,687 40,483 44,103 47,666 NWRH Burnie 30,540 32,976 34,180 35,133 NWRH Mersey 11,022 11,851 12,304 12,717 RHH 39,275 46,670 52,533 58,364 Total 116,524 131,979 143,120 153,879 Source: Greg Hardes & Associates. Maternity services at Mersey campus The Mersey campus will provide maternity services (with obstetrician supervision) for low-risk mothers, with options for shared care and/or midwife-led care and clinical protocols for referral to other sites for medium- and high-risk births. The low-risk midwifery-led birthing service will also provide ante-natal and post-natal inpatient care. Services will be based on shared care with GPs with transfer to Burnie campus or LGH as appropriate for inpatient maternity services. Clinical protocols will be in place for management of medium- and high-risk mothers elsewhere (because the distances between the campuses meet guidelines for transport of emergency births to support this strategy). Clinical Services Plan 97 Elective surgery and post procedural recovery services A 23-hour elective surgical service will be provided at the Mersey campus with completion of booked lists by Friday afternoon. Surgical specialties will include general surgery, gynaecology, orthopaedics, ENT, ophthalmology as well as procedural diagnostic GI endoscopies. A post-procedural recovery service will also be provided with adequate nursing cover. Additional non-acute services The Mersey campus will provide an extended range of medical and nurse-led specialty clinics, as well as a renal dialysis services, chemotherapy services, chronic disease management programs, ACAT team and other visiting services. The Mersey campus will provide subacute inpatient rehabilitation services, aged care services and transition care services for the North West, including services currently provided at the Burnie campus. The Mersey campus will also provide aged care rehabilitation and management of stroke patients post- discharge as a specialised service to the local community. These will necessitate a strategy to provide adequate transport for carers and family, and development of a more comprehensive day therapy area provided by allied health staff. Support services Mersey campus will have routine radiography services (general x-rays) provided on-site and an Image Intensifier Service to support same-day surgery and the emergency care centre. This service is currently provided by a private provider on-site, Regional Imaging Ltd, under a contract that has just been renegotiated. There will also be mobile ultrasound services on roster from LGH which will be a booked service offered on an outpatient basis. Pathology services will be provided as a collection service with transport of specimens to the Burnie campus. There is a laboratory service currently under contract to a private provider. Opportunities exist for this service to be supported by LGH or Burnie and should be negotiated as part of the arrangements of the state-wide pathology service. Anticipated activity levels – Burnie and Mersey campuses The following two tables indicate the anticipated level of activity at the two campuses over the planning period. The modelling of activity for this Plan has assumed that: • two-thirds of patients from the Mersey sub-catchment who require services that are not available at the Mersey campus will travel to Burnie to access those services and one-third will travel to Launceston to access services there; • 50% of patients from the Launceston campus who require same-day surgery will access those services at the Mersey campus (allowing for quicker and more reliable access to same-day surgery and increased volume of same day surgery at the Mersey campus); and • some demand for rehabilitation services for residents of the North region, West of Launceston, will also be met by services provided on the Mersey campus. Table 72 also shows the effect of Mersey shifting from an acute short-stay facility with an overnight average length of stay of 5.8 days to a profile of rehabilitation (ALOS = 23 – 30 days), transition care services (ALOS = 22 – 24 days), and day-only surgical and obstetric services. The effect of the long average length of stay for transition care and rehabilitation patients is partially offset by the very short ALOS of obstetric and day only patients. 98 Clinical Services Plan Table 71: Estimated inpatient activity, 2004-05 to 2021-22, Burnie Campus Year Change Stay type 2004-05 2008-09 2011-12 2016-17 2021-22 Nos % Day only 4,960 6,400 7,513 8,643 9,647 4,688 95% Separations Overnight + 5,909 7,945 8,788 9,195 9,604 3,695 63% Total 10,869 14,345 16,301 17,838 19,251 8,383 77% Day only 5,287 6,972 7,970 9,147 10,196 4,909 93% Beddays Overnight + 38,375 54,315 57,739 62,460 67,592 29,217 76% Total 43,662 61,287 65,709 71,606 77,788 34,126 78% Source: Greg Hardes & Associates. Table 72: Estimated inpatient activity, 2004-05 to 2021-22, Mersey Campus Year Change Stay type 2004-05 2008-09 2011-12 2016-17 2021-22 Nos % Day only 1,999 6,578 7,264 8,461 9,619 7,620 381% Separations Overnight + 3,418 885 974 1,151 1,206 -2,212 -65% Total 5,417 7,463 8,238 9,612 10,825 5,408 100% Day only 1,999 6,578 7,264 8,461 9,619 7,620 381% Beddays Overnight + 19,894 10,626 12,793 16,827 17,380 -2,514 -13% Total 21,893 17,204 20,057 25,288 26,999 5,106 23% Note: Excludes chemotherapy and medical day only procedures. Source: Greg Hardes & Associates. Implications of the changed services in the North West for Launceston General Hospital16 There is a natural flow of residents from the eastern end of the North West region to the LGH, due to the proximity of Launceston and because it is a major regional centre. It is anticipated that some 50% of patients now attending LGH for same-day surgery will be able to attend Mersey for elective day surgery services with increased capacity and resulting reduction in waiting times. These assumptions have major implications for the modelling of service requirements at each site and the capacity of the sites to accommodate the extra activity within existing resources. The demand for rehabilitation services for residents of the North region west of Launceston has also been factored into the estimated volume of rehabilitation services on the Mersey campus. 16 Note: The activity figures for each facility shown in this Section do not adjust projected inpatient activity for ambulatory care sensitive conditions. The level at which these patients are currently managed in the facilities is shown in Section 5, and the hospitals could significantly improve their throughput if the health system managed these patients in other settings and reduced the need for hospital admission. Clinical Services Plan 99 8. State-wide; single service and network strategies Key points The Plan proposes 20 statewide and 9 single site services for Tasmania Statewide service Single site service Adult and Paediatric cystic fibrosis services Bariatric surgery Adult medical retrieval services Brachytherapy Bone marrow transplantation Cardiac electrophysiology Cardiothoracic surgery Complex ENT and head and neck surgery Complex materno-foetal medicine Complex upper GI including pancreatic, Forensic pathology Major oesophageal & hepatobiliary surgery Genetics services Gynaecological oncology Hyperbaric medicine Paediatric surgery Infection Control PET/CT scanning Inpatient child and adolescent mental health Retinal surgery Major burns Major neurosurgery Medical imaging* Neonatal intensive care Paediatric intensive care Paediatric retrieval Pathology services* Pharmacy Specialist pain management Vascular surgery (at two sites) Note: The Department of Health and Human Services considers that there are opportunities to move to a statewide service model for both pathology and medical imaging services. With the introduction of new models of care, there will be significant changes to a number of key service areas (Adult medicine and surgery; women’s and children’s services; critical care services; cancer services and clinical support services), including the implementation of clinical networks as outlined in Section 7.1.3. 8.1 State-wide and single site services The Service Capability Framework set out in Chapter 7 identifies some services, which must be managed from a single site in Tasmania because of workforce, service volume, cost or equipment constraints or because they are critically dependent on other single-site services. Some elements of these services may be provided on an outreach basis in distributed locations, either on an inpatient or non-admitted patient basis. A summary of state-wide services and single site services follows in Table 73. Some of the specific issues raised during consultation are discussed in this section at 8.2. Details of other service strategies are set ot in Appendix L. 100 Clinical Services Plan Table 73: Summary description of state-wide and single site service strategies Proposed service strategies - state-wide and single site services State-wide services Adult and paediatric cystic The RHH is the state-wide provider and provides outreach clinics in the fibrosis services North and North West Adult medical retrieval The LGH is the state-wide provider with current arrangements supported services by RHH – in process of review Bone marrow The Royal Melbourne Hospital continues to provide allogeneic BMT for transplantation Tasmanian residents RHH provides stem cell harvesting and is the state-wide provider of autologous BMT LGH provides stem cell harvesting only, and transfers stem cells the RHH for cryopreservation Cardiothoracic surgery RHH is the state-wide provider Consolidate and formalise agreements with interstate hospitals to ensure ongoing cover Consider strategies for interstate flow reversal back to the RHH to ensure service volumes Complex materno-foetal RHH is the state-wide provider medicine Forensic pathology Forensic Pathology Services is a state-wide service provided from Hobart Genetics Services The Tasmanian Clinical Genetics Service (TCGS) is the state-wide service provider of clinical genetics services TCGS provides clinical genetics outreach services to the North and North West, with contractual arrangements with Genetics Health Services Victoria for visiting clinical geneticists and genetic testing Genetics Health Services Victoria conducts testing of new born babies on a contract basis Establish a familial cancer registry in line with other Australian states Hyperbaric medicine RHH is the state-wide provider Review the demand for hyperbaric medicine services and infrastructure available to meet demand Review opportunities for integration of hyperbaric medicine with other specialties to enhance treatment efficiency Infectious diseases RHH is the state-wide provider, and provides outreach services to the LGH and NWRH Inpatient child and Consider a dedicated state-wide facility that could provide assessment adolescent mental health and treatment for children and adolescents that present with acute and complex mental health disorders which have not responded to treatment at the local acute facility or who require more specialised treatment options Major burns RHH is the state-wide provider for burns treatment and management Refer extensive burns cases to Victoria for specialised treatment LGH and NWRH Burnie treat and manage minor burns Major neurosurgery RHH is the state-wide provider of complex neurosurgery in the public sector Consolidate and formalise agreements with interstate hospitals to ensure ongoing cover Clinical Services Plan 101 Proposed service strategies - state-wide and single site services Medical imaging* Consider establishing a state-wide service coordinated through a single administrative structure Neonatal intensive RHH is the state-wide provider care/Paediatric intensive care/Paediatric surgery Paediatric/neonatal retrieval Pathology services* Consider establishing a state-wide service to improve service coordination through a single administrative structure. Any review should consider: • greater role delineation of services with complex and specialized specimen testing provided from a single site; • the public contract with the private sector be reviewed, and considered for re-introduction to the public sector within a state-wide service. The LGH pathology service should be considered for providing pathology services to the North West; and • a state-wide pathology service is supported by access to a specialised diagnostic transport service. Pharmacy Consider establishing a state-wide service Specialist pain management RHH is a specialist provider of pain management services Develop a state-wide approach with RHH as the state-wide provider, through a partnership approach with Drug and Alcohol Services and the Pharmaceutical Service Branch Vascular surgery RHH is the state-wide provider of vascular surgery services from two sites (RHH and LGH) within a clinical network structure Relocate vascular surgery from the NWRH Mersey to LGH Review infrastructure requirements for the relocation of vascular services to the LGH Single site services Bariatric surgery RHH is the sole provider of public sector bariatric surgery Review scope of practice for bariatric surgery Brachytherapy LGH is the state-wide provider of brachytherapy services Cardiac electrophysiology Consider introduction of cardiac electrophysiology as part of a tertiary centre for the delivery of the full range of cardiac services according to interventional cardiology inpatient demand Complex ENT and head and RHH is the state-wide provider of complex head and neck surgery, although neck surgery some cases will continue to be transferred interstate Review the scope of practice for head and neck surgery Complex upper GI LGH is the sole provider of hepatobiliary surgery in Tasmania including pancreatic, major oesophageal and hepatobiliary surgery Gynaecological oncology RHH is the state-wide provider of gynaecological oncology services and provides specialist outreach services to the LGH PET/CT scanning Review business case for introduction of a PET/CT scanner to RHH to augment the delivery of multidisciplinary cancer care in Tasmania Note: The Department of Health and Human Services considers that there are opportunities to move to a state-wide service model for both pathology and medical imaging services 102 Clinical Services Plan 8.2 Specific service strategy issues 8.2.1 Bariatric surgery Bariatrics is the branch of medicine which deals with the causes, prevention and treatment of obesity. Bariatric surgical procedures include adjustable gastric banding (lap banding). Presently, bariatric surgery is provided in the public sector only at the RHH. There are mixed views among clinicians about the appropriateness of this procedure – some, including those with specialty interests in diabetes, strongly support the availability of the service, while others submitted that this procedure is inappropriate in a public hospital setting. The American College of Physicians recommends that bariatric surgery should be used judiciously and reserved for the morbidly obese who have a Basal Metabolic Index of 40 or higher and have failed, with or without adjuvant drug therapy, to lose weight through diet and exercise. Patients should show other clinical signs such as impaired glucose tolerance, diabetes, hypertension, sleep apnoea or hyperlipidaemia. The American College of Physicians also recommends that all patients should be referred to high-volume centres with surgeons who are experienced in bariatric surgery and where there is adequate support for all aspects of perioperative assessment and management. The following approach is recommended: • bariatric surgery is conducted only at the RHH as a single site service; • surgeons wishing to undertake bariatric surgery at the RHH should undergo specific credentialing and definition of scope of practice to include this procedure; • only people who are assessed as meeting agreed criteria for appropriateness should be admitted to the program. These criteria should be adopted by the Division of Surgery at the RHH and could be based on the American College of Physicians guidelines; • the number of persons to be offered surgery each year should be determined by the division according to indicators of demand, including waiting list numbers of people who meet the criteria for appropriateness, agreed by the division and resource constraints in light of competing demands; • the number of people who meet the agreed criteria for appropriateness and who are waiting for surgery should be monitored by the Division of Surgery; and • all outcomes of bariatric surgery should be audited through a peer review process within the Division of Surgery. 8.2.2 Bone Marrow Transplantation Bone Marrow Transplantation (BMT) is an element of an integrated cancer service. It involves the infusion of blood stem cells, usually for patients with cancer or platelet disorders. There are two types of BMT, depending on the source of the blood stem cells. Allogenic BMT uses the blood stem cells from a donor who is an identical or near identical tissue type match. Autologous BMT uses the patient’s own stem cells, which previously have been collected (harvested) and preserved. The Royal Melbourne Hospital provides allogenic BMT for Tasmanian residents. The RHH is accredited to harvest bone marrow from Tasmanian donors for allogenic transplants for the benefit of other patients nationally and internationally, but allogenic transplants are not performed in Tasmania and there is (appropriately) no proposal to introduce them. The remainder of this discussion focuses on a current proposal by the LGH to commence an independent autologous BMT service. Clinical Services Plan 103 Presently, autologous BMT for patients from the North of Tasmania involves the following steps: • Peripheral blood cells are collected while the patient is in remission. A cell separator is required to undertake this collection. Collection of sufficient cells may take several collection episodes of up to four days. The RHH has supported the LGH to develop a collection service and there are no concerns about its continuation. • The plasma and stem cells are transferred to the RHH, where they are processed and stored. This is a technically complex procedure requiring specialist scientific staff. • If a decision is made to proceed to transplant, the patient receives high dose chemotherapy. Chemotherapy administration is concluded 48 hours prior to the transplant. This treatment is provided currently at the LGH, following which the patient is transferred to Hobart. • On the day of transplantation, the stored stem cells are thawed and administered intravenously. The infusion process is more complex than the infusion of peripheral blood and requires expert scientific support. • Most patients then are monitored as non-admitted patients, although 90% require admission at some stage during the ensuing 10-12 days when the patient’s existing blood cells are dying from chemotherapy and the transplanted cells are engrafting and starting new blood cell production. During that period patients are pancytopaenic and at risk of opportunistic infections and other complications and require the support of transplant physicians, haematologists, oncology nurses, transplant and medical scientists, infectious diseases specialists, dieticians, psychologists and social workers. There is a proposal to purchase a flow cytometer for Launceston. This equipment will help to determine when sufficient cells have been collected for storage, but is not sufficient to establish a full BMT service. Establishment of a full service would require a substantial and expensive investment in cryopreservation equipment and storage facilities, as well as in scientific, medical, nursing and allied health support. The current standards against which this proposal should be assessed are the FACT-JACIE International Standards for Cellular Therapy Product Collection, Processing and Administration Third Edition 200717 (the Standards). The Standards define detailed infrastructure and process requirements for clinical programs, collection and processing and are incorporated into a 115-page document encompassing: clinical program standards; cellular therapy product collection standards; and cellular therapy product processing standards. The Standards require that a dedicated transplant team including a Clinical Programme Director and at least one other physician trained and/or experienced in cell therapy shall have been in place for at least twelve months. They also highlight the need for support by nurses and scientists who are formally trained and experienced. They require independent quality audits to be conducted and reported regularly. It is clear that a high technology procedure such as BMT is associated with significant costs which are not fixed and tend to decrease with time and the increasing experience of the transplant centre.18 In accordance with the principles for the introduction of new clinical services, procedures or other interventions, proponents of the proposed service need to demonstrate: • it is safe to introduce the service in the setting and manner proposed; • the costs that will be incurred by introducing the service are reasonable in the circumstances; and • there will not be a substantial detrimental impact on the quality and/or cost of existing services. 17 http://www.factwebsite.org/uploadedFiles/Standards/Stds%203rd%20Ed_FinalCopy.pdf 18 Cl Bennett, JL Armitage , GO Armitage et al. Costs of care and outcomes for high-dose therapy and autologous transplantation for chronic lymphoid leukaemia: preliminary results. J Clin Oncol 1994;12:748-758. 104 Clinical Services Plan For the following reasons, the planning team has concluded that it would be inappropriate to introduce an independent BMT service in Launceston: • BMT is a volume-dependent service. The RHH BMT service is a very safe service, as evidenced by its mortality rate of 1% over the past four years, compared with internationally reported rates of 2-5%. While current transplant numbers meet the minimum requirement of the Standards (five new patients annually) and are increasing because some patients are receiving tandem transplants, they are insufficient to support two independent services – in 2006 there were 17 transplants on 12 patients, and in 2007 to date there have been 12 transplants on eight patients. Splitting the service on the basis of geography would result in both sites performing a small number of transplants annually. This would dilute expertise at the RHH while providing insufficient workload at the LGH to develop expertise. As a consequence, quality of care and patient safety would be reduced. • BMT requires substantial infrastructure. The RHH has six staff specialists who perform BMT and who are experienced in the management of these patients. There are two registrars and two resident medical officers attached to the BMT team. There is a team of dedicated laboratory and clinical scientists and experienced nurses. There also is a substantial investment in physical facilities necessary for call manipulation and preservation. The RHH service has capacity to accommodate an increased number of patients without additional infrastructure. Duplication of expensive capital and scientific resources would be wasteful in light of competing demands for resources. • There is a clear burden on patients who are required to travel from the North or North West of the State to Hobart. This occurs once or at most twice during the entire period of a patient’s care for a condition requiring BMT. The burden could be reduced for appropriate patients by discharging them earlier to the care of Launceston clinicians once the BMT has been completed. These decisions should be made on a case-by-case basis as appropriate, depending on patient circumstances. • The inevitable dependence of the proposed LGH service on a small number of clinicians raises serious concerns about its sustainability. The planning team has been advised that from 1 January 2008 the Therapeutic Goods Administration (TGA) will require all collection centres and processing laboratories to be licensed. Standards are being developed by the National Pathology Accreditation Advisory Council (NPAAC), based on the FACT-JACIE Standards. All facilities will be required to be accredited by the National Association of Testing Authorities (NATA) against the NPAAC standards. A key to the new arrangement will be a “Class 1” licence which will apply to hospital-based blood stem cell collection facilities and processing laboratories. This licence will be issued upon receipt of a statutory declaration from the Medical Director stating that the collection facility(s) and laboratories under their direction meet the TGA- defined standard. The facility will be audited every three years by NATA, at the same time that pathology laboratories are assessed. A Class 1 licence will apply to facilities responsible to a single director that are using common quality assurance systems and common protocols. Cells collected in a Class 1 service apheresis ward will not be able to be processed in a different Class 1 laboratory as the laboratory will have no control over the collection quality assurance – hence it will be deemed to be a higher risk activity requiring the receiving laboratory to be licensed to Class 2, involving a direct audit by the TGA. However, multiple collection services will be able to feed into a single laboratory if all facilities come under the direction of a single Responsible Person (the Medical Director) and operate to common protocols. Clinical Services Plan 105 The current practice of harvesting stem cells at LGH and transporting to RHH for processing and storage will be deemed a Class 2 activity requiring direct regulation, inspection, auditing and licensing by the TGA. A Class 2 licence would require the RHH processing lab to operate in effective isolation from the rest of pathology services at the RHH, because Class 2 labs will only be permitted to use testing from other TGA licensed labs. This would require duplication of basic tests in the RHH processing laboratory or outsourcing of these tests to external TGA licensed laboratories on the mainland. The level of documentation, internal auditing and process control required by the TGA for a Class 2 license would be far in excess of that required for a Class 1 licence and would be resource intensive to implement and maintain. The consequence of continuing current arrangements will be a significant increase in costs for little direct patient benefit. There are three potential ways in which the Tasmanian BMT service could be developed in compliance with forthcoming TGA requirements while minimising unnecessary expenditure: • form a state-wide service with a single director; • establish independent Class I services at the RHH and LGH; and • obtain a Class 2 license for the RHH service. The planning team does not support the development of the Launceston service as a Class 1 service because of the excessive cost and potential impact on the RHH service. Nor is the development of the RHH service as a Class 2 service supported, because of the additional expenditure without direct patient benefit. The clear direction for development of this service is to designate it as a state-wide service with an appointed director who is responsible for TGA compliance across both sites. The relevant clinical teams should develop protocols for early transfer back to Launceston for appropriate patients. Although evidence clearly shows that a second site conducting autologous BMT in Tasmania is not viable, the Department of Health and Human Services will engage an independent expert to give additional advice about the viability of a second site. 8.2.3 Cardiac electrophysiology Cardiac electrophysiology refers to the diagnosis, assessment and interventional treatment of cardiac rhythm disturbance using radiofrequency, surgical and other methods of ablation and specialised pacing techniques. It also includes treatment or prophylaxis of patients with or prone to arrhythmias using implantable defibrillation. Tasmanian residents currently access these services from providers on the mainland. Accurate information was not available about the number of procedures performed for Tasmanian residents. Table 74 shows the number of interstate procedures for Tasmanian residents funded by the Patient Transport Assistance Scheme. 106 Clinical Services Plan Table 74: Number of interstate cardiac electrophysiology procedures funded by the Patient Transport Assistance Scheme, 2003-04 to 2005-06 Region 2003-04 2004-05 2005-06 South 55 91 76 North 25 24 33 North West 20 31 23 Tasmania 100 146 132 Source: DHHS PTS data. It is likely that some residents are not accessing this service because it is not provided locally – the volume of procedures would be expected to increase if a local service became available. To assure quality and continued competence of interventional cardiologists, it is recommended that clinicians perform at least 50 procedures per year, of which at least 30 should be radiofrequency ablation procedures. The British Cardiac Society has published guidelines on the provision of electrophysiology services as follows: • electrophysiology: 250 per million population; • implantable cardioverter-defibrillators: 200 to 300 per million population; and • pacemakers: 550 per million population. Based on these figures, there would be sufficient patient volume in Tasmania to support a cardiac electrophysiology service. A Tasmanian cardiac electrophysiology service necessarily would depend on one or at most two specialist clinicians. Although this may raise concerns about sustainability, electrophysiology services generally are elective and dependence on a sole clinician is not as serious a concern as it would be for an equivalent emergency service. The benefits of introducing this service locally need to be weighed against the likely additional cost and reliability. The following factors need to be taken into account: • access to services for Tasmanian patients is likely to be improved with a local service; • future recruitment of cardiologists may be enhanced if this service is able to be provided locally; and • patients who access services in larger interstate units are likely to gain some benefit from the significantly higher throughput and staffing depth in those units compared with a local service. The planning team has concluded that it is clinically appropriate for a single site electrophysiology service to be developed in Tasmania. The service is not critically dependent on services that are provided only at the RHH – it could be located at either the LGH or the RHH – and the centrality of the LGH to people of both the North and the South favours a Launceston location. Further work needs to be undertaken on the affordability of this service. As many patients can be managed on a non-admitted basis. However, consideration could be given to establishing the service at the LGH in partnership with the private sector. Clinical Services Plan 107 8.2.4 Cardiothoracic surgery Some concerns have been expressed about the sustainability of cardiothoracic surgical services because of a perception of falling case numbers. The Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) recommends: • a hospital should reach a caseload of 400 cases per year within two years of commencing cardiac surgery; • an individual cardiac surgeon should achieve a minimum caseload of 200 cardiac surgical cases per year and an optimal caseload of more than 250 cases per year; • cardiothoracic surgical units should have a minimum of two fully trained cardiothoracic surgeons, one available at all times; and • the population catchment for a sustainable cardiothoracic surgical unit is approximately 300,000 to 400,000. Resident demand for cardiothoracic surgery is projected to increase marginally between 2004-05 and 2021-22. Some Tasmanian patients access private services interstate. The projected volume of activity in the public sector in Tasmania is only marginally above the caseloads recommended by the ASCTS. Table 75: Projected resident demand for cardiothoracic surgery, 2004-05 to 2021-22 Region Sector 2004-05 2011-12 2016-17 2021-22 South Public 226 245 242 235 Private 34 35 37 39 North Public 94 107 109 112 Private 11 13 13 13 North West Public 106 116 114 108 Private 7 7 7 6 Total Public 426 468 465 455 Private 52 54 57 57 Total 478 522 522 512 Note: Excludes 0-14 year olds. Source: Greg Hardes & Associates A state-wide cardiothoracic surgical service is considered to be essential for Tasmania. Although patient numbers are marginal, distance from reasonable alternatives means that the service should be supported fully with particular efforts to establish formal support arrangements with a designated mainland unit. 8.2.5 Complex upper gastrointestinal including hepatobiliary surgery Complex upper gastrointestinal surgery, including major oesophageal, pancreatic and hepatobiliary surgery, has been offered as a specialist service at the LGH. There is clear evidence that, in general, patients who require these procedures have better outcomes if the surgery is conducted in a small number of centres by practitioners who provide such services regularly. 108 Clinical Services Plan The following approach is recommended: • complex upper gastrointestinal and hepatobiliary surgery should be conducted as a single site service which could be based either at the LGH or the RHH – at present, the service is provided by the LGH and it is logical for it to continue there; • credentialing and scope of practice processes should explicitly exclude the provision of elective major upper gastrointestinal and hepatobiliary surgery at any other site; and • all procedures should be the subject of audit, conducted through the designated single site. 8.2.6 Cystic Fibrosis (adult and paediatric) Cystic Fibrosis (CF) is a complex multi-system genetic disease that principally affects the lungs and digestive system. The prevalence of CF in the Tasmanian population is reported to be high in comparison with other Australian States and Territories. The 2003 Annual Report from the Australian CF Data Registry confirms that a high proportion of Tasmanians with CF have a sibling with cystic fibrosis in comparison to all other States and Territories. This is a troubling statistic and confirms representations made by respiratory physicians that genetic counselling for CF families needs to be increased in Tasmania. There is clear evidence that high quality treatment can improve the quality and length of life of people who suffer from CF. The United Kingdom’s CF Trust has published standards for CF care which include standards for clinical teams in specialist centres. Generally, specialist teams treat either adults or children, and a patient population of at least 100 per specialist team is required for optimal care. It is estimated that approximately 50 Tasmanian adults and 50 Tasmanian children have CF. A specialist adult CF service was established in 2006 but there are concerns that there are insufficient multidisciplinary resources to provide effective care across the State. Paediatric care is provided through general paediatricians with support from visiting specialists from the Royal Children’s Hospital. A paediatrician to be appointed at the RHH in the future is expected to provide significant support to the state-wide paediatric CF service. It is clear that CF patients benefit from specialist multidisciplinary team care and it is highly likely that there will be both quality and system-wide cost benefits if preventive care can be improved. Although adult and paediatric CF multidisciplinary teams traditionally operate with separate clinical infrastructure, the relatively small Tasmanian CF patient population may necessitate reconsideration of this model. One alternative that has been suggested is that the specialist adult and paediatric CF services based at the RHH are supported by dedicated allied health professionals who work with both adult and paediatric patient groups. The RHH should continue to provide a state-wide service for both paediatric and adult CF patients. There should be a significant outreach element to these services and they will need to be structured and funded accordingly. The composition of the team should comply with internationally accepted standards, and the potential to identify allied health members of the multidisciplinary team to provide both paediatric and adult services should be explored. Clinical Services Plan 109 8.2.7 Endocrinology and diabetology All Australian Health Ministers have endorsed National Service Improvement Frameworks for National Health Priority Areas, which includes diabetes. Tasmania has developed a Diabetes Action Plan which sets out clear goals for reducing the incidence and improving the management of diabetes in the State. The three major policy directions are: • primary prevention to target the known modifiable lifestyle risk factors associated with type 2 diabetes, involving health promotion, early intervention, health workforce education, screening and skills development, undergraduate training and monitoring and surveillance systems; • early detection and intervention for type 2 diabetes, focusing on support for the development and implementation of a nationally accredited risk assessment tool; coordinated access to health coaching; expanded management of diabetes in general practice and with other private providers coordinated with community-based services and staff; strengthening of tertiary multi-disciplinary models and community linkages for podiatry services; and • Establishing best practice diabetes prevention and care services will be a priority for service development in Tasmania. A substantial increase in community-based specialist resources will be necessary, with a focus on specialist multidisciplinary teams, GPs and specialist nursing and allied health clinicians. Resources should be available in all regions of the State and services should, in the main, be organised and delivered on a local basis with subspecialist medical support to the North West from the LGH and state-wide multidisciplinary networking through a diabetes and chronic disease clinical network. Tasmania should adopt a suite of performance indicators to enable close surveillance and monitoring of the prevalence of diabetes and the effectiveness of its management. 8.2.8 Medical imaging services Issues of importance to future strategy determination include: • The need to manage information electronically – across hospitals and providers, including the urgent need to acquire a PACS/radiology information system. A single state-wide unit record number system and state-wide archive that contains all patient details for state-wide access is the preferred system. A single state archive would require all facilities to have the same radiology information system. • Workforce recruitment and retention, including the urgent need to implement consistent registrar training. Medical imaging faces the same problems training and retaining medical staff experienced across the health sector. • Governance issues – and the need to strengthen the working relationship between the imaging departments in the State. • Increasing cost and complexity of technology. Service strategies: • Under the implementation of clinical networks, review the State-wide Imaging Services Committee. The review would include development of arrangements to strengthen the working relationships between the Imaging Departments at RHH and LGH. 110 Clinical Services Plan • Adopt a planned and coordinated approach to infrastructure development, in order to maintain pace with improvements in technology, and ensure equitable distribution of infrastructure across the State. Implement a committee to review the introduction of new equipment and take over the role of determining future imaging equipment needs, giving priority to a decision on PET/CT scanning. • Develop a capital replacement plan for the State. • Review the current provision of radiology consultation and reporting services via the private sector through a tendering or contractual arrangement. 8.2.9 Pain management services There is a dedicated pain management unit at the RHH. It is the only publicly funded service in the State and acts as a state-wide service. There are concerns about the quality of pain management in Tasmania, with reported high levels of prescriptions of opiates. A state-wide approach needs to be developed through a partnership approach with Drug and Alcohol Services and the Pharmaceutical Service Branch. The recommended service structure is for local services supported by a specialist state-wide outreach consulting service. 8.2.10 Pathology services Pathology services are provided by the RHH, LGH, and in the North West through a public contract with a private provider. Pathology issues include: • Governance and coordination: integration and coordination of pathology services across the State has been an issue for more than ten years. In 1998 a review of pathology services was undertaken, including consideration of establishing a State-wide Pathology Service. The proposal was not endorsed. However, there has been a significant improvement in the integration and coordination between the LGH and RHH and improved liaison with respect to the purchase of major equipment items and appointments to key positions. • Workforce recruitment, retention and shortages. Pathology service strategies Consider a state-wide pathology service for Tasmania and in doing so consider the following issues: • greater role delineation of services between providers with complex and specialised specimen testing provided at dedicated sites; and • implementing an effective specimen transport service. 8.2.11 Pharmacy services Tasmanian Hospital Pharmacy is developing a strong, state-wide network through common interests. These include similar business requirements for the purchasing and accountability of drugs and the requirement for equity and safety within hospitals to protect patients and staff. Multinational pharmaceutical companies are developing a new generation of products that provide targeted therapies for many chronic and acute diseases. These products are marketed forcefully and access to these new drugs is a pressure for public hospitals. Formal evidence of cost effectiveness is required for the Commonwealth Government to list drugs on the Pharmaceutical Benefits Scheme (PBS). If the drug is not listed for certain indications there is a strong expectation that the public sector will provide the drug. Clinical Services Plan 111 Assessment of effectiveness and cost effectiveness is necessary if public funds are to be used to provide these therapies. We need to make explicit the trade-offs between financial cost and health outcomes such as additional pain and suffering or time in hospital. This can only be managed equitably on a state-wide basis. The State-wide Therapeutic Drug Committee (STDC) sets policies that benefit people throughout the State within the limits of what specialist services can be provided outside specialist centres. While the policies for this committee are developed jointly and are consistent across the State, the services at a local level respond to local needs. In addition recent moves are to explore state-wide coordination of other sectors such as Primary and Community Health, Mental and Public Health and individual pharmacies in urban and rural settings to measure the extent to which efficiencies can be achieved. Safe management of medications is paramount. An appropriate management structure for this includes the establishment of a Therapeutic Advisory Group (TAG). This committee would work closely with the Joint Therapeutic Advisory Group, which is a committee of similar groups from other states targeted with addressing national policies and guidelines to provide consistent responses to the challenges of safe medication management. Resources for the establishment of this committee and for the implementation of decisions will be considered in the future. The cost of drugs, which are new technology, would have appropriate quality assurance, support and benchmarking, through such a committee. In early 2008 a new Clinical and Pharmacy IT system will be implemented to enable the provision of decision support for pharmacists and other health professionals. This system will be common to all hospitals to enable shared information management. To augment this, planning is underway for state-wide e-prescribing and e-drug administration. This capability will enhance our capacity to promote safe procedures and policies for drug usage within the State. The activities outlined above are occurring under a national commitment to a program of Pharmaceutical Reform throughout Australia. Key steps include access to PBS prescribing in hospitals and significant moves to reduce harm and optimise the use of medicines for patients. These reforms, the IT capability and the state-wide approach will position Tasmania favourably to manage the demand for drugs in a safe and equitable manner. 8.2.12 Positron Emission Tomography Positron Emission Tomography (PET) is an imaging technique that produces a three-dimensional image or map of functional processes in the body. PET is an extremely useful modality for a number of conditions, particularly for many types of cancer. Combined PET/CT technology is available, with the CT component able to be used independently to augment existing CT resources. Under current arrangements, Tasmanians are sent to Victoria for PET scans. Delays have been reported in accessing services, which are likely to be particularly distressing for patients awaiting PET for cancer staging and treatment planning purposes. Table 76 demonstrates that the demand for PET scans is increasing, with increasing numbers of Tasmanians referred to Victorian hospitals for treatment. These figures are only for patients who are eligible for assistance from the Patient Travel Assistance Scheme (PTAS). 112 Clinical Services Plan Table 76: Number of PTAS-compensable trips to Victoria for PET scans 2002-03 2003-04 2004-05 2005-06 Trips 203 248 286 344 Cost $137,832.29 $124,251.04 $112,133.93 $136,626.28 Average cost per trip $678.98 $501.01 $392.08 $397.17 Source: DHHS data. A benchmark supply level for PET is 0.5 funded PET scanners per million population. A PET scanner in Tasmania serving 500,000 people will result inevitably in some degree of redundancy of the technology, although procedural volumes should be sufficient to achieve quality benchmarks. PET/CT is an appropriate technology for Tasmania. Appropriate quality assurance and support arrangements could be made with interstate units if necessary. Over time, the recommended number of scanners per million population is likely to increase and the cost of the technology may well reduce. The decision to be made in the short-term, however, is whether the additional cost of providing the technology locally will have a sufficient benefit in terms of improving patient experiences and outcomes, in the context of competing budgetary priorities. The business case for PET needs to be reviewed as the 2008-09 budget is developed. This will include consideration of which benchmark supply level is apporpriate. If the service is affordable in the context of that budget, it should be introduced. 8.2.13 Radiation oncology services Radiation oncology (otherwise referred to as radiotherapy) services are delivered from the Holman Clinic at the RHH and the LGH, with the LGH providing services to the residents of the North West. Each clinic operates two linear accelerators (one low- and one dual-energy) and delivers approximately 50% of the treatments required in the State. The current distribution of services in Tasmania is appropriate, although patients from the North West remain relatively disadvantaged in terms of access to services. Table 77: Linear accelerator attendances, RHH and LGH, 2000 to 2006 Treatment 2000 2003 2006 Change (%) Low Energy (RHH) 5,011 4,948 7,506 49.8% Dual Energy (RHH) 8,504 9,335 9,846 15.8% Low Energy (LGH) 6,650 7,279 8,181 23.0% Dual Energy (LGH) 6,978 8,273 9,343 33.9% Total 27,143 29,835 34,876 28.5% Source: DHHS data. Radiation oncology treatment usually is planned and provided on an outpatient basis and can be delivered quickly and efficiently once treatment planning is completed. It can be extremely demanding for patients, because courses of treatment require frequent visits, often five days a week for six weeks. Attending a treatment centre can be highly disruptive, particularly if patients have to travel long distances at a time when they need the close support of family and friends. To improve access for rural communities, efforts have been made throughout Australia to locate radiation oncology services as close as possible to where people live. Clinical Services Plan 113 Traditionally, radiation oncology services have been structured with a minimum of two linear accelerators, because of concerns about potential safety and quality problems in isolated single machine units. Over the past several years, however, a number of single machine trials have been conducted by the DoHA in conjunction with Victoria. Anecdotal reports suggest that these trials have been highly successful and in particular that service safety and quality concerns are able to be addressed, although a formal evaluation has not been published. There is a need for a fifth linear accelerator in Tasmania. Three of the four existing linear accelerators are operating above accepted workloads and benchmark waiting times are not being achieved. The projected requirement for linear accelerators is calculated based on the application of benchmark data for radiation therapy treatment targets to the projected cancer incidence in the Tasmanian population in 2021. A sensitivity analysis was also undertaken which extrapolated base-year radiation therapy service utilisation into the future based on projected increases in cancer incidence in the Tasmanian population in 2021. The facility requirements are based on: • 2004 Tasmanian population projections to 2021; • projected number of cancers in the Tasmanian community to 2021, based on the projected cancer incidence rate to 2021; • benchmark target for treatment of new cancers with radiation therapy at 52.3% and each cancer; • each cancer requiring on average a course of 19.5 treatments; • benchmark re-treatment target rate of 25% for new cases treated; and • each linear accelerator providing approximately 400 new courses of radiation therapy per annum (based on assumptions of treatments per hours, operating hours per day, operating days per annum). This calculation supported the report on Increasing Demand for Radiation Oncology Services in Tasmania, 2005-06 to 2009-10 that Tasmania requires a fifth linear accelerator by 2011 and a sixth linear accelerator by 2016. There is increasing demand for radiation therapy to 2021, and this demand would require the consideration of a seventh linear accelerator in 2021. Because demand for services is distributed relatively evenly between the North and the South, the new linear accelerator could be located in either Launceston or Hobart. On a population basis, though, the North West will generate sufficient patient demand to support a single machine service and consideration should be given to developing such a service as a regional outreach service of the Holman Clinic at the LGH. The Department will undertake a careful feasibility study to assess: • the ability to recruit radiation therapists and technical support staff including physicists to a more remote service; • the cost burden to the system of developing a single machine service compared with an additional linear accelerator at the existing Holman Clinic; and • whether additional Commonwealth support could be attracted because of the potentially substantial benefits to the community of developing such a service. 114 Clinical Services Plan 8.2.14 Renal dialysis services Renal dialysis services are provided by the RHH and the LGH. The RHH supports patients from the South of the State through an acute unit at the RHH and a satellite unit at St John’s Park. The LGH service provides dialysis services in both Launceston and Burnie. There will be major growth in demand for renal dialysis. There is a range of service models available including home-based haemodialysis, home-based peritoneal dialysis, haemodialysis conducted in satellite centres with moderate levels of clinical support and haemodialysis conducted in acute hospital settings for patients requiring high levels of clinical support. Table 78: Renal dialysis patients Renal dialysis patients 2006 Capacity Current people In-facility RHH – acute dialysis 20 5 5 RHH – satellite haemodialysis 72 53 53 RHH – peritoneal dialysis 42 RHH – home haemodialysis 6 LGH – hospital 48 44 44 LGH – peritoneal dialysis 5 LGH – home haemodialysis 2 NWRH – satellite haemodialysis 60 24 24 NWRH – peritoneal dialysis 6 NWRH – home haemodialysis 3 Total 200 190 126 Source: DHHS data. Admitted patient separations for in hospital and satellite dialysis increased by 39.7% between 2000- 01 and 2004-05 and account for 18% of all public hospital separations. Major growth in renal dialysis demand is expected, with the highest growth expected in the South followed by the North and North West. Growth in demand will be managed by: • a continuing focus on home-based services where possible; • relocation in the future of the St John’s Park service to the redeveloped RHH site, incorporated within an integrated care centre; • development of a community-based satellite service for the Launceston community, within the proposed integrated care centre; and • continuation of satellite services at Burnie and development of a satellite service at Mersey on an outreach basis from the LGH. 8.2.15 Vascular surgery Vascular surgery deals with conditions of the circulatory system. This includes common procedures such as carotid endarterectomy, abdominal aortic aneurysm, amputations, vascular access for dialysis and varicose vein ligation/stripping. Clinical Services Plan 115 Three vascular surgeons at the RHH, and a single vascular surgeon at the NWRH Mersey currently provide vascular surgery to the Tasmanian community. Patients from the North are either referred to a vascular surgeon at the NWRH Mersey or the RHH. The RHH provides a weekly visiting outpatient and surgical service to the LGH and NWRH Burnie. The vascular surgery service in the North West has developed a local service based at the Mersey campus. Demand for vascular surgery in the State, including the North West, is predicted to increase as shown in Table 79 below: Table 79: Projected resident demand for vascular surgery, 2004-05 to 2021-22 Region Sector 2004-05 2011-12 2016-17 2021-22 South Public 531 568 570 565 Private 500 568 595 620 North Public 398 450 473 487 Private 170 185 189 190 North West Public 330 375 387 389 Private 60 68 69 68 Total Public 1,259 1,392 1,429 1,442 Private 730 821 852 877 Total 1,989 2,213 2,281 2,319 Note: Excludes 0-14 year olds. Source: Greg Hardes & Associates Vascular surgical services should only be provided in locations where there is adequate clinical support available, including cardiology, neurology, intensive care, renal medicine and anaesthesia. There is also evidence that the safety and effectiveness of vascular surgical interventions is enhanced if procedures are undertaken in units that are conducting larger numbers of procedures. Independent standards suggest that stand-alone vascular units should serve populations of at least 500,000, while units serving smaller populations should develop collaborative arrangements.19 Any service which involves frequent out-of-hours recall for specialist practitioners should not be established unless there is sufficient patient demand to support a service comprising a minimum of three (and preferably four) specialist practitioners, with a realistic prospect of recruiting those practitioners in the foreseeable future. The most appropriate longer term structure for vascular surgery in Tasmania is for a designated state- wide service to operate from the RHH, responsible for equitable service delivery to residents of the entire State, and to provide substantial outreach services to the North and North West. There should be four surgeons participating equitably in an emergency roster. It would be inappropriate for the vascular surgical service for the North West to continue to be based at the Mersey campus following relocation of the intensive care service and other necessary support services. 19 UK DOH, Specialised Services National Definitions Set (2nd edition), Specialised Vascular Services (Adult), Definition number 30. 116 Clinical Services Plan Because there is an established service operating in the North West provided by a resident clinician, and there have been significant concerns about access to and the responsiveness of vascular surgical services for patients from Launceston, in particular for renal patients, the following structure will be implemented: • vascular surgery designated as a state-wide service, led from Hobart; • the existing surgeon in the North West offered the opportunity to move his practice to Launceston and be appointed to the LGH as a member of the state-wide vascular surgical team; • the state-wide vascular surgical team to ensure that there is backup and support for the Launceston service through the continuing provision of visiting consultancy services and by offering on-call, professional and locum support to the resident vascular surgeon; • outreach services continue to be provided from Hobart and/or Launceston to the North West, by arrangement with the state-wide service; and • all vascular surgeons, as a condition of their appointments, participate in a state-wide audit, which may be linked to the Victorian State Vascular Surgical audit. 8.3 Key service areas As discussed in section 7.1.3, Clinical Networks, it is proposed to establish the following clinical networks: • adult medical services; • adult surgical services. • aged care and rehabilitation; • cancer services; • cardiology/cardiac surgery; • diabetes and chronic disease; • emergency, critical care services and trauma services; • renal medicine; and • women’s and children’s (including paediatric medicine and surgery; maternal and perinatal services). These services are discussed in this section. 8.3.1 Adult medical services Data analysis by specialty for adult medical services showed that the public sector is the major provider of adult medical services, accounting for 73.6% of separations in 2004-05. There was a growth of 36.2% between 2000-01 and 2004-05 in adult medical separations in the public sector, and 8.2% in the private sector. Therefore the major issues associated with the delivery of adult medical services are that the public sector will continue to be the major provider of these services, and that there is significant growth both recently and projected for these services. NOTE: Adult medicine is defined as services to persons 15 years and over because of the data definitions in the projection model. Service strategies for adult medical services by region are identified in the following tables. Strategies for cardiology, renal medicine, renal dialysis, neurology and endocrinology are identified separately following the tables. Clinical Services Plan 117 Profile of adult medical services All general adult medical and medical subspecialties will be provided in Tasmania. Services will provide care to patients requiring planned and emergency consultation, diagnosis and treatment for a range of medical conditions. This will include access to an extensive range of inpatient and ambulatory/same-day services operating in individual hospitals as well as in the community. Table 80: Projected resident demand, adult medical activity by sector, 2004-05 and 2021-22 Sector Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays Public Day Only 43,320 82,621 43,320 82,621 91% 91% Overnight+ 17,607 24,987 115,323 148,018 42% 28% Public Total 60,927 107,608 158,643 230,639 77% 45% Private Day Only 11,869 16,943 11,869 16,943 43% 43% Overnight+ 7,382 10,589 45,130 61,033 43% 35% Private Total 19,251 27,532 56,999 77,976 43% 37% Total Day Only 55,189 99,564 55,189 99,564 80% 80% Overnight+ 24,989 35,576 160,453 209,051 42% 30% Total 80,178 135,140 215,642 308,616 69% 43% Source: Greg Hardes & Associates. Table 80 above indicates a projected resident demand for adult medical inpatient services of 69% (separations), with a higher rate of growth in the public sector (77%) compared with the private sector (43%). The highest projected growth is for day-only separations (80%) compared with overnight separations growth of 42%. This is explained mainly by the large number of projected chemotherapy and renal dialysis separations, which are day-only separations. These projections make no adjustment for Ambulatory Care Sensitive Conditions, and the extent to which these patients can be managed in other settings will influence the projected inpatient activity. This is commented on further below in relation to specific specialty areas. 118 Clinical Services Plan Table 81: Projected resident demand, adult medical public hospital activity by region, 2004-05 and 2021-22 Region Sector Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays South Public Day Only 22,530 41,273 22,530 41,273 83% 83% Overnight+ 6,897 9,747 42,830 54,660 41% 28% Public 29,427 51,020 65,360 95,933 73% 47% Total North Public Day Only 12,821 24,918 12,821 24,918 94% 94% Overnight+ 5,600 8,328 40,716 52,825 49% 30% Public 18,421 33,246 53,537 77,743 80% 45% Total North Public Day Only 7,969 16,429 7,969 16,429 106% 106% West Overnight+ 5,110 6,912 31,777 40,534 35% 28% Public 13,079 23,342 39,746 56,963 78% 43% Total Total Public Day Only 43,320 82,621 43,320 82,621 91% 91% Overnight+ 17,607 24,987 115,323 148,018 42% 28% Public 60,927 107,608 158,643 230,639 77% 45% Total Source: Greg Hardes & Associates. Table 81 above indicates that all regions will experience growth in total adult medical separations of between 73% and 80%, with the State average at 77%. The North has the highest rate of estimated growth at 80%. Clinical Services Plan 119 The following table shows the service strategies for Adult Medical Services. ADULT MEDICINE Hospital State-wide and Regional referral services Local single site services NWRH Mersey Specialised aged care and Outpatient medical specialist clinics rehabilitation services Burnie General medicine, cardiology, dermatology, endocrinology, gastroenterology, neurology, geriatric medicine, renal medicine, rheumatology, respiratory medicine; MAPU service for the short-term management of patients with average length of stay between 1 to 3 days LGH A range of outreach Adult medical service: MAPU service for medical specialist services; the short-term management of patients full range of general with average length of stay between 1 medicine and adult to 3 days medical subspecialties RHH Infectious diseases; Full range of general Adult medical service; MAPU service for Hyperbaric medicine and adult the short-term management of patients medicine; Genetics medical subspecialties with average length of stay between 1 service; Pain to 3 days management service Service implications Strengthening of governance arrangements and clinical networks; develop the services based on best practice facility guidelines and staffing standards; continue arrangements for transfer of some patients requiring specialised adult medicine services Interstate; clinical network to consider relationships with rural hospitals providing adult medicine services; clinical networks will be responsible for the development of clinical protocols to ensure that services are delivered in the North West that meet clinical guidelines for adequate staffing levels. Due to the range and scope of services that the RHH provides as the tertiary referral service for the state, the following adult medical service models could be developed at RHH. LGH could also provide these services as appropriate: • short-stay assessment unit for the rapid assessment and management of patients accessing Emergency Services; • integrated cardiac service with cardiothoracic surgery, diagnostic and interventional cardiology and coronary care unit co-located with associated clinical accommodation; • services to assess and monitor chronic patients with acute exacerbations of their disease particularly patients with cardiac and respiratory diseases; • specialised inpatient services for the management of patients with advanced heart failure, advanced lung disease, cystic fibrosis, and pulmonary hypertension; • an integrated neurosciences service to patients with neurological conditions including stroke; • a comprehensive renal medicine service including high dependency renal dialysis and inpatient and ambulatory renal dialysis; • an endocrinology department to provide inpatient and ambulatory/same-day services with management by a multidisciplinary team; 120 Clinical Services Plan • a single clinical immunology, infectious diseases and sexual health unit provide inpatient and ambulatory services, including isolation rooms equipped with negative pressure, hepafiltration and anterooms to accommodate infectious patients; and • a specialised gastroenterology service. 8.3.2 Cardiology services Table 82 shows the projected resident demand for cardiology (non-interventional) and interventional cardiology. At present there are two public cardiac catheterisation laboratories in the public sector, one at each of RHH and LGH. Both sites provide the full range of services apart from cardiac electrophysiology services (see Section 8.2.3). The future demand for cardiac catheterisation laboratories was analysed based on age- and sex-specific rates of usage (Source: NSW Health targets) which indicated hat the State had adequate demand for three laboratories in 2004-05 increasing to four laboratories in 2011-12, and five laboratories by 2021-22. This demand is for the total population, and any policy for allocation of these resources by site needs to take into account the supply of these services in the private sector. Clinical Services Plan 121 Table 82: Projected resident demand, public hospital cardiology activity by region, 2004-05 and 2021-22 Region SRG Stay Type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays South Cardiology Day Only 611 1,128 611 1,128 85% 85% Overnight+ 1,223 1,650 5,129 5,740 35% 12% Cardiology 1,834 2,778 5,740 6,868 51% 20% Total Interventional Day Only 319 615 319 615 93% 93% Cardiology Overnight+ 499 581 2,103 2,069 16% -2% Interventional Cardiology 818 1,195 2,422 2,683 46% 11% Total North Cardiology Day Only 519 892 519 892 72% 72% Overnight+ 842 1,271 4,848 5,193 51% 7% Cardiology 1,361 2,163 5,367 6,085 59% 13% Total Interventional Day Only 230 542 230 542 136% 136% Cardiology Overnight+ 389 585 1,395 1,925 50% 38% Interventional Cardiology 619 1,128 1,625 2,467 82% 52% Total North Cardiology Day Only 195 450 195 450 131% 131% West Overnight+ 1,115 1,293 4,919 4,931 16% 0% Cardiology 1,310 1,743 5,114 5,381 33% 5% Total Interventional Day Only 218 421 218 421 93% 93% Cardiology Overnight+ 318 421 1,079 1,281 32% 19% Interventional Cardiology 536 842 1,297 1,702 57% 31% Total Total Cardiology Day Only 1,325 2,469 1,325 2,469 86% 86% Overnight+ 3,180 4,214 14,896 15,865 33% 7% Cardiology 4,505 6,684 16,221 18,334 48% 13% Total Interventional Day Only 767 1,578 767 1,578 106% 106% Cardiology Overnight+ 1,206 1,587 4,577 5,274 32% 15% Interventional Cardiology 1,973 3,165 5,344 6,853 60% 28% Total 122 Clinical Services Plan Table 82 indicates a projected growth in interventional cardiology of 60% over the projection period, with 48% projected growth of other cardiology inpatients. The growth rate varies by region, with the South showing higher rates of growth in non-interventional cardiology at 51% than for interventional cardiology at 46%. The reverse trend is the case for the North and North West. Clinicians at LGH have indicated that this is based on their clinical practice which showed a high rate of growth in interventional cardiology between 2000-01 and 2004-05 as the service was enhanced at LGH. There has been no indication of any issues in the clinical consultations with delivery of interventional cardiology services at LGH with no on-site cardiothoracic surgery services, and therefore these arrangements should continue. Both RHH and LGH should provide a comprehensive cardiology service with RHH continuing its role as the State provider of cardiothoracic surgery. The following table shows the service strategies for cardiology services. CARDIOLOGY SERVICES STRATEGIES Hospital State-wide or Regional referral service Local service single service NWRH Mersey Outpatient medical specialist clinics for residents of the Devonport catchment Burnie Cardiology service, which will include the capacity to monitor and manage low- to moderate- risk patients (capacity for telemetry service to all inpatient beds to be used to establish a coronary care service within the medical inpatient unit) LGH Integrated cardiac service including Local cardiology services specialised inpatient services for the management of patients with advanced heart failure; cardiac catheterisation laboratory services; coronary care services with telemetry capability for inpatient areas; outreach cardiology medical specialist services. RHH Cardiothoracic Integrated cardiac service; specialised Local cardiology services surgery inpatient services for the management of patients with advanced heart failure; cardiac catheterisation laboratory services as part of an integrated cardiac service; coronary care services should be provided within the cardiac service with telemetry capability for inpatient areas. Service implications Strengthening of governance and clinical network arrangements; develop services based on best practice facility guidelines and staffing standards; clinical network to consider relationships with rural hospitals providing services to patients with heart conditions; services should be supported by adequate clinical measurement services and cardiac rehabilitation programs; the clinical network will be responsible for the development of clinical protocols to ensure that services are delivered in the North West that meet clinical guidelines for adequate staffing levels and that there are protocols in place for patient transfers (consider electrophysiology). Clinical Services Plan 123 8.3.3 Renal medicine and renal dialysis services Renal medicine, or nephrology, is the care of patients with a broad range of renal and other disorders including: glomerulonephritis and immune renal disease; kidney stones and infection; high blood pressure; hypertension in pregnancy; and end stage renal failure. Many types of renal disease have a chronic and often progressive course. Thus for example, a patient may progress to renal failure and require dialysis and subsequently a renal transplant over a period of time. Growth in demand for renal dialysis services is both a national and international trend. Tasmania has the highest rate of diabetes and hypertension in the nation and dialysis procedures are the most common reason for same-day admission to public hospitals. The average patient age has increased in the past few years with older, frailer patients requiring treatment. Renal services are provided by the RHH and the LGH. The RHH provides services to Southern Tasmania through an acute unit at the RHH and a satellite unit at St John’s Park. The Northern Tasmania Renal Service incorporates the LGH Dialysis Unit and the North West Satellite Dialysis Unit in Burnie. The satellite unit in Burnie was developed in 1999 in response to the growth in chronic kidney disease in the North West. The differences in service models at the RHH and LGH units should be taken into account when examining activity data trends. The activity data for the Burnie service is normally counted in the activity for LGH. Analysis of planning data was therefore based on place of residence to account for this variation. Patients are treated across a number of modalities including acute short-term haemodialysis; haemodialysis for chronic patients provided in hospitals, peritoneal dialysis, a satellite unit or at home; and home-based continuous ambulatory peritoneal dialysis or automated peritoneal dialysis. Both hospitals provide home dialysis services which is 36% of patients in the South and 15 % in the North. A patient’s medical and social circumstances often dictate which dialysis modality they choose. There is a range of treatment modalities available for patients: • Haemodialysis: this technique uses an artificial kidney (dialyser) which contains a semi-permeable membrane to remove waste products, such as urea and creatinine, from the blood. This type of treatment can occur in a range of settings, including hospital inpatient units or outpatients. • Home haemodialysis: is a variant of the first treatment modality. The patients manage their own dialysis in a home setting. This treatment modality generally requires active support from a carer to monitor the patient while treatment occurs. It needs one machine per person, training, technical support and back-up nursing. • Peritoneal dialysis: under this technique the human peritoneal membrane is used as the filtering membrane. This treatment modality is preferred when people are seeking to maintain their independence or they live some distance from a renal unit. • Haemodialysis is the most costly over time but provides a longer treatment option, Peritoneal dialysis is less expensive but can only be used for approximately three years before transplantation is required. The least expensive treatment overall is transplantation and if successful provides the best outcomes for patients. Admitted patient separations for dialysis have increased by 39.7% between 2000-01 and 2004-05 and account for 18% of all public hospital separations. Table 83 shows that the services throughout the State have almost reached capacity. Some two- thirds of patients are managed in hospital, which is higher than other state benchmarks and targets of between 50% and 60%. 124 Clinical Services Plan Table 83: Place of treatment for renal dialysis patients by capacity, no. of patients and location, 2006 2006 data on renal dialysis pts Capacity Current people In hospital RHH – acute dialysis 20 5 5 RHH – St John’s park 72 53 53 RHH – PD 42 RHH – Home HD 6 Launceston – Hospital 48 44 44 Launceston – PD 5 Launceston – Home HD 2 NW – Satellite HD 60 24 24 NW – PD 6 NW – Home HD 3 Total 200 190 126 Source: DHHS data. The following tables show that there will be major growth in renal dialysis and renal medicine demand, with highest growth in the South, North and then the North West for renal dialysis separations. However there may be variation by region in the projected demand, due to varying rates of chronic kidney disease in regional populations. This will need to be monitored and factored into ongoing services planning. Table 84: Projected resident demand, renal dialysis public hospital activity by region, 2004-05 and 2021-22 Region SRG Stay type Sum of separations Sum of beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays Renal South Day Only 8,080 16,895 8,080 16,895 109% 109% Dialysis Overnight+ 1 3 1 6 188% 480% Total 8,081 16,898 8,081 16,901 109% 109% Renal North Day Only 5,237 10,490 5,237 10,490 100% 100% Dialysis Overnight+ 2 3 23 20 57% -13% Total 5,239 10,493 5,260 10,510 100% 100% North Renal Day Only 4,494 7,982 4,494 7,982 78% 78% West Dialysis Overnight+ 1 2 1 3 82% 186% Total 4,495 7,984 4,495 7,985 78% 78% Renal Total Day Only 17,811 35,368 17,811 35,368 99% 99% Dialysis Overnight+ 4 8 25 29 96% 15% Total 17,815 35,375 17,836 35,396 99% 98% Source: Greg Hardes & Associates. Clinical Services Plan 125 Table 85: Projected resident demand, renal medicine public hospital activity by region, 2004-05 and 2021-22 Region Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays South Day Only 269 507 269 507 88% 88% Overnight+ 144 339 968 2,478 135% 156% 413 846 1,237 2,984 105% 141% North Day Only 115 245 115 245 113% 113% Overnight+ 124 242 1,090 2,094 95% 92% 239 487 1,205 2,339 104% 94% North West Day Only 62 155 62 155 150% 150% Overnight+ 97 190 719 1,599 95% 122% 159 345 781 1,754 117% 125% Total Day Only 446 906 446 906 103% 103% Overnight+ 365 770 2,777 6,171 111% 122% 811 1,677 3,223 7,077 107% 120% Source: Greg Hardes & Associates. Evidence based research conducted by the Victorian government (Renal Dialysis: A Revised Service Model for Victoria 2004) said that the best management of chronic renal failure, including increased survival with optimal health outcomes, is to undertake enhanced frequency haemodialysis. Application of this evidence in Tasmania would result in increased frequency of dialysis for patients to either daily or every second day. Planning for a possible major growth in this area would include the positioning of self-managed renal dialysis satellites in integrated care centres. Service strategies should also allow for reconfiguration of existing facilities to in-centre units at each hospital site. The provision of extra chairs at each site or change in operating hours/days will accommodate an increasing number of occasions of service. The estimate of usage of chairs applied to the activity projections is 296 occasions of service per chair (Victorian benchmark). This means that Tasmania will require 85 renal dialysis chairs by 2011-12 and 120 by 2021-22, depending on the setting. An additional strategy is the provision of additional home dialysis services. A growing collection of clinical research clearly demonstrates that the more frequent, more consistent dialysis associated with self-care provides patients with improved health outcomes such as improved mortality rates and reduced hospitalisations. This requires an intensive home dialysis training program and ongoing support for patients. 126 Clinical Services Plan The following table shows the service strategies for renal medicine. RENAL SERVICES STRATEGIES Hospital State-wide or Regional referral service Local service single service NWRH Mersey Renal dialysis satellite service based on a model of self-care with an outreach service from LGH Burnie Renal dialysis satellite service based on a model of self-care (Parkside) with an outreach service from LGH LGH Specialised inpatient services for the Satellite services in the management of high dependency proposed integrated care patients; in-centre service for patients centre; home dialysis establishing dialysis or who are in need of further supervision and management; outreach renal physician services to the North West; renal medicine ; vascular surgery for establishment of fistulas RHH Specialised inpatient services for the Satellite services in integrated management of high dependency care centres and additional patients; in-centre service for patients home dialysis establishing dialysis or who are in need of further supervision and management Service implications Strengthening of governance and clinical network arrangements; develop the services based on best practice facility guidelines and staffing standards; (consideration of renal transplantation as a future service in Tasmania). 8.3.4 Endocrinology Table 86 shows projected in patient demand for endocrinology services by region. The data underestimates the future demand for services as there is a large proportion of services delivered on an ambulatory basis. Given that patients with diabetes are the most common patient category within the Ambulatory Care Sensitive Conditions set, there is a need for a major focus on increasing the delivery of these services in a non-inpatient setting. Clinical Services Plan 127 Table 86: Projected resident demand, public hospital endocrinology activity by region, 2004-05 and 2021-22 Region Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays South Day Only 701 841 701 841 20% 20% Overnight+ 302 505 2,051 3,579 67% 74% 1,003 1,345 2,752 4,420 34% 61% North Day Only 214 326 214 326 52% 52% Overnight+ 298 464 2,368 4,263 56% 80% 512 790 2,582 4,589 54% 78% North West Day Only 115 216 115 216 88% 88% Overnight+ 200 324 1,366 2,535 62% 86% 315 540 1,481 2,751 71% 86% Total Day Only 1,030 1,383 1,030 1,383 34% 34% Overnight+ 800 1,292 5,785 10,376 62% 79% 1,830 2,675 6,815 11,759 46% 73% Source: Greg Hardes & Associates. General service strategies State, Territory and Australian government health ministers endorsed National Service Improvement Frameworks (NSIFs) for the National Health Priority Areas (NHPAs) which includes diabetes. Tasmania has recently developed a Diabetes Action Plan which sets out clear goals for the reducing the incidence of diabetes in the State. The four major policy directions are as follows: • Primary prevention to target the known modifiable lifestyle risk factors associated with type 2 diabetes. This will involve developing opportunities for health promotion, early intervention for members of the community diagnosed with pre-diabetes, health workforce education, screening and skills development, undergraduate training and diabetes monitoring and surveillance systems. • Early detection and early intervention for type 2 diabetes. This will focus on support for the development and implementation of a nationally accredited risk assessment tool; coordinated access to health coaching, expanded management of diabetes in general practice and with other private providers coordinated with community-based services and staff, strengthening of tertiary multidisciplinary care models and community linkages for podiatry services. • Improved integrated care and self-management for those recently diagnosed, or with established type 2 diabetes. This will focus on strengthening existing service models in the primary–acute spectrum, strengthening of services for children including young type 1 diabetics. • Implementation of this Plan will provide a direction and impetus for change for improvement in the prevention and management of all types of diabetes in Tasmania, and will lead to a state-wide approach to the management of people with diabetes.20 20 Department of Health and Human Services, Diabetes Pathways Clinical Focus Group Paper, Final, 2007. 128 Clinical Services Plan Potential changes to service delivery which should be considered in Tasmania are: • multidisciplinary teams in the community to provide preventive services for those at risk of developing any form of chronic disease, including services for people at high risk of developing diabetes; • multidisciplinary outpatient chronic care management units linked to acute hospitals for early intervention and management of acute episodes of chronic conditions; • increasing the available workforce of diabetes nurse educators and allied health professionals who are qualified to work independently to provide diabetes-related services in the community to support GPs in the multi-disciplinary management of people with diabetes; • support training of diabetes nurse practitioners and recruitment and retention policies for allied health professionals providing diabetes-related care; • increase availability and access to generic and disease-specific self-management approaches for people with diabetes; • changes in the delivery of services from face-to-face programs to telephone-based coaching conducted in conjunction with a client’s medical practitioner; • the use of E-Health to access specialist services for people with chronic conditions, and to provide more outreach services remotely closer to where people live (eg using tele-health); • develop multidisciplinary services for children, adolescents, their families/carers, using a range of approaches which meet the physical and psychological needs of this group; • recognise the special needs of older people with diabetes and people with end-stage diabetes complications, eg end-stage renal disease to assist them to maintain links with their community by providing more community care; • ensure diabetes health professionals are aware of and implement the special medication and lifestyle needs of older people with diabetes so that they can maintain independence in the community; • multidisciplinary community-based preventive acute care ambulatory services, eg non-hospital based emergency clinics; • establish community-based renal dialysis to overcome an increasing and unmet demand for dialysis for well and unwell patients. Currently diabetes patients make up the majority of new cases of end-stage renal disease requiring dialysis in acute care hospitals; • acknowledge the importance to health planning of data collection and surveillance of diabetes at all levels both within the health system and the population by increasing the resources for this service; • provide state-based epidemiological data (by over-sampling of national surveys if required) and support diabetes surveillance and monitoring; and • investigate the potential for sharing diabetes-related outcome data between the Department of Health and Human Services and Divisions of General Practice to monitor trends in diabetes. Clinical Services Plan 129 Service strategies for endocrinology services by region are shown below. ENDOCRINOLOGY SERVICES STRATEGIES Hospital State-wide or Regional referral service Local service single service NWRH Mersey Management of patients with diabetes; support from outreach specialist clinics Burnie Management of patients with diabetes; Diabetes Education Centres with multidisciplinary teams; support from outreach specialist clinics; integrated care centre services LGH Endocrinology services with linkages to research institutes and associated support services; Integrated care centre services including Diabetes Education Centres with multidisciplinary teams RHH Endocrinology services with linkages to research institutes and associated support services; Integrated care centre services including Diabetes Education Centres with multidisciplinary teams Service implications Strengthening of governance and clinical network arrangements; develop the services based on best practice facility guidelines and staffing standards. 8.3.5 Respiratory medicine Table 87 shows the projected inpatient activity for respiratory medicine patients. There will be growth in every region for respiratory medicine separations, although there is lower growth in inpatient beddays due to benchmarking of the average length of stay to interstate comparisons and adjustment accordingly. As for diabetes and a number of other service areas, some respiratory medicine patients are classified under Ambulatory Care Sensitive Conditions and there is a need for a major focus on increasing the delivery of these services in a non-inpatient setting. 130 Clinical Services Plan Table 87: Projected resident demand, pubic sector respiratory medicine activity by region, 2004-05 and 2021-22 Region Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays South Day Only 316 564 316 564 78% 78% Overnight+ 1,110 1,431 7,526 7,633 29% 1% 1,426 1,995 7,842 8,196 40% 5% North Day Only 234 440 234 440 88% 88% Overnight+ 835 1,177 6,759 7,653 41% 13% 1,069 1,617 6,993 8,093 51% 16% North West Day Only 83 215 83 215 159% 159% Overnight+ 793 1,019 5,462 5,786 28% 6% 876 1,234 5,545 6,001 41% 8% Total Day Only 633 1,218 633 1,218 92% 92% Overnight+ 2,738 3,627 19,747 21,072 32% 7% 3,371 4,846 20,380 22,290 44% 9% Source: Greg Hardes & Associates. The following table summarises proposed service strategies. RESPIRATORY SERVICES STRATEGIES Hospital State-wide or Regional referral service Local service single service NWRH Mersey Burnie campus & Mersey campus supported by outreach specialist clinics and integrated care centre as the basis for community management of patients with respiratory disorders Burnie Respiratory medicine services LGH Respiratory medicine services with Integrated care centre services for linkages to research institutes and ambulatory management of patients associated support services; Sleep with Chronic Disease multidisciplinary Disorder services teams RHH Respiratory medicine services with Integrated care centre services for linkages with research institutes ambulatory management of patients and associated support services; with Chronic Disease multidisciplinary Sleep Disorder services teams Service implications Strengthening of Governance arrangements and clinical network; develop the services based on best practice facility guidelines and staffing standards; clinical network to consider relationships with rural hospitals for management of patients with respiratory disorders. Clinical Services Plan 131 8.3.6 Neurology services Table 88 shows the projected inpatient activity for neurology patients. There will be growth in every region for neurology separations, although there is lower growth in inpatient beddays due to benchmarking of the average length of stay to interstate comparisons and adjustment accordingly. Table 88: Projected resident demand, pubic sector neurology activity by region, 2004-05 and 2021-22 Region Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays South Day Only 681 1,309 681 1,309 92% 92% Overnight+ 779 977 6,701 7,145 25% 7% 1,460 2,286 7,382 8,454 57% 15% North Day Only 508 911 508 911 79% 79% Overnight+ 697 891 6,314 6,562 28% 4% 1,205 1,802 6,822 7,473 50% 10% North West Day Only 205 458 205 458 123% 123% Overnight+ 605 722 4,797 5,272 19% 10% 810 1,180 5,002 5,730 46% 15% Total Day Only 1,394 2,678 1,394 2,678 92% 92% Overnight+ 2,081 2,590 17,812 18,979 24% 7% 3,475 5,269 19,206 21,657 52% 13% Source: Greg Hardes & Associates. The management of neurology patients includes: • management of stroke patients; • management of patients with degenerative neurological disorders; and • management of other categories of patients including epilepsy. Many patients present to emergency departments and are subsequently admitted because they cannot access earlier neurological advice and acute outpatient-based neurological assessment and investigations. Generally, for inpatients, delays in availability of neurological clinical expertise and imaging services compromises patient care and prolongs inpatient stays. It is preferable for many neurological conditions to be cared for in the public sector. The reasons for this include: • Neurological conditions often require higher intensity medical care, nursing care, allied health intervention and after care than are provided in the private sector, leading to a concentration of those patients towards the public hospital system. Patients in the private sector have to self-fund access to allied health services and may not be entitled to government funding for programs such as the Community Aids and Equipment program, and so have to fund their own aid and equipment needs. 132 Clinical Services Plan • Neurological disorders such as cerebrovascular disease (stroke and TIA), epilepsy, and neurodegenerative disorders such as Parkinson’s disease and Motor Neurone disease are disorders of an ageing population. The age of the patients affected, together with the effect of the associated co-morbidities means that the patients are more likely to be cared for within the public hospital system. • Patients with neurological conditions may have disabilities that prevent gainful employment, limiting or preventing access to private health insurance and the private outpatient sector. Stroke is the third leading cause of death, and a leading cause of morbidity in most Western countries, and has a major economic impact, estimated to amount to at least $1.3 billion per year in Australia. National guidelines advise that stroke patients are best managed in stroke units, since there is now clear evidence that this decreases mortality and improves neurological outcome. Public hospitals in Tasmania have recently adopted stroke units as a service model. 8.3.7 Surgical services There are key challenges for the provision of all surgical specialties in Tasmania: • Recruitment and retention of a highly skilled multidisciplinary surgical workforce. • Recruitment and retention of highly skilled surgical theatre staff. • Maintaining theatre services in line with technological advances and with the private sector, eg accessing funding for interactive imaging and videoconferencing in theatre. The need for capital funding for surgical appliances and theatre maintenance to remain abreast of evidence-based best practice and compete with the private sector. • Waiting list reduction for elective procedures, including appropriate planning for emergency theatres, while maintaining designated theatres for elective procedures. • Maintain high levels of efficiency and low-infection risk between theatres and the central sterilising service. • As for most surgical specialities workforce planning is required to ensure an adequate supply of skilled surgical and theatre staff. • An appropriate allocation of theatre sessions to surgical speciality demand is required. A process is required that improves allocation and is flexible enough to cater for seasonal variation in elective and emergency surgical demand. • Optimise logistics and management of theatre services to provide better access to theatre services for emergency and elective surgery. • The relative age of people undergoing surgery is increasing, associated with multiple co- morbidities and high anaesthetic risk. • The need to maximise surgical capacity at non-tertiary hospital sites for surgery where critical care services are not required due to the risk profile and low complexity of surgery. • Maintenance of training opportunities at tertiary hospital sites given the volume of high- complexity cases and the system-wide strategy to send low-risk surgery to the non-tertiary hospital sites. • Predicting demand and utilisation for emergency surgical services. The use of surgical short-stay units and 23-hour care units is based on the premise that the majority of surgical care can be administered within a 24-hour period in a non-ward environment. Patients can be admitted, prepared for their surgical procedure, and then monitored and appropriate pain relief given post surgery before protocol-based discharge occurs within 24 hours. Clinical Services Plan 133 Resident demand for adult surgical separations is projected to increase by 42% between 2004-05 and 2021-22. Separations in the private sector are projected to grow by 45% and the public sector by 39%. Projected resident demand Table 89: Projected resident demand, adult surgical separations, 2004-05 and 2021-22 Sector Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays Public Day Only 13,820 21,721 13,820 21,721 57% 57% Overnight+ 12,875 15,275 79,358 98,477 19% 24% Total public 26,695 36,996 93,178 120,197 39% 29% Private Day Only 17,042 26,827 17,042 26,827 57% 57% Overnight+ 13,373 17,302 60,804 78,457 29% 29% Total private 30,415 44,129 77,846 105,285 45% 35% Total Day Only 30,862 48,548 30,862 48,548 57% 57% Overnight+ 26,248 32,577 140,162 176,934 24% 26% Total 57,110 81,125 171,024 225,482 42% 32% Source: Greg Hardes & Associates Resident demand for adult surgical separations is projected to increase for all service-related groups between 2004-05 and 2021-22, with the exception of gynaecology. Head and neck surgery, ophthalmology, and colorectal surgery are projected to more than double over this period. Table 90: Projected resident demand, adult surgical separations, 2004-05 and 2021-22 Service related group 2004-05 2021-22 Change (%) Breast surgery 1,042 1,244 19% Cardiothoracic surgery 478 512 7% Colorectal surgery 1,645 3,369 105% Upper gasto-intestinal surgery 2,341 3,000 28% Head & neck surgery 523 1,103 111% Neurosurgery 841 1,177 40% Dentistry 2,458 3,948 61% Ear, nose & throat 1,653 2,099 27% Orthopaedics 13,965 20,506 47% Ophthalmology 6,418 13,277 107% Plastic and reconstructive surgery 3,968 3,642 -8% Urology 5,537 10,046 81% Vascular surgery 1,989 2,319 17% Non subspecialty surgery 7,241 9,073 25% Transplantation 7 12 67% Extensive burns 48 76 58% Tracheostomy 229 286 25% Gynaecology 6,727 5,436 -19% Total 57,110 81,125 42% Source: Greg Hardes & Associates 134 Clinical Services Plan Table 91: Percentage share of projected resident demand, adult surgical separations, sector, 2004-05 and 2021-22 Service related group 2004-05 2021-22 Public (%) Private (%) Public (%) Private (%) Breast surgery 36.2% 63.8% 36.1% 63.9% Cardiothoracic surgery 89.1% 10.9% 88.8% 11.2% Colorectal surgery 51.1% 48.9% 51.1% 48.9% Upper gasto-intestinal surgery 60.2% 39.8% 59.8% 40.2% Head & neck surgery 43.4% 56.6% 42.9% 57.1% Neurosurgery 68.1% 31.9% 69.6% 30.4% Dentistry 30.1% 69.9% 29.1% 70.9% Ear, nose & throat 31.7% 68.3% 33.4% 66.6% Orthopaedics 43.4% 56.6% 43.5% 56.5% Ophthalmology 32.4% 67.6% 37.3% 62.7% Plastic and reconstructive surgery 43.2% 56.8% 44.6% 55.4% Urology 41.0% 59.0% 39.6% 60.4% Vascular surgery 63.3% 36.7% 62.2% 37.8% Non subspecialty surgery 68.5% 31.5% 68.0% 32.0% Transplantation 100.0% 0.0% 100.0% 0.0% Extensive burns 97.9% 2.1% 98.5% 1.5% Tracheostomy 85.2% 14.8% 84.4% 15.6% Gynaecology 44.3% 55.7% 37.1% 62.9% Total 46.7% 53.3% 45.6% 54.4% Source: Greg Hardes & Associates Table 92 shows that surgical separations will increase in all regions, with day-only surgery showing higher growth rates than overnight surgical patients. The North is estimated to have the highest growth overall. Table 92: Projected resident demand, adult surgical separations, 2004-05 and 2021-22 Region Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays South Day Only 5,792 9,063 5,792 9,063 56% 56% Overnight+ 4,967 5,833 32,111 39,189 17% 22% 10,759 14,896 37,903 48,252 38% 27% North Day Only 4,805 7,814 4,805 7,814 63% 63% Overnight+ 3,938 4,902 23,772 31,014 24% 30% 8,743 12,715 28,577 38,828 45% 36% North West Day Only 3,223 4,844 3,223 4,844 50% 50% Overnight+ 3,970 4,540 23,475 28,273 14% 20% 7,193 9,384 26,698 33,117 30% 24% Total Day Only 13,820 21,721 13,820 21,721 57% 57% Overnight+ 12,875 15,275 79,358 98,477 19% 24% 26,695 36,996 93,178 120,197 39% 29% Source: Greg Hardes & Associates. Clinical Services Plan 135 Surgical service strategies Surgical service strategies set out below. SURGICAL SERVICES STRATEGIES Hospital State-wide or single Regional referral service Local service service NWRH Outpatient vascular surgery clinics provided from the LGH to the NWRH (Burnie and Mersey) Mersey Specialised 23-hour day Specialised 23-hour day surgery centre established for surgery centre established for general surgery, gynaecology, general surgery, gynaecology, orthopaedics, ENT, and orthopaedics, ENT, and ophthalmology, etc ophthalmology Burnie Overnight acute surgical services for ENT surgery, general, gynaecology, orthopaedics, ophthalmology, and urological surgery with specialist cover LGH Hepatobiliary surgery; ENT surgery, general Low complexity paediatric vascular surgery surgery, gynaecological surgery, neurosurgery, and surgery, orthopaedic surgery, minor burns ophthalmology, urological surgery In the long-term, 23- hour surgical service for appropriate level surgery including low-risk ENT, general, gynaecological, orthopaedic, ophthalmology, and urological surgery RHH Cardiothoracic surgery, Vascular surgery as part of a ENT surgery, general complex neurosurgery, state-wide clinical network surgery, gynaecological paediatric surgery; surgery, orthopaedic surgery, complex ENT and head ophthalmology, urological and neck surgery, vascular surgery surgery; extensive burns service (generally provided by plastic and reconstructive surgeons); bariatric surgery Service implications Clinical protocols developed by key stakeholders for the transfer of patients to RHH or LGH for state- wide services; specialised paediatric surgery provided by interstate public hospitals on a formal service basis; clinical referral pathways for interstate transfer of specialised paediatric surgical patients developed; establish vascular surgery clinical network; service capability for low complexity services identified through a formal scope of practice / role delineation review. 136 Clinical Services Plan 8.3.8 Women’s and Children’s Services Calculation of maternity services demand and neonatal demand The planning process involved multiple workshops and consultations in which key information was presented to clinicians regarding the projected activity for births, maternity services, paediatric services and gynaecology services. Concerns were raised during this process that the projected births and activity for maternity services based on the trend data from 2000-01 to 2004-05 were based on dated trend data when the more recent activity indicated an increase in birthing in Tasmania. This was seen as partly attributable to a shift in Government policy with the introduction of the baby bonus and partly attributable to delayed birthing patterns for older mothers. As a result of these issues, a more comprehensive analysis was undertaken of recent birth numbers by hospital to 2005-06, although the data was incomplete for the 2005-06 year. In addition, recent data on fertility rates for Tasmania in total and by region were also examined (see Table 93), as well as population projections for women of child rearing years. The analysis showed the following: • A rise in fertility rates for Tasmania from 1.83 to 1.96 if the period 2000 to 2005 is analysed, whereas the period from 2001 to 2005 shows a lower range from 1.91 to 1.96, with 2003 at 1.97 higher than 2005 with 1.96. • Regional variation in birthing levels, with the North and the South showing a growth in births between 2000 and 2005 (North: growth of 102 births or 6.6%, South: growth of 513 births, 18.8%) whereas there was a decline in births in the North West of 32 births or -2.3% over the same period. • A projected decrease in women 15 to 44 years from 2006 to 2021 from 92,826 to 80,277 (ABS population projections, based on 2001 Census data). This is a decrease of 12,549 women, or 13.5%. However, the 2006 estimated resident population census data indicates that there were 95,316 women in this age range resident in Tasmania, an increase of 2,490 or 2.7% over the 2006 estimated number based on the 2001 Census data. • A high variation in fertility rates by age group for women in Tasmania, with women 20 to 29 years show a decrease in fertility rates from 1995 to 2005, while fertility rates have increased for women from 15 to 19 years and between 30 to 44 years. These fertility rates will have a differential effect on projected births subject to the specific projected age profile of women in child rearing years. The total fertility rate by local government areas in Tasmania and births by region from 2000 to 2005 are shown in Appendix E. As a result of this analysis, it was decided to adjust the projected births from 2011-12 to 2021-22 to allow for a continuing birth rate at regional levels over the period of the projections, based on projected population numbers adjusted for 2006 estimated resident population at the State level. This is an application of a crude birth rate, but does adjust for recent trends in birthing rates. This analysis should be undertaken in more detail at age and sex cohort levels when updated population projections are available by age, sex, place of residence, and birth data are complete for 2006 and 2007. The result of this analysis is shown in Table 93. This table shows that the baseline projections accounted for a decline of 30% in births, the projection adjusted for 2006 estimated resident population resulted in a projected decline of 28%, while the projected births, allowing for a flat birthing rate by region, resulted in a 13% decline in births over the period. Clinical Services Plan 137 Table 93: Projected births, Tasmania by method of estimation, 2004-05 to 2021-22 Method of estimation Year Change 2004-05 20011-12 2016-17 2021-22 Nos % Baseline 5,603 4,777 4,325 3,921 -1,682 -30% Population adjustment 5,603 4,883 4,421 4,008 -1,595 -28% Fertility rate adjustment 5,603 5,349 5,091 4,849 -754 -13% Source: Greg Hardes & Associates. The third method has been used as the basis for analysis for this Plan, as it still reflects the projected decrease of women in child-rearing age groups in Tasmania, but adjusts for recent fertility rate patterns. However, for future planning the projections will be based on stable birthing patterns until the data is reviewed in two years time. Similar adjustments were also made to ante-natal and post-natal separations and beddays and neonatal separations and beddays within the projection modelling. The resulting facility requirements are shown in Appendix K. Another problem with the data was the application of different recording rules to the classification of qualified and unqualified neonates by facility, which resulted in all neonatal admissions being recorded as qualified at some facilities. Under planning conventions all unqualified admissions would be excluded from planning counts and analysis. A benchmarking exercise and analysis of unit record data was undertaken to determine a method for the calculation of the proportion of qualified neonatal admissions, which resulted in the following approach: • 20 % of neonates at RHH and LGH would be qualified neonates; • 12.4% of neonates at the North West Burnie campus would be qualified neonates; and • all qualified neonates at Mersey would be transferred to other sites if admission to a Special Care Nursery or NICU was required. 138 Clinical Services Plan Maternity services Table 94 shows projected births for Tasmania by place of birth based on the adjustments mentioned above. Table 94: Projected births, Tasmania by place of birth, 2004-05 to 2021-22 Place of treatment Year Change 2004-05 2011-12 2016-17 2021-22 No. % RHH 1801 1706 1618 1534 -267 -15% LGH 1513 1465 1397 1332 -181 -12% Other North public 28 24 20 17 -11 -39% NWRH Burnie campus 598 534 482 435 -163 -27% NWRH Mersey campus 376 359 344 330 -46 -12% Other NW public 31 25 20 16 -15 -48% Interstate public 17 18 18 18 1 6% Total Public 4,364 4,131 3,899 3,682 -682 -16% South private 1,090 1,080 1,062 1,044 -46 -4% North private 12 12 12 11 -1 -5% North West private 133 122 113 105 -28 -21% Interstate private 4 5 5 6 2 46% Total Private 1,239 1,219 1,192 1,166 -73 -6% Total 5,603 5,350 5,091 4,848 -755 -13% Note: Private sector is based on resident demand by place of residence and does not identify place of private hospital treatment. Source: Hardes data. RHH will continue to have the largest number of births followed by LGH. Births in all facilities in the North West will decline by facility, from 1,005 births in public facilities (including the contract to the co-located provider in Burnie) to 781 by 2021-22. This is a projected decline of 224 births or 22.3% for the North West facilities in total. Current models of care available in Tasmania include: • care in which the obstetrician is the main ante-natal care provider, with intrapartum and postpartum care provided by staff midwifes under the supervision of a specialist obstetrician; • GP and obstetrician team-based shared care, with participating GPs who meet accreditation requirements for obstetric shared-care working in conjunction with obstetricians with shared care protocols; and Clinical Services Plan 139 • care in which midwives are the main carers, providing antenatal services in hospital based or outreach clinics and intrapartum care in conjunction with an obstetric team. Some birthing facilities provide extended midwifery services either through hospital-based midwives or contracted service providers in local communities. Midwifery led models include: o birth centres, where low-risk women receive all their care from a small team of midwives with minimal medical or technological intervention, and continuity of carers in a special home-like setting; o team midwifery, where low-risk women receive the majority of ante-natal, intrapartum and postpartum care from a small team of midwives in a hospital setting; and o care in which accredited independent midwives are the main carers, usually providing the full continuum of care in the woman’s home – women who require transfer to hospital because of complications during a planned homebirth generally do not retain the services of the independent midwife because of lack of hospital visiting rights. There are recruitment and retention issues for obstetricians in rural and remote areas in particular. The AMWAC report on Specialist Obstetrics and Gynaecologist Workforces in Australia (2004) concluded that the main problem for obstetricians is a mal-distribution problem affecting specific areas and Australia is only maintaining current service levels through reliance on overseas-trained professionals. AMWAC recommended an increase in the annual RANZCOG first year intakes and that states and territories consider other models of maternity care particularly in areas were the number of births is low. Due to the projected decline in births in the North West, there is a need to develop maternity services that have clear clinical protocols in place for a low-risk birthing service for the Mersey campus and a low- to medium-risk birthing service at Burnie campus. The development of protocols for low- risk birthing need to be undertaken by the clinical network for Women’s and Children’s services as a matter of priority, together with clearly developed models of care based on midwifery led care; shared care with GPs and obstetrician supervision. This may result in a revision downwards of the number of births that are safe to be managed at the Mersey campus. The continuation of the maternity service at the Mersey campus is proposed with the following conditions: • Volumes need to be adequate to sustain the low-risk birthing service at Mersey in order to retain skilled staff on site. • There needs to be adequate staffing levels and appropriate staffing skills to sustain this model at each site. This includes trained midwives; obstetrician supervision, GPs with appropriate credentials providing shared care and ante-natal services. If this service cannot be safely provided then the service should be consolidated at Burnie. This will require development of a costed staffing model by the NWRH. • Clinical protocols need to be developed to accommodate emergency births at each site and stabilisation of women and neonates pending transfer/retrieval. Clear protocols for stabilisation and transfer also need to be given. • Emergency consultant paediatric and obstetric services including call back will be consolidated at NWRH (Burnie) in line with low- to medium-risk services for this region. • A memorandum of understanding needs to be developed between the public service and the private service at Burnie to ensure that clinical outcomes meet safety and quality standards. The development of this model does not preclude the continuation of outpatient clinics and ante-natal and post-natal clinics and classes at Mersey campus, regardless of the preferred model of inpatient care for the two campuses. Indeed, the development of the integrated care centre model will allow for these services to be provided to local communities at the proposed sites subject to adequate staffing numbers. Other service models and proposed implications are detailed in the table below. 140 Clinical Services Plan MATERNITY SERVICES STRATEGIES Hospital State-wide or single service Regional referral service Local service NWRH Mersey Low-risk birthing with immediate transfer of neonates to LGH or Burnie subject to clinical protocols Burnie Medium- to low-risk birthing LGH Maternity services Maternity services RHH Complex materno-foetal Maternity services Maternity services medicine; management of high risk pregnancies with associated complications including foetal anomalies Service implications Strengthening of Governance arrangements and clinical networks; develop the services based on best practice facility guidelines and staffing standards; develop ante-natal and post-natal outpatient services at integrated care centres; arrangements for the RHH service need to be based on appropriate partnerships with the private providers: need for clear delineation of low-risk and medium risk maternity services so that each facility understands its role in relation to management of births and neonates; continue arrangements for transfer of some patients requiring specialised surgery and other specialised services interstate. As RHH will continue to manage the high-risk births and associated complex conditions during ante- natal and post-natal care it is proposed that the size of the maternity service as shown in Appendix K be retained at existing levels, although facility design should allow for the provision of swing beds to accommodate variations in activity. Clinical Services Plan 141 Neonatal services The following table summarises proposed service models and service implications. NEONATAL SERVICES STRATEGIES Hospital State-wide or single Regional referral service Local service service NWRH Mersey Low-risk birthing with immediate transfer of neonates to LGH or Burnie subject to clinical protocols; 2 holding cots at Mersey with capacity for stabilisation pending immediate transfer/retrieval arrangements for any admitted neonates Burnie Management of medium- and low- risk births for 32 weeks and beyond with capacity to manage neonates and short-term ventilation pending retrieval and transfer; Special care nursery LGH Neonatal service for Special care nursery 30 weeks and beyond with capacity to provide nasal CPAP and short- term ventilation pending retrieval/transfer RHH Neonatal intensive Special Care Nursery Special care nursery care; neonatal retrievalNETS service Service implications Strengthening of Governance arrangements and clinical network: develop the services based on best practice facility guidelines and staffing standards: need for clear delineation of low-risk and medium risk maternity services so that each facility understands its role in relation to management of neonates: private services in the south continue to provide back-up or lower level neonates when peak demands is reached for Specialist Care Nursing at RHH. Paediatric services The major service strategies for paediatric services relate to the following issues: • The need to consolidate arrangements for state-wide service including paediatric surgery and paediatric oncology, as these services are required within Tasmania to deliver a safe and effective paediatric service to residents. • The need to determine the preferred service model for paediatric services in the North West. There have been concerns raised about the ongoing viability of the delivery of private sector paediatric medicine services in Tasmania. Consideration needs to be given to the impact a potential change in private capacity could have on public hospital inpatient paediatric services. The development of a viable public/private service should be explored in the future. Projected resident demand Table 95 indicates projected inpatient activity by place of treatment for all children 0 to 14 years in Tasmania and interstate. 142 Clinical Services Plan Table 95: Projected paediatric inpatients , Tasmania, by sector and stay type, 2004-05 to 2021-22 Separations Stay type Year Change 2004-05 2011-12 2016-17 2021-22 Nos % Public hospitals Day Only 3,083 2,966 2,941 2,930 -153 -5% Overnight+ 4,081 3,670 3,392 3,186 -895 -22% Total 7,164 6,637 6,332 6,117 -1,047 -15% Interstate public Day Only 128 122 128 134 6 5% Overnight+ 222 210 201 196 -26 -12% Total 350 332 330 331 -19 -5% Private Day Only 1,574 1,485 1,434 1,400 -174 -11% Overnight+ 556 530 504 484 -72 -13% Total 2,130 2,015 1,938 1,884 -246 -12% Total Day Only 4,785 4,574 4,502 4,465 -320 -7% Overnight+ 4,859 4,410 4,097 3,866 -993 -20% Total 9,644 8,984 8,599 8,331 -1,313 -14% Beddays Stay type Year Change 2004-05 2011-12 2016-17 2021-22 Nos % Public hospitals Day Only 3,083 2,966 2,941 2,930 -153 -5% Overnight+ 11,454 10,710 10,107 9,794 -1,660 -14% Total 14,537 13,677 13,048 12,724 -1,813 -12% Interstate public Day Only 128 122 128 134 6 5% Overnight+ 1,671 1,268 1,193 1,157 -514 -31% Total 1,799 1,390 1,321 1,292 -507 -28% Private Day Only 1,574 1,485 1,434 1,400 -174 -11% Overnight+ 1,661 1,772 1,833 1,915 254 15% Total 3,235 3,257 3,267 3,315 80 2% Total Day Only 4,785 4,574 4,502 4,465 -320 -7% Overnight+ 14,786 13,750 13,133 12,865 -1,921 -13% Total 19,571 18,324 17,636 17,330 -2,241 -11% Note: Paediatric data is understated for the RHH as the age range of 0-14 years excludes adolescents managed in a paediatric unit. Source: Greg Hardes & Associates. The table shows paediatric inpatient activity will decrease, consistent with experience in other states and territories where a greater proportion of children are being managed in non-inpatient settings. Therefore flexibility needs to be built into the model for day patients to be accommodated in swing beds which can be used in periods of peak demand. The table also indicates that 74.3% of all paediatric separations were managed in Tasmanian public hospitals, 3.6% in interstate hospitals and 22.1% in private hospitals. Private activity is largely made up of ear, nose and throat and dental procedures. Clinical Services Plan 143 This percentage shows little change over the projection period (73.4%, 4.0% and 22.65% respectively by 2021-22). By 2021-22 day-only separations will account for 53.6% of all separations, the majority of separations, compared to 49.6% in 2004-05. Table 96: Projected paediatric inpatients, Tasmania, by place of treatment, 2004-05 to 2021-22 Place of treatment Year Change 2004-05 20011-12 2016-17 2021-22 Nos % RHH 3,697 3,460 3,343 3,257 -440 -12% Other South public 5 6 6 6 1 23% LGH 2,110 1,953 1,864 1,809 -301 -14% Other North public 141 127 120 114 -27 -19% NWRH: Burnie campus 673 601 547 506 -167 -25% NWRH:Mersey campus 440 405 375 353 -87 -20% Other NW public 98 84 76 69 -29 -30% Interstate public 350 332 330 331 -19 -5% Private 2,130 2,015 1,938 1,884 -246 -12% Total 9,644 8,983 8,598 8,330 -1,314 -14% Note: Paediatric data is understated for the RHH as the age range of 0-14 years excludes adolescents managed in a paediatric unit; private activity is activity in private hospitals. Source: Greg Hardes & Associates. Table 96 indicates that there will be a projected decline in inpatient paediatric services at every site in Tasmania excluding other rural hospitals in the South (numbers too small to be counted). All three sites in the North West show relatively higher rates of projected decrease in admitted children. In terms of services in the North West, Table 97 indicates that all current sites for inpatient paediatric services will show a decline in admissions, with combined numbers at Burnie and Mersey changing from 1,113 (3 per day) to 859 (2.4 per day). Overnight separations will decline from 747 (2 per day) to 553 (1.5 per day). There will not be enough activity to sustain the paediatric inpatient service over two sites, and have enough volume to sustain clinical skills and attract clinical staff, due to lack of availability of staff locally. Table 97: Projected paediatric inpatients, North West by place of treatment, 2004-05 to 2021-22 Separations Stay type Year Change 2004-05 20011-12 2016-17 2021-22 Nos % Burnie Day Only 225 206 191 179 -46 -20% Overnight+ 448 395 357 327 -121 -27% Total 673 601 547 506 -167 -25% Mersey Day Only 141 136 131 127 -14 -10% Overnight+ 299 270 244 226 -73 -24% Total 440 405 375 353 -87 -20% Other North West Day Only 29 28 28 27 -2 -6% West Overnight+ 69 56 49 42 -27 -39% Total 98 84 76 69 -29 -30% Source: Greg Hardes & Associates. 144 Clinical Services Plan There are currently four practising consulting paediatricians in the North West region. As of August 2006, NWRH were six to seven RMOs short and there were critical shortages of junior medical staff. The Burnie paediatric unit is currently fully staffed by nurses, and Mersey has a 1.5 FTE vacancy for nursing staff. The Burnie Campus has a 10-bed purpose-built Paediatric Unit with national standard recreational facilities, care-by-parent and parent accommodation facilities. This information on the projected reduced volumes and the significantly improved service at Burnie campus indicate that Burnie should be the site for a consolidated paediatric service. Mersey campus should offer an urgent care centre service for low acuity walk-in paediatric presentations with booked outpatient clinics and a range of other services consistent with ambulatory care services models. The following table summarises proposed service models and service implications. Because RHH will continue to manage the complex paediatric admissions and deliver a paediatric intensive care service, it is proposed that the size of the paediatric service be retained at existing levels, although facility design should allow for the provision of swing beds to accommodate variations in activity. PAEDIATRIC SERVICES STRATEGIES Hospital State-wide or single service Regional referral service Local service NWRH Mersey Walk-in low acuity presentations to the emergency care centre and booked services for ambulatory care Burnie Designated inpatient General paediatric paediatric medical inpatient service with a and surgical service by major emphasis on day paediatricians supported by management of children surgical services for children over 5 years in common surgical subspecialties (ENT, general surgery, dental surgery) LGH Paediatric regional referral Local service service: paediatric medical and surgical services by paediatricians supported by surgical services for children over 5 years in common surgical subspecialties (ENT, general surgery, dental surgery) RHH PICU: paediatric surgery and Specialised paediatric Inpatient service paediatric oncology; other inpatient service with paediatric subspecialisation associated staffing, services; paediatric/neonatal equipment and facilities retrieval consistent with its role Service implications Need for development of networked services with other primary health services. Strengthening of Governance arrangements and clinical network: Paediatric transfers should be developed in conjunction with NETS and Adult Medical Retrieval Services; Review of paediatric services for liver transplantation, severe burns, trauma, neurosurgery, renal transplantation, pancreas transplantation and cardiac procedures with development of clinical protocols for referral and treatment: develop the services based on best practice facility guidelines and staffing standards. Clinical Services Plan 145 8.3.9 Critical care services Intensive care services The increasing acuity of post surgical patients (especially in countries with ageing populations) and the complexity of treatments and interventions now available result in an increasing need for intensive care and high-dependency beds in acute hospitals. Facility requirements for intensive care services The national survey undertaken by ANZICS in 2002-03 showed that there were 38 public and 21 private physical intensive care beds in Tasmania, with 31 public and 15 beds available respectively. The Joint Faculty of Intensive Care says that to be sustainable and viable, a resident intensive care service requires a minimum population of between 100,000 and 200,000. The Australian and New Zealand Intensive Care Society (ANZICS) guidelines have similar population targets to those above.21 A range of guidelines were considered for the planning of critical care services, including those of the Australian and New Zealand Intensive Care Society, Joint Faculty of Intensive Care Medicine and NSW Health Department and Department of Health, WA. These show: • average supply per capita (6.4 available beds per 100,000 population: ANZICS (see Table 98); • NSW Health Department Guidelines of 8.8 beds per 100,000 population; and • 7.5% of adult medical and surgical beddays (Department of Health, WA). Table 9822 shows that Tasmania has a slightly above average supply of intensive care beds, including ventilator beds. However, while the number of public sector intensive care beds is consistent with national averages, private sector intensive care bed numbers are below national averages. This means that the total supply of intensive care beds in Tasmania is over-reliant on public sector resources. Table 98: Benchmarking of supply of intensive care beds by sector, Tasmania and Australia, 2003 Available beds per 100,000 population Public Private Total Tasmania 6.5 3.1 9.6 Australia 6.4 2.9 9.3 Ventilator available beds per 100,000 population Tasmania 5.2 1.5 6.7 Australia 4.3 1.8 6.1 Physical and available beds include HDU/step down beds managed by the ICU team Source: Higlett et. al. (2005) Review of Intensive care resources & activity 2002-2003, ANZICS, Melbourne. 21 ANZICS, Review of Intensive Care Resources, 2002-03 22 Private sector figures were derived from several tables in the ANZICS report, as there were errata in the summary table. See tables 12, 13 and 14 of the report. 146 Clinical Services Plan Intensive care activity The number of admitted intensive care patients in 2004-05 was as follows: Facility Number of patients in 2004-05 Royal Hobart Hospital 1,713 Launceston General Hospital 1,072 NWRH Burnie 873 NWRH Mersey 590 An hourly analysis was also undertaken for every month over each of two consecutive years 2004-05 and 2005-06 in order to benchmark peak activity levels and average activity levels. Service strategy Intensive care services is an area where the Department of Health and Human Services will make particular efforts in monitoring demand with adjustments made in the future as required, for example, where growth required is demonstrably not consistent with population change. A new strategy for the North West, has already presented the case for consolidation of Intensive Care services in the North West. The Plan proposes that there be one Intensive Care service in the North West, located at the Burnie campus. The following table summarises the service strategies for intensive care. INTENSIVE CARE SERVICES STRATEGIES Hospital State-wide or single service Regional referral service Local service NWRH Mersey Limited recovery service supporting same-day surgery service; Any patients requiring ventilation will be transferred to Burnie or LGH with appropriate protocols for transfer/retrieval Burnie Designated Level 1 inpatient intensive care service for residents of the North West with referral arrangements in place to LGH and RHH LGH Intensive Care referral service for the North of the State RHH Tertiary referral level 3 ICU service Intensive Care referral for the State, including complex service for the South of multi-system life support and the State ongoing advanced management of a range of critically ill patients for an indefinite period; coordination role in the transfer of patients requiring ICU services throughout the State and for any necessary transfers interstate Service implications Strengthening of governance and clinical network arrangements. Clinical Services Plan 147 Emergency services Emergency services function is to receive, stabilise and manage adult and paediatric patients who present with a variety of urgent and non-urgent conditions (including medical and surgical emergencies, obstetric emergencies, post-trauma and psychiatric illness), whether self or otherwise referred. Both RHH and LGH will be capable of providing complex resuscitation and emergency treatment to patients with a range of medical emergencies, including major trauma, medical, surgical, paediatric, obstetrics and psychiatric emergencies (subject to the additional services at RHH in neurosurgery, paediatric surgery and cardiothoracic surgery). An emergency short-stay unit located adjacent to the ED will provide initial assessment and treatment for a range of medical and surgical conditions for patients with a reasonable expectation of discharge within 24 hours, and specific facilities will be provided for managing paediatric patients. A new strategy for the North West has already presented the case for consolidation and improvement of emergency services in the North West. The Plan proposes that Burnie provides emergency services to the North West with Mersey providing a 24-hour, 7-days-a-week Urgent Care service to the Devonport catchment. The following table summarises the service strategy for emergency services. EMERGENCY SERVICES STRATEGIES Hospital State-wide or single service Regional referral service Local service NWRH Mersey Urgent care service operating 24 hours, 7-days-a-week Burnie Local emergency service to residents of the north west LGH Adult medical retrieval service Regional Emergency referral After-hours rostered GP service; ESSU and other service for management of GP service models type presentations RHH Emergency service consistent ESSU and other service After-hours rostered GP with role in the delivery models service for management of GP of state-wide services in type presentations neurosurgery, cardiovascular surgery. Manage major trauma requiring these specialist services Service implications Strengthening of Governance arrangements and clinical network as per Section 5 of the Plan; develop the services based on best practice facility guidelines and staffing standards including management of patients presenting with mental illness; Develop staffing levels at Burnie to allow for training positions to be accredited. 8.3.10 Cancer services The Department of Health and Human Services is developing a framework in consultation with clinicians across the Tasmanian health system. The framework will promote the development of a cohesive, integrated, state-wide approach to cancer management that draws on the best available evidence, builds on national and international experience of success and seeks to provide services equal or exceeding international effectiveness benchmarks. 148 Clinical Services Plan The purpose of the framework is to optimise cancer care by: • Developing a framework for cancer to improve outcomes for patients that builds on the current expertise and service systems. • Describing the optimal structure and organisational supports for state-wide cancer services to ensure equitable access for all Tasmanians. • Describing a governance structure to oversee the development, implementation, evaluation and updating of the framework. • Promoting a patient-focused, multidisciplinary approach to cancer care. • Identifying key strategic areas of work to achieve the desired changes and outcomes. The framework identifies a six-level model for the delivery of cancer services. This includes the different levels of services, and the nature and location of those services. Table 99: Model for delivery of cancer services Service type Nature of service Location of service and links Super specialty service Gynaecological oncology Single site RHH, outreach to LGH Autologous bone marrow State-wide RHH transplantation Single site LGH (all public services) Radiation oncology – brachytherapy Single site RHH Paediatric and adolescent oncology Comprehensive cancer High-level, highly specialised cancer Two publicly managed: Northern at service care across the range of treatment LGH and Southern at RHH modalities Provision of core cancer services plus specialty services in addition to some super specialty services Mid level cancer services Cancer services affiliated with a Services affiliated with comprehensive cancer service comprehensive cancer services in the North and South Site generally a major health facility NWRH for selected services Provide less sophisticated care to that provided by the comprehensive cancer service Low level cancer services Cancer services affiliated with a Cancer services aligned with comprehensive cancer service comprehensive cancer services in the North and South (ie community Low-level services may also be hospitals and multipurpose services) affiliated with mid-level cancer services Site may be primary care service Provide basic cancer care only Access to supportive services with specialist advice from a comprehensive cancer service Supportive services Basic supportive care provided by Links with regional oncology, GPs with or without assistance of palliative care and pain management other health professionals dependent services on patient need Population services Population screening programs, Links with all levels of cancer services primary health care, general practice and community services Source: A Strategic Framework for State-wide Cancer Services draft 1.1 (January 2007) Clinical Services Plan 149 Cancer data The most common cancers identified in 2003 were (in order of magnitude) breast, colorectal, melanoma of the skin, lung, uterus and lymphomas for females and prostate, colorectal, lung, melanoma of the skin and lymphoma for males. Cancer incidence per 100,000 people in 2003 increased sharply with age. Resident demand for cancer related services will increase, largely as a result of the aging of the population. The projected crude cancer incidence rate in Tasmania will increase by 2.2% per annum between 2002 and 201123. Figure 21: Cancer incidence Tasmania, age and sex, 2003 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 Cancer incidence per 100,000 0 0-4 5-9 85+ 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 Age Males Females Source: Tasmanian Cancer Registry, Cancer in Tasmania, Incidence and Mortality, 2003 Haematology All the major acute hospitals in Tasmania provide a level of haematological oncology and well as non- oncology haematology services. The provision of bone marrow transplantation services is described in Section 8.2.2. Advances in the treatment of haematology patients has meant that up to 70% of haematology separations are “non-inpatient” so that much of the transition to non-inpatient care has already occurred. Management of more complex haematologic illness in the outpatient/ambulatory/domiciliary setting can be performed safely when adequate resources are available for urgent assessment and care of acutely unwell patients. Resident demand for haematology will increase significantly across all regions, and particularly in the North West. 23 AIHW, Projected Cancer Incidence Australia, 2002-2011 150 Clinical Services Plan Table 100: Projected haematology activity, by region, 2004-05 to 2021-22 Region Stay type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays South Day Only 1,604 3,228 1,604 3,228 101% 101% Overnight+ 293 579 1,527 3,596 98% 135% Total 1,897 3,807 3,131 6,824 101% 118% North Day Only 957 2,135 957 2,135 123% 123% Overnight+ 226 470 1,638 3,408 108% 108% Total 1,183 2,605 2,595 5,543 120% 114% North West Day Only 234 1,011 234 1,011 332% 332% Overnight+ 187 387 1,263 2,609 107% 107% Total 421 1,397 1,497 3,620 232% 142% Total Day Only 2,795 6,373 2,795 6,373 128% 128% Overnight+ 706 1,436 4,428 9,613 103% 117% Total 3,501 7,809 7,223 15,987 123% 121% Source: Greg Hardes & Associates Surgical oncology Cancer surgery is provided at the major hospital and at varying levels at the other major acute hospitals. RHH is the main tertiary referral hospital and provides a range of surgical services such as neurosurgery and cardiothoracic surgery. Medical oncology All hospitals provide varying degrees of medical oncology services in Tasmania. Table 101 shows a major growth in the number of patients requiring chemotherapy services, particularly in the North West. The projected trend may be influenced by the substantial rate of growth in the delivery of these services over the last five years. However, there is a high level of growth in both the incidence and prevalence of cancers also underpinning these projections. Most of Australia is now carefully monitoring growth patterns to ensure that services are planned to account for these growth rates. Clinical Services Plan 151 Table 101: Projected chemotherapy activity, by region, 2004-05 to 2021-22 Region Stay Type Separations Beddays Change (%) 2004-05 2021-22 2004-05 2021-22 Separations Beddays South Day Only 3,813 7,336 3,813 7,336 92% 92% Overnight+ 1 2 1 3 147% 186% 3,814 7,339 3,814 7,339 92% 92% North Day Only 1,878 3,873 1,878 3,873 106% 106% Overnight+ 0 1 0 1 0% 0% 1,878 3,874 1,878 3,875 106% 106% North West Day Only 521 2,210 521 2,210 324% 324% Overnight+ 0 1 0 0 0% 0% 521 2,210 521 2,210 324% 324% Total Day Only 6,212 13,419 6,212 13,419 116% 116% Overnight+ 1 4 1 4 306% 331% 6,213 13,423 6,213 13,424 116% 116% Source: Greg Hardes & Associates Radiation oncology Radiation oncology services are provided from the Holman Clinic at the RHH and the LGH. Each clinic operates two linear accelerators, a low-energy linear accelerator and a dual-energy linear accelerator. The review on Increasing Demand for Radiation Oncology Services in Tasmania, 2005-06 to 2009-10, undertaken in 2006, argued that there would be increasing demand for radiation therapy services in Tasmania: • cancer incidence is expected to increase by around 2.5%-3% per annum due to population ageing; • the referral rate for radiation therapy in 2003 was 40.4%, below the national referral target rate of 52.3%; • there has been a significant increase in the use of radiation oncology services in recent years; and • existing radiation therapy services at the LGH and the RHH are operating at or near capacity. The report recommended the installation of a fifth linear accelerator to increase clinical capacity and referral rates in Tasmania. The report noted the fifth linear accelerator could be justified in the short- term and would be nearing capacity at around 2008. The need for a fifth linear accelerator is discussed in Section 8.2.13, Radiation Oncology Services. Cancer service strategies (common to all cancer specialties) • Implement the service model for the delivery of cancer services in Tasmania. • Target strategies to improve equity of access to cancer screening, diagnosis and treatment services for Tasmanians living in rural and remote regions and Aboriginal and Torres Strait Islanders. • Review patient transport services for cancer patients and their families/carers. • Review the financial contribution provided to cancer patients under the patient transport assistance scheme. 152 Clinical Services Plan Chemotherapy • Develop chemotherapy services in integrated care centres provided that there is a nurse with training in the administration of chemotherapy agents on site, as well as access to supportive services and allied health through community services. Radiation therapy services • Invest in a third linear accelerator in the North or North West. • Plan to accommodate a third linear accelerator in the South, as part of the new RHH in the medium term (by 2016). Mammography services In the recent state election, the government identified funding to improve access to public diagnostic mammography. Current plans are to create a conjoint appointment as Director of Breast Imaging across both the Acute Health Services and Community Health Services groups. The position would be responsible for all public sector breast imaging – both diagnostic and screening. 8.4 Interface with other services 8.4.1 Aged Care/GEM Aged Care services provide specialised, integrated and comprehensive care across the entire continuum of ambulatory, acute, assessment, transitional, preventative and restorative care. This requires coordinated, collaborative services and a strong educational focus. A commitment to teaching should support clinical service delivery. The aged care services in Tasmania provide a range of specialised programs to deal with the problems associated with disease and disability affecting older people, with an emphasis on independence and participation. Different levels of government deliver care across a range of settings. Research and teaching of undergraduates and postgraduates should be major components of the service. There have been significant improvements in the delivery of aged care services with the development of a Geriatric Evaluation and Management service at the RHH. This service is the first one of its kind in Tasmania. These services are being developed as local services associated with acute care services in other jurisdictions in Australia. The scope of aged care services includes: Inpatient Services Rehabilitative and restorative care; acute care with facilities appropriate to care for people with acute organic brain syndromes; evaluation and management, including care of patients with dementia; contribution to joint programs (particularly in stroke, palliation for older people and orthogeriatrics); and ACAT services Outpatient Services Assessment, coordinated with the ACAT functions; rehabilitation, with recognition of neurological and orthogeriatric rehabilitation as streams requiring staff specialisation; specialised clinics (memory, falls, movement, continence) Consultation–Liaison Teaching, Research and Quality Assurance The Department of Health and Human Services recognises the importance of specialised acute aged care as it maximises efficiencies in multidisciplinary care of the acutely unwell frail older person, avoids iatrogenic harm, and facilitates linkages to other care services. Clinical Services Plan 153 The development of integrated care centres provides an opportunity to develop new models of care. Geriatric medicine is likely to be able to contribute significantly to care at a level between hospital (secondary and tertiary care) and primary care through involvement in centres supported by aged care specialists and subspecialists, together with allied health support, and primary care-based nurse outreach to the community. The new model of care would allow for the development of services across the continuum of care, subacute beds, assessment and restorative beds, day hospital and access to ACAT coordinated community care services. This could also involve participation of GPs in shared care models and GP triage for referral to more specialised services. These services would be linked or integrated into chronic disease management teams. Supporting implementation of the nurse practitioner role in both community- and hospital-based aged care settings and developing allied health support roles in providing care to lower complexity clients in aambulatory settings, are considered important steps to achieving a model of care that facilitates rapid access to aged care services when required. Other initiatives could include: • Fast-tracking older patients through Emergency Services. • Facilitating coordinated care of older people in the acute setting and from the acute setting to the community. • Improved care in the home setting. • Improved management of older people in Residential Aged Care facilities. Transition care The Transition Care program provides temporary support and active management of older people while longer term care arrangements are being finalised. The key strategy is to develop the range and scope of aged care services within an aged care and rehabilitation clinical network and with representation of all key service providers and stakeholders. This structure is essential if the State is to develop appropriate and targeted services for older persons. 8.4.2 Rehabilitation services There will be a major increase in inpatient rehabilitation services, even after adjusting for inpatient length of stay to benchmark levels. Projected inpatient separations are projected to more than double over the period, while inpatient beddays are also projected to increase at 114%. 154 Clinical Services Plan Table 102: Projected resident demand, public sector rehabilitation activity by region, 2004-05 to 2021-22 Separations Year Change 2004-05 20011-12 2016-17 2021-22 Nos % South 969 1,293 1,673 2,152 1,183 122% North 540 770 1,031 1,357 817 151% North West 336 506 695 916 580 173% Total 1,845 2,569 3,399 4,425 2,580 140% Beddays South 22,706 29,602 37,876 47,643 24,937 110% North 15,247 18,187 23,535 29,854 14,607 96% North West 6,530 10,211 13,858 17,850 11,320 173% Total 44,483 58,001 75,270 95,348 50,865 114% The projected increase is even more pronounced in the North West than in other parts of Tasmania, and therefore service strategies need to be consistent with accommodating this projected demand. In addition, there are strategies such as home-based and centre-based rehabilitation which should be further developed to offer alternatives to inpatient care. There has been a recent review of rehabilitation services in Tasmania which has highlighted a need to strengthen overall clinical direction for rehabilitation services, both state-wide and at regional level, including the capacity for program planning and management across both hospital and community settings. The review proposed a strategy with nine key elements: • Formalise the establishment of the Tasmanian Rehabilitation Network to enhance the status of rehabilitation and provide state-wide policy direction, service planning and training. • Re-balance the investment in inpatient services by increasing provision for rehabilitation and other subacute care. • Establish integrated rehabilitation programs and organisational structures within each region, linking acute care, subacute care and community rehabilitation programs. • Promote an integrated, patient-focused model of service delivery that extends across settings and includes patient identification/referral, assessment, care planning, case management and discharge planning. • Change current utilisation patterns to make more effective use of available rehabilitation resources and improve patient outcomes. • Align rehabilitation service development and specialisation with relevant acute clinical service planning and delivery. • Develop and implement a rehabilitation workforce strategy. • Support the development of specialist rehabilitation programs. • Address infrastructure deficiencies that restrict service capacity and effectiveness. Clinical Services Plan 155 Service Strategies: • Provide specialised rehabilitation services at LGH and RHH with further development of these services in integrated care centres as proposed in Chapter 7. • Provide and strengthen specialised subacute rehabilitation and associated services at the Mersey campus in the North West. This would support services to all residents of the North West, as well as residents to the west of Latrobe including West Tamar and Meander valley. This will require development of services and infrastructure to support the service. • Develop the nine key elements of the Rehabilitation Services Framework, as above and establish a clinical aged care and rehabilitation services network to provide state-wide policy direction, service planning and training. 8.4.3 Palliative care services The Department of Health and Human Services commissioned a review of Tasmania’s palliative care services in June 2004.24 This review recommended a model for delivery of palliative care services in Tasmania based on patients receiving different levels and types of service depending on their needs. The model has four levels, and patients may move between levels of care if their needs change (subject to negotiation between the patient, their carer and the care providers). The major change proposed in this model is a clearer delineation of roles based on the intensity of palliative care service provision. The review used Palliative Care Australia Guidelines which recommend 6.7 designated beds per 100,000 population, based on an 85% occupancy rate, to identify the need for 31.5 designated palliative care beds in Tasmania: 15.4 in the South, 8.7 in the North and 6.7 in North West. Compared with current service provision, Tasmania has approximately half the recommended number of designated palliative care beds, are not distributed according to population needs across the State. There are ten beds in the South; six in the North and none in the North West. The Department of Health and Human Services is implementing the recommendations of the palliative care review in Tasmania. 8.4.4 Mental health services There has been a major planning process for the delivery of mental health services in Tasmania, including the development of the Mental Health Services Strategic Plan 2006-2011. The Mental Health Services Strategic Plan has six priority action areas. It comments on the significant proportion of acute mental health care provided in an inpatient hospital setting. Services that are currently incorporated into the acute mainstream hospital setting include acute psychiatric emergency services presentations and inpatient care, and services for clients whose primary reason for admission is a non-psychiatric medical and/or surgical condition. These clients are accommodated in non- psychiatric settings in acute hospitals, but have considerable mental health needs. Department of Health and Human Services Mental Health Services’ preferred policy for delivery of services is that it should remain community focused in line with the National Mental Health Strategy. This is consistent with the Clinical Services Plan’s model that advocates delineation of responsibilities of healthcare organisations, so that there is an integrated approach to deciding which services are provided in which setting. 24 Centre for Health Service Development, Palliative Care in Tasmania: current situation and future directions, June, 2004. 156 Clinical Services Plan This approach should optimise resource use, avoid unnecessary duplication of services and ensure that an appropriate range of services is provided to the entire community. Specific service strategies The specific service strategies proposed by (and within the scope of) this Plan are to: • Deliver safe and quality mental health services within emergency services associated, adequate staffing with appropriate skills and facility arrangements for the safe and secure assessment, treatment and observation of clients presenting with mental illness. The facility approach should be a dedicated mental health room(s) that meets the standards identified under the Tasmanian Mental Health Act and be gazetted under this legislation. • Develop a memorandum of understanding with RHH for the delivery of mental health services within that facility. • Create mechanisms to share information between credentialling committees, which are currently restricted by qualified privilege. • Review projected inpatient demand and supply of mental health inpatient units consistent with the strategic direction of the delivery of mental health services. • Develop a service strategy for the management of children and adolescents with mental illness in an acute inpatient setting to meet the broad range of complex mental health disorders and illnesses which present in this age group. 8.4.5 Drug and alcohol services Service strategies The following identify structural and functional intersections between drug and alcohol services and the clinical services plan focused primarily around redevelopment of the RHH and the restructuring of the tertiary health care system in Tasmania. Key initiatives are: • Establish specialised Alcohol and Drug Services consultation/liaison capacity with services provided to all areas of the RHH and Launceston General Hospital including the Emergency Department, the medical and surgical wards, the ante-natal clinic, the obstetrics and the psychiatric wards. • Implement a well-structured clinical capacity and relationship between the acute and chronic pain teams at the RHH and the consultation/liaison team of the Alcohol and Drug Services. • Enhance the capacity to teach medical students, interns, registrars and specialist medical, nursing and allied healthcare staff at the hospitals. • Support and undertake medically supervised alcohol and other drug withdrawal management in the clinic and hospital ward settings of patients admitted for management of medical and surgical problems (and in obstetrics), and in whom a withdrawal syndrome emerges or is anticipated. • Establishment a semi-secure medical detoxification ward within the hospital grounds of the new RHH, co-located with the Emergency Department and possibly with additional functions such as a sobering-up service capacity, a needle and syringe program, an opioid pharmacotherapy program with a dispensing service and an amphetamine-type stimulant treatment service. • Formally establish a medical detoxification capacity with suitably trained staff and in the Launceston General and North West Hospitals. • Establish clinical networks around the intersection between addiction and pain medicine. Clinical Services Plan 157 • Devise a range of strategies aimed at ensuring doctors (alongside other healthcare professionals) in Tasmania develop better skills in the assessment and management of persons presenting with an alcohol, tobacco and/or other drug dependence and related problems, such as those arising from chronic non-malignant pain, sleep disturbance and anxiety disorders. 8.4.6 Private sector interface The planning process has clearly identified the high level of interrelationship between the public and private sectors in Tasmania. Each of the major acute hospitals has contractual arrangements for the provision of specific services with local private hospitals. There are arrangements in place by which patients move between local public and private hospitals if there are constraints with capacity, such as the provision of intensive care beds in the South. In the North West, the Burnie campus operates as an integrated model – the private sector has the facility infrastructure and contract with the public hospital for maternity, imaging and pathology services. There are risks to the public sector in these close relationships. Some private sector services are at risk due to lack of clinician availability and impending retirements, especially general medicine, paediatric, obstetric, emergency medicine and geriatric medicine. The major and immediate implication of these risks is the possibility that the public sector will have to find the capacity to deliver these extra services. The private sector in turn is dependent on public sector viability, as the public sector provides many of the support services that together form comprehensive services in areas such as cancer services, acute aged care, renal medicine, and so on. Therefore, there is a need to have close and effective working relationships with the private sector and the organisations delivering these services in the State. The following strategies are proposed: • Establish a Health Industry Forum with participation from the private sector which meets regularly to discuss key issues. • Participate with the private sector on clinical network structures. • Develop memorandums of understanding, which identify health outcomes based on clinical indicators, with all contracts for the delivery of services to public patients. • Identify opportunities for public/private sector partnerships on capital works projects. 158 Clinical Services Plan 9. Enablers for services strategies Key points: • Implementation of the preferred service strategies requires strategic planning and investment in key areas including workforce, teaching and research, transport and retrieval, accommodation, and information and communication technology. • A range of service strategies are proposed for these key areas. These are high-level strategies, and detailed strategic planning is required in each area. 9.1 Workforce In April 2004 the Australian Health Minister’s Conference endorsed the National Health Workforce Strategic Framework. This is the first national framework for health workforce and is designed to guide national health workforce policy and planning, and Australia’s investment in its health workforce throughout the decade. The framework identified seven principles that provide the basis for workforce policy and planning, and identified strategic actions for consideration for each of the principles. These principles are: • ensuring and sustaining supply; • workforce distribution that optimises access to health care and meets the health needs of all Australians; • health environments being places in which people want to work; • ensuring the health workforce is always skilled and competent; • optimal use of skills and workforce adaptability; • recognising that health workforce policy and planning must be informed by the best available evidence and linked to the broader health system; and • recognising that health workforce policy involves all stakeholders working collaboratively with a commitment to the vision, principles and strategies outlined in the framework.25 Richardson Report The Richardson review outlined the need to effectively recruit, use and retain the hospital workforce, and suggested work on developing a strategic workforce framework underpinned by improved planning processes; enhancing partnerships between the Department of Health and Human Services, education providers, and the private sector; and reducing Tasmania’s reliance on overseas trained doctors. Key workforce issues reflect the need for strategies outlined by Richardson and in the National Health Workforce Strategic Framework. These are: • While numbers of health professionals have generally increased, there has been an overall net reduction in supply of many professions due to reducing work hours, increasing feminisation of the workforce and particularly the medical workforce (who generally choose to work part-time), and the ageing of the workforce. • The increasing and changing demand for health workers will require innovation within the health workforce, including the introduction of new roles, realignment of existing roles, and service substitution between roles. 25 Australian Health Ministers Conference, National Health Workforce Strategic Framework, April 2004. Clinical Services Plan 159 • Recruitment and retention of health professionals will become increasingly important as the pool of potential health professionals declines. In Australia today the national workforce grows at an annual rate of around 170,000 per year. By 2020 this is predicted to be just 12,500 per year.26 In a tightening labour market, employers will have to compete for fewer health professionals, which will require innovative strategies to differentiate employer benefits. • There are shortages in and/or mal-distribution of the health workforce in Tasmania. This is a major factor affecting the sustainability of Tasmania’s health system. • Due to Tasmania’s population size, many health professional courses are not provided locally, contributing to leakage of health professionals interstate. Allied health training in Tasmania is limited. Further partnership arrangements with interstate universities should be considered and the introduction of new courses reviewed. • Linked to the above point, Tasmania relies heavily on locums and overseas trained doctors and needs to implement a long-term strategic plan which links service needs with health care education and workforce. Workforce strategies (see also Teaching and Research Strategies, Section 9.2) The Department of Health and Human Services will continue to progress workforce strategies during the implementation phase of this plan including the following: • Invest in workforce data and planning systems. • Continue active participation in national health workforce planning structures. • Action recommendation 6.1 of the Richardson Review (below) as a matter of priority: That the Tasmanian and Australian Governments (including health and education departments), the private health sector, the University of Tasmania and the TAFE, develop and implement a long-term strategic plan that links Tasmania’s health care education and workforce needs, including: o exploration of different models of professional education across all sectors; o use of flexible delivery to increase and improve access throughout the State for all professions; o the strengthening of the links between service delivery, education, audit, and research; and o examination of means for improving the retention of health care professionals after they have completed their training. 26 Access Economics, Population Ageing and the Economy, 2001. 160 Clinical Services Plan • Invest in recruitment and retention strategies to minimise the leakage of health professionals from the Tasmanian health workforce, and reduce Tasmania’s dependency on overseas trained professionals and locums. Strategies include: o a review of Department of Health and Human Services’ recruitment processes, whether this is aligned to recruitment opportunities, and, if required, a complementary realignment of processes to support planned and opportunistic recruitment (noting for example that up to half of new nursing graduates are unable to gain employment in Tasmania); o increased decision making capacity for the major acute public hospitals under the direction of a strategic framework set out by the Department of Health and Human Services; o reconfiguration of public acute services to enable effective recruitment of critical workforce mass, and to improve working conditions and the overall sustainability of the existing workforce (eg by reducing excessive work hours, demand for on call roster); o investment in health infrastructure recognising that high quality facilities are an important component of recruitment and retention; o develop a state-wide strategy for the use of locums, agency staff and alternatives; o support opportunities for further education, professional development, and accreditation; o strengthening partnerships between the Department of Health and Human Services and the University of Tasmania; o innovative workforce incentives; o increased support for new graduates, including targeted transition programs for entry into the workforce; and o a review of career pathways and opportunities for enhancement. • Invest in quality improvement processes to support health workforce recruitment and retention, including: o improved entry processes upon employment to the health system including comprehensive orientation processes; o improved processes for performance review; and o improved exit processes upon exit from the health system including comprehensive exit interviews, and mechanisms for this information to be incorporated into an overall strategic workforce framework. • Optimise undergraduate and postgraduate training opportunities for health care professionals by: o Pursuing additional training places for doctors, nurses, and allied health professionals (complemented by changing workforce roles, see below). o Expanding the number of health professional courses available locally subject to demand and economic analysis. o Encouraging the University of Tasmania to pursue strategic partnerships with interstate universities for the provision of health education and training (where courses are not available locally in Tasmania or where partnerships are required to fulfil educational requirements which are not available within Tasmania). o Continuing the focus within the Partners in Health agreement on inter-professional education and training. Clinical Services Plan 161 • Consider innovation in workforce roles and skills mix, including opportunities for skill development within existing roles, new workforce roles, and the realignment of existing roles. Roles for further investigation include: o primary care workers; o GP liaison officers working with acute facilities; o cancer care coordinators to assist cancer patients to navigate through the health system; and o advanced practitioners (for example, advanced paramedic practitioners and nurse practitioners). • For specialties which are clinician dependent or highly specialised (eg paediatric surgery), seek to formalise service arrangements with interstate clinicians to ensure the ongoing availability of services. o invest in short-term recruitment strategies targeting specialists in areas of high shortage or which are clinician dependent (for example, medical oncologists); o review equipment infrastructure supporting the clinical workforce, and in particular the allied health workforce, and where necessary, appropriate investments in equipment to support clinical staff to perform their roles and maximumise patient outcomes; and o seek to achieve and/or maintain training accreditation at all the acute hospitals. 9.2 Teaching and research interface Teaching, training and research are core elements of Tasmania’s health care system, because: • teaching, training and research all contribute to a culture and environment of inquiry, learning and reflection which is crucial to service quality; • teaching and training is vital to assure the future availability of a skilled health workforce; • engagement in teaching, training and research makes a significant contribution to the professional satisfaction of the health workforce, thereby assisting in recruitment and retention; • research enables an understanding of factors that contribute to the health and wellbeing of Tasmanians, thereby contributing to the development of the health care system over time – it can be argued that all developed health care systems have a responsibility to engage in these activities; • engagement in and publication of research enables Tasmania to contribute to the broader national health care agenda and fosters pride in the Tasmanian health care community; and • the relationship between service and education providers is fundamental to the achievement of a flexible, sustainable, and robust health care system, and teaching and research is important to support culture change in Tasmania’s health system and should be maximised. Teaching and research strategies (see also Workforce Strategies, Section 9.1) The following teaching and research strategies are based on consultation with key stakeholders and a collaborative approach to defining key issues. • Strengthen the Partners in Health agreement as the vehicle to drive the strategic relationship and framework for teaching and research in Tasmania and broaden it to include partnership arrangements with primary health and community service providers. • Optimise existing undergraduate and postgraduate training opportunities, and review the viability of providing new training courses to meet Tasmania’s health care needs. 162 Clinical Services Plan • Develop a formal strategy for health research for Tasmania, which is focused on the needs of Tasmanians and Tasmania’s health care system, and builds up the evidence base for clinical practice. This could be incorporated into the Partners in Health agreement. • Implement sections of Recommendation 6.1 of the Richardson Review relevant to teaching and research as part of the long-term strategic plan referred to in Section 9.1 (workforce): o increase accredited trainee positions in the state, in particular target Tasmanian graduates; o strengthen the links between service delivery, education, audit, and research; and o explore different models of professional education across all sectors. • Institute transparent reporting arrangements for teaching and research funding provided to Tasmania’s major acute public hospitals and the University of Tasmania. • Implement processes to improve and enhance the relationship between the University of Tasmania and hospital clinicians. • Include teaching and research as a key infrastructure component in all proposed services models and health facility design. • Enhance health professional training facilities and consider innovative ways of training health professionals for introduction to Tasmania (eg inter-professional simulated skills centres). 9.3 Transport and retrieval services The Department of Health and Human Services will undertake a comprehensive review of all ambulance, medical retrieval and patient transport services. Transport and retrieval service strategies • Develop a modern strategy for transport and retrieval services in response to the proposed reconfiguration of public acute services. • Consider implementing a state-wide service for central coordination of the Patient Transport Service and medical retrieval services to enhance service quality, optimise appropriate resource utilisation and improve service efficiencies. • Review innovative forms of transportation between health services, for example the potential for regular health bus transport services between acute sites. • Establish transit centres in acute hospitals to streamline bed management and improve patient transport efficiency. • Develop a strategy for the retention of volunteer ambulance service providers and develop targeted strategies for the recruitment and retention of paramedic officers. • Review training opportunities for new Tasmanian Ambulance Service staff and for continuing professional development, reaccreditation, and skills training for all staff. • Review existing appointment booking and hospital discharge policies and identify opportunities to support patients to access services and to return to their place of residence following treatment. 9.4 Accommodation Patients may face significant difficulties in accessing health services because of age, mobility, long distances, the presence of disease or illness, and a lack of family or carer support. Other international and Australian jurisdictions have developed a range of patient and carer accommodation models. Examples include complexes with self-contained rooms and or shared facilities established by cancer societies and associations to support care for cancer patients; and medi-hotel type arrangements for patients with or without a carer in residence. Clinical Services Plan 163 The medi-hotel approach used in Victoria, for instance, operates principally as an alternative patient accommodation for people who do not need 24-hour nursing supervision and therefore do not need to stay overnight in hospital. People in this type of accommodation must be self-managed and may have a carer staying with them. In addition to accommodation support, the scheduling of appointments needs to be arranged systematically so that collaboration between different health professionals to group health visits can be arranged consecutively. The time of clinical consultation or treatment should be allocated according to the patient’s travelling arrangements, to minimise unnecessary overnight stays for patients. Service strategies • Review innovative options for providing accommodation services to patients, and their family/ carer. • Invest in accommodation options in or near public acute hospitals and health facilities. • Consider the development of a medi-hotel in Tasmania, in particular in the scope of the RHH redevelopment. 9.5 Information and communication technology High-quality information and communication technology is critical for the delivery of high quality, efficient, effective and sustainable health services. Service strategies Over the next five years the E-Health priorities for the Department of Health and Human Services are to implement an integrated suite of client management information systems across the care continuum, which are supported by a quality ICT infrastructure, training and support service. These include: • Integrated state-wide Patient Administration System (including Bed Management). • Integrated state-wide Pharmacy System. • Integrated state-wide Picture Archiving Computer System (PACS) and Radiology Information System (RIS). • Integrated state-wide Community Health Client Management Information System. • Integrated state-wide Human Services Client Management Information System. • State-wide Oncology Decision Support System. • Enhanced connectivity and remote monitoring between Emergency, Critical Care, Cardiology and Neurology Services state-wide. • Evaluation and extension of the RHH Digital Medical Record System across all Hospitals. • Clinical Information Portal (Decision Support at the point-of-care). • Order entry Systems (Diagnostic tests and result reporting). • Telehealth systems supporting direct clinical care and remote diagnostic capability. • Extension of the Electronic Incident Management System into Community Health. • State-wide network infrastructure upgrades. • State-wide desktop fleet management service and training program. The E-Health priorities will be delivered by the following work programs: • Client Management Information Systems Acquisition & Implementation Program. 164 Clinical Services Plan • eHealth Integration and Interoperability Program. • Organisational enabler Information Systems Program. • Information Management Quality and Standards Program. • IT Service Management Program. • Infrastructure Improvement Program. • VirtualCare@Tas Program. Clinical Services Plan 165 10. Bibliography Access Economics, Population Ageing and the Economy, 2001. Acute Health Services: An Overview of Structure and Governance. AIHW, Cancer AIHW, Cancer Incidence Projections, Australia 2002-2011 (supplementary information Tasmania). American Society for Bariatric Surgery, Rationale for the surgical treatment of morbid obesity, updated November 23, 2005 (available at http://www.asbs.org/html/patients/rationale.html). AMWAC, Specialist Obstetrics and Gynaecologist Workforces in Australia (2004). AMWAC, Sustainable Specialist Services: A Compendium of Requirements, 2004. AMWAC, The Cardiothoracic Surgery Workforce in Australia, 2001. ANZCA, Guidelines for Hospitals seeking College Approval of Posts for Vocational Training in Diving and Hyperbaric Medicine, 2002. ANZICS, Review of Intensive Care Resources and Activity 2002-03. Applying Australian Medical Workforce Advisory Committee Medical Specialist Population Benchmarks to Tasmania August 2006. Australasian College of Emergency Medicine – Hospital ED Services for Children 10-28-2005. Australian and New Zealand Society of Nuclear Medicine Inc, Application for Accreditation as a site for advanced training in nuclear medicine in 2007 (http://www.anzapnm.org.au/qaprograms/ts_annual_ report_20052007.pdf). Australian and New Zealand Society of Nuclear Medicine Inc, Technical Standards Subcommittee, Interim Recommendations for PET accreditation (Technical Aspects). Australian Bureau of Statistics, Australian Demographic Statistics, Catalogue no. 3101.0. Australian Bureau of Statistics, Census of Population and Housing 2001. Australian Department of Health and Ageing, Aged Care Stocktake of Places, 2006. Australian Department of Health and Ageing, Medicare Statistics, available at http://www.health.gov. au/internet/wcms/publishing.nsf/Content/Medicare+Statistics-1. Australian Government, Medicare Australia, Statutory Declaration Instructions for PET services. Australian Health Ministers Conference, National Health Workforce Strategic Framework, April 2004. Bridging the Gap, Mental Health Services Review, 2004. Business Plan for Radiation Oncology 2004-05 to 2009-10 (Internal Document: February 2004). Cardiac Services in the Northern Territory, 2006 to 2015. Cardiology Services Tasmania Business Plan (Internal Document: February 2004). Centre for Health Service Development, Palliative Care in Tasmania: current situation and future directions, June 2004. 166 Clinical Services Plan Clinical Need paper: Overview of Health System and Morbidity Patterns in Tasmania (Internal Document: August 2003). Department of Health and Ageing Consultations for the way forward on PET’, October 2005. Department of Health and Human Resources, Tasmania Together. Department of Health and Human Services, Tasmania, Directions in Services for People Living with Dementia 2007-2010. Department of Health and Human Services, Tasmania, Maternity Services Strategic Plan 2005-2008. Department of Health and Human Services, Tasmania, Primary Health Services Plan, 2007. Department of Health and Human Services, Tasmania, Strengthening the Prevention and Management of Chronic Conditions, Policy Framework, 2005. Department of Health and Human Services, Tasmania, A Strategic Framework for State-wide Cancer Service (draft version 1.1January 2007). Department of Health and Human Services, Tasmania, Aboriginal Health and Wellbeing Strategic Plan, 2005. Department of Health and Human Services,Tasmania, Corporate Plan 2003-2006. Department of Health and Human Services, Tasmania, Diabetes Pathways Clinical Focus Group Paper, Final. Department of Health and Human Services, Tasmania, Draft Business Case for a PET-CT scanner, 2007. Department of Health and Human Services, Tasmania, Epidemiology of Diabetes in Tasmania, 2003. Department of Health and Human Services, Tasmania, fit Program 2006. Department of Health and Human Services, Tasmania, Mental Health Services Strategic Plan 2006- 2011. Department of Health and Human Services, Tasmania, NorthWest Tasmanian Emergency Departments, Review of the Management of Trauma and Critically Ill Patients. Department of Health and Human Services, Tasmania, Palliative Care in Tasmania: current situation and future directions, June 2004. Department of Health and Human Services, Tasmania, Primary Health Services Plan, 2007. Department of Health and Human Services, Tasmania, Review of Hospital Services in the North West (the ‘Cameron Report’). Department of Health and Human Services Tasmania, Rural Hospitals Role Delineation Project 2003. Department of Health and Human Services, Tasmania, Rural Hospitals, Service Capability Framework, Version 2, 2006. Department of Health and Human Services, Tasmania, State-wide Strategic Plan for Rehabilitation Services in Tasmania, 2003. Department of Health and Human Services, Tasmania, Strengthening the Prevention and Management of Chronic Conditions, Policy Framework, 2005. Clinical Services Plan 167 Department of Health and Human Services, Tasmania, Tasmanian Health Services Plan 2007. Department of Health and Human Services, Tasmania, Tasmanian Renal Services, Current and Future Service Provision (draft – work in progress, September 2006). Department of Health Western Australia Clinical Services Consultation 2005: Clinical Services Framework Definitions. Department of Health and Human Services, Aged Care and Rehabilitation Services Plan. External Review of the NWRH Department of Emergency Medicine (Internal Document: July 2003). Halm, E., Lee, C., Chassin, M, Is Volume Related to Outcome in Health Care? A Systematic Review and Methodologic Critique of the Literature, Annals of Internal Medicine, September 2002, Volume 137, Issue 6. Healthy Hospitals come from Healthy Debate: A Review into Key Issues for Public and Private Hospital Services in Tasmania. Issues paper for public discussion. Improvements in Cancer Staging with PET/CT: Literature-Based Evidence as of September 2006’ (Johannes Czernin, Martin Allen-Auerbach, and Heinrich R. Schelbert); The Journal of Nuclear Medicine, Vol 48, No. 1 (Suppl), January 2007. Jain, K.K, Summary of International Indicators for HBO, Textbook of Hyperbaric Medicine. Menzies Research Institute website (http://www.menzies.utas.edu.au/aboutus.html). Neurology Services Tasmania: Business Plan (Internal Document: March, 2004). NSW Health (2002) Guide to the Role Delineation of Health Services (Third Edition) State-wide Services Development Branch: Sydney. Obstetrics and Midwifery Services Report to Government, November, 2004 (The Alexander Report). Pharmacologic and Surgical Management of Obesity in Primary Care: A Clinical Practice Guideline from the American College of Physicians, American College of Physicians, Annals of Internal Medicine 2005, 142: 525-531. Recruitment and Retention of Health Professionals Working Group. Summary of Issues facing Retention and Recruitment of Health Professionals, 2006. Responses to Clinical Services Plan Issues Paper, 2007. Review of Tasmanian Medical Retrieval Services, Final Report, August 2003. Smith, G. Increasing Demand for Radiation Oncology Services in Tasmania 2005-06 to 2009-10. Strengthening the Prevention and Management of Chronic Conditions, Policy Framework, 2005. Tasmanian General Practice Divisions Limited, Census of Tasmanian General Practitioners, October, 2006. Tasmanian Neonatal Care Review 2005. Tasmanian Plan for Positive Ageing 2006-2011. Tasmanian Radiation Oncology Skill Mix and Work Analysis Final Project Report (Internal Document: March, 2005). 168 Clinical Services Plan Tasmanian Renal Services, Current and Future Service Provision (draft – work in progress, September 2006). The Cardiac Society of Australia and New Zealand, Recommended Guidelines for Subspecialty Training in Adult Cardiac Electrophysiology. The Role and Development of Brachytherapy Services in the United Kingdom, Board of Faculty of Clinical Oncology, The Royal College of Radiologists, 2001. http://www.rcr.ac.uk/docs/oncology/pdf/ brachytherapy.pdf. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Certification in Gynaecological Oncology, Training Program Handbook, 2007. The Royal College of Anaesthetists, Guidelines for the Provision of Anaesthetic Services. The Tasmanian Hospital System: Reforms for the 21st Century. Report of the Expert Advisory Group Review into Key Issues for Public and Private Hospital Services in Tasmania, May, 2004 (The Richardson Report). The Tasmanian Hospital System: Reforms for the 21st Century. Report of the Expert Advisory Group Review into Key Issues for Public and Private Hospital Services in Tasmania, May, 2004 (The Richardson Report). UK DOH, Specialised Services National Definitions Set (2nd edition), 2007. Victorian Government Department of Human Services Care in your community: A planning framework for integrated ambulatory health care, Melbourne, 2006. Eddie Lau, W.F., Binns, D.S., Ware, R.E, Ramdave, S., Cachin, F., Pitman, A.G., and Hicks, R.J. Clinical experience with the first combined positron emission tomography/computed tomography scanner in Australia. Medical Journal of Australia 2005, 182 (4); 172-176. Clinical Services Plan 169 11. Tables Table 1: Estimated resident population, Sex, Tasmania, June 2006 12 Table 2: Estimated resident population, Age, Tasmania and Australia, June 2006 12 Table 3: Analysis of projected resident population, Tasmania, 2006 to 2021 12 Table 4: Projected population by planning region, 2006 to 2021 12 Table 5: Current and Projected Population, Population by Age Group, asmania and Regions, 2006 and 2021 14 Table 6: Current and Projected Population, Proportion of Population by Age Group, Tasmania and Regions, 2006 to 2021 15 Table 7: Number and Proportion of Indigenous Population, Region, Tasmania, 2001 16 Table 8: Socio-Economic Index of Disadvantage, State and Territory, 2001 17 Table 9: Life expectancy at birth by sex and state and territory, 2002-2004 18 Table 10: Health risk factors, Tasmania and Australia, various years 18 Table 11: Morbidity and disease prevalence, percentage of population, asmania and Australia, 2004-05 19 Table 12: Leading causes of hospitalisation in Tasmania, 2000 to 2004 19 Table 13: Separation rate per 1,000 population for ambulatory care sensitive conditions, chronic conditions, Tasmania and Australia, 2004-05 20 Table 14: Standardised mortality rate, Tasmania and Australia, 2000 to 2005 20 Table 15: Infant mortality rate (per 1,000 live births), Tasmania and Australia, 2000-2005 21 Table 16: Leading causes of mortality in Tasmania, 2004 21 Table 17: Age-standardised death rates, selected causes of death,, Tasmania and Australia, 2004 22 Table 18: Royal Hobart Hospital Activity, 2000-01 to 2005-06 24 Table 19: Launceston General Hospital Activity, 2000-01 to 2005-06 24 Table 20: North West Regional Hospital Activity, 2000-01 to 2005-06 25 Table 21: Number and type of ambulance station by region, 2006 26 Table 22: Aged care places, ACAT region, 2006 27 Table 23: Residential aged care places, CACPs, and EACH packages per 1,000 persons aged 70 years and over, Tasmanian ACAT region, 30 June 2006 28 Table 24: Resident utilisation of acute services, sector, 2000-01 and 2004-05 29 Table 25: Resident utilisation of acute services, age group, 2000-01 and 2004-05 29 Table 26: Resident utilisation, adult medical services, 2000-01 and 2004-05 30 Table 27: Resident utilisation, adult surgical services, 2000-01 and 2004-05 31 170 Clinical Services Plan Table 28: Resident utilisation, paediatric services, 2000-01 and 2004-05 31 Table 29: Resident utilisation, obstetric services, 2000-01 and 2004-05 32 Table 30: Resident utilisation, separations for births, 2000-01 and 2004-05 32 Table 31: Adult medical services, major acute public hospitals and public contracts, 2000-01 and 2004-05 34 Table 32: Adult surgical services, major acute public hospitals and public contracts, 2000-01 and 2004-05 35 Table 33: Emergency Department presentations, major acute public hospitals, 2000-01 and 2005-06 37 Table 34: Obstetric services, major acute public hospitals and public contracts, 2000-01 and 2004-05 38 Table 35: Births, major acute public hospitals and public contracts, 2000-01 and 2004-05 38 Table 36: Paediatric services, major acute public hospitals and public contracts, 2000-01 and 2004-05 40 Table 37: Gynaecology separations and beddays, major acute public hospitals and public contracts, 2000-01 and 2004-05 40 Table 38: Adult medical oncology separations and beddays, major public acute hospitals and public contracts, 2000-01 and 2004-05 41 Table 39: Adult chemotherapy separations and beddays, major public acute hospitals and public contracts, 2001-02 and 2004-05 42 Table 40: Number of brachytherapy treatments, LGH, 2000 to 2006 42 Table 41: Adult haematology separations and beddays, major public acute hospitals and public contracts, 2000-01 and 2004-05 43 Table 42: Linear accelerator attendances, RHH and LGH, 2000 to 2006 44 Table 43: Allied Clinical outpatient occasions of service, 2005 and 2006 45 Table 44: Clinical workforce overview, RHH, 2007 47 Table 45: Clinical workforce overview, LGH, 2007 47 Table 46: Clinical workforce overview, NWRH Burnie, 2007 48 Table 47: Clinical workforce overview, NWRH Mersey, 2007 48 Table 48: Number of patient transport services, 2001-02 to 2005-06 51 Table 49: Number of PTAS services, 2001-02 to 2005-06 51 Table 50: Summary of adjustments to projections of acute inpatient demand 56 Table 51: Projected resident demand, separations and beddays, sector, 2004-05 and 2021-22 57 Table 52: Projected resident demand, South, 2004-05 and 2021-22 57 Table 53: Projected resident demand, North, 2004-05 and 2021-22 58 Clinical Services Plan 171 Table 54: Projected resident demand, North West, 2004-05 and 2021-22 58 Table 55: Projected outpatient occasions of service, region, 2006 to 2021 64 Table 56: Projected outpatient occasions of service, tier, 2006 to 2021 65 Table 57: Projected outpatient occasions of service, region, 2006 to 2021 65 Table 58: Projected outpatient occasions of service, tier, 2006 to 2021 65 Table 59: Service Capability Framework for Acute Hospital Services 70 Table 60: Projected inpatient activity, separations and beddays, RHH base case, 2004-05 to 2021-22 80 Table 61: Projected inpatient activity, separations and beddays, RHH adjusted for development of two integrated care centres, 2004-05 to 2021-22 81 Table 62: Estimated inpatient activity, 2004-05 to 2021-22, Eastern Shore integrated care centre in Hobart 82 Table 63: Estimated inpatient activity, 2004-05 to 2021-22, Kingborough integrated care centre 82 Table 64: Projected inpatient activity, LGH, 2004-05 to 2021-22, baseline estimates 83 Table 65: Projected inpatient activity, LGH with Launceston integrated care centre and enhanced referral role for North and North West, 2004-05 to 2021-22 84 Table 66: Projected inpatient activity, Launceston integrated care centre, 2004-05 to 2021-22 84 Table 67: LGAs for the North West of Tasmania 87 Table 68: Services to be provided from the Burnie and Mersey campuses of the North West Regional Hospital 95 Table 69: Estimated inpatient activity, 2004-05 to 2021-22, Burnie Campus 96 Table 70: Projected emergency service presentations, by place of treatment, 2004-05 to 2021-22 97 Table 71: Estimated inpatient activity, 2004-05 to 2021-22, Burnie Campus 99 Table 72: Estimated inpatient activity, 2004-05 to 2021-22, Mersey Campus 99 Table 73: Summary description of state-wide and single site service strategies 101 Table 74: Number of interstate cardiac electrophysiology procedures funded by the Patient Transport Assistance Scheme, 2003-04 to 2005-06 107 Table 75: Projected resident demand for cardiothoracic surgery, 2004-05 to 2021-22 108 Table 76: Number of PTAS-compensable trips to Victoria for PET scans 113 Table 77: Linear accelerator attendances, RHH and LGH, 2000 to 2006 113 Table 78: Renal Dialysis Patients 115 Table 79: Projected resident demand for vascular surgery, 2004-05 to 2021-22 116 Table 80: Projected resident demand, adult medical activity by sector, 2004-05 to 2021-22 118 Table 81: Projected resident demand, adult medical public hospital activity by region, 2004-05 to 2021-22 119 172 Clinical Services Plan Table 82: Projected resident demand, public hospital cardiology activity by region, 2004-05 and 2021-22 122 Table 83: Place of treatment for renal dialysis patients by capacity, no. of patients and location, 2006 125 Table 84: Projected resident demand, renal dialysis public hospital activity by region, 2004-05 and 2021-22 125 Table 85: Projected resident demand, renal medicine public hospital activity by region, 2004-05 and 2021-22 126 Table 86: Projected resident demand, public hospital endocrinology activity by region, 2004-05 and 2021-22 128 Table 87: Projected resident demand, pubic sector respiratory medicine activity by region, 2004-05 and 2021-22 131 Table 88: Projected resident demand, pubic sector neurology activity by region, 2004-05 and 2021-22 132 Table 89: Projected resident demand, adult surgical separations, 2004-05 and 2021-22 134 Table 90: Projected resident demand, adult surgical separations, 2004-05 and 2021-22 134 Table 91: Percentage share of projected resident demand, adult surgical separations, sector, 2004-05 and 2021-22 135 Table 92: Projected resident demand, adult surgical separations, 2004-05 and 2021-22 135 Table 93: Projected births, Tasmania by method of estimation, 2004-05 to 2021-22 138 Table 94: Projected births, Tasmania by place of birth, 2004-05 to 2021-22 139 Table 95: Projected paediatric inpatients , Tasmania, by sector and stay type, 2004-05 to 2021-22 143 Table 96: Projected paediatric inpatients, Tasmania, by place of treatment, 2004-05 to 2021-22 144 Table 97: Projected paediatric inpatients, North West by place of treatment, 2004-05 to 2021-22 144 Table 98: Benchmarking of supply of Intensive Care Beds by sector, Tasmania and Australia, 2003 146 Table 99: Model for delivery of cancer services 149 Table 100: Projected haematology activity, by region, 2004-05 and 2021-22 151 Table 101: Projected chemotherapy activity, by region, 2004-05 and 2021-22 152 Table 102: Projected resident demand, public sector rehabilitation activity by region, 2004-05 to 2021-22 155 Clinical Services Plan 173 12. Figures Figure 1: Catchment areas 11 Figure 2: Projected resident population by LGA, 2006 and 2021 13 Figure 3: Projected Change (%) in Resident Population 2006 and 2021 15 Figure 4: Socio Economic Index of Disadvantage, Tasmanian LGAs, 2001 17 Figure 5: Resident utilisation of acute services by age group as a proportion of total services, 2004-05 30 Figure 6: Ambulance services by region of residence, 2003-04 to 2005-06 50 Figure 7: Ambulance services by urgency category 2003-04 to 2005-06 50 Figure 8: South resident demand, place of treatment, 2004-05 and 2021-22 59 Figure 9: North resident demand, place of treatment, 2004-05 and 2021-22 60 Figure 10: North West resident demand, place of treatment, 2004-05 and 2021-22 61 Figure 11: State-wide projected resident demand for emergency department presentations, 2005-06 to 2021-22 62 Figure 12: Regional projected resident demand for emergency department presentations, 2005-06 to 2021-22 62 Figure 13: Current and projected emergency department presentations by age group, 2005-06 and 2021-22 63 Figure 14: Projected emergency department presentations, service related groups, 2005-06 and 2021-22 64 Figure 15: Current and projected resident demand by LGA, South region, 2004-05 and 2021-22 (inpatient separations, excludes renal dialysis & neonates) 79 Figure 16: Current and projected resident demand by LGA, North region, 2004-05 and 2021-22 (excludes renal dialysis & neonates) 83 Figure 17: North West public hospital resident demand by place of treatment, 2004-05 (ex. renal dialysis & unqual. neonates, n=20,342) 87 Figure 18: Current and projected North West resident demand by place of treatment 88 Figure 19: Number of presentations to LGH by NW LGA residents 90 Figure 20: Annual DEM LGH Attendances excluding residents in the North by Origin 93 Figure 21: Cancer incidence Tasmania, age and sex, 2003 150 174 Clinical Services Plan 13. Abbreviations ABS Australian Bureau of Statistics ACAT Aged Care Assessment Team ACMI Australian College of Midwives Incorporated ACSC Ambulatory Care Sensitive Conditions ACT Australian Capital Territory AIHW Australian Institute of Health and Welfare ALOS Average Length of Stay AMWAC Australian Medical Workforce Advisory Committee ANZCA Australian and New Zealand College of Anaesthetists ANZICS Australian and New Zealand Intensive Care Society ASCTS Australasian Society of Cardiac and Thoracic Surgeons BMI Body Mass Index BMT Bone Marrow Transplantations CACP Community Aged Care Packages CCU Coronary Care Unit CF Cystic Fibrosis CMO Career Medical Officer CPAP Continuous Positive Airways Pressure CT Computerised Tomography DHHS Department of Health and Human Services Tasmania DOA Dead On Arrival DoHA Department of Health and Ageing EACH Extended Aged Care in the Home ED Emergency Department ENT Ear, Nose and Throat ERP Estimated Resident Population ESSU Emergency Short Stay Unit FTE Full Time Equivalent GEM Geriatric Evaluation and Management GI Gastro-Intestinal GP General Practitioner HACC Home and Community Care HDU High Dependency Unit ICU Intensive Care Unit LGA Local Government Area LGH Launceston General Hospital MAPU Medical Assessment and Planning Unit MOU Memorandum of Understanding MRI Magnetic Resonance Imaging NETS Neonatal Emergency Transfer Service NHPAs National Health Priority Areas NICU Neonatal Intensive Care Unit NSIFs National Service Improvement Frameworks NSW New South Wales NT Northern Territory NW North West NWRH North West Regional Hospital OOS Outpatients Occasions of Service Clinical Services Plan 175 PACS Picture Archiving Communications System PECC Psychiatric Emergency Care Centre PET Positron Emission Tomography PICU Paediatric Intensive Care Unit PTAS Patient Travel Assistance Scheme QLD Queensland RACP Residential Aged Care Places RACS Royal Australasian College of Surgeons RANZCOG Royal Australian and New Zealand College of Gynaecologists RHH Royal Hobart Hospital RMO Resident Medical Officer RU Relative Utilisation SA South Australia SCN Special Care Nursery SEIFA Socio-Economic Indexes for Area SLA Statistical Local Area Tas Tasmania TAS Tasmanian Ambulance Service TCGS Tasmanian Clinical Genetics Service UK DOH United Kingdom Department of Health Vic Victoria WA Western Australia 176 Clinical Services Plan 14. Glossary of Terms Age-standardised A set of techniques used to remove as far as possible the effects of differences in age when comparing two or more populations. Admitted patient A patient who undergoes a hospital’s formal admission process to (or inpatient) receive treatment and/or care. This treatment and/or care is provided over a period of time and can occur in hospital and/or in the person’s home (for hospital-in-the-home patients). Ambulatory Care Hospitalisations that are thought to be avoidable if timely and adequate sensitive conditions non-hospital care, such as GP or primary care, is provided. Also referred to as avoidable hospitalisations. Average length of stay The average number of patient days for admitted patient episodes. Patients admitted and separated on the same day are allocated a length of stay of one day. Beddays A bed day (or patient day) represents the number of full or partial day stays for patients who separated from hospital during the reporting period. Day only separation Admitted patients who are admitted and separate on the same date. Paediatric Refers to children generally aged 14 years or under. Role delineation A process that determines what support services, staff profile, minimum safety standards and other requirements are provided to ensure that clinical services are provided safely and appropriately supported. Separation An episode of care for an admitted patient, which can be a total hospital stay (from admission to discharge, transfer or death), or a portion of a hospital stay beginning or ending in a change of type of care (for example, from acute to rehabilitation). Separation also means the process by which an admitted patient completes an episode of care either by being discharged, dying, transferring to another hospital or changing type of care. Service Related Group This classification categorises admitted patient episodes into groups representing clinical divisions of hospital activity. service related groups are used to assist the planning of services, in analysing and comparing hospital activity, examining patterns of service needs and access, and projecting potential trends in services. Clinical Services Plan 177 15. Appendices For a full list of appendices please refer to www.health.tas.gov.au. 178 Clinical Services Plan 0 For more information on Tasmania’s Health Plan Freecall 1300 795 311 or visit www.health.tas.gov.au
Clinical Services Plan May 2007
