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NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane

NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital Canterbury District Health Board 23 rd August 2010. NEUROSURGERY (Neurological Surgery).

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NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane

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  1. NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital Canterbury District Health Board 23rd August 2010

  2. NEUROSURGERY (Neurological Surgery) OPERATIVE and NON OPERATIVE management

  3. WHAT TYPES OF CONDITIONS/OPERATIONS DO NEUROSURGEONS TREAT/PERFORM ?

  4. Public expectations Healthcare expectations subspecialisation: better surgery: better outcomes: succession planning Neurosurgery Neurosurgery for pain Movement disorders Peripheral nerves Brain tumours Spinal surgery Pituitary tumours Paediatric neurosurgery Skull base Vascular - craniotomies & endovascular Head & spinal trauma Epilepsy Surgery

  5. Shunt valve for hydrocephalus Hudson brace, perforator & conical burr Fibreoptic endoscope Coil for aneurysm Sugita aneurysm clips & applicator Vessel stent Image Imtensifier Stereotactic frame Endoscopic tower OT of the near future Operating microscope Tools, Equipment and Instrumentation

  6. Neurosurgery in Christchurch – 1981/1982 to 2009/2010 Growth of a Specialist Service

  7. NEUROSURGERY and NEUROSURGICAL UNITS in New Zealand Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital 21st August 2010

  8. Auckland (1945) • • Hamilton (2006) • Wellington (1965) • Christchurch (1981) • Dunedin (1943) New Zealand Neurosurgical Units 3.3m 5 units for 4.327 m population 1.027m

  9. 14 (15) 1 NS Per 253,846 (220,000) • Christchurch Neurosurgical Unit • 4 neurosurgeons (+ one in sole pp) 5 (6) 1 NS per 205,400 (171,166) • Dunedin • O neurosurgeons – using sole locums Neurosurgical Services in New Zealand North Island • Auckland Neurosurgical Unit incl Starship • 6 neurosurgeons • Waikato Neurosurgical Unit • 4 neurosurgeons • Wellington Neurosurgical Unit • 5 neurosurgeons (one currently partial clinical) South Island

  10. Neurosurgical Services in New Zealand South Island • In the 1970s  changing population demographics in the South Island •  continuing growth of Christchurch as the major tertiary referral centre in the South Island • 1979: Decision made by Dept/Ministry of Health to commision a • Neurosurgical Unit in Christchurch (1st Review) • The neurosurgical unit in Christchurch was established in August 1981 and was able to function as a fully-equiped independent unit in April 1982 • The Minister of Health stated at that time that: “the Dunedin Neurosurgical Unit would function on a week to week basis • with there to be no replacement of neurosurgeons as they retired” • Christchurch Unit now has 4 neurosurgeons (747,000 people) • Dunedin Unit has no permanent neurosurgeons – using locums (280,000 people

  11. Reviews of the provision of Neurosurgical Services since 1979 2nd : 1988 “Hospital/Area Health Board Service Planning Guidelines Neurosurgery” June 1988 Graham Martin, Martin MacFarlane, Owen Mooney (AHB), John Mills (OHB), Liz Webb (Nursing, AHB), Dr Ray Dowden (PMO, DoH), Ray Collinge (DoH) with input from Sam Bishara, Graeme MacDonald • This was the first of two specific reviews of the requirements for/of a • Neurosurgical Unit in New Zealand and the provision of neurosurgical • services (population, staffing, bed numbers, affiliated surgical, medical, allied • health, support services, equipment, radiology etc). • Basis for neurosurgeons was 1:300,000 • Minimum population to be served by a unit was 900,000 with 3 neurosurgeons • in a Unit • Minimum of 8 adult beds per 300,000 - plus ICU beds, paediatric beds and • rehabilitation beds • To ensure equitable access to neurosurgical services for the whole population

  12. Reviews of the provision of Neurosurgical Services since 1979 3rd : May 1995 “TERTIARY SERVICES ISSUES PAPER Neurosurgical Services” p15: Looked at ratios of neurosurgeons to population: 1:100,000 in US (Congress of Neurological Surgery) 1:400,000 in UK (SBNS) 1:250,000 previously in Australasia to 1:175,000 (Neurosurgical Society of Australasia) p15: “Neurosurgery cover should be available on a 24-hour basis due to the semi-urgent nature of the surgical intervention and nonsurgical consultation. Because of this, the recommended minimum number of neurosurgeons per unit is three. Fewer than three neurosurgeons per unit may reduce quality outcomes. (It has been noted by the Core Services Committee that ‛centres that currently meet quality criteria but have fewer than three neurosurgeons per unit may be at serious risk of compromised quality if there are changes of key staff, particularly neurosurgeons’)”

  13. Reviews of the provision of Neurosurgical Services since 1979 4th : Nov 1995 “Recommendations for the configuration of Tertiary Services in New Zealand A report from The Tertiary Services Committee November 1995” ReNeurosurgery: • “The Tertiary Services Committee agreed with the recommendations from • professional bodies and clinical groups, both in NZ and overseas, that the • interests of the NZ patient would be best served by having three neurosurgical • centres, with a minimum of three neurosurgeons per centre, and with each • Neurosurgeon performing a minimum of 100 major neurosurgical • procedures a year.” • “The Tertiary Services Committee’s preferred option is that RHAs purchase • neurosurgical services from three centres – in Auckland, Wellington • and one in the South Island”.

  14. The neurosurgery workforce in Australia and New Zealand 1996 Discussion “The NSA has attempted to maintain a balance between competency, accountability and quality of life for the surgeon, and has nominated a surgeon to population ratio of 1:175,000. Notably, this figure is markedly different from the ratio in the US (1:61,000) And from the whole world (1:230,000), but not dissimilar from that of the UK (1:181,500. Additionally, this figure may need to be reconsidered over time as the practice of neurosurgery and medicine in general changes”.

  15. Reviews of the provision of Neurosurgical Services since 1979 5th :1996/97 “Policy Guidelines for Regional Health Authorities 1996/97”

  16. Reviews of the provision of Neurosurgical Services since 1979 6th :1997

  17. Considered positives and negatives for: • Dual Site Service: Dunedin 2 neurosurgeons, Christchurch 4 neurosurgeons Discussion document for Neurosurgery Services, South Island, New Zealand Andrew Law and Nicholas Finnis, Neurosurgeons, Dunedin 1998 7th : 1998 “Looking at operating statistics from 1996 and 1997 from Dunedin Hospital, there are between 6 and 10 cases each year requiring urgent neurosurgical intervention. Of these, less than half are from the Dunedin are, with surgical stabilisation already performed in some cases in Invercargill by the general surgeons prior to transfer to the (Dunedin) neurosurgical centre for definitive treatment. This does raise the issue of excess morbidity in a few cases each year due to a change in service. …there is likely to remain a few cases each year that need some form of life-saving surgical intervention prior to transfer” • Single Site Service: Christchurch 6 neurosurgeons with appropriate outreach and • professional and other linkages

  18. Reviews of the provision of Neurosurgical Services since 1979 8th: 2001

  19. Safe Neurosurgery 2000 A Report from the Society of British Neurological Surgeons • Neurosurgical units should be situated within a multi-disciplinary Neurosciences • Centre and on a General Hospital site. Each unit must provide a full core neuro- • surgical service before any subspecialties are developed • For maintenance of neurosurgical expertise and satisfactory training there must be • an adequate volume and diversity of work and sufficient population to generate this. • Whilst this must be reconciled with equity of access, a 1 million catchment • population should be the minimum • All neurosurgical units must provide a full twenty-four hour consultant-led service • and be staffed accordingly, i.e. a minimum of 6 WTE consultant surgeons • increasing with populations of more than 1.5 million • Thirty neurosurgical beds and four dedicated neurosurgical intensive therapy beds • per million population are needed to provide safe practice • Every neurosurgical unit should have at least two fully resourced operating theatres; • those serving a population of more than 2 million need three

  20. Reviews of the provision of Neurosurgical Services since 1979 9th: 2009 February 2009 – meeting of all six SI DHB CEOs and others incl clinicians from Dunedin, Christchurch, Spencer Beasley and MoH personnel • June 2009: Prof Spencer Beasley  Draft Neurosurgical Service Plan • given to the SI DHBs • DHBs agreed: • that there would be a single integrated Neurosurgical Service for the • South Island • that a single interim clinical leader would be appointed to the • Service for 12 months to recommend future configuration of the Service • Dr Ian Brown appointed as clinical leader

  21. Reviews of the provision of Neurosurgical Services since 1979 10th: 2010

  22. 747,000 with 4 neurosurgeons = 1 to 186,750 and 1 in 4 on-call 280,000 with 1 sole locum neurosurgeon = 1 to 298,000 and 1 in 1 on-call Neurosurgery for the South Island – the Present • Guidelines from the RACS • (Royal Australasian College • of Surgeons) and the • Neurosurgical Society of • Australasia: • 1 neurosurgeon to 175,000 • 1 in 4 on-call roster (max) • Minimum of 3 neurosurgeons • required for a neurosurgical unit • but note: 1 in 4 on-call

  23. Neurosurgical services to • international standards for • the people of the SI • Funding advantages for high • tech equipment and staff • Will attract appropriately-trained • staff • Allows for subspecialisation • Allows for succession planning Neurosurgery for the South Island – the Future • One Service • One site: Christchurch • 6+ neurosurgeons: 1 to 171,166 • Appropriately resourced • Good & robust Outreach • Suitable transport links 1,027,000 population

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