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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

NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

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Page 1: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

NEUROSURGICAL SERVICES

now and for the futureNew Zealand

South Island

Martin MacFarlaneClinical Director

Department of NeurosurgeryChristchurch Hospital

Canterbury District Health Board23rd August 2010

Page 2: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

NEUROSURGERY (Neurological Surgery)

OPERATIVE and NON OPERATIVE management

Page 3: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

WHAT TYPES OF CONDITIONS/OPERATIONS DO NEUROSURGEONS TREAT/PERFORM

?

Page 4: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital
Page 5: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

Pituitary tumours

Spinal surgery

Head & spinal trauma

EpilepsyVascular -

craniotomies&

endovascular

Skull basePaediatric

neurosurgery

Surgery

Brain tumours

Peripheral nerves

Neurosurgery for pain

Movement disorders

Neurosurgery

subspecialisation: better surgery: better outcomes: succession planning

Public expectations

Healthcare expectations

Page 6: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

Hudson brace, perforator & conical burr

Tools, Equipment and Instrumentation

Sugita aneurysm clips & applicator

Stereotactic frame

Image Imtensifier

Operating microscope

Shunt valve for hydrocephalus

Coil for aneurysm

Vessel stent

Endoscopic tower

Fibreoptic endoscope

OT of the near future

Page 7: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

0

500

1000

1500

2000

2500

1982/83 1987/88 1992/93 1998/99 2003/04 2008/09

Neurosurgical Outpatients

OP

0

200

400

600

800

1000

1200

1982/83 1986/87 1990/91 1995/96 1999/00 2003/04 2007/08

Neurosurgical Inpatients

IP

0

100

200

300

400

500

600

700

1982/83 1987/88 1992/93 1998/99 2003/04 2008/09

Neurosurgical Operations

Ops

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

Page 8: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

NEUROSURGERY and

NEUROSURGICAL UNITS

in New Zealand

Martin MacFarlaneClinical Director

Department of NeurosurgeryChristchurch Hospital

21st August 2010

Page 9: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

Auckland(1945)•

Hamilton(2006)

Christchurch(1981)

Dunedin (1943)

New ZealandNeurosurgical Units

3.3m

1.027m

5 units for 4.327 m population

•Wellington

(1965)

Page 10: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

North Island

Neurosurgical Services in New Zealand

• Auckland Neurosurgical Unit incl Starship– 6 neurosurgeons

• Wellington Neurosurgical Unit– 5 neurosurgeons (one currently partial clinical)

• Waikato Neurosurgical Unit– 4 neurosurgeons

South Island

• Christchurch Neurosurgical Unit– 4 neurosurgeons (+ one in sole pp)

• Dunedin– O neurosurgeons – using sole locums

14 (15)1 NS Per

253,846(220,000)

5 (6)1 NS per

205,400(171,166)

Page 11: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

Neurosurgical Services in New Zealand

• 1979: Decision made by Dept/Ministry of Health to commision a Neurosurgical Unit in Christchurch (1st Review)

• In the 1970s changing population demographics in the South Island

continuing growth of Christchurch as the major tertiary referral centre in the South Island

– 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”

South Island

– Christchurch Unit now has 4 neurosurgeons (747,000 people)

– Dunedin Unit has no permanent neurosurgeons – using locums (280,000 people

Page 12: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

Reviews of the provision of Neurosurgical Services since 1979

2nd : 1988 “Hospital/Area Health Board Service Planning Guidelines

Neurosurgery”June 1988

• 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

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

• To ensure equitable access to neurosurgical services for the whole population

• Minimum of 8 adult beds per 300,000 - plus ICU beds, paediatric beds and rehabilitation beds

Page 13: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

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 to1:175,000 (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 neurosurgeonsper unit may be at serious risk of compromised quality if there are changes of key staff, particularly neurosurgeons’)”

Page 14: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

Reviews of the provision of Neurosurgical Services since 1979

4th : Nov 1995

“Recommendations for the configuration of Tertiary Servicesin New Zealand

A report from The Tertiary Services CommitteeNovember 1995”

Re Neurosurgery:

• “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”.

Page 15: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

The neurosurgery workforce in Australia and New Zealand

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”.

1996

Page 16: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

Reviews of the provision of Neurosurgical Services since 1979

5th :1996/97 “Policy Guidelines for

Regional Health Authorities1996/97”

Tertiary Services Current service configuration

Preferred option

Neurosurgical Services

Four centres –

Auckland, Wellington, Christchurch and Dunedin

Three centres – Auckland, Wellington and one in the South Island.

Affiliation of satellite units possible if quality criteria

are met

Page 17: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

Reviews of the provision of Neurosurgical Services since 1979

6th : 1997

Page 18: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

“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 issueof 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”

Discussion document for Neurosurgery Services, South Island, New Zealand

Andrew Law and Nicholas Finnis, Neurosurgeons, Dunedin1998

Considered positives and negatives for:

• Dual Site Service: Dunedin 2 neurosurgeons, Christchurch 4 neurosurgeons

• Single Site Service: Christchurch 6 neurosurgeons with appropriate outreach and professional and other linkages

7th : 1998

Page 19: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

Reviews of the provision of Neurosurgical Services since 1979

8th: 2001

Page 20: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

Safe Neurosurgery 2000A Report from the

Society of British Neurological Surgeons

• 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

• 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

Page 21: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

9th: 2009

Reviews of the provision of Neurosurgical Services since 1979

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

February 2009 – meeting of all six SI DHB CEOs and others incl clinicians from Dunedin, Christchurch, Spencer Beasley and MoH personnel

Page 22: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

10th: 2010

Reviews of the provision of Neurosurgical Services since 1979

Page 23: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

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

747,000 with 4 neurosurgeons= 1 to 186,750

and1 in 4 on-call

280,000 with 1 sole locum neurosurgeon

= 1 to 298,000and 1 in 1 on-call

Page 24: NEUROSURGICAL SERVICES now and for the future New Zealand South Island Martin MacFarlane Clinical Director Department of Neurosurgery Christchurch Hospital

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

• 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