Strategic Framework for the Modernisation of Tertiary Hospital Services

DISCUSSION DOCUMENT

STRATEGIC FRAMEWORK FOR THE MODERNISATION OF TERTIARY HOSPITAL SERVICES

Modernisation of Tertiary Services Project Team National Department of Health May 2003

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

CONTENTS

Page Introduction 3 Objectives of the Strategic Framework Document 4 Future Trends and Likely Developments 4 An Enabling Framework for the Modernisation of Tertiary Services 7 - Human Resources – Recruitment & Retention 8 - Human Resources – Training & Skills 9 - Equipment and Infrastructure 10 - Rationing Services and Technologies 11 - Management and Organisation 12 - Transport and Communication 14 Categorising Specialties – A Planning Approach 14 Organisational Models – General Discussion 22 Strategic Planning Framework – Scenarios and Options 23 - Model A 26 - Model B 30 - Model C 34 - Model D 38 - Overview of Models 42 Next Steps 43 MTS Project Team Contact Details 44 Appendix 1: Specialty Focus Groups Held and Reports Received 45 Appendix 2: Organisational Models – Ideal Scenario 46 Appendix 3: Organisational Models – Pessimistic Scenario 62 Appendix 4: Minimum Staffing Requirements for an Ideal Unit 78

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Introduction

The Modernisation of Tertiary Services (MTS) Process seeks to develop a consensus on the appropriate future direction of tertiary and highly specialised care in the South African public health system. Its aim is to ensure that Government can plan for and provide affordable and efficient tertiary health care of the highest quality, which can be accessed by all South Africans, wherever they may live in our country and whoever they may be. By working with specialists across all disciplines, with health sciences faculties, other Government departments and many other stakeholders, the Department of Health aims to identify how best to modernise and upgrade our tertiary services, while taking into account the economic, social and epidemiological realities which face South Africa today and in the years to come. Through this work, we wish to develop a common vision for tertiary care, which can be shared within the health community and with the wider public to ensure their support in preparing our major hospitals to face the future.

Between August and October 2002, the Modernisation of Tertiary Services team of the National Department of Health convened a series of workshops, which brought together public sector clinical experts from fifty specialties and sub-specialties from across the country. The purpose of the first round of workshops was to brief participants on the MTS process as a whole, and to provide each specialty and sub-specialty group with an opportunity to debate in detail the current status and likely future of their field. Groups were asked to provide a detailed written report on the outcomes of their discussions, using a structured reporting format. Fifty separate reports were completed and submitted to the MTS Project Team (a full list is provided at Appendix 1).

All the reports received have been the subject of detailed analysis by the MTS Project Team. They contained a wealth of detail, insight and innovative and exciting proposals to stabilise and strengthen the public hospital sector. Throughout all the reports, and underlying all the technical and clinical minutiae they necessarily contained, the profound commitment of the participants in this process to strengthening the accessibility and the quality of specialised health services for ordinary South Africans shone through clearly. The MTS Project Team used these specialty reports as the basis for a first draft of this document – the Draft Strategic Framework. The Draft Strategic Framework was disseminated to all specialty group members, and a second round of workshops was held during February and March 2003. The second round workshops aimed to provide specialty groups with an opportunity to provide feedback on the Draft Strategic Framework itself, and to revise and improve their earlier reports in the light of the contents of the DSF. The second round also afforded the opportunity to involve a larger number of participants, as a number of

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES specialists had not been able to attend the first round of workshops. Groups were set a deadline of the end of March to submit their comments on the DSF, and to provide revised versions of their earlier reports. By the end of April, all groups had succeeded in providing these inputs, allowing the MTS Project Team to finalise the Strategic Framework, which is presented here.

Objectives of the Strategic Framework Document

This document, the “Strategic Framework”, is the product of our analysis of the written outputs of the specialty workshops. Its purpose is to extract the critical messages and information from each of the report, and to synthesise them into a set of specific options and scenarios, and thus to generate a small number of alternative visions of the development of the public tertiary hospital system over the next decade. Considerable further quantitative modelling will be performed on these basic scenarios (especially with regard to their investment requirements and cost implications); from that basis, it will then be possible to conduct a detailed option appraisal, and to allow an informed public and political debate, with the ultimate aim of agreeing a long-term national plan for this sector. The Strategic Framework does not itself constitute either a “plan” or a policy in its own right. Rather, it is a distillation of the key challenges and choices, which a plan for the development of the public hospital system will have to face, and resolve, and is an intermediate step towards developing such a plan. Having been subjected to detailed discussion and revision during the second round specialty workshops, and by a parallel workshop of hospital managers and planners, it is now appropriate that the Strategic Framework receive broader discussion by a wider set of stakeholders and service users.

Future Trends and Likely Developments

Specialty groups each spent some time considering the key trends and developments they felt would be likely to influence their discipline over the next decade. At the level of specific diseases and technologies, their reports are obviously detailed and specific to their own discipline. However, it is useful to attempt to extract the more important generic themes which emerged from the “futures scanning” exercise; indeed, it is striking that a few very clear common themes run across almost all specialties.

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Demand Factors Specialties examined the likely future need and demand for their services, with many providing supporting documents to illustrate and expand the summary presented in their reports. It is hard to do justice to the wealth of information presented in the individual reports, but at the grossest level a few crucial themes emerge. Most importantly, at the epidemiological level, the reports together present a clear picture of a society facing a triple epidemiological burden: • Communicable diseases and diseases of poverty are still a major burden in South Africa, most crucially the HIV/AIDS and TB epidemics (although these are by no means the only culprits); these diseases have a significant impact on tertiary services, despite efforts to manage them at primary and secondary level. • Non-communicable diseases reflecting the demographic and epidemiological transition (sometimes referred to as “diseases of affluence”, in reality a strikingly inappropriate misnomer) are predictably increasing as the population grows older and more urbanised; key diseases in this category include coronary heart disease, stroke, diabetes, lung cancer, breast cancer, and rheumatoid arthritis (to name but a few of the more prominent examples). The very fact of an ageing population itself requires the availability of geriatric services properly aligned with the needs of older people. • South Africa also suffers especially severely from a third source of disease burden which is directly linked to the process of social, political and economic transition itself – in the broadest sense, the epidemic of trauma and injury which has accompanied rapid social change. Clearly, the key drivers of this epidemic are injuries from road traffic accidents and injuries from intentional violence (domestic and sexual violence, alcohol-related violence, and other forms of violent crime); smaller in scale, but of great significance to specialised hospital services is the epidemic of serious burns, driven primarily by the continued use of dangerous fuels for cooking and lighting in crowded informal settlements. The secondary impacts of this epidemic on mental health are only dimly understood, but are felt by many to be of grave significance. The trauma epidemic can reasonably be expected to decline in future as specific preventative measures (e.g. road safety, crime prevention, electrification) and the benefits of general economic growth (e.g. better housing, declining crime rates) have an increasing impact. However, there are strong grounds to believe that the final peak of the injury epidemic may lie as far as ten or fifteen years in the future – and that the situation will therefore get worse before it gets better.

These three parallel groups of diseases and ill-health combine to suggest that objective measures of “need” for health services in the South African population will continue to rise for several years. Communicable diseases and the epidemic of injury can be mitigated and controlled by robust

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES preventative interventions (as, indeed, can many non-communicable diseases), but even under the very best scenarios of commitment to controlling these problems, it would be some years before a definitive turning point can be reached. Even then, reductions in expenditure and health care infrastructure would only conceivably become possible some years after a downward trend in either group of epidemics had been clearly established – and would most likely be offset by the growing pressures of ageing and non-communicable diseases.

In common with developed country health systems, many specialties note that patients are becoming more assertive in demanding health care. In the case of South Africa, this represents a highly desirable break with the past, and reflects an improved understanding by the majority of the population of their rights and entitlements. However, such “consumerism” does place an additional workload on the public health system; raised expectations of service require both improved practices and improved resources if they are to be achievable or sustainable.

A final demand factor, which may be important in years to come, is the continuing evolution of the medical schemes and private health care industry. Deliberate attempts to encourage utilisation of public hospitals by medical scheme members are beginning to bear fruit; while this initiative obviously provides revenue to cover the costs of such care, it will also increase the workload of public hospitals (especially in the tertiary centres, which are most acceptable to private patients). Less predictably, it is conceivable that medical scheme cover will start to become too expensive for many current members, leading them to drop out of private cover and into the state system. Alternatively, moves towards social health insurance or national health insurance might expand medical scheme cover, or radically change the basis of health funding nationally.

Supply Factors The futures scanning exercise looked in detail at the likely technological developments to be expected in each specialty over the next decade. This clearly generated a mass of detail, which cannot easily be presented in summary form, although key factors will be incorporated into the scenarios for each individual specialty. In brief, the most important likely developments reported were as follows: • Improved capabilities in diagnostic imaging were regarded as being of great importance by a majority of specialties. They referred mainly to technologies which are already available internationally, but which are either limited in their deployment or not yet available in South Africa, especially multi-slice CT scan, MRI scan and PET scan. • New drugs predictably attracted attention from certain specialties – although it is striking that attention focused overwhelmingly on introducing or expanding access to drugs that are

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

already in widespread use overseas (e.g. statins, ACE inhibitors, antiretrovirals etc.), but which have to date been regarded as beyond the means of the South African public health system; there was apparently little expectation that truly new drugs would make much of an impact in the next decade. A number of specialties also sounded a cautionary note on the worldwide trend of increasing antibiotic resistance among both community-acquired and nosocomial infections; the magnitude of this problem appears set to continue to grow, with little prospect of a breakthrough in new anti-microbials. • Several specialties regarded improvements in our understanding of the genetic basis of disease as likely to be important in the coming decade – although all agreed that this field is rather unpredictable. It seems clear that screening technology will advance rapidly, but opinions differ as to the likely utility of much genetic screening for disease susceptibility; and many feel that the use of genetics for therapeutic purposes remains some way off, while others contend that important breakthroughs are imminent. • Increased use of minimally invasive procedures seems to be a safe bet in many surgical disciplines; similarly, new imaging technologies offer the prospect of reducing invasive diagnostic procedures (such as angiography) in certain disciplines. • Developments in information technology and telecommunications were generally seen as likely to be an important force in the coming decade. Likely developments range from the transition to digital (film-free) imaging and data transmission, through electronic patient records, to wide-scale use of telemedicine, remote consultation, and even robotics in some areas of surgery. Indeed, other than developments in diagnostic imaging technologies, most specialties’ discussion of likely developments in clinical equipment seem to be dominated by IT and computerisation of existing functions, rather than the introduction of wholly new processes.

An Enabling Framework for the Modernisation of Tertiary Services

In order to improve the quality and sustainability of tertiary hospital services, different specialties and disciplines will clearly require different emphases and tailored planning solutions. Nonetheless, a number of very important common themes are clearly visible in the specialty reports, and these themes will require common solutions. These broad themes are: • Human resources • Equipment and infrastructure • Management and organisation

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

• Transport and communications This section identifies the most frequent and/or important improvements proposed by specialty groups to some of the problems that currently inhibit the revitalisation of tertiary services; it also identifies a few issues on which the views of specialty groups were contradictory or ambiguous.

Perhaps two messages stand out most clearly from the reports submitted. The first can be paraphrased as “humans before hardware” – namely, while important problems exist in relation to equipment and infrastructure, their solution would achieve little or nothing if the crucial human resources questions cannot be answered successfully. The second is that the functionality and future development of both regional hospital and tertiary level services are inextricably interdependent. Failure in one level will compromise the other, and therefore development plans must proceed in tandem for both regional and tertiary hospital services. It is clearly essential that the development and planning process take both these messages to heart.

Human Resources – Recruitment & Retention

The grave problems in retaining skilled professionals within the public service were perhaps the problem most frequently cited by groups, followed by the related problem of recruiting appropriately skilled staff to serve in regional hospitals and non-metropolitan areas. Complementary proposals to alleviate these problems included the following: • General upgrading of salaries of skilled health professionals (not only medical), at all levels of the health service, making these professions more attractive to enter and to stick with • Reinstatement of small benefits which make the working environment more pleasant and which improve motivation (e.g. tea and sandwiches for staff in theatre, funding to attend conferences etc.) • Targeted incentives to attract candidates to under-staffed areas – e.g. rural allowances / “scarce skills” allowances / “hard to fill” post allowances; and that such incentives need to combine both salary and other benefits (e.g. housing subsidies, bursaries for children’s education etc) • Significant upgrading of the status of general specialists in regional hospitals and the creation of generalists posts in the tertiary level who will take responsibility for the whole patient rather than an organ system, including career pathing, increased opportunities for university joint appointments at regional hospital level, accelerated promotion etc. • Creation of new posts where there are currently shortages in key departments, especially in regional hospitals

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

• Creation of mid-career posts for doctors and improved career pathways for newly qualified specialists • Compulsory community service for newly qualified specialists (a highly contentious proposal – attractive to some groups, vigorously opposed by others) • Continuous review of RWOPS policy to ensure that it can be used as an incentive to retain talent in the public sector without undermining public services • A significant change in attitude by the HPCSA and member bodies to make it far easier for well-qualified foreign health professionals to work in South Africa (including proposals to limit registration to allow practice in the public service only) • Active advertisement of SA posts in key “brain drain” destination countries (e.g. UK, Australia, New Zealand, Canada, USA), perhaps with assistance / funding from these governments, to i) recruit back SA staff and ii) attract well-trained foreign professionals. Offering incentives or assistance with relocation costs for returning SA staff could further strengthen this. Readers should note that concrete action is already being taken on a number of these proposals (e.g. rural allowances, foreign health professionals), but the need for a multi-level response is clearly accepted.

Human Resources – Training & Skills

Clearly, training and skills development go hand in hand with recruitment and retention strategies. A number of significant improvements to training were regarded by many groups as being important foundations for the future improvement of both regional and tertiary services. Nowhere does this appear to be more urgent than in the area of improving the availability of nurses with post-basic specialised training. The shortage of nurses with specialised training appears to be a problem in virtually every specialised discipline; in some specialties this shortage is extreme (e.g. adult ICU); in others it verges on the absurd (e.g. the Paediatric ICU group reported that there are only two registered paediatric ICU nurses currently working in South Africa). Proposals to strengthen the availability of specialised nursing expertise include: • The urgent need to expand the availability of and funding for specialised nursing training (both locally, via distance learning, and through bursaries and arrangements for overseas training) • Incentivising the acquisition and updating of skills, by offering better career pathways and remuneration for nurses who acquire specialised qualifications and who continue to practice in their specialised field • End immediately the obsolete practice of regularly rotating nurses through different wards and departments; this practice (still disturbingly widespread) is seen as a near-guaranteed method of destroying team-working and preventing the acquisition of specialised expertise

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

In the area of training medical specialists, some practical improvements to the current system were proposed: • Develop a mechanism by which to link training (registrar) posts to permanent posts after qualification • Similarly, to ensure that the number of training posts offered in each discipline should be organically linked to long-term service plans for these specialties • Develop mechanisms for the sharing of a single highly specialised service unit by two or more medical schools (i.e. where it is not cost-effective for each medical school to have its “own” unit) • To train larger numbers of “general specialists” (general medicine, general surgery, obstetrics and gynaecology, paediatrics, radiology, anaesthetics), and to make these disciplines more attractive to junior doctors choosing their direction for advanced training • To establish training posts in regional hospitals, whose holders could spend some of their time under supervision in the nearest tertiary centre • Make available “quasi-specialist” training and diplomas for general specialists working in regional hospitals (e.g. cardiology or oncology diplomas for general physicians)

Finally, there is a clear need to continue to improve the availability of well-trained managers and administrative personnel, especially to improve their practical training and skills.

Equipment & Infrastructure

Specific proposals on particular equipment requirements were made by most specialties, and will be dealt with in the presentation of organisational models below. However, several generic issues will need to be dealt with in any overall framework: • There is an urgent need for a large-scale replacement of clinical equipment in most specialties, as one of the first steps in the modernisation process – under-investment in equipment replacement has resulted in an ageing, obsolescent equipment stock, a large proportion of which is not functional at any given moment • Such an equipment replacement programme must then be sustained on a rolling basis, to ensure that this backlog does not build up again in future – and must encompass both regional hospitals and tertiary hospitals

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

• All equipment must be properly maintained, and maintenance must be adequately funded; several specialties regarded annual maintenance costs in the region of 20% of original purchase price as an appropriate rule of thumb • Innovative approaches to equipment management (e.g. leasing, contracts for re-usables etc.) should be adopted, to reduce the risk of future under-funding of maintenance and replacement • Equipment utilisation rates can be greatly improved, through a combination of appropriate staffing, extended hours of operation, intelligent scheduling of patients over extended hours, and adequate funding of consumables and materials • Finally, while relating primarily to a single specialty (radiology), it is important to note that over half of all specialty reports explicitly argued for improved investment in and availability of various diagnostic imaging technologies (primarily CT Scan and MRI); this level of demand for improved imaging can legitimately be described as a generic issue

Rationing Services and Technologies

Many specialty reports dealt with the problem of “under-servicing” of the SA population relative to likely needs. Prevalence rates and/or international intervention rates were frequently cited, often indicating that the public sector may currently meet only a fraction of the likely burden of disease in various specialties. Concerns about lack of explicit guidance on difficult clinical rationing decisions were also raised in several reports. While the MTS process itself is unlikely to resolve these underlying problems (especially in the short term), it seems likely that a policy mechanism by which to address rationing dilemmas will need to be established as an adjunct to the planning and implementation process. This mechanism would need to address three recurrent themes: • Even with significant investment and expansion of services, it is highly unlikely that all “need” in all specialties will be met any time soon; therefore, the generic question of prioritising access to treatment (both at the individual and the population level) will remain highly pertinent • Certain manifestations and complications of HIV/AIDS ideally require treatment from tertiary services (e.g. Kaposi’s Sarcoma, lymphomas etc), which are well beyond the routine treatment of opportunistic infections or even antiretroviral therapy in terms of cost or complexity; specialties reporting significant direct increases in complex HIV-related workload included oncology, haematology, dermatology, neurology, paediatric gastroenterology and ophthalmology. The growing HIV load raises questions about the relative priority to be accorded to these cases versus HIV negative patients of these specialties; more widely, the HIV epidemic raises difficult questions about the extent to which – when resources are limited – HIV negative patients should or should not receive precedence over HIV positive patients for

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

expensive interventions for other conditions. There also appears to be an assumption that any future introduction of antiretroviral therapy might further change these equations (in different directions for different conditions). • Finally, several specialties noted the de facto restriction of access to expensive services for persons with congenital disorders and/or learning disabilities; the handling of this issue clearly also requires attention at a wider level.

The futures scanning exercise undertaken by the specialties gives a very clear foretaste of some of the policy decisions, which will soon be required on many different technological developments. Just some of the more expensive and imminent pressures include whether or not to expand access to statins and ACE inhibitors in adult cardiac patients; closure devices for paediatric cardiac patients; Xigris for ICU patients; and PET scanner technology. Most of these issues are well beyond the scope of the Essential Drugs List mechanisms at present. There is therefore a need to further develop the national health technology assessment capability to provide an institutional process for evaluating and developing guidelines on the introduction (or non-introduction) of expensive new technologies in the tertiary sector, in a way that is proactive and legitimate in the eyes of stakeholders. The Gastroenterology group made detailed proposals for a specialty-level committee to advise on technology uptake, but such an approach would obviously need to be system-wide.

Management and Organisation

A number of generic organisational themes also stand out from the specialty reports. These can be summarised as follows: • The need to create stronger linkages between each tertiary hospital (and individual service) and its linked network of regional hospitals, especially in the area of follow-up management and effective mechanisms to supply and fund repeat prescriptions of “tertiary” drugs at local level • The need to define these regional-tertiary networks in terms of “natural” regions based on patient flows and transport links, and not on arbitrary provincial borders • Repeated calls for funding and planning of tertiary services to be separated from provincial control and to be managed as a national function. This proposal is motivated partly by a desire to avoid arbitrary restrictions upon treating patients due to provincial boundaries (see previous point), but also due to a sense that national funding and management would be more

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

effective than that of provincial health departments. It should be noted that, while elements of this argument have very strong grounds to commend them, groups often gave a sense that they believed that national funding would somehow remove tertiary services from any form of cost control or management influence – which is clearly an unrealistic expectation! • A strong consensus that appropriate forms of outreach from tertiary to regional levels should be seen as a “normal” element of service, and not as a “special” activity • The need to end verticalised, “silo” management of medical, nursing, paramedical and administrative functions, and to move towards integrated departments or clinical directorates • The need to improve flexibility and decentralisation of decision-making on key areas which currently cause much frustration e.g. filling of posts, cost-centre management, working hours etc. • Expanding this theme, specific requests from many groups to have fully-fledged cost-centre budgeting by department / specialty, with heads of units having significant control over the management of these budgets (i.e. to allow them to prioritise within budgets, rather than having arbitrary cost control measures imposed on them externally) • Different groups appeared to have conflicting attitudes to management questions. Some wish to reduce the administrative load on clinicians, allowing them to concentrate on patient care. Others, by contrast, call for clinicians to be given much greater management responsibility over all aspects of their services, from personnel and financial issues through to direct procurement of supplies. These visions are clearly contradictory – but they do highlight a common theme of dissatisfaction with the current reality of management and administration systems • Repeated calls to establish much better systems and registries for recording disease and intervention data, to provide a basis for evaluation and planning of services in future • Most groups raised the issue of separate children’s hospitals at supra provincial tertiary level and the lack of adolescent care facilities at all levels of care; however there seemed to be no consensus on how to deal with this matter. Many paediatric groups viewed separate children’s hospitals as an ideal goal. Others pointed to important areas of overlap between adult and paediatric services, which mean that children’s hospitals may sometimes impede efficiency and quality. Shared equipment and administration with separate facilities and accommodation for adults, adolescents and children on the same site were viewed as the most sensible solution given the existing resource constraints within the health sector.

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Transport and Communication

Transport and communication systems were another universal problem area, which will clearly require a unified approach to improve: • Patient transfers to and from hospital are currently very poor, and a key cause of delayed discharge and excessive length of stay • Lack of basic subsidised transport and overnight accommodation are a key deterrent to patients referred on an ambulatory basis; a simple, well-organised and well-scheduled system of free or subsidised transport between different levels of hospital, combined with “patient hotels”, could dramatically improve patient access from outlying areas to the main referral centres • It was noted that a functioning transport system could also overcome the long-standing problem of drug availability at lower level facilities – a good basic transport system could also be used to routinely deliver follow-up prescriptions from tertiary centres, for patients to collect at their local facility • Emergency transfers of critically ill patients need to be greatly improved and speeded up, with appropriate use of aircraft expanded; several groups argued strongly that current transfer times between levels of care are leading to adverse (and entirely preventable) outcomes in many patients • Most groups also saw telemedicine as a significant vehicle for improving communication and patient management (but enthusiasm was not universal, with certain groups arguing that current technologies do not yet deliver all they claim to offer); beyond telemedicine per se, there is clearly a need to strengthen the availability of telephone, fax and email facilities for clinical staff at lower level hospitals, and hence allow better access to advice and coordination with tertiary centres.

Categorising Specialties – A Planning Approach

The preceding section has discussed the generic responses required to stabilise the situation of all specialties and services, and to allow the development of a more efficient, responsive and sustainable tertiary hospital sector. Obviously, though, beyond this broad framework different specialties will have specific needs and priorities. It is therefore useful to attempt to develop a system for categorising specialties and sub-specialties in very broad terms. The categorisation developed in this section seeks to meet the needs of service and resource planning. Thus it does not pretend to be based upon the inherent characteristics of specialties, or to reflect traditional

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES methods of grouping specialties. Rather, it aims to identify the general direction of development within specialties, likely trends in demand for services, and the extent to which current patterns of service delivery are appropriate to meet future needs. It then develops a categorisation of specialties based upon the planning response required for each; hence quite different and unrelated specialties may appear in the same category, simply because they require a broadly similar approach to planning, and not because of any inherent similarities in other respects.

A first step in developing such a categorisation involved an analysis of specialty group reports along several dimensions – futures scanning (in terms of disease burden and technological change); an assessment of whether current services achieve a sustainable critical mass for the future survival of the specialty; the extent to which other specialties regarded a service as an essential prerequisite (or a bottleneck) for their own successful operation; and groups’ own assessment of the urgency of changing the geographical distribution of units.

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

/ ritical C

/ eographical G ecialists / Trainin ecialists ajor New Drugs New ajor rowing HIV/AIDS and TBrowing HIV/AIDS and Violence & Injury rowing apability Next in Likely ecade? of Availability urrent ependencies urrent of Units istribution urden? ottlenecks vailable Now? vailable echnical

mpact? nterventions Specialties? or Other nadequate? Growing Non-Communicable Non-Communicable Growing Disease Burden? G I G B M I A T C D C Sp B D f C D I Anaesthetics Yes Yes Yes Yes Burns Yes Yes Yes Yes Cardiology Yes Yes Cardiothoracic surgery Yes Yes Clinical Immunology Yes Yes Yes Clinical pharmacology Yes Yes Yes Yes Cranio/maxillofacial Yes Critical care / ICU Yes Yes Yes Yes Yes Yes Dermatology Yes Yes Yes Yes Yes Yes Diagnostic Radiology Yes Yes Yes Yes Yes Yes Endocrinology Yes ENT Yes Gastroenterology & Hepatology Yes Yes General medicine Yes Yes General Surgery Yes Yes Yes Geriatrics Yes Yes Yes Haematology Yes Yes Human Genetics Yes Yes Yes YesYes ? Infectious Diseases Yes Yes Medical & Radiation oncology Yes Yes Yes Mental Health Services Yes Yes Yes Neonatology Yes Yes Yes Nephrology Yes Yes Neurology Yes Yes Yes Neurosurgery Yes Yes Yes Yes Yes Yes Yes Nuclear Medicine Yes Yes Yes ? Obstetrics and Gynaecology Yes Yes Yes Yes Yes Opthalmology Yes Yes Yes Yes Yes Yes Orthopaedics Yes Yes

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

fails to reach Critical Critical reach to fails y acit p Ca g urrent Availability of Specialists / Specialists of Availability urrent rainin Growing HIV/AIDS and TB Impact? Growing TB HIV/AIDS and Non-Communicable Growing Disease Burden? Growing Injury & Violence Burden? Major New Drugs /Interventions Now? Available Technical in Developments Major Decade? in Next Likely Capability C T BottlenecksCritical / Dependencies for Other Specialties? Current Geographical Inadequate? of Units Distribution Other Rehab Specialists Yes Yes Yes Yes Yes Paediatric Medicine Yes Yes Yes Paediatric Cardiology Yes Yes Yes Paediatric Child Development Yes Yes Yes Yes Yes Yes Yes Yes Paediatric Critical care (ICU) Yes Yes Yes Yes Yes Paediatric Endocrinology/Diabetes Yes Paediatric Gastroenterology Yes Yes Yes Yes Yes Yes Yes Paediatric Haematology/ oncology Yes Paediatric Infectious diseases Yes Yes Paediatric Neph. and Transplant Yes Paediatric Neurology Yes Yes Paediatric Allergology Yes Yes Yes Yes Paediatric Respiratory Medicine Yes Yes Paediatric Rheumatology Yes Yes Paediatric Surgery (all subspecialties) Yes Yes Yes Yes Yes Yes Yes Yes Plastic & Reconstructive Yes Renal / Liver transplantation Yes Respiratory Medicine Yes Yes Rheumatology Yes Spinal Injury Rehab & Mgt Yes Yes Yes Trauma Yes Yes Yes Urology Yes Yes Vascular surgery Yes Yes Yes Yes Yes Yes

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

This assessment, combined with the general description of priorities for development and service strengthening contained in each report, allows a tentative grouping of specialties according to the degree and nature of investment likely to be required. These groups can be described as follows:

A. “Basic Strengthening” – Those specialties which are well established, with a strong skills base, and with a reasonably appropriate geographical distribution. The main effort in planning the future provision of these services will be in applying the basic package of improvements (i.e. improved recruitment, retention and training of specialised personnel, adequate funding of drugs and consumables, replacement and maintenance of equipment, improved efficiency of organisation and operation, improved IT, communications, transport and outreach). Under more pessimistic resource scenarios, a limited degree of consolidation of sites may be required; but even under more optimistic scenarios these specialties would probably not be leading candidates for an expansion in the number of sites. Most will require quite significant additional investment over time, but they do not appear to require a fundamental overhaul of current patterns of provision

B. “Significant Deepening” – These are specialties which probably require very significant upgrading of their current capabilities in situ, but which do not necessarily require expansion in the number of locations at which they are offered. These are primarily “bottleneck” specialties upon which other services are heavily dependent (including some of the critical general specialties at both tertiary and regional level), and/or heavily capital-intensive specialties requiring significant re-equipping and ongoing maintenance expenditures. These specialties require a level of investment in additional personnel and/or equipment which is above and beyond that envisaged in the “basic strengthening” package.

C. “Expansion of Sites” – Those specialties which are a) heavily affected by the transition epidemics (e.g. HIV/AIDS, TB, violence and injury) and b) which require better coverage of the population in geographical terms. These services would require the “basic strengthening” package and an investment in specialised personnel to allow them to be provided at progressively more locations (primarily in the currently under-served provinces). As noted earlier, certain of these services may well offer opportunities for partial downscaling in the very long term (i.e. 15-20 years plus) as the transition epidemics are brought under control, but that must not obscure the need for expansion in the medium to long term.

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

D. “Achieving Critical Mass” – A small number of specialties or sub-specialties that are presently very small and lack the critical mass for sustainability, but that are likely to become much more important in future. They therefore need directed investment and promotion now to ensure that adequate capacity exists in the future to meet changing needs.

A first attempt to group specialties in terms of these categories is presented below.

Proposed Categorisation of Planning Response Required by Specialty

A: Basic Strengthening

Cardiology Paediatric Endocrinology Cardiothoracic Surgery Paediatric Haematology Clinical Immunology Paediatric Nephrology Craniofacial Surgery Paediatric Neurology Dermatology Plastic & Reconstructive Surgery ENT Surgery Renal & Liver Transplant Surgery Gastroenterology & Hepatology Rheumatology Neurosurgery Urology Neurology Vascular Surgery Ophthalmology

B: Significant Deepening

Anaesthetics Obstetrics & Gynaecology Clinical Pharmacology Orthopaedic Surgery Critical & Intensive Care Other Rehabilitation Diagnostic Radiology Paediatric Surgery General Medicine Paediatric Medicine General Surgery Paediatric Cardiology & Cardiothoracic Oncology (Medical, Radiation & Surgical) Mental Health Services Nuclear Medicine Endocrinology (overlap with A)

C: Expansion of Sites

Burns Neonatology (overlap with B) Critical & Intensive Care (overlap with B) Oral and Maxillofacial facial Haematology Paediatric Infectious Diseases Haematology Paediatric Critical Care & ICU (overlap with B) Infectious Diseases Respiratory Medicine Nephrology / Dialysis (Adult Only) Spinal Injury Rehabilitation Trauma

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

D: Achieve Critical Mass

Geriatric Medicine Paediatric Gastroenterology Human Genetics Paediatric Rheumatology Paediatric Respiratory Medicine Paediatric Allergology Paediatric Child Development

Discussion of Proposed Categorisation

It is obviously anticipated that this categorisation will provoke considerable discussion, and as such it is only a proposal. It is important to make a few comments to inform discussions by individual specialty groups.

First, it is important to appreciate that category A (“Basic Strengthening”) does not represent a “do nothing” category – the basic package of service strengthening interventions would, in fact, represent a very significant improvement and level of investment for these services.

Critical Care & ICU overlaps categories B and C in that ICU clearly requires both significant efforts to strengthen it where services currently exist and to support any geographical expansion of specialised tertiary trauma services.

It is important to note that the actions required in category D (“Achieve Critical Mass”) may be very different for each specialty. For example, a large programme of training to increase the number of specialists in geriatric medicine, itself allowing a significant expansion in the number of specialised geriatric units may be required, which would themselves become training centres in due course. By contrast, paediatric rheumatology might require a more modest action plan, whereby the sub- specialty becomes registered for training, and (for example) a single national training centre produces a small number of qualified sub-specialists. The common theme in this category is the need to reconstitute or expand specialist capacity. Other paediatric sub-specialties may be in a similar position to paediatric rheumatology (i.e. not formally recognised or no formal training currently available in SA).

Finally, it is important to note that a number of specialty groups e.g. Obstetrics and Gynaecology were concerned about the increasing number of subspecialties (especially in the area of Paediatrics). It was thought that such proliferation of subspecialties undermined holistic care, led to the duplication of services and was also not cost-effective. These concerns are significant,

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES although it is also important to acknowledge the de facto reality of increasing sub-specialisation. A reasonable compromise would appear to be to accept that sub-specialisation is not in itself a bad thing, as long as it is controlled and directed at a limited number of centres, and forms part of a comprehensive package of services and care. Uncontrolled sub-specialisation outside these few designated centres should clearly not be permitted.

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Organisational Models – General Discussion

A key objective of the specialty discussion groups was to ensure that each specialty considered in detail appropriate organisational models for its services, in particular to consider the organisation of services across the care continuum from regional hospitals to tertiary and quaternary services. All groups gave this question considerable attention, with many providing substantial detail in their reports. Appendix 2 summarises in a standardised format the output of each group regarding its proposed “ideal” organisational model under the “optimistic” resource scenario. Appendix 3 does the same for the “pessimistic” resource scenario. Appendix 3 necessarily contains rather more interpretation by the MTS team, as a number of groups did not provide details of how they would propose to organise services under the pessimistic scenario. Appendix 4 attempts to extract details on precise staffing requirements for an “ideal” unit wherever groups have provided such information. Tabulation of the standardised details in Appendices 2 and 3 proves to be a useful exercise, as it brings out quite clearly a number of important structural issues, which seem likely to be very important for future planning.

Clearly, there is a group of basic specialties (General Medicine, General Surgery, Paediatrics, Obs & Gynae, Psychiatry, Orthopaedic Surgery) which form the backbone of regional hospital services, and which feed referrals logically up to sub-specialist services at higher level. However, a number of specialties (Clinical Pharmacology, Dermatology, ENT Surgery, Ophthalmology, Plastic & Reconstructive Surgery, Urology, Vascular Surgery) envisage in their “ideal” model a specialist service at regional level (i.e. the permanent or substantive presence of a full Specialist-led service at each regional hospital). While not denying the benefits to patients of such an arrangement, this model would require very dramatic increases in specialist human resources (alongside strengthening of tertiary units, in most cases) relative to current availability – to such an extent that it seems reasonable to ask whether this is actually an attainable goal in the next ten years.

Analysis of the reports indicates that there is also considerable variety in groups’ interpretations of the general concept of “tertiary” services. This relates critically to such questions as the degree of sub-specialisation required, dependencies upon other sub-specialty services, and the degree to which a service needs to be population-based rather than referral-based. For example, Neurosurgery proposes that its services are, in effect, “national tertiary” centres (of which there would, however, be several); ENT sees a clear continuum from regional services to tertiary to one or two national super-specialist centres; while Burns and Trauma, for example, see themselves as requiring population-based tertiary centres, but with no higher national referral level. Most of the paediatric sub-specialties also present some complexity; a comprehensive range of paediatric sub-

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES specialty services can only be offered at a fairly small number of centres – but they are nonetheless something rather less than “unique” services requiring a single national centre. This suggests that there are a number of possible ways of thinking about tertiary services. Some tertiary services are supra regional in character, sitting above regional hospital level (although possibly covering a natural group of regions that cross provincial borders). Another group is clearly supra provincial, requiring a limited number of “dense” hospitals offering many sub-specialty services. Another involves the concept of unique services, where a service can only be justified at one (or maybe two, in certain cases) site nationally.

From the preceding discussion, it is clear that a number of possible permutations could easily be developed to cluster different services at different levels. A limited number of these will therefore be addressed in the Strategic Planning Framework below, to form the basis for future modelling and to gain a clearer understanding of what the implications of different combinations of services might be.

Finally, Appendices 2 and 3 show very clearly the importance attached by almost every specialty to strengthening services at regional hospital level. Almost every group has drawn clear linkages to general specialist services at this level, frequently with proposals for strengthening skills and/or equipment. Planning must incorporate these measures to strengthen the regional level if the overall process is to be successful, and the reports make these prerequisites clear. They do also reveal one danger, however – namely, that the expectations placed by tertiary-level specialists on their regional counterparts may be rather too ambitious and exacting. For example, nine individual tertiary specialties propose that regional General Physicians should have diplomas or specific training in their areas. Clearly, not every General Physician would need to have all nine qualifications – but there are equally not usually too many Physicians in any one regional hospital, raising the question of how achievable such otherwise laudable intentions might be in practice. Further thought will need to be given to this question, both by planners and by the specialties concerned.

Strategic Planning Framework – Scenarios and Options

The following section attempts to sketch out a few possible organisational models at system level, in terms of the configuration of specialties and sub-specialties at different levels, the proposed categorisation for future development of specialties, and different resource availability scenarios. The purpose of these options is to form the basis for quantitative and cost modelling, in order to elaborate their costs, benefits and implications. None of the options represents the policy of the

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Department of Health, or even the desired direction of the Department – they are purely the starting point for analysis and development.

Four alternative models have been developed, using the outputs of the specialty reports and the summary descriptions of services by level of care presented in Appendices 2 and 3. They have been adjusted and revised where groups disagreed with our initial formulations.

Each model is presented in detail over the following pages. While quite lengthy, this is viewed as essential to allow group members to visualise what each model would mean for their own discipline. Each model is presented in a common format, using four levels: • Regional Hospital Services – services to be provided at every regional hospital • Tertiary Hospital Services – services to be provided at a referral hospital serving several regional hospitals, i.e. supra-regional services • National Referral Hospital Services – a set of very specialised services which would be provided at a small number of hospitals nationwide (where they would be “added on top” of tertiary hospital services), i.e. supra-provincial services • Central Referral Units – very highly specialised services to be provided at one (or maximum two) tertiary hospitals nationwide, i.e. “unique” services. Within this category, services that would need to be co-located are indicated as being linked.

To assist readers to understand the proposed relationships and interactions between the four levels of services proposed, a simplified diagram is presented below:

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Diagrammatic Representation: Relationship between levels of care and hospital referral chain

Central Referral Unit

National National Referral Referral Services Services Tertiary Tertiary Tertiary Tertiary Hospital Hospital Hospital Hospital

Regional Hospitals Regional Hospitals

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model A:

Model A Regional Hospital Services

Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Clinical Pharmacology Specialist Dermatology Specialist Service Ambulatory care & telemedicine link Diagnostic Radiology X-Ray, CT Scan, Ultrasound, Fluoroscopy Telelinked Nuclear Medicine Radiographer, Interventional radiology (basic interventions e.g. image guided aspirations) ENT Surgery Specialist Service General Medicine Service Echocardiography, Stress ECG Specialist Immunology Nurse Regional ICU Service Diabetes / Endocrine clinic GIT incl. endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Regional Dialysis Service & Organ Donation Geriatric Care Genetic Nurse & Counselling Oncology palliation and basic care Neurology basic care Spirometry & oximetry Basic Rheumatology Basic infectious diseases Pathology services Infection control Proctoscopy, Sigmoidoscopy General Surgery Service Regional Burns Service 24 hour Level II Trauma Service, Accident & Emergency Mental Health Services Acute Inpatient & Outpatient (Psychiatry & Psychology) Child & Adolescent Psychiatry ECT Liaison Psychiatry Community mental Health Services Neonatology Obstetrics & Gynaecology Service Emergency and standard Obs & Gynae Ultrasound, prenatal diagnosis Kangaroo Care Basic urogynaecology Mid trimester abortions and adequate pain relief systems Basic oncology, menopause and screening programmes Preliminary infertility investigations Ophthalmology Specialist Service Neonatal Low & High Care, Neonatal Intensive Care

Orthopaedic Surgery General Orthopaedic Surgery 24 hour Level II Trauma Service, Accident & Emergency Paediatrics Service General Paediatric Medicine Service (General Surgeon?) Plastic & Reconstructive Surgery Specialist Service Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry Acute Rehabilitation Team incl. Spinal beds Urology Specialist Service Vascular Surgery Specialist Service

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model A Tertiary Hospital Services

Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Burns Unit Specialised Burns ICU & Theatre Clinical Immunology Service Clinical Pharmacology Specialist Critical Care & ICU Full ICU Service Dermatology Specialist Service Inpatient & ambulatory Diagnostic Radiology X-Ray, Multi-slice CT Scan, Ultrasound, Fluoroscopy, MRI, Mammography, Colour Doppler US, interventional radiology, angioplasty ENT Surgery Specialised Service Gastroenterology Tertiary GIT Service General Medicine Service Angiography AT Scan Coronary Care Echocardiography, Stress ECG Endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Genetic Nurse & Counselling Oncology palliation and basic care General Surgery Service Complex & High Acuity Care - Procedure driven Geriatrics Specialised Geriatric Service Infectious Diseases Tertiary Infectious Diseases Service, Pathology services, Infection control, Dietician, Counselling services esp. for HIV and social worker Mental Health Services Child and adolescent psychiatry; Old-age psychiatry; Forensic psychiatry; (Psychiatry & Psychology) Substance abuse; Liaison psychiatry; Eating disorders; Inpatient psychotherapy; Social psychiatry; Acute psychotic (complicated); Acute non-psychotic (complicated) Neonatology Neonatal Intensive Care Unit Nephrology Acute renal failure / clinical nephrological problems / dialysis complication Neurology Neurology & Stroke Unit Obstetrics & Gynaecology Service As Regional plus: Fetal / Maternal Medicine Ophthalmology Specialised Ophthalmology Service Orthopaedic Surgery Sub-Specialty Orthopaedics i.e. Primary Athroplasty, Spinal Surgery Paediatric Medicine Specialist General Paediatricians with special interest Paediatric Surgery Services preferably provided in an independent Children’s Hospital with the following components: Specialist paediatric surgery Cardiothoracic surgery. General paediatric surgery Neurosurgery Opthalmology Orthopaedics Plastic and reconstructive surgery ENT Urology Paediatric anaesthesiology Paediatric ICU Full Paediatric ICU Service Paediatrics Service Neonatal Low & High Care General Paediatric Medicine Service General Paediatric Surgery Plastic & Reconstructive Surgery Specialist Service Tertiary Plastic & Reconstructive Surgery Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, & Spinal Injury Unit Podiatry, Audiology Acute Rehabilitation Team incl. Spinal beds Respiratory Medicine Comprehensive Pulmonology Service Rheumatology Tertiary Rheumatology Service Trauma Tertiary Major Trauma Centre (n.b. protocol-based transfer only, no walk-in A&E service) Urology Specialist Service Tertiary Urology Service Vascular Surgery Specialist Service Tertiary Vascular Surgery Service

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model A National Referral Hospital Services (“Adds on” to a Tertiary Hospital)

Specialist Service Available On-Site Specific Components Explicitly Included: Cardiology Echocardiography, Ultrasound, Electrocardiography, Stress Testing, ECG Holter Pacemaker follow-up, Cath Lab, Electrophysiology Ablation Cardiothoracic Surgery Full Cardiothoracic Service Craniofacial Surgery Critical Care & ICU Additional ICU Capacity Endocrinology Tertiary Endocrinology Service Haematology Tertiary Haematology Service Human Genetics Tertiary Genetics Service Infectious Diseases Clinical Research Capacity Medical & Radiation Oncology Tertiary Oncology Centre Neurosurgery Tertiary Specialist Neurosurgery Service, Interventional Neuroradiology, Nuclear Medicine Tertiary Nuclear Medicine Centre Obstetrics & Gynaecology Service Oncology Urogynaecology Reproductive Medicine Ophthalmology Super-Specialist Ophthalmology Service Orthopaedic Surgery Orthopaedic Oncology (Revision arthroplasty and spinal surgery, basic oncology, Paediatric Oncology Renal Transplant Renal Transplant Unit

Paediatric Cardiology Paediatric ICU Additional Paediatric ICU Capacity Paediatric Endocrinology Paediatric Gastroenterology Paediatric Haematology & Oncology Paediatric Infectious Diseases Paediatric Nephrology Dialysis & Renal Transplant Paediatric Neurology Paediatric Respiratory Medicine & Allergology Paediatric Rheumatology

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model A Central Referral Units (“Add on” to a National Referral Hospital)

Specialist Service Available On-Site Specific Components Explicitly Included:

{ Cardiology Cardioverter Defibrillator & LV Assist Devices Unit { Cardiothoracic Surgery Heart & Lung Transplant Unit { Respiratory Medicine National Pulmonology Referral Centre: Lung volume reduction, Lung Transplant /Maxillofacial Surgery Narional Referral Centre

{ Diagnostic Radiology National PET Scan { Interventional Neuroradiology { Cardiac Imaging { Nuclear Medicine PET or gamma-PET { Medical & Radiation Oncology National Oncology Referral Centre: { Bone Marrow Transplant, IMRT, Intraoperative { Radiation, Stereotactic Radiation, PET Scan planning; { laminar flow, cryopreservation, stem cell harvesting, T- { cell depletion facilities { Haematology Bone Marrow Transplantation Unit

{ Hepatology Specialist Liver Unit { Liver Transplant Liver Transplant Unit { General Surgery National Surgical Referral Centre: { Liver and major pancreatic resections, TME { Nephrology National Nephrology Centre: { Pancreas-kidney / Liver-kidney Transplant

Clinical Immunology National Referral Centre Clinical Pharmacology National Policy Support Unit Dermatology National Referral Centre Endocrinology National Endocrinology Referral Centre ENT Cochlear Implant Skull Base Surgery Human Genetics National Genetics Centre Infectious Diseases National Institute of Communicable Diseases National Paediatric Referral Centre: { Paediatric Medicine & Surgery Organ transplantation, epilepsy surgery, craniofacial { surgery; certain high-cost / complexity medical { interventions. Cochlear and layngeal implants, limb salvage oncology and eye salvaging oncology. { Paediatric Gastroenterology Transplant Surgery, Metabolic Laboratory { Paediatric Haematology & Oncology Bone Marrow Transplant { Paediatric Neurology Complex epileptic surgery, complex neuromuscular { patients, neurodegenerative and metabolic patients, { Video telemetry, intracranial mapping, neuro-metabolic { lab. { Paediatric Rheumatology Bone Marrow Transplant, DEXA scans, Interleukin { levels, joint replacement

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model B:

Model B Regional Hospital Services

Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Diagnostic Radiology X-Ray, CT Scan, Ultrasound, Fluoroscopy Telelinked Nuclear Medicine Radiographer, Interventional radiology (basic interventions e.g. image guided aspirations) General Medicine Service Echocardiography, Stress ECG Specialist Immunology Nurse Regional ICU Service Diabetes / Endocrine clinic GIT incl. endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Regional Dialysis Service & Organ Donation Geriatric Care Genetic Nurse & Counselling Oncology palliation and basic care Neurology basic care Spirometry & oximetry Basic Rheumatology Basic Infectious Diseases Pathology Services Infection Control Proctoscopy, Sigmoidoscopy General Surgery Service Regional Burns Service 24 hour Level II Trauma Service, Accident & Emergency Mental Health Acute Inpatient & Outpatient (Psychiatry & Psychology) Child & Adolescent Psychiatry ECT Liaison Psychiatry Community Mental Health Services Neonatology Neonatal Low & High Care, Neonatal Intensive care Obstetrics & Gynaecology Service Emergency Obs & Gynae Ultrasound, prenatal diagnosis Kangaroo Care Basic urogynaecology Mid trimester abortions and adequate pain relief systems Basic oncology, menopause and screening programmes Preliminary infertility investigations Orthopaedic Surgery General Orthopaedic Surgery 24 hour Level II Trauma Service, Accident & Emergency Paediatrics Service General Paediatric Medicine Service General Paediatric Surgery (General Surgeon?) Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry Acute Rehabilitation Team incl. Spinal beds

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model B Tertiary Hospital Services

Ophthalmology Specialised Ophthalmology Service Orthopaedic Surgery Sub-Specialty Orthopaedics Paediatric Medicine Specialist General Paediatricians with special interest Paediatric Surgery Specialist Paediatric Surgery Service Paediatric ICU Full Paediatric ICU Service Paediatrics Service Neonatal Low & High Care General Paediatric Medicine Service General Paediatric Surgery Plastic & Reconstructive Surgery Specialist Service Tertiary Plastic & Reconstructive Surgery Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry, Audiology Acute Rehabilitation Team incl. Spinal beds ,Stroke Unit Respiratory Medicine Comprehensive Pulmonology Service Trauma Tertiary Major Trauma Centre (n.b. protocol-based transfer only, no walk-in A&E service) Urology Specialist Service Tertiary Urology Service Vascular Surgery Specialist Service Tertiary Vascular Surgery Service

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model B National Referral Hospital Services (“Adds on” to a Tertiary Hospital)

Specialist Service Available On-Site Specific Components Explicitly Included: Cardiology Echocardiography, Ultrasound, Electrocardiography, Stress Testing, ECG Holter Pacemaker follow-up, Cath Lab, Electrophysiology Ablation Cardiothoracic Surgery Full Cardiothoracic Service Craniofacial Surgery Critical Care & ICU Additional ICU Capacity Endocrinology Tertiary Endocrinology Service Haematology Tertiary Haematology Service Human Genetics Tertiary Genetics Service Infectious Diseases Clinical Research Capacity Medical & Radiation Oncology Tertiary Oncology Centre Neurosurgery Tertiary Specialist Neurosurgery Service, Interventional Neuroradiology Nuclear Medicine Tertiary Nuclear Medicine Centre Obstetrics & Gynaecology Service Oncology Urogynaecology Reproductive Medicine Ophthalmology Super-Specialist Ophthalmology Service Orthopaedic Surgery Orthopaedic Oncology Renal Transplant Renal Transplant Unit Rheumatology Tertiary Rheumatology Service

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model B Central Referral Units (“Add on” to a National Referral Hospital)

Specialist Service Available On-Site Specific Components Explicitly Included:

{ Diagnostic Radiology National PET Scan { Interventional Neuroradiology { Cardiac Imaging { Nuclear Medicine PET or gamma-PET { Medical & Radiation Oncology National Oncology Referral Centre: { Bone Marrow Transplant, IMRT, Intraoperative Radiation, { Stereotactic Radiation, PET Scan planning; laminar flow, { cryopreservation, stem cell harvesting, T-cell depletion { facilities { Haematology Bone Marrow Transplantation Unit

Clinical Immunology National Referral Centre Clinical Pharmacology National Policy Support Unit Dermatology National Referral Centre Endocrinology National Endocrinology Referral Centre ENT Cochlear Implant Skull Base Surgery Human Genetics National Genetics Centre Infectious Diseases National Institute for Communicable Diseases National Paediatric Referral Centre: { Paediatric Medicine & Surgery Organ transplantation, epilepsy surgery, craniofacial { surgery; certain high-cost / complexity medical { interventions { Paediatric Gastroenterology Transplant Surgery, Metabolic Laboratory { Paediatric Haematology & Oncology Bone Marrow Transplant { Paediatric Neurology Complex epileptic surgery, complex neuromuscular { patients, neurodegenerative and metabolic patients, Video { telemetry, intracranial mapping, neuro-metabolic lab. { { Paediatric Rheumatology Bone Marrow Transplant, DEXA scans, Interleukin levels, { joint replacement

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model C:

Model C Regional Hospital Services

Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Diagnostic Radiology X-Ray, CT Scan, Ultrasound, Fluoroscopy, Interventional radiology (basic interventions e.g. image guided aspirations) General Medicine Service Echocardiography, Stress ECG Specialist Immunology Nurse Regional ICU Service Diabetes / Endocrine clinic GIT incl. endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Geriatric Care Genetic Nurse & Counselling Oncology palliation and basic care Neurology basic care Spirometry & oximetry Basic Rheumatology Basic Infectious Diseases Pathology Services Infection Control Proctoscopy, Sigmoidoscopy General Surgery Service Regional Burns Service 24 hour Level II Trauma Service, Accident & Emergency Mental Health Services Acute Inpatient & Outpatient (Psychiatry & Psychology) Child & Adolescent Psychiatry ECT Liaison Psychiatry Community Mental Health Services Neonatology Neonatal Low & High Care, Neonatal Intensive care Obstetrics & Gynaecology Service Emergency Obs & Gynae Ultrasound, prenatal diagnosis Kangaroo Care Basic urogynaecology Mid trimester abortions and adequate pain relief systems Basic oncology, menopause and screening programmes Preliminary infertility investigations Orthopaedic Surgery General Orthopaedic Surgery 24 hour Level II Trauma Service, Accident & Emergency Paediatrics Service General Paediatric Medicine Service General Paediatric Surgery (General Surgeon?) Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry Acute Rehabilitation Team

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model C Tertiary Hospital Services

Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Burns Unit Specialised Burns ICU & Theatre Clinical Pharmacology Specialist Critical Care & ICU Full ICU Service Dermatology Specialist Service Inpatient & ambulatory Diagnostic Radiology X-Ray, Multi-slice CT Scan, Ultrasound, Fluoroscopy, Mammography, Colour Doppler US, Interventional Radiology, Angiography ENT Surgery Specialised Service General ENT Surgery Gastroenterology Tertiary GIT Service General Medicine Service Angiography AT Scan Coronary Care Echocardiography, Stress ECG Endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Genetic Nurse & Counselling Oncology palliation and basic care General Surgery Service Complex & High Acuity Care Infectious Diseases Tertiary Infectious Diseases Service, Pathology Services, Infection Control, Dietician, Counselling Services, Social Worker Mental Health Services Child and adolescent psychiatry; Old-age psychiatry; Forensic (Psychiatry & Psychology) psychiatry; Substance abuse; Liaison psychiatry; Eating disorders; Inpatient psychotherapy; Social psychiatry; Acute psychotic (complicated); Acute non-psychotic (complicated) Neonatology Neonatal Intensive Care Unit Nephrology Acute renal failure / clinical nephrological problems / dialysis complication Obstetrics & Gynaecology Service As Regional plus: Fetal / Maternal Medicine Ophthalmology General Ophthalmology Service Orthopaedic Surgery Sub-Specialty Orthopaedics Paediatric Medicine Specialist General Paediatricians with special interest Paediatric Surgery Specialist Paediatric Surgery Service Paediatric ICU Full Paediatric ICU Service Paediatrics Service Neonatal Low & High Care General Paediatric Medicine Service General Paediatric Surgery Plastic & Reconstructive Surgery Specialist General Plastic & Reconstructive Surgery Service Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry, Audiology Acute Rehabilitation Team incl. Spinal beds Stroke Unit Respiratory Medicine Comprehensive Pulmonology Service Trauma Tertiary Major Trauma Centre (n.b. protocol-based transfer only, no walk-in A&E service) Urology Specialist Service General Urology Service Vascular Surgery Specialist Service General Vascular Surgery Service

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model C National Referral Hospital Services (“Adds on” to a Tertiary Hospital)

Specialist Service Available On-Site Specific Components Explicitly Included: Cardiology Echocardiography, Ultrasound, Electrocardiography, Stress Testing, ECG Holter Pacemaker follow-up, Cath Lab, Electrophysiology Ablation Cardiothoracic Surgery Full Cardiothoracic Service Clinical Immunology Tertiary Clinical Immunology Craniofacial Surgery Critical Care & ICU Additional ICU Capacity Diagnostic Radiology MRI Interventional Neuroradiology ENT Surgery Specialised ENT Service Endocrinology Tertiary Endocrinology Service Geriatrics Specialised Geriatric Service Haematology Tertiary Haematology Service Human Genetics Tertiary Genetics Service Infectious Diseases Clinical Research Capacity Medical & Radiation Oncology Tertiary Oncology Centre Neurosurgery Tertiary Specialist Neurosurgery Service Nuclear Medicine Tertiary Nuclear Medicine Centre Obstetrics & Gynaecology Service Oncology Urogynaecology Reproductive Medicine Ophthalmology Specialised Ophthalmology Service Orthopaedic Surgery Orthopaedic Oncology Plastic & Reconstructive Surgery Tertiary Plastic & Reconstructive Surgery Renal Transplant Renal Transplant Unit Rheumatology Tertiary Rheumatology Service Urology Tertiary Urology Service Vascular Surgery Tertiary Vascular Surgery Service

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model C Central Referral Units (“Add on” to a National Referral Hospital)

Specialist Service Available On-Site Specific Components Explicitly Included:

Clinical Immunology National Referral Centre Clinical Pharmacology National Policy Support Unit Dermatology National Referral Centre Endocrinology National Endocrinology Referral Centre ENT Cochlear Implant Skull Base Surgery Human Genetics National Genetics Centre Ophthalmology Super-Specialist Ophthalmology Service Infectious Diseases National Institute for Communicable Diseases National Paediatric Referral Centre: { Paediatric Medicine & Surgery Organ transplantation, epilepsy surgery, craniofacial { surgery; certain high-cost / complexity medical { interventions { Paediatric Gastroenterology Transplant Surgery, Metabolic Laboratory { Paediatric Haematology & Oncology Bone Marrow Transplant { Paediatric Neurology Complex epileptic surgery, complex neuromuscular { patients, neurodegenerative and metabolic patients, { Video telemetry, intracranial mapping, neuro-metabolic { lab. { Paediatric Rheumatology Specialised Paediatric Rheumatology including Bone { Marrow Transplant, DEXA scans, Interleukin levels, joint replacement

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model D:

Model D Regional Hospital Services

Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Diagnostic Radiology X-Ray, Ultrasound, Fluoroscopy, General Medicine Service Echocardiography, Stress ECG Specialist Immunology Nurse Regional ICU Service Diabetes / Endocrine clinic GIT incl. endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Geriatric Care Genetic Nurse & Counselling Oncology palliation and basic care Neurology basic care Spirometry & oximetry Basic Rheumatology Basic Infectious Diseases Pathology Services Infection Control Proctoscopy, Sigmoidoscopy General Surgery Service Regional Burns Service 24 hour Level II Trauma Service, Accident & Emergency Mental Health services Acute Inpatient & Outpatient (Psychiatry & Psychology) Child & Adolescent Psychiatry ECT Liaison Psychiatry Community Mental Health Services Neonatology Neonatal Low & High Care, Short stay ventilatory support Obstetrics & Gynaecology Service Emergency Obs & Gynae Ultrasound, prenatal diagnosis Kangaroo Care Basic urogynaecology Mid trimester abortions and adequate pain relief systems Basic oncology, menopause and screening programmes Preliminary infertility investigations Orthopaedic Surgery General Orthopaedic Surgery 24 hour Level II Trauma Service, Accident & Emergency Paediatrics Service General Paediatric Medicine Service General Paediatric Surgery (General Surgeon?) Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry Acute Rehabilitation Team

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model D Tertiary Hospital Services

Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Burns Unit Specialised Burns ICU & Theatre Clinical Pharmacology Specialist Critical Care & ICU Full ICU Service Dermatology Specialist Service Inpatient & ambulatory Diagnostic Radiology X-Ray, Multi-slice CT Scan, Ultrasound, Fluoroscopy, Mammography, Colour Doppler US, Interventional Radiology, Angiography ENT Surgery Specialised Service General ENT Surgery Gastroenterology Tertiary GIT Service General Medicine Service Coronary Care Echocardiography, Stress ECG Endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Genetic Nurse & Counselling Oncology palliation and basic care General Surgery Service Complex & High Acuity Care Infectious Diseases Tertiary Infectious Diseases Service, Pathology Services, Infection Control, Dietician, Counselling Services, Social Worker Mental Health Services Child and adolescent psychiatry; Old-age psychiatry; (Psychiatry & Psychology) Forensic psychiatry; Substance abuse; Liaison psychiatry; Eating disorders; Inpatient psychotherapy; Social psychiatry; Acute psychotic (complicated); Acute non-psychotic (complicated) Neonatology Neonatal Intensive Care Unit Nephrology Acute renal failure / clinical nephrological problems / dialysis complication Obstetrics & Gynaecology Service As Regional plus: Fetal / Maternal Medicine Ophthalmology General Ophthalmology Service Orthopaedic Surgery Sub-Specialty Orthopaedics Paediatric Medicine Specialist General Paediatricians with special interest Paediatric Surgery Specialist Paediatric Surgery Service Paediatric ICU Full Paediatric ICU Service Paediatrics Service Neonatal Low & High Care General Paediatric Medicine Service General Paediatric Surgery Plastic & Reconstructive Surgery Specialist Service General Plastic & Reconstructive Surgery Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry, Audiology Acute Rehabilitation Team Stroke Unit Respiratory Medicine Comprehensive Pulmonology Service Trauma Tertiary Major Trauma Centre (n.b. protocol-based transfer only, no walk-in A&E service) Urology Specialist Service General Urology Service Vascular Surgery Specialist Service General Vascular Surgery Service

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model D National Referral Hospital Services (“Adds on” to a Tertiary Hospital)

Specialist Service Available On-Site Specific Components Explicitly Included: Cardiology Angiography, Echocardiography, Ultrasound, Electrocardiography, Stress Testing, ECG Holter Pacemaker follow-up, Cath Lab, Electrophysiology Ablation Cardiothoracic Surgery Full Cardiothoracic Service Clinical Immunology Tertiary Clinical Immunology Craniofacial Surgery Critical Care & ICU Additional ICU Capacity Diagnostic Radiology MRI, Interventional Neuroradiology Endocrinology Tertiary Endocrinology Service ENT Surgery Specialised ENT Service Geriatrics Specialised Geriatric Service Haematology Tertiary Haematology Service Human Genetics Tertiary Genetics Service Infectious Diseases Clinical Research Capacity Medical & Radiation Oncology Tertiary Oncology Centre Neurosurgery Tertiary Specialist Neurosurgery Service Nuclear Medicine Tertiary Nuclear Medicine Centre Obstetrics & Gynaecology Service Oncology Urogynaecology Reproductive Medicine Ophthalmology Specialised Ophthalmology Service Orthopaedic Surgery Orthopaedic Oncology Plastic & Reconstructive Surgery Tertiary Plastic & Reconstructive Surgery Rehabilitation Spinal Injury Unit Renal Transplant Renal Transplant Unit Rheumatology Tertiary Rheumatology Service Urology Tertiary Urology Service Vascular Surgery Tertiary Vascular Surgery Service

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Model D Central Referral Units (“Add on” to a National Referral Hospital)

Specialist Service Available On-Site Specific Components Explicitly Included:

{ Diagnostic Radiology Interventional Neuroradiology { Cardiac Imaging { Medical & Radiation Oncology National Oncology Referral Centre: { Bone Marrow Transplant, Stereotactic Radiation; { laminar flow, cryopreservation, T-cell depletion facilities { { Haematology Bone Marrow Transplantation Unit

{ Hepatology Specialist Liver Unit { Liver Transplant Liver Transplant Unit { General Surgery National Surgical Referral Centre: { Liver and major pancreatic resections, TME Maxillofacial Surgery National Referral Centre Clinical Immunology National Referral Centre Clinical Pharmacology National Policy Support Unit Dermatology National Referral Centre Endocrinology National Endocrinology Referral Centre ENT Cochlear Implant Skull Base Surgery Human Genetics National Genetics Centre Ophthalmology Super-Specialist Ophthalmology Services Infectious Diseases National Institute for Communicable Diseases National Paediatric Referral Centre: { Paediatric Medicine & Surgery Organ transplantation, epilepsy surgery, craniofacial { surgery; certain high-cost / complexity medical { interventions { Paediatric Gastroenterology Transplant Surgery, Metabolic Laboratory { Paediatric Haematology & Oncology Bone Marrow Transplant { Paediatric Neurology Complex epileptic surgery, complex neuromuscular { patients, neurodegenerative and metabolic patients, { Video telemetry, intracranial mapping, neuro-metabolic { lab. { Paediatric Rheumatology Specialised Paediatric Rheumatology including Bone { Marrow Transplant, DEXA scans, Interleukin levels, joint replacement

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Overview of Models

Clearly, each of Models A to D reflects a slightly different resource scenario, but also a different emphasis in the balance of service delivery across levels. Model A reflects a very optimistic resource scenario, in which sufficient funds and skills are available to achieve a significant deepening of specialist services at regional hospital level, so that all regional hospitals could have basic specialist services such as Dermatology, ENT, Ophthalmology, Urology and Vascular Surgery, as well as comprehensive radiology services up to and including single-slice CT scanners. Once consequence of Model A would be the need to have relatively fewer tertiary hospitals – on the grounds that regional hospitals are significantly stronger in this model than in others. Model B also reflects an optimistic scenario – but one in which it is not feasible to have such a wide range of specialist skills at regional hospital, and which rather seeks to offer a larger number of concentrated tertiary hospitals. Model C reflects a rather more resource-constrained scenario. Under this model, a number of services have to confine their tertiary presence to entry-level specialist services, with complex activities only affordable at national referral level. Model D then offers the most pessimistic view, requiring a further degree of concentration and foregoing a number of significant investments (e.g. no CT at regional hospital level, no PET centre nationally etc.).

Readers should also note that, in all these models, Regional Hospitals offer the highest level of access to health care at which the public can directly “walk in” without referral (i.e. via A&E or open access out-patients clinic). From the tertiary level upwards, models A to D all clearly assume that patients will arrive at their doors following referral or transfer, and that tertiary and national referral hospitals would be physically configured to prevent walk-in access by unreferred patients (e.g. by not providing ambulatory A&E facilities, but a Major Trauma facility for EMS-delivered casualties only). This does not preclude offering regional hospital services on site – but there would always need to be a significant degree of physical separation of regional and tertiary facilities on the same campus.

While the precise number of hospitals affordable under each model and scenario is itself a critical output of the modelling which will shortly be undertaken, it is probably helpful to readers to have some illustration of how these models might translate into numbers of hospitals by type. Please do not construe these numbers as in any way a “plan” or an intention – their purpose is simply to help readers to visualise the models. Currently, there are 45 public regional hospitals, and 26 “tertiary” hospitals – the ten “central” hospitals (in Gauteng, Western Cape, KwaZulu Natal and Free State) plus another 16 across the country offering a significant level of more specialised services, and

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES receiving funding under the National Tertiary Services Grant. Compared to this baseline, it might be helpful to imagine Models A to D looking something like this:

Model Regional Hospital Tertiary Hospital Combined Central Referral Tertiary and Units (by type of National Referral unit) Hospitals A 45 14 to 16 5 or 6 1 or 2 B 45 18 to 22 5 or 6 1 or 2 C 45 16 to 20 4 or 5 1 D 45 14 to 20 4 or 5 1

Next Steps

Over the coming months, the MTS Project Team will be using the concepts and service models developed in this document as the basis for a substantial quantitative modelling exercise. We will use cost and activity data, and the information generated by specialties on optimal unit sizes, to develop costed scenarios for the future configuration of tertiary hospital services. These data will be combined with the outputs of a spatial model (which considers the costs of patient travel between hospitals, and uses GIS software to model alternative hospital and service location scenarios), and a review of the evidence on hospital efficiency and quality of care, to generate and evaluate specific options for the configuration and distribution of tertiary hospital services across the country. The best options will be presented to health decision makers in the form of an option appraisal and plan for the modernisation of tertiary services. It is anticipated that this plan would probably take up to ten-years to implement, to ensure that essential human resources can be developed and nurtured to match the required expansion and reconfiguration of services in key areas, and to ensure that capital investments are matched by the human resources required to make them work effectively. We anticipate that the plan itself would be subject to detailed consultation before its final adoption.

In the meantime, the MTS Project Team is eager to receive feedback and comments from anyone who has not participated in the MTS workshop process – be they patients, carers, health care professionals, academics, or simply concerned members of the public. If you would like to submit comments or suggestions to the team, please provide them in written form to the individuals overleaf:

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

MTS Project Team Contact Details

Ms. Matsie Seritsane, MTS Project Manager Email: [email protected]

Ms. Rolize Kruger, MTS Administrator Email: [email protected]

Fax: 012 312 0552

Post: MTS Project Team Civitas Room 2420 Department of Health Private Bag X828 Pretoria 0001

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

Appendix 1 – Specialty Focus Groups Held and Reports Received Reports Received Anaesthetics Burns Cardiology Cardiothoracic surgery Clinical Immunology Clinical pharmacology Craniofacial Surgery Critical care / ICU Dermatology Diagnostic Radiology Endocrinology Ear, Nose & Throat Surgery Gastroenterology & Hepatology General Medicine General Surgery Geriatrics Haematology Human Genetics Infectious Diseases Medical & Radiation Oncology Neonatology Neurosurgery Nephrology Neurology Nuclear Medicine Obstetrics and Gynaecology Opthalmology Orthopaedics Other Rehab Specialists Oral and Maxillofacial Surgery Paediatric Surgery Paediatric Medicine (incl. Infectious Diseases) Paediatric Cardiology Paediatric Critical Care (ICU) Paediatric Endocrinology / Diabetes Paediatric Gastroenterology Paediatric Haematology/ Oncology Paediatric Nephrology and Transplant Paediatric Neurology Paediatric Respiratory Medicine & Allergology Paediatric Rheumatology Plastic & Reconstructive Surgery Mental Health Services Renal / Liver transplantation Respiratory Medicine Rheumatology Spinal Injury Rehabilitation & Management Trauma Urology Vascular surgery

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Regional Hospital Tertiary Hospital National Referral Centre Anaesthetics Not Described Not Described Not Described Description General Burns Service Specialised Burns Unit Possible Future Development Burns Personnel General Surgeon, MOs, Nursing Specialist Burn Care Surgeons, Specialised Nursing Not described in detail

Resources & Dedicated burn care facility for minor and moderate Dedicated Burns ICU and Theatre Activities burns, Telemedicine link

Also On-Site High care, general or plastic surgery Trauma, Plastic & Reconstr Surgery, Rehabilitation Team, Dietician, Social Work Cardiology Description General Physician Service with Cardiology Training Specialist Cardiologist Service As Tertiary plus:

Personnel General Physicians, Technologists, General Nursing Cardiologists, Snr. Registrars, Radiographers, Cardiac / Cath Lab Technologists, ICU staff, Dietician, OT, Physio, Other Rehab

Resources & Echocardiography, Ultrasound, Electrocardiography, Echocardiography, Ultrasound, Electrocardiography, Heart Transplant, Cardioverter Defibrillators, LV assist Activities Stress Testing Stress Testing, ECG Holter Pacemaker follow-up, devices Cath Lab, Electrophysiology Ablation,

Also On-Site ICU, Internal Medicine Cardiac Surgery, MRI, Nuclear Medicine, ICU, Respiratory Med, Diabetes care, Dialysis, Neurology, Vascular Surgery, Anaesthetics, Paediatrics, Full Rehabilitation Service Description Not Described / Required Specialised Cardiothoracic Surgery Centre National Cardiothoracic Hub Cardiothoracic surgery Personnel Specialist Cardiothoracic Surgeons, Registrars, As Tertiary MOs, Nursing

Resources & Full Cardiothoracic service As Tertiary plus heart / lung transplant Activities ICU, Radiology, Cardiology & Paediatric Cardiology, ICU, Radiology, Cardiology & Paediatric Cardiology, Also On-Site Respiratory Medicine Respiratory Medicine

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Clinical Immunology Description Regional Immunology Services Tertiary Clinical Immunology National Referral Centre

Personnel General Physician, MOs, Specialist Nurse Specialist Clinical Immunologist, MOs Specialist Clinical Immunologists & Scientists

Resources & Diagnosis and basic treatment Advice centre, Inpatient beds, Immunotherapy As Tertiary plus gene sequencing, sophisticated and Activities modalities, Research & Teaching, Preventative innovative immunotherapy Immunology

Also On-Site Laboratory Access to all major disciplines, Laboratory As Tertiary plus Technical College Description Regional Clinical Pharmacology Service Tertiary Clinical Pharmacology Service National Policy Support Unit Clinical pharmacology Personnel Clinical Pharmacologist (or trainee) Clinical Pharmacologists, Specialised Laboratory As Tertiary Scientists

Resources & Training and advice for regional and PHC service Training and advice, patient-level consultation, Support for Government policy and regulation of Activities providers laboratory support and advice pharmaceuticals and traditional medicines

Also On-Site Basic assays / laboratory Forensic Laboratories As Tertiary Description Not envisaged Not envisaged National referral centre with 2 units nationally Craniofacial Personnel Neurosurgeon, plastic surgeon, MFOS, ENT, Audiologist, Dietician, OT, Orthodontist, Paed. Dentist, Social Worker, Physiotherapist, Paed. Anaesthetist Critical care / ICU Description Regional ICU Service Tertiary ICU Service ICU Support for Quaternary Services

Personnel Medical ICU Director (general specialist with ideally 24 hr on-site cover by dedicated medical staff (MO/ As Tertiary but larger, sub-specialty training for ICU 6 months experience in Intensive Care), 24 hr Registrar) in addition to 24 hour cover by trained nurses, 24 hour ICU Technologists availability medical cover provided by a doctor with intensivists (not necessarily on site) ICU trained advanced life support skills. Nurse Manager (Critical nurses, ICU Technologists and dedicated Care Trained), Medical & Nursing Support, professions allied to medicine services Professions allied to medicine services

Resources & Int. care for patients with not more than 1 organ Full ICU services includes both intensive care and Additional support for transplantation and cardiac Activities failure & not expected to require >3 days ventilation high care beds surgery and certain other quaternary services

Also On-Site 24-hour lab & radiology services 24-hour lab & radiology services As Tertiary Dermatology Description Regional Dermatology Service Tertiary Dermatology Service National Dermatology Referral Service

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Personnel Specialist Dermatologist, Specialised Nursing Specialist Dermatologists, Regs, Specialised NursingSpecialist Dermatologists, Regs, Specialised Nursing n.b. only 20 dermatologists in public sector today Resources & Ambulatory Dermatology Service, Telemedicine link Full dermatology inpatient service and specialised As Tertiary plus super-specialists for ‘hi-tech” and Activities to Tertiary clinics rare conditions

Also On-Site Not stated Not stated Not stated Description General Radiology Service Specialised Radiology Service Specific High-Cost Facilities Diagnostic Radiology Personnel Radiologist, Radiographers, Ultrasonographer, Radiologists, Radiographers, Ultrasonographer, As Tertiary Resources & Nursing, Technical Nursing, Technical, Medical Physics, IT

Activities X-Ray, Fluoroscopy, Ultrasound, Single-slice CT X-Ray, Fluoroscopy, Ultrasound, Multi-slice CT PET Scan, Interventional Neuroradiology, Cardiac Scan & telelink to tertiary centre Scan, MRI, Mammography, Colour Doppler US, Imaging Gamma cameras

Also On-Site General Surgery Anaesthetics, Clinical Engineering Description General ENT Service Specialised ENT Service Super-Specialist Service attached to Tertiary Ear, Nose & Throat Surgery Personnel ENT Specialist, MOs ENT Specialists, Registrars, MOs ENT Specialists with specific expertise

Resources & Basic ENT surgical equipment, Audiometry / ENT Surgery, Bone Laboratory, Vestibular Studies, Cochlear Implants, Skull Base Surgery Activities Audiology Laser Endoscopic Surgery, Audiometry / Audiology

Also On-Site Radiology MRI, ICU, Neurosurgery, Oncology, Radiology (and access to all other tertiary depts as required) Description General Medical Endocrinology Tertiary Endocrinology Service National Endocrinology Referral Centre

Personnel General Physician, MOs and Nurses with specific Specialist Endocrinologists, Registrars, MOs and Adult and Paediatric Specialist Endocrinologists, training Nurses with specific training Registrars, MOs, Nursing Endocrinology Resources & Type 2 Diabetes and common thyroid disorders All diabetes requiring referral, all other endocrine All endocrine conditions, including transplants and Activities (incl. Metabolic, bone, lipid disorders) and thyroid fertility management , . pancreatic islet cell disorders and dyslipidaemia transplantation and or highly specialised services like proton beam radiotherapy

Also On-Site Dietician, General Surgery, Ophthalmology Sonar, CT, Nuclear Medicine, Ophthalmology, Dietician, Podiatrist, General Surgery, Chemical Pathology MRI, bone density, Invasive Radiology,

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Endocrine Surgeon, Neurosurgery, Vascular Surgery, Obstetrics, Dialysis, Transplant Surgery, Radiation Oncology Description Level II GIT Service Tertiary GIT Service Specialist Liver Unit

Gastroenterology & Personnel Specialist General Physician or Surgeon (with GIT Specialist Medical and Surgical Gastroenterologists, Specialist Clinical Hepatologists, Hepatic Surgeons, training), GIT Nurses, Registrars on rotation Registrars, MOs, Specialised Nursing, Technicians Pathologist Hepatology Resources & Upper GI endoscopy, Proctoscopy, sigmoidoscopy Super-specialist activities: Upper GIT, hepatico- MARS machine, bioartifical liver support devices Activities and colonoscopy, acute GIT emergencies pancreatic-biliary diseases, colon diseases

Also On-Site Not stated Virology, Immunology, CT, ICU Liver Transplant Unit Description General Medicine Service General Medicine & Sub-Specialist Medicine Service No difference from Tertiary

Personnel Generalist Specialist Physician, Visiting Sub- Generalist Specialist Physicians, Sub-Specialist General Medicine Specialists, Registrars, MOs, Nursing Physicians, Registrars, MOs, Nursing

Resources & Coronary care, ICU, Haemodialysis, Coronary care, ICU, Haemodialysis, Activities Echocardiography, Scopes, Sonar Echocardiography, AT Scan, Angiography, Scopes, Sonar, Outreach to Regional Hospitals

Also On-Site CT Scan, Radiology, General Surgery, Obs & MRI, CT Scan, Radiology, General Surgery, Obs & Gynae, Paediatrics, Allied Health Professionals e.g. Gynae, Paediatrics, Allied Health Professionals e.g. Physiotherapy, Nutrition, OT. Physiotherapy, Nutrition, OT.

Description Regional General Surgery Service Tertiary General Surgery National Surgical Referral Centre General Surgery Personnel Specialist General Surgeons, Registrars, MOs, Specialist General Surgeons with special interests, Super-Specialists, Registrars, MOs, Nursing, Nursing, Anaesthetists Registrars, MOs, Nursing, Anaesthetists Anaesthetists

Resources & “All general surgery” Complex and high acuity Specific procedures e.g. liver and major pancreatic Activities resections, TME

Also On-Site All general disciplines, Radiology, Allied Health Anaesthetists, Radiology with CT and interventional As Tertiary Disciplines incl. Stoma therapists and Nutrition Units. capability, ICU Geriatrics Description General Medicine for Geriatric Patients Specialised Geriatric Service No Quaternary Level Envisaged

Personnel General Physicians, MOs, Nursing, Physio, OT, Specialist Geriatricians, Registrars, MOs, Nursing, SS OS S 49

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Speech Therapist, Social Worker, dietician and Physio, OT, Speech Therapist, Social Worker chiropodist. dietician, clinical psychologist and chiropodist.

Resources & Integrated General Medical Unit and Rehabilitation Acute Geriatric Care, Stroke Unit, Psycho geriatric Activities Service Care, Rehabilitation Service

Also On-Site CT, Radiology, Echocardiography, ICU, General MRI, CT, Radiology, Echocardiography, ICU, All Surgery, Urology, Gynaecology, Psychiatry, Other Adult Tertiary Specialties especially Orthopaedics Neurology, Cardiology, Orthopaedics, Urology Description Consultation Services Tertiary Haematology Service Bone Marrow Transplantation Unit

Personnel Part time haematologist MO with interest, Specialist Clinical Haematologists, Pathologists with Linked to a Tertiary unit Haematology trained nurses special interest, Registrars, MOs, Nursing, Min. 3 consultants Haematology Resources & Possible Outreach Activities (not specified) Malignant haematological, lymphoproliferative and Allogeneic Bone Marrow Transplantation Activities clonal disorders, non-malignant haematological disorders; Apheresis, isolation, stem cell harvesting and storage facilities

Also On-Site Palliation and supportive services e.g. Medicine Oncology (Medical & Radiation), Radiology, Research facilities Description Genetic Diagnosis & Counselling Service Tertiary Genetics Service National Genetics Centre Human Genetics Personnel Genetic Nurse, Regional Coordinator (nurse) for Specialist Medical Geneticists, Genetic Nurses / As Tertiary district hospital genetic services Counsellors, Medical Technologists

Resources & Basic diagnostic, counselling and therapeutic Diagnostic services and complex counselling and Specialised molecular diagnostic tests, Inborn Error of Activities support (incl. Amniocentesis) care Metabolism screening & diagnosis

Also On-Site Radiology, Obs & Gynae, Paediatrics, Gen. Med., As regional plus Ultrasound As Tertiary Gen. Surg., Social Workers Infectious Diseases Description Regional General Medicine Tertiary Infectious Diseases Not Envisaged however, there is a need for a National Centre for Communicable Diseases. Personnel Specialist General Physician, Registrars, Nurses Specialist Infectious Diseases, Registrars, MOs, with specific training, infection control, microbiologist Specialist Nursing, infection control, microbiologist (n.b. no mention of containment facilities?) and virologist. and virologist.

Resources & Complex conditions not manageable at Level I; Unusual infections, complicated malaria and HIV, Activities endoscopy bronchoscopy isolation facilities HIV HAART isolation facilities complicated TB novel 50

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Activities endoscopy, bronchoscopy, isolation facilities, HIV, HAART, isolation facilities, complicated TB, novel HAART and expanded antibiotic formulary. antibiotics and training in infectious diseases

Also On-Site Radiology, CT, ICU, microbiology, virology, Radiology, CT, MRI, ICU, dialysis, microbiology, immunology, social work virology, immunology, social work Description Regional General Medicine Tertiary Oncology Service National Oncology Referral Service

Personnel MO with oncology diploma, Oncology Nurses Specialist Medical and Radiation Oncologists, As Tertiary Therapy Radiographers, Oncology Nurses, Research Coordinators, Medical Physicists, Pharmacists, Social Workers, Mould room Technicians

Resources & Basic medical oncology: basic care, follow-up, Linear Accelerator, CT scan planning, Brachytherapy Bone Marrow Transplant, IMRT, Intraoperative Medical & Radiation Oncology Activities palliation, Laminar Flow, Basic Laboratory and R-ray Cobalt Isolation facilities, Single bed units, Most Radiation, Stereotactic Radiation, PET Scan planning; services standard chemotherapy and biological drugs, laminar flow, cryopreservation, stem cell harvesting, T- Monoclonal antibody therapy cell depletion facilities, inter operative radiation, autologous and allogeneic stem cell transplant units and further development of the South African Bone Marrow Transplant Registry to obtain volunteer unrelated donors for stem cell transplant patients.

Also On-Site Radiology, Laboratory, Chemotherapy, General Radiology, CT, ICU, Surgical Oncology, As Tertiary plus Nuclear Medicine & PET, Surgery, Obs & Gynae, Dietician, Psychiatry, Social Gynaecological Oncology, Neutropenic isolation Haematology Work, Pharmacists areas for chemotherapy patients, Therapeutic Isolation areas for patients receiving radioactive isotopes Mental Health Services Description Regional Mental Health Service Tertiary Mental Health Service Not Envisaged

Personnel Specialist Psychiatrist, Clinical Psychologist, Specialist and sub-specialist Psychiatrists, Clinical Registrars, Psychiatric Nurses, OT, Social Work, Psychologists, Registrars, Psychiatric Nurses, OT, Psychiatry interns. Social Work, Psychiatry interns.

Acute inpatient, outpatient; child and adolescent Child and adolescent psychiatry; Old-age psychiatry; Resources & psychiatry, ECT, liaison, satellite clinics Forensic psychiatry; Substance abuse; Liaison Activities psychiatry; Eating disorders; Inpatient psychotherapy; Social psychiatry; Acute psychotic (complicated); Acute non-psychotic (complicated)

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Also On-Site General Medicine, Neurology (?), Paediatrics All Specialties Neonatology Description Neonatal Low & High Care Unit Neonatal Intensive Care Unit Not Envisaged

Personnel Specialist Paediatricians, MOs, Nurses with specific Specialist Neonatologists, Paediatricians, MOs, Specialist training Nursing

Resources & Low and high care; short-term ventilation awaiting transfer, Intensive and high care, obstetric and perinatal services, Activities Kangaroo care Kangaroo care

Also On-Site Radiology, CT, Ultrasound, Physio, OT, Dietician, Speech As Regional plus MRI; access to all Paediatric Sub- Therapist, Social Work, Technical Support Specialties Nephrology Description Regional Dialysis Service Tertiary Nephrology Service National Referral Centre

Personnel Specialist General Physician and nurses with renal Specialist Nephrologists, Registrars, Spec. nurses, dialysis As tertiary plus psychologist training, dialysis therapists, clinical technologist therapists, clinical technologists, social worker

Resources & Haemodialysis & peritoneal dialysis for stable chronic Haemodialysis & peritoneal dialysis chronic & acute, Haemodialysis & peritoneal dialysis chronic & acute, renal, Activities patients, primary prevention, organ donation primary prevention, organ donation, referral for transplant pancreas-kidney, liver-kidney transplantation

Radiology, Dietician Also On-Site Social worker, dietician As Tertiary; Transplant Surgery Description Regional General Medicine Tertiary Neurology Service Not Envisaged

Neurology Personnel Physician with Neurology Diploma Specialist Neurologists, Registrars, MOs, Specialist Nurses, Technologists Resources & Activities Not specified Neurology, EEG, Stroke Unit

Also On-Site Radiology, CT Rehabilitation Team, Radiology, MRI, CT, ICU Description General Surgeon / Trauma Service Only two levels envisaged “National Tertiary” Specialist Neurosurgeon Service Neurosurgery Personnel General Surgeon, Rehab staff Neurosurgeons, Registrars, MOs, nursing

Resources & Trauma and Neuro-rehabilitation Neurosurgical theatres & equipment for full range of Activities neurosurgical operations and management

Also On-Site CT Scan, ICU, Rehab Team, Telemedicine CT & Neuroradiology, Neurology, Full Rehabilitation team, ICU Description Regional Nuclear Medicine Tertiary Nuclear Medicine Centre PET or gamma-PET Nuclear Medicine Personnel Specialised Radiographer only Specialist Nuclear Physician, Specialised Radiographers, As Tertiary

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Medical Physics, Technologists

Resources & Limited equipment, telemedicine link to tertiary Diagnostic and Therapy Nuclear Medicine Positron Emission Tomography or gamma-PET Activities

Also On-Site Not Stated in Report Not Stated in Report Adequate Cyclotron capacity for isotope production Description Regional Obstetrics & Gynaecology Service Tertiary Obstetrics & Gynaecology Service Not Envisaged Obstetrics and Gynaecology Personnel Specialist General Obstetricians & Gynaecologists, Specialist & Sub-Specialist Obstetricians & Registrars, MOs, Nursing Gynaecologists, Registrars, MOs, Nursing

Resources & Basis and Emergency obstetrics, ultrasound, prenatal As regional plus: Fetal / Maternal medicine, Oncology, Activities diagnosis, Kangaroo care, Basic and Emergency. Urogynaecology, Reproductive Medicine Gynaecology, diagnosis, basic urogynaecology mid trimester abortions or adequate systems for pain relief, basic menopause and screening programmes, preliminary investigations for infertility

Anaesthesiology, High Care / ICU (adult and baby) basic Also On-Site oncology Anaesthetics, Radiology, ICU, Neonatology, Human Genetics, All Medical Sub-Specialities, Paediatric Surgery, Radiation Oncology, Colorectal Surgery, Urology, Endocrinology, Plastic Surgery, Physio, Pathology, Psychology Description General Ophthalmology Service Specialised Ophthalmology Service Super-Specialist Ophthalmology Service Opthalmology Personnel Specialist Ophthalmologist, Registrars / MOs, Nursing Specialist Ophthalmologists, Registrars and MOs, As Tertiary Orthoptist, Nursing Resources & Operating Room & Microscope, Argon & Yag Lasers, Activities routine ophthalmic surgery Complex surgery, B Scan Ultrasound & imaging, Electro Oncological surgery, Genetics, Specialised paediatric, diagnostics Photodynamic therapy Also On-Site Anaesthetics, Radiology, Maxillo facial, Plastic Surgery and Pathology Neurology, Neurosurgery, Radiology, Anaesthetics, As Tertiary plus MRI, Human Genetics Maxillo facial, Plastic Oncology, Paediatrics, Physicians Maxillo facial, Plastic Surgery and Pathology Surgery and Pathology Description General MFOS services Full Spectrum of MFOS Services Non e envisaged

Specialists or Academic Appointments Personnel Part or Full time specialist assisted by MO or dentist

Resources & Oral and Maxillofacial Surgery Oral Sepsis, Basic Trauma, Dento-alveolar surgery Activities

Radiology, laboratories, Anaesthetics 53

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Also On-Site Description General Orthopaedics Sub-Specialty Orthopaedics Orthopaedic Oncology Centre

Personnel General Specialists, MOs, Nursing Specialists with special interests, Registrars, Nursing Super-Specialists

Orthopaedics Resources & All general orthopaedic surgery Arthroplasty, Spinal Surgery, Hand and Upper Limb Orthopaedic Oncology, Spinal, Tissue Engineering Activities Surgery, Spinal Surgery, Athroscopic Surgery e.g. Limb Salvage (revision surgery) Paediatrics, Foot and Ankle, Chronic Sepsis and Oncology

Also On-Site High Care, X-Ray, Ultrasound, General Medicine, As regional plus MRI, CT, ICU, access to all other General Surgery, Rehabilitation Team, Orthotics, tertiary specialties As tertiary (n.b presumably close link to Oncology) Prosthetics Description Regional Rehabilitation Centre Tertiary Rehabilitation Centre Not Envisaged Other Rehab Specialists Personnel Physiotherapy, Occupational Therapy, Orthotics & Physiotherapy, Occupational Therapy, Orthotics & Prosthetics, Speech therapy, Dietetics, Podiatry Prosthetics, Speech therapy, Dietetics, Podiatry, Audiology

Resources & Combined Rehabilitation Team & Facility to provide Combined Rehabilitation Team & Facility to provide Activities integrated rehabilitation integrated rehabilitation (excl. spinal injury unit)

Also On-Site All Regional Hospital Services All Tertiary Hospital Services Description Regional Paediatric Medicine Service Tertiary Paediatric Medicine Service National Paediatric Referral Centre

Paediatric Medicine Personnel Specialist General Paediatrician, MOs, Nursing Specialist General and Sub-specialist Paediatricians, Super-specialist Paediatricians / Surgeons, Registrars, MOs, Specialist Nursing Registrars, MOs, Specialist Nursing

Resources & General & emergency paediatrics, neonatology, child General Paediatrics plus Genetics, Child Psychiatry Organ transplantation, epilepsy surgery, craniofacial Activities abuse, child health service & Behavioural Paediatrics, Infectious Diseases and surgery; certain high-cost / complexity medical full range of Paediatric Sub-Specialties interventions

Also On-Site Radiology, Neonatal High Care, Isolation facilities, As Regional plus all surgical sub-specialties, As Tertiary Anaesthetics, Obs & Gynae, Paed Surgery, Oncology, Nuclear Medicine, ICU, NICU Rehabilitation Team, Social Work Description Paediatric Allergology Personnel M O with (Diploma in Allergy), Trained nurses Specialist, M O with Dip. in Allergy, specialist nurse, Specialists 54

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

dietician

Resources & Clinic facilities with resuscitation, skin tests, spacers, Spirometry, skin pricks tests (titrated). Spacers, Full diagnostic allergy clinic able to develop in house Activities basic spirometry radiology indigenous allergen Specific IgE tests, Western blotting, lymphocyte proliferation and cytokine assays, Aerobiology asthma education, epidemiological surveillance, clinical trials, Double blind placebo controlled food challenges Expertise in immunotherapy, allergy and asthma Also On-Site education Laboratory able to determine Specific IgE, nasal Full lung function facilities, radiology and immunology eosinophils, tryptase, immunotherapy clinics (bee, clinics, drug desensitisation expertise venom and inhalant, double blind placebo controlled food challenges Description Regional Paediatric Medicine Service Tertiary Paediatric Cardiology Service National Paediatric Cardiology Referral Centre

Personnel Specialist General Paediatrician with cardiology Specialist Paediatric Cardiologists & Cardiac As Tertiary Paediatric Cardiology training Surgeons, Cardiac Anaesthetists, Clinical Technologists, ECG Technicians

Resources & Echocardiography Echocardiography, Cardiac Cath & Cardiac Surgery As Tertiary plus Transplants, Electrophysiology Activities

Also On-Site Not specified Paediatric ICU, MRI, CT, Nuclear Medicine As Tertiary Paediatric Child development Description Paediatric Medicine Services Child Development Services National referral services

Personnel General Paediatricians, Nurses, Physiotherapist, Specialist Child Developmentalist, Nurses, As Tertiary Occupational therapist, Speech Therapist, Dietician, Physiotherapist, Occupational therapist, Speech Social Worker Therapist, audiologist (specialised for child development) Dieticians, Pharmacist (paediatric trained), Clinical Geneticists, Social Worker

Resources & Basic paediatric development screening e.g. vision, Full developmental services with outreach No quaternary services exist yet. Activities hearing and addressing rehabilitation of programmes. Telemedicine may play a role. chronic/static conditions.

Also On-Site Radiology (CT Scan) Neurophysiology (e.g. BAER, EEG, EIMG). Relevant PET Scan? ƒMRI Vision and hearing screening. laboratory services (e.g. genetics) Radiology: CT, MRI. Neuropsychology, Paediatric Psychiatry, Pditi thdi Pditi 55

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Paediatric orthopaedics, Paediatric nuerosurgery, ICU, Playrooms and observation rooms. Description Critical Care of Children Paediatric ICU Service ICU Support for Quaternary Paediatric Services

Personnel Paediatricians, MOs and nurses with paediatric Paed. Intensivist as Medical Director, Paed ICU- As Tertiary, but with personnel possessing sub- Paediatric Critical Care (ICU) resuscitation skills trained Nurse as Nursing Director, Paed ICU nurses, specialty skills ICU technologist

Resources & Recognise critically ill children, resuscitate and Full Paediatric ICU Service Support to e.g. transplant, cardiac surgery, Activities stabilise for transfer, telemedicine link to tertiary neurosurgery etc.

Paediatric Endocrinology / Personnel Specialist General Paediatrician, Trained Nurses andSpecialist General Paediatrician with interest in Specialist Paediatric Endocrinologist, Molecular Diabetes MOs Endocrinology, Staff & Patient Educators Laboratory

Resources & Diagnosis, early referral, emergency care Comprehensive Endocrinology Service, outreach, Complex and rare metabolic disorders, advanced Activities screening investigations

Also On-Site Telemedicine, Social Work, Social Services, Psychology, Paediatric Surgery, Paediatric As Tertiary laboratories Radiology, Genetics, Social Services, Genetics, Lab Description Regional Paediatric Medicine Service Tertiary Paediatric Gastroenterology Service National Paediatric Referral Centre Paediatric Gastroenterology Personnel Specialist General Paediatrician Specialist Paediatric Gastroenterologists Super-specialist Transplant Team

Resources & Diagnosis, basic treatment, follow-up management Clinical, endoscopic and lab evaluation, treatment Transplant Surgery, Metabolic laboratory Activities of tertiary cases

Also On-Site Radiology, Counsellors, Social Work, Paed Surgery As Regional plus: ICU, Other Paediatric Sub- As Tertiary plus Pharmacology lab specialties, Dietetics, Infectious Diseases, Adult GIT Paediatric Haematology/ Description Regional Paediatric Medicine Service Tertiary Paediatric Medicine Service National Referral Paediatric Haematology & Oncology Centres Oncology Personnel Specialist General Paediatrician / Visiting Consultant Specialist General Paediatrician Sub-Specialist Haematologist / Oncologists, Specialist Nurses

Resources & Palliative care and identification for possible Chemotherapy under guidance, palliative care, Full diagnostic and treatment services with autologous

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Activities diagnosis diagnosis and allogeneic Bone Marrow Transplant at selected site(s)

Also On-Site Radiology, Ultrasound, Social Worker Radiology, CT, High Care, Social Worker, Physio, Radiology, CT, Radiation Oncology, ICU, High Care, Paediatric Surgery Hospital School, Paediatric Surgery and Surgical Sub- specialties

Paediatric Infectious diseases No Separate Report – No Separate Report – No Separate Report –

See Paediatric Medicine See Paediatric Medicine See Paediatric Medicine Paediatric Nephrology Description Regional Paediatric Medicine Service Characterised as Quaternary Service Quaternary Paediatric Nephrology Service and Transplant Personnel Specialist General Paediatrician, MOs Specialist Paediatric Nephrologists, Specialist Nurses, Technologists, Specialist Paediatric Surgeons

Biopsies, Peritoneal and Haemodialysis, Renal Resources & Screening and treatment of basic conditions, Transplant Activities Telemedicine link to referral unit Radiology, Sonar, ICU, Nuclear Medicine, Psychology, Also On-Site Radiology, Social Work Social Work Description Regional Paediatric Medicine Service Paediatric Neurology Service National Referral Service Paediatric Neurology Personnel General Paediatricians, Nursing, Physio, OT, Specialist Paediatric Neurologists, Developmental As Tertiary Speech Therapy Paediatricians, Nursing, Physio, OT, Speech Therapy

Resources & Basic paediatric care e.g. epilepsy, CPs, chronic Full paediatric neurology services and telemedicine Complex epileptic surgery, complex neuromuscular Activities rehabilitation support to regional patients, neurodegenerative and metabolic patients, Video telemetry, intracranial mapping, neuro- metabolic lab.

Also On-Site Radiology CT, MRI, spectroscopy, ICU, Neurosurgery, As Tertiary plus histopathology, molecular genetics, Radiology, EEG & EMG, Psychology, Psychiatry, metabolic specialists Social Work Paediatric Respiratory Description General Paediatric Medicine Tertiary Paediatric Respiratory & Allergology Service Not Envisaged Medicine & Allergology Personnel General Paediatricians Specialist Paediatric Pulmonologists & Allergologists, (Spit between the two sub Specialist Nursing

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

specialties suggested as the only overlap between them is Resources & Spacer devices for infants, peak flow metres, pulse Spirometry, skin prick testing, spacers, histamine asthma management) Activities oximetres and X-rays challenges, bronchoscopy, Lung function facilities

Also On-Site Physiotherapy, Microbiology laboratory and Radiology, Spiral CT, Paediatric ICU, NICU, Radiology. Paediatric Cardiothoracic Surgery, Dieticians, Physio, Psychology Description General Paediatric Medicine, continuation of therapy Tertiary Paediatric Rheumatology Service National Paediatric Referral Centre

Paediatric Rheumatology Personnel General Paediatricians Registered Specialist Paediatric Rheumatologist, As Tertiary Dedicated Specialist Nurse Practitioner

Resources & Screening, follow-up and step-down of tertiary cases Diagnosis and treatment: lupus, dermatomyositis all Bone Marrow Transplant, DEXA scans, Interleukin Activities vasculitides, problem JCA and systemic onset levels, joint replacement disease. All connective tissue diseases and immunomodulatory therapy. Also On-Site Radiology, Phsyio, OT, Orthopaedics, step down As Tertiary plus: Laminar Flow unit, Haematology, facilities Radiology, MRI, Paed ICU, Rehabilitation Team, Infectious Diseases, Immunology and BMT Adult Rheumatology, Nephrology, Ophthalmology, Paed Orthopaedics Description Regional Paediatric Surgery Service Tertiary Paediatric Surgery Service National Paediatric Referral Centre

Paediatric Surgery Personnel General surgeon with paediatric interest, or an MO Specialist Paediatric Surgeons and other Super-specialist Paediatric Surgeons and sub (including the cardiothoracic with general and paediatric surgical experience. subspecialties i.e. cardiothoracic and general specialists , Registrars, MOs, Specialist Nursing surgery, general paediatric paediatric surgery, ophthalmology, neurosurgery, surgery, neurosurgery, orthopaedics and plastic and reconstructive, ENT, ophthalmology, orthopaedics, urology, Registrars, MOs, Specialist Nursing plastic & reconstructive surgery, ENT, urology subspecialties) Resources & Basic paediatric surgery Comprehensive paediatric surgery – general and Organ transplantation, epilepsy surgery, craniofacial Activities sub-specialties surgery, cochlear implants, laryngeal reconstruction, limb salving oncology, eye salvaging oncology.

Also On-Site Specialist Anaesthetics, Radiology, General As regional, All Paediatric disciplines, ICU, As Tertiary Paediatrics, Care, Physiotherapy, Laboratory Paediatric Anaesthetics, Oncology, Radiology, Services Pathology Plastic & Reconstructive Description Regional Plastic Surgery Service Tertiary Plastic & Reconstructive Surgery Mentioned but not Elaborated Surgery Personnel Specialist Plastic Surgeon, Rotating Registrars, MOs Specialist Plastic Surgeon, Registrars, MOs, S 58

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Specialist Nurses

Resources & Secondary plastic surgery; Dermatome, Osteotomy, All services: Dermatome, Osteotomy, Microscope, Activities Microscope Laser, Endoscopy

Also On-Site Radiology, CT, Anaesthetics, General Surgery, Radiology, CT, MRI, Anaesthetics, ICU, Rehabilitation Team Rehabilitation Team Description See General Medicine and Nephrology Renal Transplant Unit Liver Transplant Unit Renal / Liver transplantation Personnel Specialist Surgeon, Specialist Nephrologist, As Renal Unit plus Specialist Hepatologists Specialist Nursing, Transplant Coordinator, Registrars

Resources & Dedicated renal transplant unit Dedicated Liver Transplant Unit Activities

Also On-Site Dialysis, Radiology, Anaesthetics, ICU, Immunology As Renal Unit plus Virology Lab, Pharmacology, Bacteriology Description Regional General Medicine Service Tertiary Pulmonology Service National Pulmonology Referral Centre Respiratory Medicine Personnel Specialist General Physician and MOs , Specialist Pulmonologists, Registrars, MOs, As Tertiary Technologists Pulmonology Technologists

Resources & Diagnosis, acute care and referral, spirometry, Comprehensive Pulmonology service, including As Tertiary plus: lung volume reduction surgery, lung Activities oximetry, outreach from referral centre Respiratory ICU transplantation (with Thoracic Surgery)

Also On-Site ICU (?) Radiology Radiology, CT, Nuclear Medicine, Thoracic Surgery, As Tertiary Occupational Health, Tuberculosis Control Program, Infectious disease specialities, Radiation Oncology (n.b. No mention of specialist services, and Physiotherapy MDR TB facilities?) Rheumatology Description Regional General Medicine Service Tertiary Rheumatology Service Not Envisaged

Personnel Specialist General Physician and/or MOs with Specialist Rheumatologists, Registrars, MOs, Rheumatology diploma Specialist Nursing

Resources & Uncomplicated rheumatoid arthritis, gout, All Rheumatology, DEXA scans Activities osteoarthritis, follow-up of tertiary cases

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Also On-Site Radiology Radiology, MRI, Pulmonology, Nephrology, Neurology, Dermatology and Haematology, Orthopaedics Description Acute Rehabilitation Service Acute Rehabilitation Service No Quaternary Level Spinal Injury Rehabilitation & Management Personnel “Acute Care team” (composition not specified) “Acute Care team” (composition not specified) (n.b. Strong focus on strengthening PRIMARY rehabilitation services in report, requiring a Resources & Theatres, Spinal Beds, Turning Teams / Beds Theatres, Spinal Beds, Turning Teams / Beds comprehensive PHC rehab centre) Activities

Also On-Site ICU, CT, Anaesthetics, General Surgery, ICU, CT, MRI, Anaesthetics, General Surgery, Orthopaedic Surgery, Psychology, Physician Orthopaedic Surgery, Urology, Neurosurgery, Plastic Surgery, Psychology, Physician Description Level II Trauma Services Tertiary Major Trauma Centre Not Envisaged Trauma Personnel Specialist General Surgeons & Physicians, SpecialistSpecialist Trauma Surgeons (sub-specialist General Orthopaedic Surgeons Surgeons)

Resources & 24 hour initial definitive trauma care regardless of Comprehensive care for all trauma in coordination Activities severity of injury, stabilisation for transfer of complex with other specialties trauma (coordinated by General Surgery)

Also On-Site Anaesthetics, Radiology, High Care Anaesthetics, Radiology, ICU, All other major specialties and surgical sub-specialties Description Regional General Surgery Service Tertiary Urology Service Not Envisaged Urology Personnel Specialist General Surgeon, Urology Registrar Specialist Urologists, Registrars, MOs rotated from tertiary centre

Resources & Basic urology service Comprehensive Urology Service and outreach to Activities regional hospitals

Also On-Site Radiology Not Specified Vascular surgery Description Regional Vascular Surgery Service Tertiary Vascular Surgery Service Not Envisaged

Personnel Specialist Vascular Surgeon, General Surgeon Specialist Vascular Surgeons

APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO

Resources & Majority of Vascular Surgery cases All Vascular Surgery Activities

Also On-Site Anaesthetics, Radiology, Duplex Doppler, General Anaesthetics with special interest, Radiology (incl. Medicine, ICU Interventional), Duplex Doppler, General Medicine, ICU, Cardiology, Neurology, Endocrinology

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

Regional Hospital Tertiary Hospital National Referral Centre Anaesthetics Not Specified Not Specified Not Specified Description Burns Service at Selected Regional Hospitals Only Specialised Burns Unit None Burns Personnel General Surgeon, MOs, Nursing Specialist Burn Care Surgeons, Specialised Nursing

Resources & Dedicated burn care facility for minor and moderate Dedicated Burns ICU and Theatre Activities burns, Telemedicine link

Also On-Site High care, general or plastic surgery Trauma, Plastic & Reconstructive Surgery, Rehabilitation Team, Dietician, Social Work Cardiology Description Regional General Medicine Service Specialist Cardiologist Service As Tertiary plus:

(No alternative scenarios Personnel General Physicians with Cardiology Training, Cardiologists, Snr. Registrars, Radiographers, offered; main difference Technologists, General Nursing Cardiac / Cath Lab Technologists, ICU staff, probably in number of units Dietician, OT, Physio, Other Rehab affordable?) Resources & Echocardiography, Ultrasound, Electrocardiography, Echocardiography, Ultrasound, Electrocardiography, Heart Transplant, Cardioverter Defibrillators, LV assist Activities Stress Testing Stress Testing, ECG Holter Pacemaker follow-up, devices Cath Lab, Electrophysiology Ablation,

Also On-Site ICU, Internal Medicine Cardiac Surgery, MRI, Nuclear Medicine, ICU, Respiratory Med, Diabetes care, Dialysis, Neurology, Vascular Surgery, Anaesthetics, Paediatrics, Full Rehabilitation Service Description Regional General Medicine & Surgery Specialised Cardiothoracic Surgery Centre National Cardiothoracic Hub

Cardiothoracic surgery Personnel Specialist Cardiothoracic Surgeons, Registrars, As Tertiary MOs, Nursing

(No alternative scenarios Resources & Full Cardiothoracic service As Tertiary plus heart / lung transplant offered; main difference Activities probably in number of units ICU, Radiology, Cardiology & Paediatric Cardiology, ICU, Radiology, Cardiology & Paediatric Cardiology, affordable?) Also On-Site Respiratory Medicine Respiratory Medicine

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

Description Regional General Medicine Service Tertiary Clinical Immunology National Referral Centre Clinical Immunology Personnel General Physician, MOs, Specialist Nurse Specialist Clinical Immunologist, MOs Specialist Clinical Immunologists & Scientists

(No alternative scenarios Resources & Diagnosis and basic treatment Advice centre, Inpatient beds, Immunotherapy As Tertiary plus gene sequencing, sophisticated and offered; main difference Activities modalities, Research & Teaching, Preventative innovative immunotherapy probably in number of units Immunology affordable?) Also On-Site Laboratory Access to all major disciplines, Laboratory As Tertiary plus Technical College Description None Tertiary Clinical Pharmacology Service National Policy Support Unit Clinical pharmacology Personnel (Group please comment, especially how many Clinical Pharmacologists, Specialised Laboratory As Tertiary regional specialists outside tertiary centres at Scientists (No alternative scenarios present?) offered; MTS team queries Resources & Training and advice to all levels of care, patient-level Support for Government policy and regulation of feasibility of regional service Activities consultation, laboratory support and advice pharmaceuticals and traditional medicines under this scenario?) Also On-Site Forensic Laboratories As Tertiary Description Not Envisaged Not Envisaged 1 National Referral Centre Craniofacial Surgery Personnel Not specified Not specified Not specified

Resources & Not specified Not specified Not specified Activities

Also On-Site Not specified Not specified Not specified Description Regional ICU Service Tertiary ICU Service ICU Support for Quaternary Services Critical Care / ICU Personnel Medical ICU Director, Nurse Manager (Critical Care 24 hour cover by trained intensivists and ICU trained As Tertiary but larger, sub-specialty training for ICU Trained), Medical & Nursing Support nurses, ICU Technologists nurses, 24 hour ICU Technologists (No alternative scenarios offered; main difference Resources & Int. care for patients with not more than 1 organ Full ICU services Additional support for transplantation and cardiac probably in number of tertiary Activities failure & not expected to require >3 days ventilation surgery and certain other quaternary services and national referral units affordable?) Also On-Site 24-hour lab & radiology services 24-hour lab & radiology services As Tertiary Dermatology Description Regional General Medicine Service Tertiary Dermatology Service None (No alternative scenarios offered; MTS team queries Personnel General Physician, MOs, Specialist Nurse Specialist Dermatologists, Regs, Specialised Nursing

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

feasibility of “ideal” specialist Full dermatology inpatient service and specialised regional service?) Resources & clinics Activities Also On-Site Not stated Description General Radiology Service Specialised Radiology Service Specific High-Cost Facilities Diagnostic Radiology Personnel Radiologist, Radiographers, Ultrasonographer, Radiologists, Radiographers, Ultrasonographer, As Tertiary Resources & Nursing, Technical Nursing, Technical, Medical Physics, IT (No alternative scenarios offered; MTS team proposes no Activities X-Ray, Fluoroscopy, Single-slice CT, Ultrasound, X-Ray, Fluoroscopy, Ultrasound, Multi-slice CT Interventional Neuroradiology, Cardiac Imaging PET under this scenario, smaller Telelink to tertiary centre Scan, MRI, Mammography, Colour Doppler US number of tertiary centres) Also On-Site General Surgery Anaesthetics, Clinical Engineering Ear, Nose & Throat Surgery Description Supra-regional General ENT Service Specialised ENT Service Super-Specialist Service attached to Tertiary

(No alternative scenarios Personnel ENT Specialist, MOs ENT Specialists, Registrars, MOs ENT Specialists with specific expertise offered; MTS team proposes Resources & Basic ENT surgical equipment, Audiometry / ENT Surgery, Bone Laboratory, Vestibular Studies, Cochlear Implants, Skull Base Surgery General ENT service at only Activities Audiology – Selected Hospitals Only Laser Endoscopic Surgery, Audiometry / Audiology selected Regional hospitals e.g. 1 in 3 under this scenario; plus Also On-Site Radiology MRI, ICU, Neurosurgery, Oncology, Radiology (and fewer tertiary centres?) access to all other tertiary depts as required) Description Regional General Medicine Service Tertiary General Medicine Service National Endocrinology Referral Centre

Endocrinology Personnel MOs and Nurses with specific training Specialist General Physicians, Registrars, MOs and Adult and Paediatric Specialist Endocrinologists, Nurses with specific training Registrars, MOs, Nursing

Resources & Type 2 Diabetes and common thyroid disorders Thyroid and Type 1 & 2 Diabetes, all complex All highly complex metabolic / endocrine conditions, Activities diabetics, all other endocrine disorders (incl. including transplants and fertility management Metabolic, bone and lipid disorders)

Also On-Site Dietician, General Surgery, Ophthalmology Sonar, CT, Nuclear Medicine, Ophthalmology, As Tertiary plus MRI, bone density, Invasive Dietician, Podiatrist, General Surgery, Chemical Radiology, Endocrine Surgeon, Neurosurgery, Pathology Vascular Surgery, Obstetrics, Dialysis, Transplant Surgery, Radiation Oncology Gastroenterology & Description Level II GIT Service Tertiary GIT Service Specialist Liver Unit Hepatology Personnel Specialist General Physician or Surgeon (with GIT Specialist Medical and Surgical Gastroenterologists, Specialist Clinical Hepatologists, Hepatic Surgeons, )G OS 64

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

(No alternative scenarios training), GIT Nurses, Registrars on rotation Registrars, MOs, Specialised Nursing, Technicians Pathologist offered; MTS team proposes smaller number of Tertiary and Resources & Upper GI endoscopy, Proctoscopy, sigmoidoscopy Super-specialist activities: Upper GIT, hepatico- MARS machine, bioartifical liver support devices National units under this Activities and colonoscopy, acute GIT emergencies pancreatic-biliary diseases, colon diseases scenario) Also On-Site Not stated Virology, Immunology, CT, ICU Liver Transplant Unit Description General Medicine Service General Medicine & Sub-Specialist Medicine Service No difference from Tertiary

General Medicine Personnel Generalist Specialist Physician, Visiting Sub- Generalist Specialist Physicians, Sub-Specialist Specialists, Registrars, MOs, Nursing Physicians, Registrars, MOs, Nursing (Smaller number of tertiary centres, reduced capability for Resources & Coronary care, ICU, Haemodialysis, Coronary care, ICU, Haemodialysis, Activities Echocardiography, Scopes, Sonar Echocardiography, AT Scan, Angiography, Scopes, outreach to regional under this Sonar, Outreach to Regional Hospitals scenario) Also On-Site CT Scan, Radiology, General Surgery, Obs & MRI, CT Scan, Radiology, General Surgery, Obs & Gynae, Paediatrics, Allied Health Professionals e.g. Gynae, Paediatrics Allied Health Professionals e.g. Physiotherapy, Nutrition, OT Physiotherapy, Nutrition, OT. Description Regional General Surgery Service Tertiary General Surgery National Surgical Referral Centre

General Surgery Personnel Specialist General Surgeons, Registrars, MOs, Specialist General Surgeons with special interests, Super-Specialists, Registrars, MOs, Nursing, Nursing, Anaesthetists Registrars, MOs, Nursing, Anaesthetists Anaesthetists (Smaller number of tertiary and Resources & “All general surgery” Complex and high acuity Specific procedures e.g. liver and major pancreatic national centres under this Activities resections, TME scenario) Also On-Site All general disciplines, Radiology, Allied Health Anaesthetists, Radiology with CT and interventional As Tertiary Disciplines incl. Stoma therapists and Nutritional capability, ICU units Geriatrics Description General Medicine for Geriatric Patients Specialised Geriatric Service No Quaternary Level Envisaged

(Smaller number of tertiary Personnel General Physicians, MOs, Nursing, Physio, OT, Specialist Geriatricians, Registrars, MOs, Nursing, Speech Therapist, Social Worker, dietician and Physio, OT, Speech Therapist, Social Worker, , centres under this scenario) chiropodist. dietician, clinical psychologist and chiropodist. Resources & Integrated General Medical Unit and Rehabilitation Activities Service Acute Geriatric Care, Stroke Unit, Psycho geriatric Care, Rehabilitation Service Also On-Site CT, Radiology, Echocardiography, ICU, General

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

Surgery, Gynaecology, Psychiatry, Orthopaedics andMRI, CT, Radiology, Echocardiography, ICU, All old age psychiatry with suitably trained nursing staff. Other Adult Tertiary Specialties especially Neurology, Cardiology, Orthopaedics, Urology Description No Regional Service Tertiary Haematology Service Bone Marrow Transplantation Unit Haematology Personnel Specialist Clinical Haematologists, Pathologists with Linked to a Tertiary unit (No alternative scenarios special interest, Registrars, MOs, Nursing offered; main difference Resources & Possible Outreach Activities (not specified) Malignant haematological and clonal disorders, non- Allogeneic Bone Marrow Transplantation probably in number of tertiary Activities malignant haematological disorders; Apheresis, and national referral units isolation, stem cell harvesting and storage facilities affordable?) Also On-Site Oncology (Medical & Radiation), Radiology, Not specified Description Genetic Diagnosis & Counselling Service Tertiary Genetics Service National Genetics Centre Human Genetics Personnel Genetic Nurse, Regional Coordinator (nurse) for Specialist Medical Geneticists, Genetic Nurses / As Tertiary (No alternative scenarios offered; district hospital genetic services Counsellors, Medical Technologists main difference probably in number of tertiary and national referral units Resources & Basic diagnostic, counselling and therapeutic Diagnostic services and complex counselling and Specialised molecular diagnostic tests, Inborn Error of affordable?) Activities support (incl. Amniocentesis) care Metabolism screening & diagnosis

Also On-Site Radiology, Obs & Gynae, Paediatrics, Gen. Med., As regional plus Ultrasound As Tertiary Gen. Surg., Social Workers Description Regional General Medicine Tertiary Infectious Diseases National Institute for Communicable Diseases. Infectious Diseases Personnel Specialist General Physician, Registrars, Nurses Specialist Infectious Diseases, Registrars, MOs, (n.b. no mention of containment facilities?) (No alternative scenarios offered; with specific training, infection control, microbiologist Specialist Nursing, infection control, microbiologist main difference probably in number and virologist. and virologist. of tertiary units affordable?) Resources & Complex conditions not manageable at Level I; Unusual infections, complicated malaria and HIV, Activities endoscopy, bronchoscopy, isolation facilities, HIV, HAART, isolation facilities, complicated TB, novel HAART and expanded antibiotic formulary. antibiotics and training in infectious diseases.

Also On-Site Radiology, CT, ICU, microbiology, virology, Radiology, CT, MRI, ICU, dialysis, microbiology, immunology, social work virology, immunology, social work Medical & Radiation Oncology Description Regional General Medicine Service Tertiary Oncology Service National Oncology Referral Service iThemba Labs.

(n.b. fewer tertiary centres under Personnel MO with oncology diploma or Mos working under the Specialist Medical and Radiation Oncologists, As Tertiary

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

this scenario) supervision from a major centre. Social workers and Therapy Radiographers, Oncology Nurses, Clinical oncology nurses with necessary onsite training, as Research Coordinators, medical physicists, technicon training alone is insufficient. pharmacists, social workers, mould room technicians, radiation laboratory technicians and radiobiologists

Resources & Basic medical oncology: basic care, follow-up, Linear Accelerator, CT scan planning, Brachytherapy Bone Marrow Transplant, Stereotactic Radiation, Activities general palliative therapy and terminal care. Cobalt Isolation facilities, Single bed units, Most laminar flow, cryopreservation, T-cell depletion standard chemotherapy and biological drugs, facilities, inter operative radiation, autologous and monoclonal antibody therapy, neutropenic isolation allogeneic stem cell transplant units and further areas for patients receiving chemotherapy esp. development of the South African Bone Marrow leukaemias and lymphomas, and therapeutic Transplant Registry to obtain volunteer unrelated isolation areas for patients receiving radioactive donors for stem cell transplant patients. isotopes.

Also On-Site No radiation oncology on site. Radiology, basic Radiology, CT, ICU, Surgical Oncology, As Tertiary plus Nuclear Medicine, Haematology laboratory and X-ray services, Luminar flow and Gynaecological Oncology, MRI scanning, nuclear pharmacists, basic chemotherapy, General Surgery, medicine, laboratories, general surgery, Obs & Gynae, Dietician, Psychiatry, Social Work gynaecology, central venous access facilities and research laboratories. Description Regional Mental Health Service Tertiary Mental Health Service Not Envisaged

Mental Health Services Personnel Specialist Psychiatrist, Clinical Psychologist, Specialist and sub-specialist Psychiatrists, Clinical Registrars, Psychiatric Nurses, OT, Social Work Psychologists, Registrars, Psychiatric Nurses, OT, (No alternative scenarios Social Work offered; main difference probably in number of tertiary Resources & Acute inpatient, outpatient; child and adolescent Child and adolescent psychiatry; Old-age psychiatry; Activities psychiatry, ECT, liaison, satellite clinics Forensic psychiatry; Substance abuse; Liaison units affordable?) psychiatry; Eating disorders; Inpatient psychotherapy; Social psychiatry; Acute psychotic (complicated); Acute non-psychotic (complicated)

Also On-Site General Medicine, Neurology (?), Paediatrics All Specialties Neonatology Description Neonatal Low & High Care Unit Neonatal Intensive Care Unit Not Envisaged

(n.b. fewer tertiary centres under Personnel Specialist Paediatricians, MOs, Nurses with specific Specialist Neonatologists, Paediatricians, MOs, this scenario) training Specialist Nursing

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

Resources & Low and high care; short-term ventilation awaiting Intensive and high care, obstetric and perinatal Activities transfer, Kangaroo care services, Kangaroo care

Also On-Site Radiology, CT, Ultrasound, Physio, OT, Dietician, As Regional plus MRI; access to all Paediatric Sub- Speech Therapist, Social Work, Technical Support Specialties Description Supra-Regional Dialysis Service Tertiary Nephrology Service National Referral Centre Nephrology Personnel Specialist General Physician and nurses with renal Specialist Nephrologists, Registrars, Spec. nurses, As tertiary plus psychologist (Dialysis offered only at selected training, dialysis therapists, technologist dialysis therapists, technologists, social worker regional hospitals, fewer tertiary Resources & Haemodialysis & peritoneal dialysis for stable Haemodialysis & peritoneal dialysis chronic & acute, Haemodialysis & peritoneal dialysis chronic & acute, centres, only renal transplant Activities chronic patients, primary prevention, organ donation primary prevention, organ donation, referral for renal transplantation under this scenario) transplant

Also On-Site Social worker, dietician Radiology, Dietician As Tertiary; Transplant Surgery Description Regional General Medicine Service Tertiary Neurology Service Not Envisaged Neurology Personnel Physician with Neurology Diploma Specialist Neurologists, Registrars, MOs, Specialist Nurses, Technologists (No alternative scenarios offered; main difference Resources & Not specified Neurology, EEG, Stroke Unit probably in number of tertiary Activities units affordable?) Also On-Site Radiology, CT Rehabilitation Team, Radiology, MRI, CT, ICU Description General Surgeon / Trauma Service Only two levels envisaged “National Tertiary” Specialist Neurosurgeon Service

Neurosurgery Personnel General Surgeon, Rehab staff Neurosurgeons, Registrars, MOs, nursing

(No alternative scenarios offered; main Resources & Trauma and Neuro-rehabilitation Neurosurgical theatres & equipment for full range of difference probably in number of tertiary Activities neurosurgical operations and management units affordable?) Also On-Site CT Scan, ICU, Rehab Team CT & Neuroradiology, Neurology, Full Rehabilitation team, ICU Nuclear Medicine Description None Tertiary Nuclear Medicine Centre None

Personnel Specialist Nuclear Physician, Specialised Radiographers, Medical Physics, Technologists

Resources & Diagnostic and Therapy Nuclear Medicine Activities 68

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

Also On-Site Not Stated in Report Description Regional Obstetrics & Gynaecology Service Tertiary Obstetrics & Gynaecology Service Not Envisaged

Personnel Specialist General Obstetricians & Gynaecologists, Specialist & Sub-Specialist Obstetricians & Registrars, MOs, Nursing Gynaecologists, Registrars, MOs, Nursing

Resources & Emergency obstetrics, ultrasound, prenatal diagnosis, As regional plus: Fetal / Maternal medicine, Oncology, Activities Kangaroo care, Emerg. Gynaecology, diagnosis, basic Urogynaecology, Reproductive Medicine Obstetrics and Gynaecology urogynaecology, mid trimester abortions or adequate systems for pain relief, basic menopause and screening (No alternative scenarios offered; main programmes, preliminary investigations for infertility difference probably in number of tertiary units affordable?) Anaesthesiology, High Care / ICU (adult and baby) basic Also On-Site oncology Anaesthetics, Radiology, ICU, Neonatology, Human Genetics, All Medical Sub-Specialities, Paediatric Surgery, Radiation Oncology, Colorectal Surgery, Urology, Endocrinology, Plastic Surgery, Physio, Pathology, Psychology Description Supra-Regional General Ophthalmology Service Specialised Ophthalmology Service Super-Specialist Ophthalmology Service Opthalmology Personnel Specialist Ophthalmologist, Registrars / MOs, Specialist Ophthalmologists, Registrars and MOs, As Tertiary (No alternative scenarios Nursing Orthoptist, Nursing offered; Ophthalmology only at Resources & Operating Room & Microscope, Argon & Yag Lasers, Complex surgery, B Scan Ultrasound & imaging, Oncological surgery, Genetics, Specialised paediatric, selected Regional Hospitals, Activities routine ophthalmic surgery Electro diagnostics Photodynamic therapy fewer tertiary centres under this scenario?) Also On-Site Anaesthetics, Radiology Neurology, Neurosurgery, Radiology, Anaesthetics, As Tertiary plus MRI, Human Genetics Oncology, Paediatrics, Physicians Description Regional dental services Not Envisaged Not Envisaged Oral and Maxillofacial Surgery Personnel Not specified

Resources & Not Specified Activities

Also On-Site Not Specified Orthopaedics Description General Orthopaedics Sub-Specialty Orthopaedics Orthopaedic Oncology Centre

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

(No alternative scenarios Personnel General Specialists, MOs, Nursing Specialists with special interests, Registrars, Nursing Super-Specialists offered; main difference probably in number of tertiary Resources & All general orthopaedic surgery Arthroplasty, Spinal Surgery, Hand Surgery (?) Spinal, Tissue Engineering and national units affordable?) Activities

Also On-Site High Care, X-Ray, Ultrasound, General Medicine, As regional plus MRI, CT, ICU, access to all other As tertiary (n.b presumably close link to Oncology?) General Surgery, Rehabilitation Team, Orthotics, tertiary specialties prosthetics Description Regional Rehabilitation Centre Tertiary Rehabilitation Centre

Personnel Physiotherapy, Occupational Therapy, Orthotics & Physiotherapy, Occupational Therapy, Orthotics & Prosthetics, Speech therapy, Dietetics, Podiatry Prosthetics, Speech therapy, Dietetics, Podiatry, Audiology Other Rehab Specialists Resources & Combined Rehabilitation Team & Facility to provide Combined Rehabilitation Team & Facility to provide (No alternative scenarios Activities integrated rehabilitation integrated rehabilitation Spinal Surgery, Arthroplasty Surgery, Arthroscopic Surgery (including revision offered; main difference surgery) Paediatrics, hand and Upper Limb Surgery, probably in number of tertiary Foot and Ankle, Chronic Sepsis, oncology units affordable?) All Tertiary Hospital Services Also On-Site All Regional Hospital Services Description Regional Paediatric Medicine Service Tertiary Paediatric Medicine Service National Paediatric Referral Centre

Personnel Specialist General Paediatrician, MOs, Nursing Specialist General and Sub-specialist Paediatricians, Super-specialist Paediatricians / Surgeons, Paediatric Medicine Registrars, MOs, Specialist Nursing Registrars, MOs, Specialist Nursing

(Main difference probably in Resources & General & emergency paediatrics, neonatology, child General Paediatrics plus Genetics, Child Psychiatry Organ transplantation, certain high-cost / complexity number of tertiary and national Activities abuse, child health service & Behavioural Paediatrics, Infectious Diseases and medical interventions units affordable?) full range of Paediatric Sub-Specialties

Also On-Site Radiology, Neonatal High Care, Isolation facilities, As Regional plus all surgical sub-specialties, As Tertiary

Anaesthetics, Obs & Gynae, Paed Surgery, Oncology, Nuclear Medicine, ICU, NICU Rehabilitation Team, Social Work Paediatric Cardiology Description Regional Paediatric Medicine Service Tertiary Paediatric Cardiology Service National Paediatric Cardiology Referral Centre

(No alternative scenarios Personnel Specialist General Paediatrician with cardiology Specialist Paediatric Cardiologists & Cardiac As Tertiary offered; main difference training Surgeons, Cardiac Anaesthetists, Clinical Thlit ECG Thii 70

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

probably in number of tertiary Technologists, ECG Technicians units affordable?) Resources & Activities Echocardiography Echocardiography, Cardiac Cath & Cardiac Surgery As Tertiary plus Transplants, Electrophysiology

Also On-Site Not specified Paediatric ICU, MRI, CT, Nuclear Medicine As Tertiary Description General Paediatric Medicine Service Child Development Services As Tertiary

Personnel General paediatrics, Nurses, Physiotherapy, OT, Specialist child developmentalist, Nurses, None Speech Therapy Physiotherapy, OT, Speech Therapy, Audiology, Dieticians, Social Workers

Paediatric Child Development Resources & Basic paediatric development, screening e.g. vision Full developmental service. None Activities and hearing

Also On-Site Vision and hearing screening Neurophysiology (BAER, VER, EEG, EMG) Basic None laboratory services, Radiology: CT and MRI,

Psychology, Paediatric Psychiatry, Orthopaedics, Neurosurgey, ICU, General out patient facilities. Description Critical Care of Children Paediatric ICU Service ICU Support for Quaternary Paediatric Services

Paediatric Critical Care (ICU) Personnel Paediatricians, MOs and nurses with paediatric Paed. Intensivist as Medical Director, Paed ICU- As Tertiary, but with personnel possessing sub- resuscitation skills at least 1 specialist with post trained Nurse as Nursing Director, Paed ICU nurses, specialty skills (No alternative scenarios graduate paediatric resuscitation and stabilisation ICU technologist training offered; main difference probably in number of tertiary Resources & Recognise critically ill children, resuscitate and Full Paediatric ICU Service Support to e.g. transplant, cardiac surgery, units affordable?) Activities stabilise for transfer, telemedicine link to tertiary neurosurgery etc.

Also On-Site Radiology, Paediatric Surgery & Medicine 24-hour Lab & Radiology, access to all Paeds As Tertiary Description Regional Paediatric Medicine Service Tertiary Paediatric Endocrinology Service National Paediatric Endocrinology Referral Unit Paediatric Endocrinology / Diabetes Personnel Specialist General Paediatrician, Trained Nurses andSpecialist General Paediatrician with interest in Specialist Paediatric Endocrinologist, Molecular MOs Endocrinology, Staff & Patient Educators Laboratory

(n.b. fewer tertiary centres under Resources & Diagnosis, early referral, emergency care Comprehensive Endocrinology Service, outreach, Complex and rare metabolic disorders, advanced this scenario) Activities screening investigations

Also On-Site Telemedicine, Social Work Psychology, Paediatric Surgery, Radiology, Genetics As Tertiary

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

Description Regional Paediatric Medicine Service Tertiary Paediatric Gastroenterology Service National Paediatric Referral Centre

Paediatric Gastroenterology Personnel Specialist General Paediatrician Specialist Paediatric Gastroenterologists Super-specialist Transplant Team,

(No alternative scenarios Resources & Diagnosis, basic treatment, follow-up management Clinical, endoscopic and lab evaluation, treatment Transplant Surgery, Metabolic laboratory, complex Activities of tertiary cases liver and intestinal surgery offered; main difference probably in number of tertiary Also On-Site Radiology, Counsellors, Social Work, Paed Surgery, As Regional plus: ICU, Other Paediatric Sub- As Tertiary plus Pharmacology lab, interpreters, child units affordable?) Chemical pathology, haematology specialties, Dietetics, Infectious Diseases, Adult GIT, mental health services, social workers, paediatric Full laboratory service, including histopathology, EM, surgery microbiology, endoscopy theatre Paediatric Haematology/ Description Regional Paediatric Medicine Service Tertiary Paediatric Medicine Service National Referral Paediatric Haematology Oncology Personnel Specialist General Paediatrician / Visiting Consultant Specialist General Paediatrician Sub-Specialist Haematologist / Oncologists, Specialist (n.b. fewer national centres Nurses under this scenario) Resources & Palliative care and identification for possible Chemotherapy under guidance, palliative care, Full diagnostic and treatment services with autologous Activities diagnosis diagnosis and allogeneic Bone Marrow Transplant at selected site(s)

Paediatric Infectious diseases No Separate Report – No Separate Report – No Separate Report –

(n.b. fewer national centres Biopsies, Peritoneal and Haemodialysis, Renal under this scenario) Resources & Screening and treatment of basic conditions, Transplant Activities Telemedicine link to referral unit Radiology, Sonar, ICU, Nuclear Medicine, Psychology, Also On-Site Radiology, Social Work Social Work Paediatric Neurology Description Regional Paediatric Medicine Service Paediatric Neurology Service National Referral Service

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

Personnel General Paediatricians, Nursing, Physio, OT, Specialist Paediatric Neurologists, Developmental As Tertiary (No alternative scenarios Speech Therapy Paediatricians, Nursing, Physio, OT, Speech offered; main difference Therapy probably in number of tertiary Complex epileptic surgery, complex neuromuscular Resources & Basic paediatric care e.g. epilepsy, CPs, chronic Full paediatric neurology services and telemedicine patients, neurodegenerative and metabolic patients, units affordable and scope of Activities rehabilitation support to regional Video telemetry, intracranial mapping, neuro- activity at national referral metabolic lab. centre?) Also On-Site Radiology CT, MRI, spectroscopy, ICU, Neurosurgery, Radiology, EEG & EMG, Psychology, Psychiatry, As Tertiary plus histopathology, molecular genetics, Social Work metabolic specialists Description General Paediatric Medicine Tertiary Paediatric Respiratory & Allergology Service Not Envisaged Paediatric Respiratory Medicine & Allergology Personnel General Paediatricians Specialist Paediatric Pulmonologists & Allergologists, Specialist Nursing (No alternative scenarios Resources & No specific activities described Spirometry, skin prick testing, spacers, histamine offered; main difference Activities challenges, bronchoscopy probably in number of tertiary units affordable?) Also On-Site Radiology, Spiral CT, Paediatric ICU, NICU, Paediatric Cardiothoracic Surgery, Dieticians, Physio, Psychology Description General Paediatric Medicine Tertiary Paediatric Rheumatology Service No National Referral Centre

Paediatric Rheumatology Personnel General Paediatricians Specialist Paediatric Rheumatologist, Specialist Nurse Practitioner (No alternative scenarios offered; main difference Resources & Screening, follow-up and step-down of tertiary cases Diagnosis and treatment: lupus, dermatomyositis all probably in number of tertiary Activities vasculitides, problem JCA and systemic onset disease. All connective tissue diseases. units affordable?) Also On-Site Radiology, Phsyio, OT, Orthopaedics Radiology, MRI, Paed ICU, Rehabilitation Team, Adult Rheumatology, Nephrology, Ophthalmology, Paed Orthopaedics

Paediatric Surgery Description Regional Paediatric Surgery Service Tertiary Paediatric Surgery Service National Paediatric Referral Centre

(No alternative scenarios Personnel Specialist General Surgeon, MO with Diploma in Specialist Paediatric Surgeons, Registrars, MOs, Super-specialist Paediatric Surgeons, Registrars,

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

offered; main difference Surgery Specialist Nursing MOs, Specialist Nursing probably in number of tertiary and national units affordable?) Resources & Basic and general paediatric surgery Comprehensive paediatric surgery – general and Organ transplantation, epilepsy surgery, craniofacial Activities sub-specialties surgery

Also On-Site Anaesthetics, Radiology, General Paediatrics, ICU As regional, All Paediatric disciplines As Tertiary Description None Tertiary Plastic & Reconstructive Surgery Mentioned but not Elaborated Plastic & Reconstructive Surgery Personnel Specialist Plastic Surgeon, Registrars, MOs, Specialist Nurses

Resources & All services: Dermatome, Osteotomy, Microscope, Activities Laser, Endoscopy

Also On-Site Radiology, CT, MRI, Anaesthetics, ICU, Rehabilitation Team Description See General Medicine and Nephrology Renal Transplant Unit Liver Transplant Unit Renal / Liver transplantation Personnel Specialist Surgeon, Specialist Nephrologist, As Renal Unit plus Specialist Hepatologists Specialist Nursing, Transplant Coordinator, (Fewer renal transplant units Registrars under this scenario) Resources & Dedicated renal transplant unit Dedicated Liver Transplant Unit Activities

Also On-Site Dialysis, Radiology, Anaesthetics, ICU, Immunology As Renal Unit plus Virology Lab, Pharmacology, Bacteriology Respiratory Medicine Description Regional General Medicine Service Tertiary Pulmonology Service National Pulmonology Referral Centre

Personnel Specialist General Physician and MOs , Specialist Pulmonologists, Registrars, MOs, As Tertiary (n.b. fewer tertiary centres under Technologists Pulmonology Technologists this scenario) Resources & Diagnosis, acute care and referral, spirometry, Comprehensive Pulmonology service, including As Tertiary plus: lung volume reduction surgery, lung Activities oximetry, outreach from referral centre Respiratory ICU transplantation (with Thoracic Surgery)

Also On-Site ICU (?), Radiology Radiology, CT, Nuclear Medicine, Thoracic Surgery, As Tertiary (n.b. No mention of specialist Occupational Health, Tuberculosis Control Program, MDR TB facilities?) Infectious disease specialities, Radiation Oncology

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

services, and Physiotherapy

Description Regional General Medicine Service Tertiary Rheumatology Service Not Envisaged Rheumatology Personnel Specialist General Physician and/or MOs with Specialist Rheumatologists, Registrars, MOs, Rheumatology diploma Specialist Nursing (No alternative scenarios Resources & Uncomplicated rheumatoid arthritis, gout, All Rheumatology, DEXA scans offered; main difference Activities osteoarthritis, follow-up of tertiary cases probably in number of tertiary units affordable?) Also On-Site Radiology Radiology, MRI, Pulmonology, Nephrology, Neurology, Dermatology and Haematology, Orthopaedics Description Acute Rehabilitation Service Acute Rehabilitation Service No Quaternary Level

Spinal Injury Rehabilitation & Personnel “Acute Care team” (composition not specified) “Acute Care team” (composition not specified) (n.b. Strong focus on strengthening PRIMARY Management rehabilitation services in report, requiring a Resources & Theatres, Spinal Beds, Turning Teams / Beds Theatres, Spinal Beds, Turning Teams / Beds comprehensive PHC rehab centre) Activities (n.b. fewer tertiary centres under this scenario) Also On-Site ICU, CT, Anaesthetics, General Surgery, ICU, CT, MRI, Anaesthetics, General Surgery, Orthopaedic Surgery, Psychology, Physician Orthopaedic Surgery, Urology, Neurosurgery, Plastic Surgery, Psychology, Physician

Description Level II Trauma Services Tertiary Major Trauma Centre Not Envisaged Trauma Personnel Specialist General Surgeons & Physicians, SpecialistSpecialist Trauma Surgeons (sub-specialist General (No alternative scenarios Orthopaedic Surgeons Surgeons) offered; main difference Resources & 24 hour initial definitive trauma care regardless of Comprehensive care for all trauma in coordination probably in number of tertiary Activities severity of injury, stabilisation for transfer of complex with other specialties units affordable?) trauma (coordinated by General Surgery)

Also On-Site Anaesthetics, Radiology, High Care Anaesthetics, Radiology, ICU, All other major specialties and surgical sub-specialties Urology Description Regional General Surgery Service Tertiary Urology Service Not Envisaged

(No alternative scenarios Personnel Specialist General Surgeon Specialist Urologists, Registrars, MOs

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

offered; main difference probably in number of tertiary units affordable, plus no rotation Resources & Basic urology service Comprehensive Urology Service and outreach to of registrars to regional Activities regional hospitals hospitals?) Also On-Site Radiology Not Specified Description Regional General Surgery Service Tertiary Vascular Surgery Service National Vascular Surgery Referral Centre Vascular surgery Personnel Specialist General Surgeon Specialist Vascular Surgeons Specialist Vascular Surgeons with special interests

Resources & Trauma without ICU need Majority of Vascular Surgery Thoracic-abdominal aneurysms, Endovascular AA Activities repair

Also On-Site Anaesthetics, Radiology, Duplex Doppler, General Anaesthetics with special interest, Radiology (incl. As Tertiary Medicine Interventional), Duplex Doppler, General Medicine, ICU, Cardiology, Neurology, Endocrinology

APPENDIX 4 IDEAL / MINIMUM UNIT SIZES

Minimum Staffing Requirements for an Ideal Unit – as per specialty reports

Anaesthetics Report not submitted Cardio thoracic surgery Not specified Cardiology Not specified Clinical immunology 1 clinical immunologist/medical school 2 specialist scientists 1 MO/hospital 1 clinical immunology trained nurse/referral centre Use NHLS for personnel issues Clinical pharmacology Not specified Dermatology National referral centre Super specialists with expertise e.g. gene therapy Tertiary hospital Adequate ratio of specialists and registrars (numbers and type not specified) Regional hospitals Full time specialists (numbers and type not specified)

Diagnostic radiology Number of staff will depend on the size of department and work load Baseline 24 hr busy general X-ray unit: 7 radiographers 2 radiologists who could cover a group of hospitals 3 nurses 2 typists 2 cleaners 1 regional clinical engineer (to be shared with other centres) 3 darkroom staff 3 clerks 3 porters Low-activity unit without after hour cover: 3 radiographers Central hospital 2 Medical Physicists Radiology workload calculation 0.45 FTE radiologist / 1,000 examinations / month 0.25 FTE radiologists / additional service point added e.g. 0.25 FTE for 1 mammographic unit, 0.25 FTE for 1 fluoroscopic unit 1 FTE / CT scanner in use to be added. If ≥ 1,000 CT examinations are performed / month and additional 1 FTE radiologist to be added

APPENDIX 4 IDEAL / MINIMUM UNIT SIZES

0.5 FTE should be added if the radiology department performs images for full radiotherapy / oncology departments 2 FTE added / MRI For registrars a factor of 1.5 registrars / consultant Radiographers: ≈ 2.7 radiographers / doctor (registrar and consultant) Endocrinology Requirements for 200 out patients and 15 inpatients/week: Endocrinologist 3 (ideal) 1 (minimum) Specialist physician 2 (ideal) 1(min) MO/registrars 3 (ideal) 2 (min) Trainee 1 Diabetes nurse educators 4 (ideal) 2 (min) Other sisters 2 (ideal) 1 (min) Nurses in training 2 (ideal) 1 (min) Clerks 2 (ideal) 1 (min) Secretary 1 (ideal) 1 (part-time) Dietician 2 (ideal) 1 (min) Podiatrist 1 (ideal) 1 (part-time) Biokineticist 1 (ideal) Ophthalmologist (ideal) 1 (part-time) ENT 1 x Chief Specialist 2 x Specialists 8 x Registrars 2 x Medical Officers 1 x Research assistant 1 x Secretary Gastroenterology and Tertiary Liver Units: hepatology It was felt that at this stage, two liver units were enough. Each centre should have at least 3 clinical hepatologists, 2 hepatic surgeons and

one pathologist whose main pathological interest should be the liver. All Liver Transplant Units should be attached to a Liver Unit. Acceptable Norms regarding tertiary GIT Units: It was necessary to obtain figures as to what are acceptable norms as regards the number of the population needed for one gastroenterologist or one tertiary GIT unit or one tertiary Liver unit. It was noted that these would be figures derived in Western countries and it needed to be decided whether these would be appropriate for South Africa or not. Each of the present GIT units should have 3 medical and 3 surgical GIT consultants. It is hoped that both the Department of Health and the clinicians should try and obtain these figures. It would appear that we are short of the British norms as regards

APPENDIX 4 IDEAL / MINIMUM UNIT SIZES

endoscopy units. General medicine In-patient: 60 patients / specialist physician 2 interns and 2 MO or registrars / specialist General surgery At least two sub-specialists, or the equivalent FTE’s. A norm of specialist per beds for tertiary general surgery should be about one-specialist/ 12 beds. It should however be noted that all tertiary units must have a training responsibility; some will be for generalist specialists and other for subspecialty training. Therefore a system providing for academic increments must be incorporated. The norm for specialists at LII one specialist for 15 – 20 beds is appropriate. To determine unit sizes by patient volumes will lead to many of the inequities that have given rise to this process. We should rather be developing our own South African norms for the number of specialists per 100 000 population. Based on this and the available human resources one can then start to allocate units. This however cannot ignore the historically developed units, which have shown proven sustainability. These units must be incorporated into any new system where appropriate. (e.g. don’t close down three of the four gastroenterology units in Johannesburg, rather shrink to two and ensure better referral patterns from nearby surrounding provinces) Geriatrics For 100 patients / week In-patient services: Acute beds: 24 beds Stroke unit: 10 beds Psycho geriatrics beds: 24 managed with psychiatrists Rehabilitation services Out patient services; Multi disciplinary assessment clinics Specialised clinics e.g. dementia, osteoporosis, falls etc. 1 Chief specialist 1 Principal specialist 1 Specialist 2 Career registrars 1 Medical officer 1 Rotating registrars 1 Secretary Trained nurses, PT, OT, speech therapists, social worker, dietician, clinical psychologist, chiropodist (to be shared with other subspecialties) Haematology Not specified

APPENDIX 4 IDEAL / MINIMUM UNIT SIZES

Human genetics Four medical geneticists and 16 Genetic Nurses/counsellors 20 Scientists/medical technologists for laboratory testing ICU/ Critical care Full range of medical and surgical subspecialties (especially paediatric subspecialties for paediatric intensive care. For adult women full time obstetrics and gynaecological services. Physiotherapy and pharmacy services. Regional hospitals Minimum 6-bed high care with capacity for ventilation for 24-48 hours. Provincial tertiary hospitals 8-12 beds (minimum) 12 bed (ideal) High care beds National referral centre 12 ICU beds (minimum) 20 ICU beds (ideal) High care beds (overall 4-8% of hospital beds) Ideal ICU nurse: patient ratio 1 ICU trained staff: 2 (preferably) 1 patient 1 non ICU trained RN: 1 patient Ideal high Care Unit nurse: patient ratio 1 RN: 1-2 patients depending on severity of illness and turnover Infectious diseases Sizes of units should be estimated using the number of Infectious diseases physicians looking after them and the rest of the staff should be in proportion. For every infectious disease physician the unit should manage eight to ten patients. Medical and radiation Not specified oncology Mental health Not specified Neonatology Level III (NICU) facilities should have a minimum of 4-6 beds per unit. Given the low birth weight rates, high sepsis rates and the need for neonatal surgery, the requirements for NICU beds appropriate for South Africa should not less than 1 to 1,5 per 1000 annual delivery. Nurses: baby ratio: Neonatal ICU care unit 1:1 Neonatal High Care unit 1:3 Neonatal Low Care unit 1:5

APPENDIX 4 IDEAL / MINIMUM UNIT SIZES

Nephrology All dialysis units should be supervised or serviced by a registered nephrologist and managed on a day-to-day basis by a specialist physician with recognised expertise in dialysis.

Medical staff should be readily available to deal with emergencies and review chronic patients every 3 months (min) and 1 month (ideal).

Staff: patient ratio for chronic dialysis should be 1:4 (including nurses and clinical technologists): Expanded care 1:2, Basic care 1:3

Acute dialysis; special care 1:1

A registered nurse with haemodialysis experience should be present at all times in the unit.

Neurology Not specified Neurosurgey 1 HOD, 2 Principal Specialists 4 Specialists 6 Registrars minimum

2-4 Medical Officers (Alternatively, a minimum of 8 registrars).

Rotating interns for teaching (currently no rotating interns are present).

Nuclear medicine Difficult to state however, the international guide is 1000-1200 studies/camera/year. Also, the minimum size of a unit in terms of patient work load depends on the kind of service the unit is expected to deliver (e.g. limited or comprehensive) Obstetrics and gynaecology Generic criteria (HPCSA) Sub specialty requirements (College of Medicine) Ophthalmology 2-4 Ophthalmologists per million population, 4-8 MO/Registrars,

1 x orthoptist,

2 x nurses/ OMA per doctor

Nursing staff (registered, enrolled and OMA) for theatre and ward Orthopaedics Regional level 1 specialist 4 MOs

APPENDIX 4 IDEAL / MINIMUM UNIT SIZES

Tertiary and National referral units (not specified) Dependent on size of institution and services rendered Other Rehabilitation Not specified, however should be based on patient classification specialties systems, workload measurement systems and or patient needs. Paediatric Allergology 1 Specialist 1 Medical Officer (Diplomate in Allergy) Specialised Nurse Dietician Paediatric Cardiology Minimum 2 paediatric cardiac surgical operations/surgeon/week > 500 echocardiographic studies p.a. (most units are performing 1000- 2000 paediatric cardiac echo studies p.a. ≥ 50 cardiac catheterisation procedures/cardiologist p.a. Ideal 2 Trained Paediatric Cardiologists 1 Fellow 1 Registrar ≈ 100 congenital heart operations/mil needed p.a. 10 operations/mil for acquired valve disease Paediatric Critical Care/ICU National referral centres Minimum: 4 intensivists/18-20 beds/unit Tertiary Hospitals 24 hrs intensivist to cover ICU @ all times, this is 4-5 intensivists on site Smaller centres e.g. Bloemfontein Minimum: 1 Full time intensivist as unit director Paediatric intensivists to coordinate regional critical care services Nurse: patients ratio 1 sister and 1 nurse: 2 patients 8 –10 PICUs needed in the country Maximum size of unit 20- 25 beds, 4 – 5 step down beds 20 ICU

APPENDIX 4 IDEAL / MINIMUM UNIT SIZES

Paediatric Child Development Minimum 1 General specialist and 1 career MO at regional level 2 sub specialist at supra regional level 1 sub specialist and 1 training post (Snr. Registrar) at supra provincial level 1 sub specialist at quaternary level Ideal 3 skilled generalists and 1 career MO at regional level 3 sub specialists and 1 career MO at supra regional level 2 sub specialists, 2 training posts (snr. Registrars) and 1 career MO at supra provincial level 1 sub specialist, 1 career MO at quaternary level Paediatric Endocrinology Establish ”joint” multi disciplinary clinics. Each teaching hospital should have a paediatrics endocrinology unit (with support staff and other sub specialist services including radiology and surgery). Unit size and staffing requirements not specified. Paediatric Gastroenterology Minimum At least 2 specialists and a senior registrar for training per unit. Paediatric Minimum Haematology/Oncology 2 full time sub specialists / unit Specialty nurses Ideal 2–5 dedicated consultants and sub specialists depending on size of unit 1-2 training posts per registered unit Dedicated nursing staff trained in Haematology/oncology/paediatrics Higher nurse: patient ratios (as most is HC) Outreach and home visiting nurse Paediatric medicine Regional Hospital: 3 Paediatrician 6 Registrar / MO Paediatric Nephrology and Minimum: transplantation 2 consultants/unit ICU back up GIT team Transplant surgeons (number not specified) Transplants: 50 kidneys p.a. and liver 15-20 p.a. Paediatric Neurology Not specified Paediatric Respiratory 2 Pulmonologists medicine Auxiliary staff Radiology

APPENDIX 4 IDEAL / MINIMUM UNIT SIZES

Cardio thoracic Paediatric Rheumatology 1 specialist rheumatologist 1 dedicated rheumatology nurse practitioner Paediatric surgery Ideal Each province to have at least 1- 2 specialised units At least ≥3 regional paediatric surgery units to be developed Plastic surgery Ideal norm 1 plastic surgeon per 250 000 patients Academic Centre 1 Principal Specialist 1 Senior Specialist 2 Registrars 1 MO Metro Supra Regional 1 Principal Specialist 1 Senior Specialist 2 Registrars 1 MO Peripheral Supra Regional 1 MO Renal/ Liver transplant Minimum size: (all personnel P/T = full-time practitioner but part-time commitment to transplantation) 1 Surgeon 1 physician 1 general anaesthetist 1 nurse for each of the following, ward, theatre and ICU/HC 1 coordinator 1 registrar/MO/intern Infrastructure: Radiology Pharmacology Bacteriology General ward Ideal size (F/T) 1 specialist surgeon 1 nephrologist 1 expert anaesthetist 3 nurses for each of the following, ward, theatre and ICU/HC 3 coordinator 3 registrar/MO/intern

APPENDIX 4 IDEAL / MINIMUM UNIT SIZES

Infrastructure: Radiology Pharmacology Bacteriology 2 dedicated wards Respiratory medicine Tertiary Units The numbers of equivalents required depend upon the patient load in tertiary hospitals, the number of extension programmes and additional administrative and clinical responsibilities. For most provinces at least 5 full-time equivalents are required. At least one dedicated sub-speciality trainee in pulmonology and another in critical care are required (see Critical Care document). One training registrar/community medical officer for Pulmonology. The absolute minimum requirements for critical mass and cross-cover in the ICU and extension services are 3 full time individuals in pulmonology. This does not take into account any clinical work in general medicine, teaching, training, administrative duties and University responsibilities or research. There is also a need for trainee posts and junior staff posts as indicated above. Regional Units A Specialist in General Medicine with many special interests but at least a minor interest in Pulmonology who will liase with the visiting Pulmonologist and select cases for additional specialist opinion and referral to the Tertiary Hospital. In provinces where Pulmonology Units are unlikely to be affordable, a general physician may be trained in bronchoscopy. However the poor cost efficiency of trying to maintain optimal equipment and its use without the support of an effective microbiological service, cyto- pathologist, quality assure for handling cleaning and sterilisation of the bronchoscopy equipment and surgical backup for emergencies severely limit the practicalities of this option (which has been tried in several regions). Medical Officers including community service doctors who would have the opportunity for regular supervision and teaching from a visiting pulmonologist. Medical officers will be encouraged to take the Diploma in Pulmonology on a part time basis to enhance their skills Rheumatology 3 or 4 Consultants 2 to 3 Registrars 1 to 2 Nursing Sisters 1 part-time Medical Officer Specialist sessional posts should be available. However, these

APPENDIX 4 IDEAL / MINIMUM UNIT SIZES

numbers would vary based on the service volumes and the demand for services in the different areas. Spinal injury and rehabilitation Minimum: Spinal TB: 500 beds Rehabilitation: 12 beds/ million population Units should be attached to regional hospitals with dedicated staff and access to other specialised services e.g. urology, surgery etc. Urology Ideal unit Academic head Consultants Registrars Ideal staff establishment Chief specialist Principal specialist 2 senior specialists 8 registrars 4 medical officers Ideal number of beds: 70 –100 This ideal unit will be responsible for Urological service to a region including one or more regional hospitals (level II). Urology Registrars would rotate to the regional hospital supervised by an urologist e.g. Durban metropolitan service. Vascular surgery Minimum: 400 operations p.a. (minimum) 2 vascular surgeons 2 registrars Sufficient nurses, beds, high care and ICU beds, secretaries, duplex Doppler Minimum size vascular training unit: 1 000 operations p.a. (minimum) 2 vascular surgeons 2 registrars Sufficient nurses, beds, high care and ICU beds, secretaries, duplex Doppler 2 vascular surgery fellows (post general surgical training who are vascular surgery trainees for a two year period)