Executive summary

	The focus of our audit
	Our objective in this audit was to determine how well NSW Health manages the provision and delivery of radiotherapy services.
	Cancer is a life-changing diagnosis that will affect one in two men and one in three women currently living in NSW during their lifetime, according to the Cancer Institute NSW. Large gains have been made in the treatment of and survival from many cancers. Cancer death rates have fallen by 16% in men and 10% in women over the past decade. However, because cancer risk increases with age, as the population grows and ages the number of cases of cancer is increasing. The Cancer Institute NSW has estimated that: § over the next 10 years, 412,000 people in NSW will be diagnosed with cancer and 145,000 may die of the disease § the incidence of cancer in the 10 years from 2007–2016 is expected to be more than 30 per cent higher than that in the previous 10 years (1997–2006) §   cancer will cost the NSW economy around $106 billion and $320 billion over the next 10 and 30 years respectively.
	The focus of this audit is on radiotherapy services. Along with surgery and chemotherapy, radiotherapy is one of the main treatments for cancer. Radiotherapy can be used to cure cancer and also to reduce pain. Radiotherapy services are costly to establish. Linear accelerators that deliver radiation treatment cost between $3.5 million and $5 million each. While most centres in NSW have 2 to 3 machines, there are larger centres with up to 5 machines.
	While our focus is on radiotherapy services, it is important to remember this is provided in combination with other treatments, particularly surgery and chemotherapy.
	During the course of the audit we were impressed by the dedication and efforts of medical, nursing and allied health staff in NSW radiotherapy treatment centres, and cancer services more broadly, in providing care and support for patients and families dealing with a diagnosis of cancer.
	Audit opinion
	Overall radiotherapy services are managed in a reasonably efficient and effective manner. Much is being done to further improve efficiency and effectiveness, and more can be done. The projected growth in demand for radiotherapy services will further challenge NSW Health and it needs to more clearly demonstrate how it will have the right facilities in the right place at the right time.
	Are radiotherapy services provided efficiently and effectively? We found that, overall, radiotherapy services are provided in a reasonably efficient manner. Most patients have reasonable access to radiotherapy services. NSW has as many linear accelerators per 1000 cancer patients as other comparable jurisdictions. Centres are for the most part adequately staffed, well equipped and well utilised.
	We were unable to obtain similar assurance in relation to the effectiveness of the provision of radiotherapy treatment. We looked for, but did not find, clarity and agreement on what the results for patients should be from the use of radiotherapy.
	We found that the foundation for many improvements in efficiency and effectiveness appears to be in place. This includes improving: § accessibility of radiotherapy services such as by more timely referrals, reducing waiting times, and locating radiotherapy facilities in regional centres §  operational performance of radiotherapy treatment centres by waiting list management, patient booking systems and staff rostering.
	Are radiotherapy services likely to be adequate in the future?
	We expected that NSW Health would have a strategy or plan to help ensure that the provision and delivery of radiotherapy services are directed to areas of need and the highest priorities. We also expected its assessments to support value for money.
	We found that NSW Health had undertaken significant planning in relation to the development of a draft Radiotherapy Services Plan 2007-2011, but not released it due to the need to resolve the significant funding required.
	Although there has been no published plan, we found that implementation of state-wide planning has progressed. We also found assessments in the Business Case for the Radiotherapy Services Plan 2007 to support value for money.
	Key audit findings
	Are radiotherapy services provided efficiently and effectively?
Framework	As radiotherapy is but one means of tackling cancer, and cancer treatment is one of many health services, we looked to see if there was an overall framework for providing radiotherapy services within that context.
	We found that a number of policies and strategic planning documents provide the strategic framework for the delivery of health services in relation to cancer in NSW.
	We found that radiotherapy services operate as part of broader cancer networks, and these networks often reflect long standing referral patterns and the existence of outreach services. We agree with the view of the Cancer Care Model that there would be benefit in formalising such arrangements between Area Health Services. We also found that there are a range of measures to ensure the quality of radiotherapy operations. We looked to see if there was a quality accreditation program specifically focused on radiotherapy services. The Cancer Institute NSW reported that it has been examining the feasibility of such a process. In our view, it would provide an ongoing independent assurance of quality and do much to promote public confidence in the delivery of radiotherapy services.
Alternatives	As there are a number of alternatives to the use of radiotherapy, and as it is almost always used in conjunction with other treatments, we looked to see if the alternatives were considered and evaluated.
	We found that NSW Health and the Cancer Institute NSW promote the use of multidisciplinary approaches to cancer care, increasingly through the use of multidisciplinary teams. In a multidisciplinary approach to care, the treatment options for patients are considered by a team, including medical specialists, nurses and allied health professionals from the various oncology sub-specialities with relevant expertise. In 2006, 69% of patients had their care considered by a multidisciplinary team.
Accessibility	We looked to see if patients had reasonable access to radiotherapy services. We found that most patients have reasonable access to radiotherapy services, and that there are a number of measures to improve access – particularly for patients in regional and rural areas.
distance to treatment facilities	We found that NSW has as many linear accelerators per 1000 cancer patients as other comparable jurisdictions (with the singular exception of the USA). NSW is a large state and radiotherapy services have historically been provided through a concentrated service delivery model. More recently, a more distributed model has been developed. However, because this type of treatment cannot be delivered in all hospitals, patients still need to travel some distance and be away from their homes for up to seven weeks. Although significant contributions are made by the public sector towards travel and accommodation, we found that not all costs are able to be fully covered by these programs.
	We see scope for further analysis to identify those people who are not within reasonable distance of radiotherapy facilities – where additional service and support efforts may be needed. This could then be subject to more detailed consideration and assessment by Area Health Services of cancer outreach services or special transport measures.
waiting times	We found that problems including poor waiting time data quality, and a lack of consistency of approach to data definitions, have precluded systematic state-wide monitoring and analysis of patient waiting times. A study by NSW Health undertaken during our audit indicated that the average number of days between ‘ready for care’ and the start of their radiotherapy treatment in 10 centres has been reduced from 18.5 days in 2004 to 14.2 days in 2008. Actual times vary between centres with the average waiting times ranging between 9.7 days to 18 days in 2008. In six centres waiting times were reduced. In four centres waiting times increased. The percentage of patients who were treated in 2008 within target times also showed an overall improvement; with 57% of priority one patients, 72% of priority two patients and 82% of priority three patients treated within the maximum acceptable times recommended by the Royal Australian and New Zealand College of Radiologists. We looked for, but were unable to find, similar information on the time between referral and initial specialist consultation, as this is often outside the data capture of NSW Health. This time contributes to overall waiting times. We see scope to further improve waiting time performance by: ensuring consistency of definitions for all centres to enable inter-centre comparison; ensuring all centres include priority codes for patients; ensuring roll-out of the Business Improvement ‘tool kit’ to all public centres; ensuring consistency in setting of ready for care dates; systematically monitoring and benchmarking the performance of radiotherapy centres state-wide; developing centralised booking systems; and ensuring that patients faced with extended waiting times have been offered access to alternative radiotherapy centres.
Location	We looked at how NSW Health ensures that facilities are located appropriately for effective service delivery.
	We found strategic analysis at Department and Area Health Service level to identify and assess alternative locations and service delivery options state-wide. We found these aspects addressed in the more detailed planning for services undertaken by Area Health Services, for example in relation to Orange and Lismore. We found that decisions concerning the location of facilities consider a number of factors including population distribution and size, workforce training and availability, and patient access. Other regional centres could be similarly considered. NSW Health needs to conduct further detailed analysis of options for radiotherapy services (including public or private sector provision) and sites in the geographic areas of need, including the Central Coast, Hunter New England and Illawarra Shoalhaven areas.
Productivity	We looked to see whether full and effective use was being made of the existing facilities. We found that while centres are well utilised during the week, there is potential for further improvement.
	We found that it was possible to increase throughput within existing resources by waiting list management, patient booking systems and staff rostering. We agree with the findings of a NSW Health improvement project that centres need to develop and benchmark a set of key performance measures. This will require a workload measure that facilitates comparison of centres with different case-mixes and different techniques. We found that it may also be possible to extend the hours of operation at some centres. This presents the opportunity to test whether there is additional demand, without having to build new facilities.
Staffing	We looked at whether there are appropriate numbers of staff with the requisite skill levels. We found that generally there seemed to be enough staff, but that staffing levels varied considerably.
	We found that there have been workforce shortages, both nationally and internationally, that in the past have resulted in reduced productivity of radiotherapy machines. NSW Health undertook a number of strategies to address the situation and in recent years NSW vacancy rates have declined. These efforts need to be sustained to ensure adequate staffing into the future.
	We observed that centres appear to have quite different staffing levels when related to the throughput achieved. The reasons for such variations were not clear, but could be due to more complex treatments, more training commitments and more involvement in research. NSW Health needs a process to analyse this and establish the staffing required at each centre.
Effectiveness	We looked to see if the effectiveness of radiotherapy services had been assessed to establish the impact of centre facilities on patient outcomes.
	We found there was no means of systematically reviewing the effectiveness of services provided at individual centres. We looked for, but did not find, clarity and agreement on what the results for patients should be from the use of radiotherapy.
	NSW Health proposals for new radiotherapy services usually cite improvement in morbidity and mortality, and radiotherapy treatment rates as primary objectives. In particular, a treatment rate of at least 50% of all cancer patients has been a NSW target since 1995. Current radiotherapy treatment rates for NSW residents who received radiotherapy in NSW and interstate, in either the public or private sector, are considerably lower than this target. Treatment rates in other states and overseas appeared similar to those achieved in NSW. NSW Health needs to look closely at the changing evidence basis for this target, particularly considering that treatments have changed over time and radiotherapy is provided in combination with other treatments.
	We see a need for more realistic 5 year and 10 year treatment benchmarks for each Area Health Service as a basis for assessing performance and planning the expansion of facilities.
	Are radiotherapy services likely to be adequate in the future?
Planning	The establishment of radiotherapy centres requires extensive planning. Over the next 10 to 12 years demand for cancer services is expected to increase significantly. We looked to see how well NSW Health was planning to provide the services that will be needed.
	We found that NSW Health had undertaken significant planning in relation to the development of a draft Radiotherapy Services Plan 2007-2011, but not released it due to the need to resolve the significant funding required. In our view the Plan should be extended to a 10 year timeframe and released to provide overall direction - resourcing and the availability of funding being risks that need to be managed. Although there has been no published plan, we found that state-wide planning has progressed. This has included consideration of the estimated number of new cancer cases, flow patterns and the impact of new and expanded services. This enables assessment of the impact of adjustments to flow patterns and the supply of radiotherapy services. This planning process has identified areas of geographic need including the Central Coast, Illawarra/Shoalhaven, Hunter/New England, and Sydney West/Sydney South West regions.
Value for money	We looked to see how well NSW Health had evaluated the economic or ‘value for money’ aspects of the projected replacement and expansion of radiotherapy services.
	We found that the Business Case for the Radiotherapy Services Plan 2007 evaluated replacement and expansion of radiotherapy services in NSW in terms of a limited number of options. We looked for, but did not find at a state-wide level, economic or value for money assessments of the economies of scale comparing facilities with 1, 2, 3 and 4 or more machines, or optimal replacement of existing machinery based on service need, age, state of repair, productivity, and life cycle costs.
Resources	We looked to see if future planning had clearly identified the resources needed.
	We found that the Business Case for the Radiotherapy Services Plan 2007 provided a broad estimate of the overall funding needed, identified the linear accelerators required and was supported by an economic analysis that includes assumptions in relation to staffing, equipment, and other related costs such as maintenance. We also found Area Health Services identifying radiotherapy resources they need. A key issue for Area Health Services is the operational funding required to operate these services.
Capacity/ affordability	We were particularly interested in seeing if the planned increase in radiotherapy services was likely to be affordable – for NSW Health as well as the patients.
	We have found analysis of the affordability of options at the Project Definition Planning phase. We expected to see, but did not find, analysis of affordability at a state-wide level including: § assessments of the likely adequacy of funding for development, operations, and maintenance of all radiotherapy treatment centres in the system §   efforts to identify, secure and leverage further funding sources as necessary to address any shortfalls.
Risks	We looked to see if future planning had identified and assessed the risks to service delivery – particularly the risks associated with limited public sector funding.
	The Business Case for the Radiotherapy Services Plan 2007 identified risks to the development program as including lack of funding, workforce availability, and program delays.
	Our view is that NSW Health has more to do on the assessment and risk management of funding, workforce support (particularly at non-metropolitan locations), and private sector involvement.
	Recommendations
	Providing services more efficiently and effectively
	We recommend that NSW Health: 1. establishes by December 2010 formal cancer networks that link radiotherapy centres in a way that clarifies, assures and specifies access to a complete range of cancer services for rural and regional residents (page 27) 2. continues to work with accreditation agencies to adopt by June 2010 agreed accreditation standards for radiation oncology services within their hospital accreditation processes (page 28) 3. systematically and consistently by June 2010 monitors, benchmarks and analyses the actual times taken between receipt of the referral to radiotherapy treatment centres and initial specialist consultation, and from ‘ready for care’ to treatment (page 41) 4. develops centralised booking systems by December 2009 for all radiotherapy treatment centres within a service network (page 41) 5. identifies by June 2010 those people who are not within a reasonable distance or do not have reasonable access to radiotherapy facilities, and analyses where additional service and support efforts may be needed (page 41) 6. conducts detailed analysis of options for radiotherapy services (including public or private sector provision) and sites in the geographic areas of need, including the Central Coast, Hunter New England and Illawarra Shoalhaven areas (page 46)
	7. develops a workload measure by June 2010 that facilitates comparison of centres with different case-mixes and different techniques (page 50) 8. monitors and benchmarks by December 2009 operational performance measures for radiotherapy treatment centres including for quality, patient safety, waiting times, throughput, cost of treatment and outcomes (page 50) 9. assesses by June 2010 the value for money of working extended hours (including Saturday mornings), including the value to patients (page 50) 10. analyses by December 2010 the variations of current staff levels between radiotherapy centres and develops staffing profiles for each centre which reflect volume, case-mix and complexity (page 53) 11. establishes by June 2010 more realistic 5 year and 10 year treatment benchmarks for each Area Health Service as a basis for assessing performance and planning the expansion of facilities (page 60) 12. continues to monitor international evidence and assess the impact that radiotherapy services are having on patient outcomes as part of their overall cancer treatment, in order to clarify and agree what the patient outcomes and performance measures should be (page 60).
	Ensuring radiotherapy services are adequate in the future
	We recommend that NSW Health:
	13. develops and publishes by June 2010 a 10 year strategic plan for radiotherapy services, noting that the progress of its implementation will be determined by resource and funding availability (page 67) 14. assesses by June 2010 economies of scale to assist in considering the most cost effective machine configuration and the impact on access to services (page 69) 15. develops by June 2010 a firm funding strategy to support the replacement of existing machinery based on service need, age, state of repair, productivity, and life cycle costs (page 69) 16. analyses by June 2010 the affordability of its strategic plan, particularly in relation to Commonwealth payments and the implications of private sector involvement (page 71).

Response from NSW Department of Health

Thank you for the opportunity to provide a response to the performance audit report Tackling Cancer with Radiotherapy.

The impact and subsequent challenges of a cancer diagnosis on individuals; their families; and, their carers is well is understood. While the focus for this review has been on radiotherapy services, the burden of cancer means that there needs to be continued efforts on many fronts; from prevention and screening, through treatment; and, to rehabilitation and palliation; as part of maintaining and improving the response to this disease. Ongoing improvement in people’s experiences; recovery; and, survival from cancer will depend upon action across many parts of the NSW Health system.

As the report indicates, NSW has survival rates for cancer which are among the best in the world. NSW Health aims to continue to ensure that gains that have been made in the treatment of, and survival from, many cancers are sustained and survival rates continue to improve. The Cancer Institute, NSW will continue to lead NSW Health efforts in this regard.

Since 1995, NSW has invested over $150 million to expand the capacity of services to treat cancer through new and replacement linear accelerators. This has occurred through the expansion of services at Calvary Mater Hospital, Newcastle, and the establishment of the North Coast Cancer Institute at Coffs Harbour and Port Macquarie. Over $50 million additional funding has been committed to establish new services at Lismore and Orange, and provide for the replacement of three linear accelerators. In addition to the capital investment made, since 2003/04 funding of over $13 million has been allocated to operate the additional treatment machines at existing and new centres.

Our cancer services owe much to the dedicated staff who diagnose, treat, and support cancer patients. NSW Health has made major investments in a range of workforce initiatives to grow and support the necessary workforce for radiation oncology. Some of these initiatives include $2.2 million, each year, for a range of strategies for Radiation Oncology Medical Physicists; $0.8 million each year for Radiation Therapist tutor positions; and, support for approximately 50 positions each year for Professional Development Year positions for Radiation Therapists.

In an area such as cancer, it is recognised that more can always be done and the recommendations of the report identify a number of areas where the efficiency and effectiveness of our existing services can continue to be improved.

All of the recommendations are supported. However, I would note that the response to a number of the recommendations will be dependent on availability of resources and will also need careful consideration as to the broader implications of these recommendations. A schedule is attached which outlines the summary position from NSW Health in response to each of the recommendations.

Service quality should, and does, remain a major focus of all service provision, and accreditation is an important part of this overall process; accreditation is also part of the national agenda. Recommendation 2 will be raised through the Australian Health Ministers Council process.

Some recommendations, such as recommendations 10, 14 and 16 will require additional resources, as external expertise in health economics, will need to be sourced to undertake more detailed analyses. Progress on these recommendations will therefore be dependent on the availability of these resources, balanced against service provision.

Recommendation 12 will require continued assessment of cancer outcomes, within overall cancer treatment, in line with international best practice, and close monitoring of the role of radiotherapy, both now and into the future.

The role of the Commonwealth in radiotherapy is significant and NSW will continue to work closely with the Commonwealth; other jurisdictions; and, the private sector, in the planning and provision of radiotherapy services. The important contributions and achievements of the Radiation Oncology Reform Implementation Committee, and its associated Quality, Workforce and Planning Working Groups, will continue to provide a venue to respond to some recommendations regarding service provision.

NSW is fortunate in having access to comprehensive data and information regarding the provision of radiotherapy services. The availability of this information makes the results of reviews such as this audit review and service planning, more generally, of significant standard. This is the result of the contribution by public and private sector providers, both in NSW and interstate, over many years; the participation of these service providers is appreciated.

The commitment and cooperation of the clinicians responsible for delivering radiotherapy on a day to day basis, and for cancer services more broadly, is acknowledged and greatly appreciated.

I would also like to take this opportunity to thank the many clinicians and stakeholders who were consulted and provided assistance in the development of this report. I also wish to acknowledge the Audit Team for the collaborative manner in which this Performance Audit was conducted.

(signed)

Professor Debora Picone AM

Director-General

Dated: 1 June 2009

Audit Office Report Recommendations	NSW Health Response
Providing services more efficiently and effectively
1. establishes by December 2010 formal cancer networks that link radiotherapy centres in a way that clarifies, assures and specifies access to a complete range of cancer services for rural and regional residents	Supported. This will be considered as part of the overall arrangements for new centres to be networked with larger, more established centres, where required. In developing these networks the overall service needs of residents will be considered.
2. continues to work with accreditation agencies to adopt by June 2010 agreed accreditation standards for radiation oncology services within their hospital accreditation processes	Supported with qualification. A separate accreditation process for radiotherapy, aside from other cancer services, is not supported. The accreditation of radiotherapy services needs to be incorporated into existing accreditation processes.
3. systematically and consistently by June 2010 monitors, benchmarks and analyses the actual times taken between receipt of the referral to radiotherapy treatment centres and initial specialist consultation, and from ‘ready for care’ to treatment	Supported with qualification. The Department is supportive of monitoring the time between confirmation of the patient’s “Ready for Care” date, and commencement of treatment. This information is anticipated to be available from the roll-out of the Business Improvement Toolkit. To date, the intent of developing the system and reports has been to assist clinicians in discussing with the patient possible alternate treatment locations in relation to likely time to treatment.
4. develops centralised booking systems by December 2009 for all radiotherapy treatment centres within a service network	Supported. This will require action by Area Health Services but should be facilitated by the Business Improvement Toolkit.
5. identifies by June 2010 those people who are not within a reasonable distance or do not have reasonable access to radiotherapy facilities, and analyses where additional service and support efforts may be needed	Supported. Information already available in the Source of Referral information in the Radiotherapy Management Information System Report. More detailed assessment is also undertaken as part of the detailed services’ and facility planning for specific geographic areas.
6. conducts detailed analysis of options for radiotherapy services (including public or private sector provision) and sites in the geographic areas of need, including the Central Coast, Hunter New England and Illawarra Shoalhaven areas	Supported with qualification. This detailed analysis is undertaken as part of the service and facility planning process. The timing of these analyses is determined by the annual budget cycle. These processes can have significant associated Consultant costs and need to be programmed accordingly.
7. develops a workload measure by June 2010 that facilitates comparison of centres with different case-mixes and different techniques	Supported. A Basic Treatment Equivalent model has been used previously with variable uptake by individual ROTCs.
8. monitors and benchmarks by December 2009 operational performance measures for radiotherapy treatment centres including for quality, patient safety, waiting times, throughput, cost of treatment and outcomes	Supported with qualification. Implementation will be dependent on resources to undertake the review. Not all of this information is currently readily available and will require additional resources to develop systems to capture this information.
9. assesses by June 2010 the value for money of working extended hours, (including Saturday mornings), including the value to patients	Supported.
10. analyses by December 2010 the variations of current staff levels between radiotherapy centres and develops staffing profiles for each centre which reflect volume, case-mix and complexity	Supported with qualification. Implementation will be dependent on resources to undertake review.
11. establishes by June 2010 more realistic 5 year and 10 year treatment benchmarks for each Area Health Service as a basis for assessing performance and planning the expansion of facilities	Supported. Implementation will be facilitated through the AHMAC Radiation Oncology Reform Implementation Committee.
12. continues to monitor international evidence and assess the impact that radiotherapy services are having on patient outcomes as part of their overall cancer treatment, in order to clarify and agree what the patient outcomes and performance measures should be.	Supported. Implementation will be facilitated through the AHMAC Radiation Oncology Reform Implementation Committee.
Ensuring radiotherapy services are adequate in the future
13. develops and publishes by June 2010 a 10 year strategic plan for radiotherapy services, noting that the progress of its implementation will be determined by resource and funding availability	Supported.
14. assesses by June 2010 economies of scale to assist in considering the most cost effective machine configuration and the impact on access to services	Supported with qualification. Implementation will be dependent on resources to undertake review.
15. develops by June 2010 a firm funding strategy to support the replacement of existing machinery based on service need, age, state of repair, productivity, and life cycle costs	Supported.
16. analyses by June 2010 the affordability of its strategic plan, particularly in relation to Commonwealth payments and the implications of private sector involvement.	Supported with qualification. Implementation will be dependent on resources to undertake review.