List of Recommendations

Providing a quality radiation oncology service

A forward-looking strategy to deliver improved radiation oncology services

Importance of planning

1. Planning of radiation oncology services must be based upon achieving the agreed optimal target utilisation of radiotherapy for new cases of cancer (currently set at 52.3%).
2. The commitment needs to be made now so that the target optimal utilisation rate for radiotherapy can be met by 2022.
3. Radiation oncology service planning needs to occur:
   1. Regularly on a long-term basis and coordinated at a national level.
   2. With reference to other cancer therapies.
   3. Ensuring that patients have clinically appropriate and affordable therapies.

Keeping pace with radiotherapy techniques and technologies

4. Health technology assessment processes at all levels must be improved so innovations that provide value for both the cancer patient and the health system are effectively implemented.
5. There needs to be a sustainable financial model for the introduction of new radiotherapy techniques and technologies based on comparative effectiveness.
6. A radiation oncology registry of treatments and outcomes needs to be established to provide data capture and post-market surveillance.

Harmonisation of legislation

7. Regulatory legislation and processes should be harmonized across jurisdictions.

Minimum radiation oncology data set

8. A minimum radiation oncology dataset must be established, implemented and incorporated into a future national cancer data set.
9. All radiation oncology services must comply with the requirements of a radiation oncology national dataset and provide data.

The availability of radiotherapy to all patients for whom it is clinically appropriate which can be accessed in a timely manner

Timely access

10. Planners, decision-makers and service-providers must ensure that radiation oncology services have the capacity for patients to receive radiotherapy within clinically appropriate timeframes.
11. National targets for timely access to radiotherapy (as recommended by National Health and Hospital Reform Commission) should be set and services should be reporting against these targets.

Financial impact on patients, families and carers

12. The financial impact of accessing cancer treatment should be minimized to ensure that optimal treatment is available to all patients.
13. Legislative issues must be resolved to allow out-patient radiation oncology to qualify for private health insurance

A patient-centred, evidence-based and multidisciplinary approach to practice

Empowered consumers

14. Patients, carers and families need to be empowered such that:
    1. They are provided with current, relevant and evidence-based information regarding radiotherapy.
    2. Information is available in languages other than English, where appropriate.
    3. Any costs associated with treatments are clearly described prior to treatment.
    4. Current radiotherapy waiting times information is made publicly available.
15. There needs to be a central information resource on radiation oncology that is:
    1. Reliable and appropriate
    2. Readily accessible in all geographic locations

Radiation oncology practice standards

16. The Radiation Oncology Practice Standards must be mandatory.
    1. A mechanism for oversight of compliance with the Standards needs to be established and funded.
    2. The professions to regularly review and keep the Standards contemporary.

Evidence based multi-disciplinary oncology practice

17. Multidisciplinary Team management is the gold-standard of cancer care and must be supported by services, professionals and planners.

Clinical peer-review audit

18. Peer-review practices should be supported and increased to minimise process variation and ensure that treatments comply with best practice.

Ongoing evaluation of quality assurance, patient quality of life and survivorship

Quality assurance for safety and quality care

19. A national framework for quality assurance should be developed to make radiotherapy more consistent and to ensure patient safety.

Dosimetry

20. The Australian Clinical Dosimetry Service must be made permanent to ensure safe delivery of radiotherapy.

Quality of life and survivorship

21. Patient survivorship must be a focus of cancer management.

Continuous quality improvement

A quality management system for radiation oncology

22. There must be a national reporting framework to identify issues associated with quality.
23. A formal benchmarking exercise across jurisdictions and radiation oncology facilities must be undertaken, including activity targets, waiting times and clinical patterns of care variation:
    1. Service and planning benchmarks must be agreed nationally
    2. Variability between services must be measured and reported
    3. Individual plans must be developed for services to meet the benchmarks

Incident monitoring

24. A national incident monitoring system specific to radiation oncology must be implemented.

Engendering leadership and fostering a culture of quality

25. Quality management and leadership must be included in all professional training programs.

Resourcing the radiation oncology sector

Cancer incidence is the basis for planning

26. The nationally coordinated radiation oncology planning must consider:
    1. Projected cancer incidence;
    2. Target optimal utilisation rate;
    3. Regional and rural service access;
    4. Projected changes in demographics.

Workforce and infrastructure are planned together in a coordinated way

27. Establish a system for facilities to regularly report on their activities to inform coordinated planning.
28. Implementation of new technology must consider workforce implications.
29. Overcapitalized radiotherapy services, such as brachytherapy and radiosurgery, should be rationalised.
30. New facilities should be planned with the capacity to allow expansion and service continuity.
31. All facilities must have adequate information and communication technology infrastructure and expertise.
32. Workforce planning should consider the need for multidisciplinary care and adequate supply of allied health and support services.
33. Australia needs 267 linacs by 2022 to achieve the optimal utilisation rate of 52.3% (approximately an extra 100, in addition to the replacement of current fleet).
34. Governments must have a plan for the number of new linacs that will come into use over the next ten years.
    1. Coordinated across the public and private sectors;
    2. Aligned with workforce training and development;
    3. Developed in close consultation with the professions and consumers;
    4. Taking into account the lead time of 2-5 years for starting an operational service.
35. Services should be planned to operate with 10% additional capacity such that surges in demand can be met without increasing the waiting times for treatment.
36. Development of sustainable fellowship programs for Radiation Oncologists must be a key priority to ensure the development of important clinical and research skills.
37. Develop workforce strategies offering enhanced career pathways for Radiation Therapists (RT):
    1. Support advanced practice and role evolution for RTs;
    2. Explore assistant roles in radiotherapy.
38. The Radiation Oncology Medical Physicists (ROMP) workforce crisis requires an urgent and multi-faceted response:
    1. Australia must have a nationally self-sufficient ROMP workforce by 2022;
    2. support promotion of a physics career to school students and undergraduates;
    3. increase and streamline funding for TEAP positions, and embed into the radiation oncology workforce profile;
    4. strengthen recruitment strategies to attract and retain the ROMP workforce;
    5. urgently develop innovative models of service provision that do not compromise quality;
    6. a national workforce summit must be held by June 2013 to get consensus on the implementation of workforce solutions.
39. Develop plans to support professionals returning to full-time and part-time work.

Workforce training is aligned with service demand projections and supported appropriately

40. Governments to match the funding contracts for training positions in both public and private accredited facilities to the length of the training programs.
41. Accreditation and training processes that allow for:
    1. Increased trainee numbers in the three key professional areas i.e. Radiation Oncology, Radiation Therapy and Radiation Oncology Medical Physicists;
    2. Embedded funding for clinical supervisors, preceptors and training network coordinators to adequately support the training programs; and
    3. Continued professional education and development for those in the workforce;
    4. Support of training in rural and regional areas.
42. To establish innovative models of training such as:
    1. Virtual and simulated learning programs;
    2. Nationally coordinated training networks to enable optimal utilisation of resources.

A National Cancer Action Plan which includes radiation oncology is adopted

43. There needs to be a National Cancer Action Plan developed, implemented and maintained for Australia:
    1. In consultation with the professions and consumers;
    2. Encompassing radiation oncology as a core element of quality cancer care.

Jurisdictional radiation oncology action plans are developed, maintained and integrated with the National Cancer Action Plan

44. Jurisdictions must develop, regularly review, evaluate and update 5-year action plans for radiation oncology and these must be coordinated nationally.
45. Financing options for establishing and resourcing services should be explored and must ensure access to radiation oncology services is safeguarded;
46. To ensure that infrastructure is used efficiently:
    1. Business process review must be undertaken regularly;
    2. Business process improvement must be part of standard practice;

Closer consultative collaboration between governments, policy-makers, service providers, patients and the professions to ensure most effective use of resources

47. Establish and strengthen radiation oncology networks where smaller centres are linked to major centres.
48. The existing national ROHPG capital replacement program must be maintained and regularly updated to reflect changes in radiation oncology practice.

Innovative models of quality service provision are developed to improve efficiencies

49. There should be ongoing horizon scanning for new radiotherapy techniques and technologies, to inform facilities planning;
50. Essential role of imaging in radiation oncology must be acknowledged:
    1. Regulatory constraints such as licensing must be remedied;
    2. Training and expertise of professionals must be enhanced;
    3. Funding for planning and treatment of patients must support evidence-based practice;
    4. The role of the Diagnostic Imaging Medical Physicists needs to be recognised and supported.
51. The use of essential radiotherapy techniques must align with best practice:
    1. At least 30% of radiotherapy patients should receive IMRT treatments;
    2. Benchmarks for other essential radiotherapy techniques should be developed and services should publicly report against these.

Supporting rural and regional access to radiation oncology services

Comprehensive, quality cancer care is available to patients, which includes a national patient travel and accommodation scheme

52. Adequately funded and equitable national patient transport and accommodation assistance schemes must be in place.
    1. Financial support should demonstrate a relationship between the subsidy and reasonable transport and accommodation expenses.
    2. The transport and accommodation support schemes should be simplified and disparities between jurisdictions should be addressed.
53. A comparative study of costs of providing treatment and out of pocket expenses across various private and public facilities should be developed
    1. to benchmark the costs related to radiotherapy and reimbursements or rebates;
    2. to provide governments with the necessary data to ensure equity.

Models of care are locally tailored and appropriate to rural and regional areas

54. Design models of care appropriate to the regional area and its population needs, including linkage to major radiation oncology centres;
55. Adopt a national planning approach (facilities, workforce and services) with input from regional and rural stakeholders;
56. Regional facility development should focus on patient care outcomes and experiences;
57. Establish access to specialist services through the Cancer Care Network and links between regional and comprehensive metropolitan cancer care services
58. Accommodate needs for future expansion and uptake of technology in regional facility planning and development

Planned workforce strategies are developed to support the expansion of radiation oncology services to regional and rural areas.

59. Strategies are developed to recruit trainees and radiotherapy professionals of regional and rural origin
60. Increased training opportunities in rural and regional centres; increased funding support for prioritisation of rural training placements
61. Incentives and bonuses to attract and retain rural and regional staff
62. Staffing models that support professional development, professional collaboration and research activities
63. Increased flexibility of decision-making and funding responsibilities in regional centres for specific strategies for staff retention
64. Individual regional facilities should develop areas of expertise, including research, and specific competencies in techniques and technologies to increase competitive attractiveness of rural work.

Strategies in place that recognise and ameliorate the financial and social impact of cancer on patients and carers in rural and regional areas

65. Actions to be taken such that financial consideration by rural and regional patients and carers do not influence decisions regarding treatments:
    1. Where it does not exist already, there should be expansion of arrangements for publicly funded patient access to private regional radiotherapy treatment and review of the eligibility criteria for the same.
    2. Modified billing mechanisms in private facilities where payments and reimbursements are streamlined so that patients are only required to pay the gap payments, while the facility can maintain its operating cash flow.
    3. Costs of developing regional public facilities as opposed to providing publicly-funded access to an existing local private facility need to be considered.
    4. Reimbursement of out of pocket expenses incurred should be an option for those who are forced to pay more because of their place of residence.

Innovative approaches to patient care are implemented, evaluated and supported

66. A planned adoption of telehealth into radiation oncology services for consultation, care planning and follow up of patients
    1. Such adoption should focus on cancer care outcomes and patient experiences.
    2. Clinicians should be consulted to identify clinical needs and the best supporting technology.

Supporting Aboriginal and Torres Strait Islander access to radiation oncology services

Lack of and reduced access to radiation oncology is an important factor affecting the cancer outcomes for Indigenous patients. While acknowledging the fact that there is a need for a comprehensive approach, the recommendations below relate specifically to radiotherapy access. The recommendations below are based on the relevant research and responses received during the stakeholder consultation process.

Better data collection on Indigenous access to oncological services

67. Development and implementation of a national radiation oncology dataset should include data collection on Indigenous patients.

Assessment of specific barriers to service access

68. Further research to identify the reasons for the lower survival rates of Indigenous peoples diagnosed with cancer.
69. Additional research to identify issues and barriers for Indigenous patients living in metropolitan areas.

Evidence-based strategies to improve access to treatments

70. Indigenous patients must have access to radiotherapy as close to their community as possible.
71. Accommodation facilities for Indigenous patients and their families must be appropriate and available.
72. Education and information strategies about cancer including causes, prevention and treatment options must be developed for Indigenous patients.

Improved engagement between the hospital system and community-controlled Aboriginal and Torres Strait Islander health services

73. Planning for radiation oncology services must take into account specific access issues for Aboriginal and Torres Strait Islander patients.
74. Planning must be undertaken with reference to and in close consultation with the local Aboriginal community-controlled health services.
75. Specific strategies, including Aboriginal Liaison Officers at cancer centres, must be developed.
76. Initiatives to support Indigenous people to join the radiation oncology professions must be considered and encouraged.

Research and academia as foundations of future practice

Local research that results in evidence based and timely implementation of new treatment techniques and technologies

77. Specific support for radiation oncology research is required:
    1. Clinical and health systems research in radiation oncology that produces timely evidence of safety, efficacy and cost effectiveness of new techniques and technologies must be specifically funded through a dedicated funding stream.
    2. Expansion of research support in radiation oncology that advance our understanding of biological mechanisms translating into clinical practice through specific measures such as translational training fellowships, to maximise benefits for patients.
78. Patient awareness of clinical research needs to be increased:
    1. Health care consumers must be educated in the availability and importance of clinical research, leading to increased participation in clinical research.

Increased funding allocation to radiation oncology research that is commensurate with its contribution to cancer control

79. It is recommended that radiation oncology research funding is increased so that:
    1. Research processes are developed from current levels and are sustainable with adequate dedicated funding
    2. Additional translational research capacity enables faster identification and adoption of new techniques and technologies that improve efficiency
80. Workforce and equipment planning and implementation at site, jurisdiction and national levels must include the requirements to support research as an integral component of care delivery.
81. A small grants program must be introduced to develop projects to a level of national competitiveness.

Dedicated radiation oncology research equipment and staff time are included into national service planning

82. Infrastructure planning at jurisdiction, state and national level needs to accommodate research requirements.

Access to clinical radiation oncology equipment time for (translational and implementation) research is factored into facility service planning

83. Facility planning needs to accommodate research requirements including discovery, translational and implementation research.

Integration of radiation oncology treatments into comprehensive electronic medical records (EMR)

84. All treatment facilities must have the capability to collect comprehensive data sets including treatment details that can be shared through national collaborative research programs.
85. Strategies for data support and sharing between facilities must be in place.

Research is recognised as part of core business for all radiotherapy facilities

86. The importance of research positions needs to be recognised:
    1. research career path must be developed
    2. radiation oncology services should support research activities within their facilities
    3. Programs should be developed (if not yet in place) that combine professional with academic (doctoral or masters) qualifications.
    4. Mentorship programs must be introduced to link experienced researchers with early career professionals.
87. The ethics and governance approval process needs to be streamlined to enable efficient collaboration.
88. Professions must build ethics and governance literacy amongst their members.
89. It is essential that healthcare consumers are involved in the development of trials and represented on decision-making bodies.

Multidisciplinary research teams established, incorporating discovery, translational and implementation research

90. Active cooperation and collaboration between various departments, jurisdictions, disciplines and manufacturers must be actively encouraged.
91. Clinical professionals must have protected time to conduct research.
92. International collaboration in research and participation in international research projects must be encouraged and supported.
93. Collaborative links between treatment facilities and universities need to be developed or increased (where already in place):
    1. Co-operation between universities and treatment facilities has to extend beyond teaching hospitals.
    2. Reciprocal support arrangements need to be established between universities and treatment facilities, whereby facilities provide clinical placements and universities provide research support to facilities.
    3. Support for the establishment of conjoint academic and clinical positions in all three professional groups.
    4. Research training and the creation of roles for practitioner-scientists must be fostered across the radiation oncology professions.