EXECUTIVE SUMMARY & RECOMMENDATIONS
1. Radiotherapy is a key component of modern cancer treatment and is likely to remain so for the foreseeable future.
2. Demand for radiotherapy will increase substantially over the next 10-15 years due to a combination of demographic and clinical factors. Large increases are anticipated in the number of oesophageal, prostate and colorectal cancers, with a fall in only lung, cervix and stomach cancers ( Chapter 2).
3. Of the estimated 31,500 new cancer patients that will be diagnosed annually by 2015, around 14,000-15,000 are likely to require radiotherapy as part of their initial disease management ( Chapter 3, para 39).
4. Projected future clinical demand and the basis for capacity planning is achieved by modelling stage and incidence with likely patterns of treatment, using best evidence guidelines and clinical expectations of future practice. These estimates absorb all currently unmet need.
5. In 2015, between 242,384 and 318,422 fractions of treatment (clinical demand) is expected; a 38% - 81% increase on the number of fractions delivered in 2003 ( Chapter 3, para 54-73).
6. As recommended by the Royal College of Radiologists (2004), demand should represent 90% of capacity, and therefore, the projected service capacity for 2011-2015 is between 270,000 and 354,000 fractions (Chapter 3, para 101-108). Required capacity projections include allowance for unscheduled machine downtime, research and development needs and ensure that waiting times are not built into the system.
7. By 2007-2008, Scotland will have 25 modern linear accelerators (4.98 per million of population) distributed between the five cancer centres (Glasgow - 11, Edinburgh - 6, Dundee - 3, Aberdeen - 3 and Inverness - 2).
8. This total includes a second linear accelerator (linac) in Inverness which is essential to ensure a sustainable service and secure non-surgical oncology services in the northwest of Scotland. The lack of a reliable backup linac is prejudicing the quality of treatment currently able to be offered to patients in Highland ( Chapter 4, para 111-116).
9. Continuing to operate the planned 25 linacs on the current average service model (5 fractions per hour, 8 hours per day, 5 days per week with 8 public holidays and 16 planned maintenance days) will provide capacity to deliver about 234,00 fractions per annum. To achieve 354,000 fractions, a 51% increase in capacity will be essential -an additional 13 linear accelerators for Scotland if the current service model is maintained. This is equivalent to two centres the size of the Edinburgh centre or another four the size of Dundee or Aberdeen and would be a major acute and tertiary service expansion for NHS Scotland. ( Chapter 4).
10. Service redesign and a smaller service expansion (3/4 additional linacs) provides a more feasible option for increasing service capacity ( Chapter 5). The following service change is recommended as a first step:
- Increase the core clinical service to a 10 hour day, 5 day week.
- Reduce the days lost as a result of closure for public holidays and routine maintenance to achieve 257 clinical days per annum.
- Optimise the capacity of all linacs in Scotland and redistribute workloads.
11. Increasing the clinical time of each linac through the above service redesign will achieve only 65% (providing 312,500 fractions) of the maximum additional capacity required. Assuming incremental increases in clinical demand, it is estimated that this service redesign alone will allow adequate capacity until about 2011-2012. Therefore, there is no immediate requirement to increase the number of linacs in Scotland beyond 25.
12. However, achieving the proposed service redesign will be dependent on a number of factors and require immediate action to:
- review workforce shift patterns, working practices, skill mix, new roles, and additional staff requirements to meet the new core service model.
13. Furthermore, ensuring that, as far as possible, all 25 linacs carry an equal workload is important to optimise the potential capacity across the Scottish service. This will require some changes to referral practices and further development of collaborative working. Unless this can be achieved, it is likely that demand will still exceed capacity in the central belt ( Chapter 5, para 162-165).
14. Preliminary economic evaluation suggests that the 10 hour day, 5 day week is the most cost effective option, with additional centres and machines the most expensive. Further work, including further sensitivity analysis, is ongoing ( Chapter 5, para 166).
15. Demand and capacity projections should be reviewed on a recurrent basis in-line with new available data and emerging evidence (paragraphs 22,44,46,70). This should be underpinned by monitoring of actual radiotherapy service demand and activity between now and the review period. It is recommended that the next review be carried out in 3 to 4 years time, to ensure adequate lead time for purchase of additional linacs and associated equipment - if it is concluded that these are required by 2010-2012 (as above).
16. If the review determines that demand projections hold true and capacity for 354,000 fractions per annum is required, up to 3/4 additional linacs will be necessary to enhance the service redesign detailed above to achieve the required capacity. Alternatively, a 6 day working week may be considered.
17. Assuming that an additional 3/4 linacs are required for Scotland, the location of these will need further debate. Capacity exists to house additional linacs at the Aberdeen, Dundee, Edinburgh and Glasgow cancer centres. Utilisation of this building space could provide an immediate and short-term solution but may not be the preferred permanent option and should be re-assessed as part of the review in 3-4 years time.
18. Increasing the core clinical working time of the machines will have major human resource implications (as would increasing the number of machines) not only for the medical, radiography and physics staff but for all support, administrative and clerical staff. NHS Education for Scotland ( NES) has agreed to develop a cancer service education strategy that will address current and new roles ( Chapter 5, para 152 - 157 and Chapter 7).
19. A cancer-specific human-resource strategy is required to look at:
a) workforce numbers and working practices
b) identify and address recruitment and retention issues
c) skill-mix initiatives across all cancer-related disciplines
20. Specific consideration should be give to:
a) identifying funding required to increase the number of medical physicists in training for four to six per year for therapy physics.
b) providing pump-priming funding for advanced practitioners and/or consultant therapy radiographers in at least the larger centres to enhance recruitment and retention.
21. A Radiotherapy Advisory Group, reporting to the Scottish Cancer Group is being established to:
a) monitor clinical practice, impact of extended hours and capacity constraints
b) coordinate developments such as IMRT (intensity modulated radiotherapy) and IGRT (image guided radiotherapy) to ensure equitable access across Scotland
c) coordinate efforts to ensure that all linear accelerators have an approximately equal workload
d) repeat the current review of capacity and demand in 3-4 years time to ensure adequate lead time if additional capacity is found to be required.