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DISCUSSION DOCUMENT
STRATEGIC FRAMEWORK FOR THE MODERNISATION OF TERTIARY HOSPITAL SERVICES
Modernisation of Tertiary Services Project Team National Department of Health May 2003
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CONTENTS
Page
Introduction 3
Objectives of the Strategic Framework Document 4
Future Trends and Likely Developments 4
An Enabling Framework for the Modernisation of Tertiary Services
- Human Resources – Recruitment & Retention
- Human Resources – Training & Skills
- Equipment and Infrastructure
- Rationing Services and Technologies
- Management and Organisation
- Transport and Communication
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8
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14
Categorising Specialties – A Planning Approach 14
Organisational Models – General Discussion 22
Strategic Planning Framework – Scenarios and Options
- Model A
- Model B
- Model C
- Model D
- Overview of Models
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38
42
Next Steps 43
MTS Project Team Contact Details 44
Appendix 1: Specialty Focus Groups Held and Reports Received 45
Appendix 2: Organisational Models – Ideal Scenario 46
Appendix 3: Organisational Models – Pessimistic Scenario 62
Appendix 4: Minimum Staffing Requirements for an Ideal Unit 78
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Introduction
The Modernisation of Tertiary Services (MTS) Process seeks to develop a consensus on the
appropriate future direction of tertiary and highly specialised care in the South African public health
system. Its aim is to ensure that Government can plan for and provide affordable and efficient
tertiary health care of the highest quality, which can be accessed by all South Africans, wherever
they may live in our country and whoever they may be. By working with specialists across all
disciplines, with health sciences faculties, other Government departments and many other
stakeholders, the Department of Health aims to identify how best to modernise and upgrade our
tertiary services, while taking into account the economic, social and epidemiological realities which
face South Africa today and in the years to come. Through this work, we wish to develop a common
vision for tertiary care, which can be shared within the health community and with the wider public to
ensure their support in preparing our major hospitals to face the future.
Between August and October 2002, the Modernisation of Tertiary Services team of the National
Department of Health convened a series of workshops, which brought together public sector clinical
experts from fifty specialties and sub-specialties from across the country. The purpose of the first
round of workshops was to brief participants on the MTS process as a whole, and to provide each
specialty and sub-specialty group with an opportunity to debate in detail the current status and likely
future of their field. Groups were asked to provide a detailed written report on the outcomes of their
discussions, using a structured reporting format. Fifty separate reports were completed and
submitted to the MTS Project Team (a full list is provided at Appendix 1).
All the reports received have been the subject of detailed analysis by the MTS Project Team. They
contained a wealth of detail, insight and innovative and exciting proposals to stabilise and
strengthen the public hospital sector. Throughout all the reports, and underlying all the technical
and clinical minutiae they necessarily contained, the profound commitment of the participants in this
process to strengthening the accessibility and the quality of specialised health services for ordinary
South Africans shone through clearly. The MTS Project Team used these specialty reports as the
basis for a first draft of this document – the Draft Strategic Framework. The Draft Strategic
Framework was disseminated to all specialty group members, and a second round of workshops
was held during February and March 2003. The second round workshops aimed to provide
specialty groups with an opportunity to provide feedback on the Draft Strategic Framework itself,
and to revise and improve their earlier reports in the light of the contents of the DSF. The second
round also afforded the opportunity to involve a larger number of participants, as a number of
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specialists had not been able to attend the first round of workshops. Groups were set a deadline of
the end of March to submit their comments on the DSF, and to provide revised versions of their
earlier reports. By the end of April, all groups had succeeded in providing these inputs, allowing the
MTS Project Team to finalise the Strategic Framework, which is presented here.
Objectives of the Strategic Framework Document
This document, the “Strategic Framework”, is the product of our analysis of the written outputs of the
specialty workshops. Its purpose is to extract the critical messages and information from each of
the report, and to synthesise them into a set of specific options and scenarios, and thus to generate
a small number of alternative visions of the development of the public tertiary hospital system over
the next decade. Considerable further quantitative modelling will be performed on these basic
scenarios (especially with regard to their investment requirements and cost implications); from that
basis, it will then be possible to conduct a detailed option appraisal, and to allow an informed public
and political debate, with the ultimate aim of agreeing a long-term national plan for this sector. The
Strategic Framework does not itself constitute either a “plan” or a policy in its own right. Rather, it is
a distillation of the key challenges and choices, which a plan for the development of the public
hospital system will have to face, and resolve, and is an intermediate step towards developing such
a plan. Having been subjected to detailed discussion and revision during the second round
specialty workshops, and by a parallel workshop of hospital managers and planners, it is now
appropriate that the Strategic Framework receive broader discussion by a wider set of stakeholders
and service users.
Future Trends and Likely Developments
Specialty groups each spent some time considering the key trends and developments they felt
would be likely to influence their discipline over the next decade. At the level of specific diseases
and technologies, their reports are obviously detailed and specific to their own discipline. However,
it is useful to attempt to extract the more important generic themes which emerged from the “futures
scanning” exercise; indeed, it is striking that a few very clear common themes run across almost all
specialties.
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Demand Factors
Specialties examined the likely future need and demand for their services, with many providing
supporting documents to illustrate and expand the summary presented in their reports. It is hard to
do justice to the wealth of information presented in the individual reports, but at the grossest level a
few crucial themes emerge. Most importantly, at the epidemiological level, the reports together
present a clear picture of a society facing a triple epidemiological burden:
• Communicable diseases and diseases of poverty are still a major burden in South Africa,
most crucially the HIV/AIDS and TB epidemics (although these are by no means the only
culprits); these diseases have a significant impact on tertiary services, despite efforts to
manage them at primary and secondary level.
• Non-communicable diseases reflecting the demographic and epidemiological transition
(sometimes referred to as “diseases of affluence”, in reality a strikingly inappropriate
misnomer) are predictably increasing as the population grows older and more urbanised; key
diseases in this category include coronary heart disease, stroke, diabetes, lung cancer, breast
cancer, and rheumatoid arthritis (to name but a few of the more prominent examples). The
very fact of an ageing population itself requires the availability of geriatric services properly
aligned with the needs of older people.
• South Africa also suffers especially severely from a third source of disease burden which is
directly linked to the process of social, political and economic transition itself – in the broadest
sense, the epidemic of trauma and injury which has accompanied rapid social change.
Clearly, the key drivers of this epidemic are injuries from road traffic accidents and injuries
from intentional violence (domestic and sexual violence, alcohol-related violence, and other
forms of violent crime); smaller in scale, but of great significance to specialised hospital
services is the epidemic of serious burns, driven primarily by the continued use of dangerous
fuels for cooking and lighting in crowded informal settlements. The secondary impacts of this
epidemic on mental health are only dimly understood, but are felt by many to be of grave
significance. The trauma epidemic can reasonably be expected to decline in future as specific
preventative measures (e.g. road safety, crime prevention, electrification) and the benefits of
general economic growth (e.g. better housing, declining crime rates) have an increasing
impact. However, there are strong grounds to believe that the final peak of the injury epidemic
may lie as far as ten or fifteen years in the future – and that the situation will therefore get
worse before it gets better.
These three parallel groups of diseases and ill-health combine to suggest that objective measures
of “need” for health services in the South African population will continue to rise for several years.
Communicable diseases and the epidemic of injury can be mitigated and controlled by robust
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preventative interventions (as, indeed, can many non-communicable diseases), but even under the
very best scenarios of commitment to controlling these problems, it would be some years before a
definitive turning point can be reached. Even then, reductions in expenditure and health care
infrastructure would only conceivably become possible some years after a downward trend in either
group of epidemics had been clearly established – and would most likely be offset by the growing
pressures of ageing and non-communicable diseases.
In common with developed country health systems, many specialties note that patients are
becoming more assertive in demanding health care. In the case of South Africa, this represents a
highly desirable break with the past, and reflects an improved understanding by the majority of the
population of their rights and entitlements. However, such “consumerism” does place an additional
workload on the public health system; raised expectations of service require both improved
practices and improved resources if they are to be achievable or sustainable.
A final demand factor, which may be important in years to come, is the continuing evolution of the
medical schemes and private health care industry. Deliberate attempts to encourage utilisation of
public hospitals by medical scheme members are beginning to bear fruit; while this initiative
obviously provides revenue to cover the costs of such care, it will also increase the workload of
public hospitals (especially in the tertiary centres, which are most acceptable to private patients).
Less predictably, it is conceivable that medical scheme cover will start to become too expensive for
many current members, leading them to drop out of private cover and into the state system.
Alternatively, moves towards social health insurance or national health insurance might expand
medical scheme cover, or radically change the basis of health funding nationally.
Supply Factors
The futures scanning exercise looked in detail at the likely technological developments to be
expected in each specialty over the next decade. This clearly generated a mass of detail, which
cannot easily be presented in summary form, although key factors will be incorporated into the
scenarios for each individual specialty. In brief, the most important likely developments reported
were as follows:
• Improved capabilities in diagnostic imaging were regarded as being of great importance
by a majority of specialties. They referred mainly to technologies which are already available
internationally, but which are either limited in their deployment or not yet available in South
Africa, especially multi-slice CT scan, MRI scan and PET scan.
• New drugs predictably attracted attention from certain specialties – although it is striking that
attention focused overwhelmingly on introducing or expanding access to drugs that are
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already in widespread use overseas (e.g. statins, ACE inhibitors, antiretrovirals etc.), but
which have to date been regarded as beyond the means of the South African public health
system; there was apparently little expectation that truly new drugs would make much of an
impact in the next decade. A number of specialties also sounded a cautionary note on the
worldwide trend of increasing antibiotic resistance among both community-acquired and
nosocomial infections; the magnitude of this problem appears set to continue to grow, with
little prospect of a breakthrough in new anti-microbials.
• Several specialties regarded improvements in our understanding of the genetic basis of disease as likely to be important in the coming decade – although all agreed that this field is
rather unpredictable. It seems clear that screening technology will advance rapidly, but
opinions differ as to the likely utility of much genetic screening for disease susceptibility; and
many feel that the use of genetics for therapeutic purposes remains some way off, while
others contend that important breakthroughs are imminent.
• Increased use of minimally invasive procedures seems to be a safe bet in many surgical
disciplines; similarly, new imaging technologies offer the prospect of reducing invasive
diagnostic procedures (such as angiography) in certain disciplines.
• Developments in information technology and telecommunications were generally seen as
likely to be an important force in the coming decade. Likely developments range from the
transition to digital (film-free) imaging and data transmission, through electronic patient
records, to wide-scale use of telemedicine, remote consultation, and even robotics in some
areas of surgery. Indeed, other than developments in diagnostic imaging technologies, most
specialties’ discussion of likely developments in clinical equipment seem to be dominated by
IT and computerisation of existing functions, rather than the introduction of wholly new
processes.
An Enabling Framework for the Modernisation of Tertiary Services
In order to improve the quality and sustainability of tertiary hospital services, different specialties
and disciplines will clearly require different emphases and tailored planning solutions. Nonetheless,
a number of very important common themes are clearly visible in the specialty reports, and these
themes will require common solutions. These broad themes are:
• Human resources
• Equipment and infrastructure
• Management and organisation
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• Transport and communications
This section identifies the most frequent and/or important improvements proposed by specialty
groups to some of the problems that currently inhibit the revitalisation of tertiary services; it also
identifies a few issues on which the views of specialty groups were contradictory or ambiguous.
Perhaps two messages stand out most clearly from the reports submitted. The first can be
paraphrased as “humans before hardware” – namely, while important problems exist in relation to
equipment and infrastructure, their solution would achieve little or nothing if the crucial human
resources questions cannot be answered successfully. The second is that the functionality and
future development of both regional hospital and tertiary level services are inextricably
interdependent. Failure in one level will compromise the other, and therefore development plans
must proceed in tandem for both regional and tertiary hospital services. It is clearly essential that
the development and planning process take both these messages to heart.
Human Resources – Recruitment & Retention
The grave problems in retaining skilled professionals within the public service were perhaps the
problem most frequently cited by groups, followed by the related problem of recruiting appropriately
skilled staff to serve in regional hospitals and non-metropolitan areas. Complementary proposals to
alleviate these problems included the following:
• General upgrading of salaries of skilled health professionals (not only medical), at all levels of
the health service, making these professions more attractive to enter and to stick with
• Reinstatement of small benefits which make the working environment more pleasant and
which improve motivation (e.g. tea and sandwiches for staff in theatre, funding to attend
conferences etc.)
• Targeted incentives to attract candidates to under-staffed areas – e.g. rural allowances /
“scarce skills” allowances / “hard to fill” post allowances; and that such incentives need to
combine both salary and other benefits (e.g. housing subsidies, bursaries for children’s
education etc)
• Significant upgrading of the status of general specialists in regional hospitals and the creation
of generalists posts in the tertiary level who will take responsibility for the whole patient rather
than an organ system, including career pathing, increased opportunities for university joint
appointments at regional hospital level, accelerated promotion etc.
• Creation of new posts where there are currently shortages in key departments, especially in
regional hospitals
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• Creation of mid-career posts for doctors and improved career pathways for newly qualified
specialists
• Compulsory community service for newly qualified specialists (a highly contentious proposal –
attractive to some groups, vigorously opposed by others)
• Continuous review of RWOPS policy to ensure that it can be used as an incentive to retain
talent in the public sector without undermining public services
• A significant change in attitude by the HPCSA and member bodies to make it far easier for
well-qualified foreign health professionals to work in South Africa (including proposals to limit
registration to allow practice in the public service only)
• Active advertisement of SA posts in key “brain drain” destination countries (e.g. UK, Australia,
New Zealand, Canada, USA), perhaps with assistance / funding from these governments, to i)
recruit back SA staff and ii) attract well-trained foreign professionals. Offering incentives or
assistance with relocation costs for returning SA staff could further strengthen this.
Readers should note that concrete action is already being taken on a number of these proposals
(e.g. rural allowances, foreign health professionals), but the need for a multi-level response is
clearly accepted.
Human Resources – Training & Skills
Clearly, training and skills development go hand in hand with recruitment and retention strategies.
A number of significant improvements to training were regarded by many groups as being important
foundations for the future improvement of both regional and tertiary services. Nowhere does this
appear to be more urgent than in the area of improving the availability of nurses with post-basic
specialised training. The shortage of nurses with specialised training appears to be a problem in
virtually every specialised discipline; in some specialties this shortage is extreme (e.g. adult ICU); in
others it verges on the absurd (e.g. the Paediatric ICU group reported that there are only two
registered paediatric ICU nurses currently working in South Africa). Proposals to strengthen the
availability of specialised nursing expertise include:
• The urgent need to expand the availability of and funding for specialised nursing training (both
locally, via distance learning, and through bursaries and arrangements for overseas training)
• Incentivising the acquisition and updating of skills, by offering better career pathways and
remuneration for nurses who acquire specialised qualifications and who continue to practice in
their specialised field
• End immediately the obsolete practice of regularly rotating nurses through different wards and
departments; this practice (still disturbingly widespread) is seen as a near-guaranteed method
of destroying team-working and preventing the acquisition of specialised expertise
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In the area of training medical specialists, some practical improvements to the current system were
proposed:
• Develop a mechanism by which to link training (registrar) posts to permanent posts after
qualification
• Similarly, to ensure that the number of training posts offered in each discipline should be
organically linked to long-term service plans for these specialties
• Develop mechanisms for the sharing of a single highly specialised service unit by two or more
medical schools (i.e. where it is not cost-effective for each medical school to have its “own”
unit)
• To train larger numbers of “general specialists” (general medicine, general surgery, obstetrics
and gynaecology, paediatrics, radiology, anaesthetics), and to make these disciplines more
attractive to junior doctors choosing their direction for advanced training
• To establish training posts in regional hospitals, whose holders could spend some of their time
under supervision in the nearest tertiary centre
• Make available “quasi-specialist” training and diplomas for general specialists working in
regional hospitals (e.g. cardiology or oncology diplomas for general physicians)
Finally, there is a clear need to continue to improve the availability of well-trained managers and
administrative personnel, especially to improve their practical training and skills.
Equipment & Infrastructure
Specific proposals on particular equipment requirements were made by most specialties, and will be
dealt with in the presentation of organisational models below. However, several generic issues will
need to be dealt with in any overall framework:
• There is an urgent need for a large-scale replacement of clinical equipment in most
specialties, as one of the first steps in the modernisation process – under-investment in
equipment replacement has resulted in an ageing, obsolescent equipment stock, a large
proportion of which is not functional at any given moment
• Such an equipment replacement programme must then be sustained on a rolling basis, to
ensure that this backlog does not build up again in future – and must encompass both
regional hospitals and tertiary hospitals
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• All equipment must be properly maintained, and maintenance must be adequately funded;
several specialties regarded annual maintenance costs in the region of 20% of original
purchase price as an appropriate rule of thumb
• Innovative approaches to equipment management (e.g. leasing, contracts for re-usables etc.)
should be adopted, to reduce the risk of future under-funding of maintenance and replacement
• Equipment utilisation rates can be greatly improved, through a combination of appropriate
staffing, extended hours of operation, intelligent scheduling of patients over extended hours,
and adequate funding of consumables and materials
• Finally, while relating primarily to a single specialty (radiology), it is important to note that over
half of all specialty reports explicitly argued for improved investment in and availability of
various diagnostic imaging technologies (primarily CT Scan and MRI); this level of demand for
improved imaging can legitimately be described as a generic issue
Rationing Services and Technologies
Many specialty reports dealt with the problem of “under-servicing” of the SA population relative to
likely needs. Prevalence rates and/or international intervention rates were frequently cited, often
indicating that the public sector may currently meet only a fraction of the likely burden of disease in
various specialties. Concerns about lack of explicit guidance on difficult clinical rationing decisions
were also raised in several reports. While the MTS process itself is unlikely to resolve these
underlying problems (especially in the short term), it seems likely that a policy mechanism by which
to address rationing dilemmas will need to be established as an adjunct to the planning and
implementation process. This mechanism would need to address three recurrent themes:
• Even with significant investment and expansion of services, it is highly unlikely that all “need”
in all specialties will be met any time soon; therefore, the generic question of prioritising
access to treatment (both at the individual and the population level) will remain highly
pertinent
• Certain manifestations and complications of HIV/AIDS ideally require treatment from tertiary
services (e.g. Kaposi’s Sarcoma, lymphomas etc), which are well beyond the routine
treatment of opportunistic infections or even antiretroviral therapy in terms of cost or
complexity; specialties reporting significant direct increases in complex HIV-related workload
included oncology, haematology, dermatology, neurology, paediatric gastroenterology and
ophthalmology. The growing HIV load raises questions about the relative priority to be
accorded to these cases versus HIV negative patients of these specialties; more widely, the
HIV epidemic raises difficult questions about the extent to which – when resources are limited
– HIV negative patients should or should not receive precedence over HIV positive patients for
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expensive interventions for other conditions. There also appears to be an assumption that
any future introduction of antiretroviral therapy might further change these equations (in
different directions for different conditions).
• Finally, several specialties noted the de facto restriction of access to expensive services for
persons with congenital disorders and/or learning disabilities; the handling of this issue clearly
also requires attention at a wider level.
The futures scanning exercise undertaken by the specialties gives a very clear foretaste of some of
the policy decisions, which will soon be required on many different technological developments.
Just some of the more expensive and imminent pressures include whether or not to expand access
to statins and ACE inhibitors in adult cardiac patients; closure devices for paediatric cardiac
patients; Xigris for ICU patients; and PET scanner technology. Most of these issues are well
beyond the scope of the Essential Drugs List mechanisms at present. There is therefore a need to
further develop the national health technology assessment capability to provide an institutional
process for evaluating and developing guidelines on the introduction (or non-introduction) of
expensive new technologies in the tertiary sector, in a way that is proactive and legitimate in the
eyes of stakeholders. The Gastroenterology group made detailed proposals for a specialty-level
committee to advise on technology uptake, but such an approach would obviously need to be
system-wide.
Management and Organisation
A number of generic organisational themes also stand out from the specialty reports. These can be
summarised as follows:
• The need to create stronger linkages between each tertiary hospital (and individual service)
and its linked network of regional hospitals, especially in the area of follow-up management
and effective mechanisms to supply and fund repeat prescriptions of “tertiary” drugs at local
level
• The need to define these regional-tertiary networks in terms of “natural” regions based on
patient flows and transport links, and not on arbitrary provincial borders
• Repeated calls for funding and planning of tertiary services to be separated from provincial
control and to be managed as a national function. This proposal is motivated partly by a
desire to avoid arbitrary restrictions upon treating patients due to provincial boundaries (see
previous point), but also due to a sense that national funding and management would be more
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effective than that of provincial health departments. It should be noted that, while elements of
this argument have very strong grounds to commend them, groups often gave a sense that
they believed that national funding would somehow remove tertiary services from any form of
cost control or management influence – which is clearly an unrealistic expectation!
• A strong consensus that appropriate forms of outreach from tertiary to regional levels should
be seen as a “normal” element of service, and not as a “special” activity
• The need to end verticalised, “silo” management of medical, nursing, paramedical and
administrative functions, and to move towards integrated departments or clinical directorates
• The need to improve flexibility and decentralisation of decision-making on key areas which
currently cause much frustration e.g. filling of posts, cost-centre management, working hours
etc.
• Expanding this theme, specific requests from many groups to have fully-fledged cost-centre
budgeting by department / specialty, with heads of units having significant control over the
management of these budgets (i.e. to allow them to prioritise within budgets, rather than
having arbitrary cost control measures imposed on them externally)
• Different groups appeared to have conflicting attitudes to management questions. Some wish
to reduce the administrative load on clinicians, allowing them to concentrate on patient care.
Others, by contrast, call for clinicians to be given much greater management responsibility
over all aspects of their services, from personnel and financial issues through to direct
procurement of supplies. These visions are clearly contradictory – but they do highlight a
common theme of dissatisfaction with the current reality of management and administration
systems
• Repeated calls to establish much better systems and registries for recording disease and
intervention data, to provide a basis for evaluation and planning of services in future
• Most groups raised the issue of separate children’s hospitals at supra provincial tertiary level
and the lack of adolescent care facilities at all levels of care; however there seemed to be no
consensus on how to deal with this matter. Many paediatric groups viewed separate
children’s hospitals as an ideal goal. Others pointed to important areas of overlap between
adult and paediatric services, which mean that children’s hospitals may sometimes impede
efficiency and quality. Shared equipment and administration with separate facilities and
accommodation for adults, adolescents and children on the same site were viewed as the
most sensible solution given the existing resource constraints within the health sector.
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Transport and Communication
Transport and communication systems were another universal problem area, which will clearly
require a unified approach to improve:
• Patient transfers to and from hospital are currently very poor, and a key cause of delayed
discharge and excessive length of stay
• Lack of basic subsidised transport and overnight accommodation are a key deterrent to
patients referred on an ambulatory basis; a simple, well-organised and well-scheduled system
of free or subsidised transport between different levels of hospital, combined with “patient
hotels”, could dramatically improve patient access from outlying areas to the main referral
centres
• It was noted that a functioning transport system could also overcome the long-standing
problem of drug availability at lower level facilities – a good basic transport system could also
be used to routinely deliver follow-up prescriptions from tertiary centres, for patients to collect
at their local facility
• Emergency transfers of critically ill patients need to be greatly improved and speeded up, with
appropriate use of aircraft expanded; several groups argued strongly that current transfer
times between levels of care are leading to adverse (and entirely preventable) outcomes in
many patients
• Most groups also saw telemedicine as a significant vehicle for improving communication and
patient management (but enthusiasm was not universal, with certain groups arguing that
current technologies do not yet deliver all they claim to offer); beyond telemedicine per se,
there is clearly a need to strengthen the availability of telephone, fax and email facilities for
clinical staff at lower level hospitals, and hence allow better access to advice and coordination
with tertiary centres.
Categorising Specialties – A Planning Approach
The preceding section has discussed the generic responses required to stabilise the situation of all
specialties and services, and to allow the development of a more efficient, responsive and
sustainable tertiary hospital sector. Obviously, though, beyond this broad framework different
specialties will have specific needs and priorities. It is therefore useful to attempt to develop a
system for categorising specialties and sub-specialties in very broad terms. The categorisation
developed in this section seeks to meet the needs of service and resource planning. Thus it does
not pretend to be based upon the inherent characteristics of specialties, or to reflect traditional
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methods of grouping specialties. Rather, it aims to identify the general direction of development
within specialties, likely trends in demand for services, and the extent to which current patterns of
service delivery are appropriate to meet future needs. It then develops a categorisation of
specialties based upon the planning response required for each; hence quite different and unrelated
specialties may appear in the same category, simply because they require a broadly similar
approach to planning, and not because of any inherent similarities in other respects.
A first step in developing such a categorisation involved an analysis of specialty group reports along
several dimensions – futures scanning (in terms of disease burden and technological change); an
assessment of whether current services achieve a sustainable critical mass for the future survival of
the specialty; the extent to which other specialties regarded a service as an essential prerequisite
(or a bottleneck) for their own successful operation; and groups’ own assessment of the urgency of
changing the geographical distribution of units.
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Gro
win
g H
IV/A
IDS
and
TB
Impa
ct?
Gro
win
g N
on-C
omm
unic
able
D
isea
se B
urde
n?
Gro
win
g In
jury
& V
iole
nce
Burd
en?
Maj
or N
ew D
rugs
/ In
terv
entio
ns
Avai
labl
e N
ow?
Tech
nica
l C
apab
ility
Like
ly in
Nex
t D
ecad
e?
Cur
rent
Ava
ilabi
lity
of
Spec
ialis
ts /
Trai
ning
Bo
ttlen
ecks
/ C
ritic
al
Dep
ende
ncie
s
for O
ther
Spe
cial
ties?
C
urre
nt G
eogr
aphi
cal
Dis
tribu
tion
of U
nits
In
adeq
uate
?
Anaesthetics Yes Yes Yes Yes
Burns Yes Yes Yes Yes
Cardiology Yes Yes
Cardiothoracic surgery Yes Yes
Clinical Immunology Yes Yes Yes
Clinical pharmacology Yes Yes Yes Yes
Cranio/maxillofacial Yes
Critical care / ICU Yes Yes Yes Yes Yes Yes
Dermatology Yes Yes Yes Yes Yes Yes
Diagnostic Radiology Yes Yes Yes Yes Yes Yes
Endocrinology Yes
ENT Yes
Gastroenterology & Hepatology Yes Yes
General medicine Yes Yes
General Surgery Yes Yes Yes
Geriatrics Yes Yes Yes
Haematology Yes Yes
Human Genetics Yes Yes Yes Yes Yes ?
Infectious Diseases Yes Yes
Medical & Radiation oncology Yes Yes Yes
Mental Health Services Yes Yes Yes
Neonatology Yes Yes Yes
Nephrology Yes Yes
Neurology Yes Yes Yes
Neurosurgery Yes Yes Yes Yes Yes Yes Yes
Nuclear Medicine Yes Yes Yes ?
Obstetrics and Gynaecology Yes Yes Yes Yes Yes
Opthalmology Yes Yes Yes Yes Yes Yes
Orthopaedics Yes Yes
DISCUSSION DOCUMENT MAY 2003
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17
Gro
win
g H
IV/A
IDS
and
TB Im
pact
?
Gro
win
g N
on-C
omm
unic
able
D
isea
se B
urde
n?
Gro
win
g In
jury
& V
iole
nce
Burd
en?
Maj
or N
ew D
rugs
/ In
terv
entio
ns
Avai
labl
e N
ow?
Maj
or D
evel
opm
ents
in T
echn
ical
C
apab
ility
Like
ly in
Nex
t Dec
ade?
C
urre
nt A
vaila
bilit
y of
Spe
cial
ists
/ Tr
aini
ng C
apac
ity fa
ils to
reac
h C
ritic
al
Bottl
enec
ks /
Crit
ical
Dep
ende
ncie
s
for O
ther
Spe
cial
ties?
Cur
rent
Geo
grap
hica
l D
istri
butio
n of
Uni
ts In
adeq
uate
?
Other Rehab Specialists Yes Yes Yes Yes Yes
Paediatric Medicine Yes Yes Yes
Paediatric Cardiology Yes Yes Yes
Paediatric Child Development Yes Yes Yes Yes Yes Yes Yes Yes
Paediatric Critical care (ICU) Yes Yes Yes Yes Yes
Paediatric Endocrinology/Diabetes Yes
Paediatric Gastroenterology Yes Yes Yes Yes Yes Yes Yes
Paediatric Haematology/ oncology Yes
Paediatric Infectious diseases Yes Yes
Paediatric Neph. and Transplant Yes
Paediatric Neurology Yes Yes
Paediatric Allergology Yes Yes Yes Yes
Paediatric Respiratory Medicine Yes Yes
Paediatric Rheumatology Yes Yes
Paediatric Surgery (all subspecialties) Yes Yes Yes Yes Yes Yes Yes Yes
Plastic & Reconstructive Yes
Renal / Liver transplantation Yes
Respiratory Medicine Yes Yes
Rheumatology Yes
Spinal Injury Rehab & Mgt Yes Yes Yes
Trauma Yes Yes Yes
Urology Yes Yes
Vascular surgery Yes Yes Yes Yes Yes Yes
DISCUSSION DOCUMENT MAY 2003
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18
This assessment, combined with the general description of priorities for development and service
strengthening contained in each report, allows a tentative grouping of specialties according to the
degree and nature of investment likely to be required. These groups can be described as follows:
A. “Basic Strengthening” – Those specialties which are well established, with a strong skills
base, and with a reasonably appropriate geographical distribution. The main effort in
planning the future provision of these services will be in applying the basic package of
improvements (i.e. improved recruitment, retention and training of specialised personnel,
adequate funding of drugs and consumables, replacement and maintenance of equipment,
improved efficiency of organisation and operation, improved IT, communications, transport
and outreach). Under more pessimistic resource scenarios, a limited degree of
consolidation of sites may be required; but even under more optimistic scenarios these
specialties would probably not be leading candidates for an expansion in the number of
sites. Most will require quite significant additional investment over time, but they do not
appear to require a fundamental overhaul of current patterns of provision
B. “Significant Deepening” – These are specialties which probably require very significant
upgrading of their current capabilities in situ, but which do not necessarily require expansion
in the number of locations at which they are offered. These are primarily “bottleneck”
specialties upon which other services are heavily dependent (including some of the critical
general specialties at both tertiary and regional level), and/or heavily capital-intensive
specialties requiring significant re-equipping and ongoing maintenance expenditures. These
specialties require a level of investment in additional personnel and/or equipment which is
above and beyond that envisaged in the “basic strengthening” package.
C. “Expansion of Sites” – Those specialties which are a) heavily affected by the transition
epidemics (e.g. HIV/AIDS, TB, violence and injury) and b) which require better coverage of
the population in geographical terms. These services would require the “basic
strengthening” package and an investment in specialised personnel to allow them to be
provided at progressively more locations (primarily in the currently under-served provinces).
As noted earlier, certain of these services may well offer opportunities for partial downscaling
in the very long term (i.e. 15-20 years plus) as the transition epidemics are brought under
control, but that must not obscure the need for expansion in the medium to long term.
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D. “Achieving Critical Mass” – A small number of specialties or sub-specialties that are
presently very small and lack the critical mass for sustainability, but that are likely to become
much more important in future. They therefore need directed investment and promotion now
to ensure that adequate capacity exists in the future to meet changing needs.
A first attempt to group specialties in terms of these categories is presented below. Proposed Categorisation of Planning Response Required by Specialty A: Basic Strengthening Cardiology Cardiothoracic Surgery Clinical Immunology Craniofacial Surgery Dermatology ENT Surgery Gastroenterology & Hepatology Neurosurgery Neurology Ophthalmology
Paediatric Endocrinology Paediatric Haematology Paediatric Nephrology Paediatric Neurology Plastic & Reconstructive Surgery Renal & Liver Transplant Surgery Rheumatology Urology Vascular Surgery
B: Significant Deepening Anaesthetics Clinical Pharmacology Critical & Intensive Care Diagnostic Radiology General Medicine General Surgery Oncology (Medical, Radiation & Surgical) Nuclear Medicine
Obstetrics & Gynaecology Orthopaedic Surgery Other Rehabilitation Paediatric Surgery Paediatric Medicine Paediatric Cardiology & Cardiothoracic Mental Health Services Endocrinology (overlap with A)
C: Expansion of Sites Burns Critical & Intensive Care (overlap with B) Haematology Haematology Infectious Diseases Nephrology / Dialysis (Adult Only)
Neonatology (overlap with B) Oral and Maxillofacial facial Paediatric Infectious Diseases Paediatric Critical Care & ICU (overlap with B) Respiratory Medicine Spinal Injury Rehabilitation Trauma
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D: Achieve Critical Mass Geriatric Medicine Human Genetics
Paediatric Gastroenterology Paediatric Rheumatology
Paediatric Respiratory Medicine Paediatric Child Development
Paediatric Allergology
Discussion of Proposed Categorisation It is obviously anticipated that this categorisation will provoke considerable discussion, and as such
it is only a proposal. It is important to make a few comments to inform discussions by individual
specialty groups.
First, it is important to appreciate that category A (“Basic Strengthening”) does not represent a “do
nothing” category – the basic package of service strengthening interventions would, in fact,
represent a very significant improvement and level of investment for these services.
Critical Care & ICU overlaps categories B and C in that ICU clearly requires both significant efforts
to strengthen it where services currently exist and to support any geographical expansion of
specialised tertiary trauma services.
It is important to note that the actions required in category D (“Achieve Critical Mass”) may be very
different for each specialty. For example, a large programme of training to increase the number of
specialists in geriatric medicine, itself allowing a significant expansion in the number of specialised
geriatric units may be required, which would themselves become training centres in due course. By
contrast, paediatric rheumatology might require a more modest action plan, whereby the sub-
specialty becomes registered for training, and (for example) a single national training centre
produces a small number of qualified sub-specialists. The common theme in this category is the
need to reconstitute or expand specialist capacity. Other paediatric sub-specialties may be in a
similar position to paediatric rheumatology (i.e. not formally recognised or no formal training
currently available in SA).
Finally, it is important to note that a number of specialty groups e.g. Obstetrics and Gynaecology
were concerned about the increasing number of subspecialties (especially in the area of
Paediatrics). It was thought that such proliferation of subspecialties undermined holistic care, led to
the duplication of services and was also not cost-effective. These concerns are significant,
DISCUSSION DOCUMENT MAY 2003
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21
although it is also important to acknowledge the de facto reality of increasing sub-specialisation. A
reasonable compromise would appear to be to accept that sub-specialisation is not in itself a bad
thing, as long as it is controlled and directed at a limited number of centres, and forms part of a
comprehensive package of services and care. Uncontrolled sub-specialisation outside these few
designated centres should clearly not be permitted.
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22
Organisational Models – General Discussion
A key objective of the specialty discussion groups was to ensure that each specialty considered in
detail appropriate organisational models for its services, in particular to consider the organisation of
services across the care continuum from regional hospitals to tertiary and quaternary services. All
groups gave this question considerable attention, with many providing substantial detail in their
reports. Appendix 2 summarises in a standardised format the output of each group regarding its
proposed “ideal” organisational model under the “optimistic” resource scenario. Appendix 3 does
the same for the “pessimistic” resource scenario. Appendix 3 necessarily contains rather more
interpretation by the MTS team, as a number of groups did not provide details of how they would
propose to organise services under the pessimistic scenario. Appendix 4 attempts to extract details
on precise staffing requirements for an “ideal” unit wherever groups have provided such information.
Tabulation of the standardised details in Appendices 2 and 3 proves to be a useful exercise, as it
brings out quite clearly a number of important structural issues, which seem likely to be very
important for future planning.
Clearly, there is a group of basic specialties (General Medicine, General Surgery, Paediatrics, Obs
& Gynae, Psychiatry, Orthopaedic Surgery) which form the backbone of regional hospital services,
and which feed referrals logically up to sub-specialist services at higher level. However, a number
of specialties (Clinical Pharmacology, Dermatology, ENT Surgery, Ophthalmology, Plastic &
Reconstructive Surgery, Urology, Vascular Surgery) envisage in their “ideal” model a specialist
service at regional level (i.e. the permanent or substantive presence of a full Specialist-led service at
each regional hospital). While not denying the benefits to patients of such an arrangement, this
model would require very dramatic increases in specialist human resources (alongside
strengthening of tertiary units, in most cases) relative to current availability – to such an extent that it
seems reasonable to ask whether this is actually an attainable goal in the next ten years.
Analysis of the reports indicates that there is also considerable variety in groups’ interpretations of
the general concept of “tertiary” services. This relates critically to such questions as the degree of
sub-specialisation required, dependencies upon other sub-specialty services, and the degree to
which a service needs to be population-based rather than referral-based. For example,
Neurosurgery proposes that its services are, in effect, “national tertiary” centres (of which there
would, however, be several); ENT sees a clear continuum from regional services to tertiary to one or
two national super-specialist centres; while Burns and Trauma, for example, see themselves as
requiring population-based tertiary centres, but with no higher national referral level. Most of the
paediatric sub-specialties also present some complexity; a comprehensive range of paediatric sub-
DISCUSSION DOCUMENT MAY 2003
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23
specialty services can only be offered at a fairly small number of centres – but they are nonetheless
something rather less than “unique” services requiring a single national centre. This suggests that
there are a number of possible ways of thinking about tertiary services. Some tertiary services are
supra regional in character, sitting above regional hospital level (although possibly covering a
natural group of regions that cross provincial borders). Another group is clearly supra provincial,
requiring a limited number of “dense” hospitals offering many sub-specialty services. Another
involves the concept of unique services, where a service can only be justified at one (or maybe two,
in certain cases) site nationally.
From the preceding discussion, it is clear that a number of possible permutations could easily be
developed to cluster different services at different levels. A limited number of these will therefore be
addressed in the Strategic Planning Framework below, to form the basis for future modelling and to
gain a clearer understanding of what the implications of different combinations of services might be.
Finally, Appendices 2 and 3 show very clearly the importance attached by almost every specialty to
strengthening services at regional hospital level. Almost every group has drawn clear linkages to
general specialist services at this level, frequently with proposals for strengthening skills and/or
equipment. Planning must incorporate these measures to strengthen the regional level if the overall
process is to be successful, and the reports make these prerequisites clear. They do also reveal
one danger, however – namely, that the expectations placed by tertiary-level specialists on their
regional counterparts may be rather too ambitious and exacting. For example, nine individual
tertiary specialties propose that regional General Physicians should have diplomas or specific
training in their areas. Clearly, not every General Physician would need to have all nine
qualifications – but there are equally not usually too many Physicians in any one regional hospital,
raising the question of how achievable such otherwise laudable intentions might be in practice.
Further thought will need to be given to this question, both by planners and by the specialties
concerned.
Strategic Planning Framework – Scenarios and Options
The following section attempts to sketch out a few possible organisational models at system level, in
terms of the configuration of specialties and sub-specialties at different levels, the proposed
categorisation for future development of specialties, and different resource availability scenarios.
The purpose of these options is to form the basis for quantitative and cost modelling, in order to
elaborate their costs, benefits and implications. None of the options represents the policy of the
DISCUSSION DOCUMENT MAY 2003
STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES
24
Department of Health, or even the desired direction of the Department – they are purely the starting
point for analysis and development.
Four alternative models have been developed, using the outputs of the specialty reports and the
summary descriptions of services by level of care presented in Appendices 2 and 3. They have
been adjusted and revised where groups disagreed with our initial formulations.
Each model is presented in detail over the following pages. While quite lengthy, this is viewed as
essential to allow group members to visualise what each model would mean for their own discipline.
Each model is presented in a common format, using four levels:
• Regional Hospital Services – services to be provided at every regional hospital
• Tertiary Hospital Services – services to be provided at a referral hospital serving several
regional hospitals, i.e. supra-regional services
• National Referral Hospital Services – a set of very specialised services which would be
provided at a small number of hospitals nationwide (where they would be “added on top” of
tertiary hospital services), i.e. supra-provincial services
• Central Referral Units – very highly specialised services to be provided at one (or maximum
two) tertiary hospitals nationwide, i.e. “unique” services. Within this category, services that
would need to be co-located are indicated as being linked.
To assist readers to understand the proposed relationships and interactions between the four levels
of services proposed, a simplified diagram is presented below:
DISCUSSION DOCUMENT MAY 2003
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25
Diagrammatic Representation: Relationship between levels of care and hospital referral chain
Tertiary Hospital
Tertiary Hospital
Tertiary Hospital
Tertiary Hospital
National Referral Services
Regional Hospitals Regional Hospitals
National Referral Services
Central Referral Unit
DISCUSSION DOCUMENT MAY 2003
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26
Model A:
Model A Regional Hospital Services Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Clinical Pharmacology Specialist Dermatology Specialist Service Ambulatory care & telemedicine link Diagnostic Radiology
X-Ray, CT Scan, Ultrasound, Fluoroscopy Telelinked Nuclear Medicine Radiographer, Interventional radiology (basic interventions e.g. image guided aspirations)
ENT Surgery Specialist Service General Medicine Service
Echocardiography, Stress ECG Specialist Immunology Nurse Regional ICU Service Diabetes / Endocrine clinic GIT incl. endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Regional Dialysis Service & Organ Donation Geriatric Care Genetic Nurse & Counselling Oncology palliation and basic care Neurology basic care Spirometry & oximetry Basic Rheumatology Basic infectious diseases Pathology services Infection control Proctoscopy, Sigmoidoscopy
General Surgery Service
Regional Burns Service 24 hour Level II Trauma Service, Accident & Emergency
Mental Health Services (Psychiatry & Psychology)
Acute Inpatient & Outpatient Child & Adolescent Psychiatry ECT Liaison Psychiatry Community mental Health Services
Neonatology Obstetrics & Gynaecology Service
Emergency and standard Obs & Gynae Ultrasound, prenatal diagnosis Kangaroo Care Basic urogynaecology Mid trimester abortions and adequate pain relief systems Basic oncology, menopause and screening programmes Preliminary infertility investigations
Ophthalmology Specialist Service Neonatal Low & High Care, Neonatal Intensive Care
Orthopaedic Surgery General Orthopaedic Surgery 24 hour Level II Trauma Service, Accident & Emergency
Paediatrics Service
General Paediatric Medicine Service (General Surgeon?)
Plastic & Reconstructive Surgery Specialist Service
Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry Acute Rehabilitation Team incl. Spinal beds
Urology Specialist Service Vascular Surgery Specialist Service
DISCUSSION DOCUMENT MAY 2003
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Model A Tertiary Hospital Services Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Burns Unit Specialised Burns ICU & Theatre Clinical Immunology Service Clinical Pharmacology Specialist Critical Care & ICU Full ICU Service Dermatology Specialist Service Inpatient & ambulatory Diagnostic Radiology
X-Ray, Multi-slice CT Scan, Ultrasound, Fluoroscopy, MRI, Mammography, Colour Doppler US, interventional radiology, angioplasty
ENT Surgery Specialised Service Gastroenterology Tertiary GIT Service General Medicine Service
Angiography AT Scan Coronary Care Echocardiography, Stress ECG Endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Genetic Nurse & Counselling Oncology palliation and basic care
General Surgery Service Complex & High Acuity Care - Procedure driven Geriatrics Specialised Geriatric Service Infectious Diseases Tertiary Infectious Diseases Service, Pathology services, Infection
control, Dietician, Counselling services esp. for HIV and social worker Mental Health Services (Psychiatry & Psychology)
Child and adolescent psychiatry; Old-age psychiatry; Forensic psychiatry; Substance abuse; Liaison psychiatry; Eating disorders; Inpatient psychotherapy; Social psychiatry; Acute psychotic (complicated); Acute non-psychotic (complicated)
Neonatology Neonatal Intensive Care Unit Nephrology Acute renal failure / clinical nephrological problems / dialysis complication Neurology Neurology & Stroke Unit Obstetrics & Gynaecology Service
As Regional plus: Fetal / Maternal Medicine
Ophthalmology Specialised Ophthalmology Service Orthopaedic Surgery Sub-Specialty Orthopaedics i.e. Primary Athroplasty, Spinal Surgery Paediatric Medicine Specialist General Paediatricians with special interest Paediatric Surgery Services preferably provided in an independent Children’s Hospital with
the following components: Specialist paediatric surgery Cardiothoracic surgery. General paediatric surgery Neurosurgery Opthalmology Orthopaedics Plastic and reconstructive surgery ENT Urology Paediatric anaesthesiology
Paediatric ICU Full Paediatric ICU Service Paediatrics Service
Neonatal Low & High Care General Paediatric Medicine Service General Paediatric Surgery
Plastic & Reconstructive Surgery Specialist Service Tertiary Plastic & Reconstructive Surgery Rehabilitation Centre & Spinal Injury Unit
Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry, Audiology Acute Rehabilitation Team incl. Spinal beds
Respiratory Medicine Comprehensive Pulmonology Service Rheumatology Tertiary Rheumatology Service Trauma Tertiary Major Trauma Centre
(n.b. protocol-based transfer only, no walk-in A&E service) Urology Specialist Service Tertiary Urology Service Vascular Surgery Specialist Service Tertiary Vascular Surgery Service
DISCUSSION DOCUMENT MAY 2003
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28
Model A National Referral Hospital Services
(“Adds on” to a Tertiary Hospital) Specialist Service Available On-Site Specific Components Explicitly Included: Cardiology Echocardiography, Ultrasound, Electrocardiography,
Stress Testing, ECG Holter Pacemaker follow-up, Cath Lab, Electrophysiology Ablation
Cardiothoracic Surgery Full Cardiothoracic Service Craniofacial Surgery Critical Care & ICU Additional ICU Capacity Endocrinology Tertiary Endocrinology Service Haematology Tertiary Haematology Service Human Genetics Tertiary Genetics Service Infectious Diseases Clinical Research Capacity Medical & Radiation Oncology Tertiary Oncology Centre Neurosurgery Tertiary Specialist Neurosurgery Service, Interventional
Neuroradiology, Nuclear Medicine Tertiary Nuclear Medicine Centre Obstetrics & Gynaecology Service
Oncology Urogynaecology Reproductive Medicine
Ophthalmology Super-Specialist Ophthalmology Service Orthopaedic Surgery Orthopaedic Oncology (Revision arthroplasty and spinal
surgery, basic oncology, Paediatric Oncology Renal Transplant Renal Transplant Unit Paediatric Cardiology Paediatric ICU Additional Paediatric ICU Capacity Paediatric Endocrinology Paediatric Gastroenterology Paediatric Haematology & Oncology Paediatric Infectious Diseases Paediatric Nephrology Dialysis & Renal Transplant Paediatric Neurology Paediatric Respiratory Medicine & Allergology Paediatric Rheumatology
DISCUSSION DOCUMENT MAY 2003
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Model A Central Referral Units (“Add on” to a National Referral Hospital) Specialist Service Available On-Site Specific Components Explicitly Included:
{ Cardiology Cardioverter Defibrillator & LV Assist Devices Unit { Cardiothoracic Surgery Heart & Lung Transplant Unit { Respiratory Medicine National Pulmonology Referral Centre:
Lung volume reduction, Lung Transplant /Maxillofacial Surgery Narional Referral Centre
{ { {
Diagnostic Radiology National PET Scan Interventional Neuroradiology Cardiac Imaging
{ Nuclear Medicine PET or gamma-PET { { { { {
Medical & Radiation Oncology National Oncology Referral Centre: Bone Marrow Transplant, IMRT, Intraoperative Radiation, Stereotactic Radiation, PET Scan planning; laminar flow, cryopreservation, stem cell harvesting, T-cell depletion facilities
{ Haematology Bone Marrow Transplantation Unit
{ Hepatology Specialist Liver Unit { Liver Transplant Liver Transplant Unit { {
General Surgery National Surgical Referral Centre: Liver and major pancreatic resections, TME
{ {
Nephrology National Nephrology Centre: Pancreas-kidney / Liver-kidney Transplant
Clinical Immunology National Referral Centre Clinical Pharmacology National Policy Support Unit Dermatology National Referral Centre Endocrinology National Endocrinology Referral Centre ENT Cochlear Implant
Skull Base Surgery Human Genetics National Genetics Centre Infectious Diseases National Institute of Communicable Diseases National Paediatric Referral Centre:
{ { {
Paediatric Medicine & Surgery Organ transplantation, epilepsy surgery, craniofacial surgery; certain high-cost / complexity medical interventions. Cochlear and layngeal implants, limb salvage oncology and eye salvaging oncology.
{ Paediatric Gastroenterology Transplant Surgery, Metabolic Laboratory { Paediatric Haematology & Oncology Bone Marrow Transplant { { { {
Paediatric Neurology Complex epileptic surgery, complex neuromuscular patients, neurodegenerative and metabolic patients, Video telemetry, intracranial mapping, neuro-metabolic lab.
{ {
Paediatric Rheumatology Bone Marrow Transplant, DEXA scans, Interleukin levels, joint replacement
DISCUSSION DOCUMENT MAY 2003
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30
Model B:
Model B Regional Hospital Services Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Diagnostic Radiology
X-Ray, CT Scan, Ultrasound, Fluoroscopy Telelinked Nuclear Medicine Radiographer, Interventional radiology (basic interventions e.g. image guided aspirations)
General Medicine Service
Echocardiography, Stress ECG Specialist Immunology Nurse Regional ICU Service Diabetes / Endocrine clinic GIT incl. endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Regional Dialysis Service & Organ Donation Geriatric Care Genetic Nurse & Counselling Oncology palliation and basic care Neurology basic care Spirometry & oximetry Basic Rheumatology Basic Infectious Diseases Pathology Services Infection Control Proctoscopy, Sigmoidoscopy
General Surgery Service
Regional Burns Service 24 hour Level II Trauma Service, Accident & Emergency
Mental Health (Psychiatry & Psychology)
Acute Inpatient & Outpatient Child & Adolescent Psychiatry ECT Liaison Psychiatry Community Mental Health Services
Neonatology Neonatal Low & High Care, Neonatal Intensive care Obstetrics & Gynaecology Service
Emergency Obs & Gynae Ultrasound, prenatal diagnosis Kangaroo Care Basic urogynaecology Mid trimester abortions and adequate pain relief systems Basic oncology, menopause and screening programmes Preliminary infertility investigations
Orthopaedic Surgery General Orthopaedic Surgery 24 hour Level II Trauma Service, Accident & Emergency
Paediatrics Service
General Paediatric Medicine Service General Paediatric Surgery (General Surgeon?)
Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry Acute Rehabilitation Team incl. Spinal beds
DISCUSSION DOCUMENT MAY 2003
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Model B Tertiary Hospital Services Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Burns Unit Specialised Burns ICU & Theatre Clinical Immunology Service Clinical Pharmacology Specialist Critical Care & ICU Full ICU Service Dermatology Specialist Service Inpatient & ambulatory Diagnostic Radiology
X-Ray, Multi-slice CT Scan, Ultrasound, Fluoroscopy, MRI, Mammography, Colour Doppler US, Interventional Radiology, Angiography
ENT Surgery Specialised Service Gastroenterology Tertiary GIT Service General Medicine Service
Angiography AT Scan Coronary Care Echocardiography, Stress ECG Endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg), Genetic Nurse & Counselling, Oncology palliation and basic care
General Surgery Service Complex & High Acuity Care Geriatrics Specialised Geriatric Service Infectious Diseases Tertiary Infectious Diseases Service, Pathology Services,
Infection Control, Dietician, Counselling Services, Social Worker
Mental Health Services (Psychiatry & Psychology)
Child and adolescent psychiatry; Old-age psychiatry; Forensic psychiatry; Substance abuse; Liaison psychiatry; Eating disorders; Inpatient psychotherapy; Social psychiatry; Acute psychotic (complicated); Acute non-psychotic (complicated)
Neonatology Neonatal Intensive Care Unit Nephrology Acute renal failure / clinical nephrological problems /
dialysis complication Obstetrics & Gynaecology Service
As Regional plus: Fetal / Maternal Medicine
Ophthalmology Specialised Ophthalmology Service Orthopaedic Surgery Sub-Specialty Orthopaedics Paediatric Medicine Specialist General Paediatricians with special interest Paediatric Surgery Specialist Paediatric Surgery Service Paediatric ICU Full Paediatric ICU Service Paediatrics Service
Neonatal Low & High Care General Paediatric Medicine Service General Paediatric Surgery
Plastic & Reconstructive Surgery Specialist Service Tertiary Plastic & Reconstructive Surgery Rehabilitation Centre
Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry, Audiology Acute Rehabilitation Team incl. Spinal beds ,Stroke Unit
Respiratory Medicine Comprehensive Pulmonology Service Trauma Tertiary Major Trauma Centre
(n.b. protocol-based transfer only, no walk-in A&E service) Urology Specialist Service Tertiary Urology Service Vascular Surgery Specialist Service Tertiary Vascular Surgery Service
DISCUSSION DOCUMENT MAY 2003
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32
Model B National Referral Hospital Services (“Adds on” to a Tertiary Hospital) Specialist Service Available On-Site Specific Components Explicitly Included: Cardiology Echocardiography, Ultrasound, Electrocardiography,
Stress Testing, ECG Holter Pacemaker follow-up, Cath Lab, Electrophysiology Ablation
Cardiothoracic Surgery Full Cardiothoracic Service Craniofacial Surgery Critical Care & ICU Additional ICU Capacity Endocrinology Tertiary Endocrinology Service Haematology Tertiary Haematology Service Human Genetics Tertiary Genetics Service Infectious Diseases Clinical Research Capacity Medical & Radiation Oncology Tertiary Oncology Centre Neurosurgery Tertiary Specialist Neurosurgery Service,
Interventional Neuroradiology Nuclear Medicine Tertiary Nuclear Medicine Centre Obstetrics & Gynaecology Service
Oncology Urogynaecology Reproductive Medicine
Ophthalmology Super-Specialist Ophthalmology Service Orthopaedic Surgery Orthopaedic Oncology Renal Transplant Renal Transplant Unit Rheumatology Tertiary Rheumatology Service Paediatric Cardiology Paediatric ICU Additional Paediatric ICU Capacity Paediatric Endocrinology Paediatric Gastroenterology Paediatric Haematology & Oncology Paediatric Infectious Diseases Paediatric Nephrology Dialysis & Renal Transplant Paediatric Neurology Paediatric Respiratory Medicine & Allergology Paediatric Rheumatology
DISCUSSION DOCUMENT MAY 2003
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33
Model B Central Referral Units (“Add on” to a National Referral
Hospital)
Specialist Service Available On-Site Specific Components Explicitly Included:
{ Cardiology Cardioverter Defibrillator & LV Assist Devices Unit { Cardiothoracic Surgery Heart & Lung Transplant Unit { Respiratory Medicine National Pulmonology Referral Centre:
Lung volume reduction, Lung Transplant Maxillofacial Surgery National Referral Centre
{ { {
Diagnostic Radiology National PET Scan Interventional Neuroradiology Cardiac Imaging
{ Nuclear Medicine PET or gamma-PET { { { { {
Medical & Radiation Oncology National Oncology Referral Centre: Bone Marrow Transplant, IMRT, Intraoperative Radiation, Stereotactic Radiation, PET Scan planning; laminar flow, cryopreservation, stem cell harvesting, T-cell depletion facilities
{ Haematology Bone Marrow Transplantation Unit
{ Hepatology Specialist Liver Unit { Liver Transplant Liver Transplant Unit { {
General Surgery National Surgical Referral Centre: Liver and major pancreatic resections, TME
{ {
Nephrology National Nephrology Centre: Pancreas-kidney / Liver-kidney Transplant
Clinical Immunology National Referral Centre Clinical Pharmacology National Policy Support Unit Dermatology National Referral Centre Endocrinology National Endocrinology Referral Centre ENT Cochlear Implant
Skull Base Surgery Human Genetics National Genetics Centre Infectious Diseases National Institute for Communicable Diseases National Paediatric Referral Centre:
{ { {
Paediatric Medicine & Surgery Organ transplantation, epilepsy surgery, craniofacial surgery; certain high-cost / complexity medical interventions
{ Paediatric Gastroenterology Transplant Surgery, Metabolic Laboratory { Paediatric Haematology & Oncology Bone Marrow Transplant { { { {
Paediatric Neurology Complex epileptic surgery, complex neuromuscular patients, neurodegenerative and metabolic patients, Video telemetry, intracranial mapping, neuro-metabolic lab.
{ {
Paediatric Rheumatology Bone Marrow Transplant, DEXA scans, Interleukin levels, joint replacement
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34
Model C:
Model C Regional Hospital Services Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Diagnostic Radiology X-Ray, CT Scan, Ultrasound, Fluoroscopy,
Interventional radiology (basic interventions e.g. image guided aspirations)
General Medicine Service
Echocardiography, Stress ECG Specialist Immunology Nurse Regional ICU Service Diabetes / Endocrine clinic GIT incl. endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Geriatric Care Genetic Nurse & Counselling Oncology palliation and basic care Neurology basic care Spirometry & oximetry Basic Rheumatology Basic Infectious Diseases Pathology Services Infection Control Proctoscopy, Sigmoidoscopy
General Surgery Service
Regional Burns Service 24 hour Level II Trauma Service, Accident & Emergency
Mental Health Services (Psychiatry & Psychology)
Acute Inpatient & Outpatient Child & Adolescent Psychiatry ECT Liaison Psychiatry Community Mental Health Services
Neonatology Neonatal Low & High Care, Neonatal Intensive care Obstetrics & Gynaecology Service
Emergency Obs & Gynae Ultrasound, prenatal diagnosis Kangaroo Care Basic urogynaecology Mid trimester abortions and adequate pain relief systems Basic oncology, menopause and screening programmes Preliminary infertility investigations
Orthopaedic Surgery General Orthopaedic Surgery 24 hour Level II Trauma Service, Accident & Emergency
Paediatrics Service
General Paediatric Medicine Service General Paediatric Surgery (General Surgeon?)
Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry Acute Rehabilitation Team
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Model C Tertiary Hospital Services Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Burns Unit Specialised Burns ICU & Theatre Clinical Pharmacology Specialist Critical Care & ICU Full ICU Service Dermatology Specialist Service Inpatient & ambulatory Diagnostic Radiology
X-Ray, Multi-slice CT Scan, Ultrasound, Fluoroscopy, Mammography, Colour Doppler US, Interventional Radiology, Angiography
ENT Surgery Specialised Service General ENT Surgery Gastroenterology Tertiary GIT Service General Medicine Service
Angiography AT Scan Coronary Care Echocardiography, Stress ECG Endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Genetic Nurse & Counselling Oncology palliation and basic care
General Surgery Service Complex & High Acuity Care Infectious Diseases Tertiary Infectious Diseases Service, Pathology Services,
Infection Control, Dietician, Counselling Services, Social Worker Mental Health Services (Psychiatry & Psychology)
Child and adolescent psychiatry; Old-age psychiatry; Forensic psychiatry; Substance abuse; Liaison psychiatry; Eating disorders; Inpatient psychotherapy; Social psychiatry; Acute psychotic (complicated); Acute non-psychotic (complicated)
Neonatology Neonatal Intensive Care Unit Nephrology Acute renal failure / clinical nephrological problems / dialysis
complication Obstetrics & Gynaecology Service
As Regional plus: Fetal / Maternal Medicine
Ophthalmology General Ophthalmology Service Orthopaedic Surgery Sub-Specialty Orthopaedics Paediatric Medicine Specialist General Paediatricians with special interest Paediatric Surgery Specialist Paediatric Surgery Service Paediatric ICU Full Paediatric ICU Service Paediatrics Service
Neonatal Low & High Care General Paediatric Medicine Service General Paediatric Surgery
Plastic & Reconstructive Surgery Specialist Service
General Plastic & Reconstructive Surgery
Rehabilitation Centre
Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry, Audiology Acute Rehabilitation Team incl. Spinal beds Stroke Unit
Respiratory Medicine Comprehensive Pulmonology Service Trauma Tertiary Major Trauma Centre
(n.b. protocol-based transfer only, no walk-in A&E service) Urology Specialist Service General Urology Service Vascular Surgery Specialist Service General Vascular Surgery Service
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Model C National Referral Hospital Services
(“Adds on” to a Tertiary Hospital) Specialist Service Available On-Site Specific Components Explicitly Included: Cardiology Echocardiography, Ultrasound, Electrocardiography, Stress
Testing, ECG Holter Pacemaker follow-up, Cath Lab, Electrophysiology Ablation
Cardiothoracic Surgery Full Cardiothoracic Service Clinical Immunology Tertiary Clinical Immunology Craniofacial Surgery Critical Care & ICU Additional ICU Capacity Diagnostic Radiology MRI Interventional Neuroradiology ENT Surgery Specialised ENT Service Endocrinology Tertiary Endocrinology Service Geriatrics Specialised Geriatric Service Haematology Tertiary Haematology Service Human Genetics Tertiary Genetics Service Infectious Diseases Clinical Research Capacity Medical & Radiation Oncology Tertiary Oncology Centre Neurosurgery Tertiary Specialist Neurosurgery Service Nuclear Medicine Tertiary Nuclear Medicine Centre Obstetrics & Gynaecology Service
Oncology Urogynaecology Reproductive Medicine
Ophthalmology Specialised Ophthalmology Service Orthopaedic Surgery Orthopaedic Oncology Plastic & Reconstructive Surgery Tertiary Plastic & Reconstructive Surgery Renal Transplant Renal Transplant Unit Rheumatology Tertiary Rheumatology Service Urology Tertiary Urology Service Vascular Surgery Tertiary Vascular Surgery Service Paediatric Cardiology Paediatric ICU Additional Paediatric ICU Capacity Paediatric Endocrinology Paediatric Gastroenterology Paediatric Haematology & Oncology Paediatric Infectious Diseases Paediatric Nephrology Dialysis & Renal Transplant Paediatric Neurology Paediatric Respiratory Medicine & Allergology
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Model C Central Referral Units (“Add on” to a National Referral
Hospital)
Specialist Service Available On-Site Specific Components Explicitly Included:
{ Cardiology Cardioverter Defibrillator & LV Assist Devices Unit { Cardiothoracic Surgery Heart & Lung Transplant Unit { Respiratory Medicine National Pulmonology Referral Centre:
Lung volume reduction, Lung Transplant Maxillofacial Surgery National Referral Centre
{ { {
Diagnostic Radiology National PET Scan Interventional Neuroradiology Cardiac Imaging
{ Nuclear Medicine PET or gamma-PET { { { { {
Medical & Radiation Oncology National Oncology Referral Centre: Bone Marrow Transplant, IMRT, Intraoperative Radiation, Stereotactic Radiation, PET Scan planning; laminar flow, cryopreservation, stem cell harvesting, T-cell depletion facilities
{ Haematology Bone Marrow Transplantation Unit
{ Hepatology Specialist Liver Unit { Liver Transplant Liver Transplant Unit { {
General Surgery National Surgical Referral Centre: Liver and major pancreatic resections, TME
{ {
Nephrology National Nephrology Centre: Pancreas-kidney / Liver-kidney Transplant
Clinical Immunology National Referral Centre Clinical Pharmacology National Policy Support Unit Dermatology National Referral Centre Endocrinology National Endocrinology Referral Centre ENT Cochlear Implant
Skull Base Surgery Human Genetics National Genetics Centre Ophthalmology Super-Specialist Ophthalmology Service Infectious Diseases National Institute for Communicable Diseases National Paediatric Referral Centre:
{ { {
Paediatric Medicine & Surgery Organ transplantation, epilepsy surgery, craniofacial surgery; certain high-cost / complexity medical interventions
{ Paediatric Gastroenterology Transplant Surgery, Metabolic Laboratory { Paediatric Haematology & Oncology Bone Marrow Transplant { { { {
Paediatric Neurology Complex epileptic surgery, complex neuromuscular patients, neurodegenerative and metabolic patients, Video telemetry, intracranial mapping, neuro-metabolic lab.
{ {
Paediatric Rheumatology Specialised Paediatric Rheumatology including Bone Marrow Transplant, DEXA scans, Interleukin levels, joint replacement
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Model D:
Model D Regional Hospital Services Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Diagnostic Radiology X-Ray, Ultrasound, Fluoroscopy, General Medicine Service
Echocardiography, Stress ECG Specialist Immunology Nurse Regional ICU Service Diabetes / Endocrine clinic GIT incl. endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Geriatric Care Genetic Nurse & Counselling Oncology palliation and basic care Neurology basic care Spirometry & oximetry Basic Rheumatology Basic Infectious Diseases Pathology Services Infection Control Proctoscopy, Sigmoidoscopy
General Surgery Service
Regional Burns Service 24 hour Level II Trauma Service, Accident & Emergency
Mental Health services (Psychiatry & Psychology)
Acute Inpatient & Outpatient Child & Adolescent Psychiatry ECT Liaison Psychiatry Community Mental Health Services
Neonatology Neonatal Low & High Care, Short stay ventilatory support
Obstetrics & Gynaecology Service
Emergency Obs & Gynae Ultrasound, prenatal diagnosis Kangaroo Care Basic urogynaecology Mid trimester abortions and adequate pain relief systems Basic oncology, menopause and screening programmes Preliminary infertility investigations
Orthopaedic Surgery General Orthopaedic Surgery 24 hour Level II Trauma Service, Accident & Emergency
Paediatrics Service
General Paediatric Medicine Service General Paediatric Surgery (General Surgeon?)
Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry Acute Rehabilitation Team
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Model D Tertiary Hospital Services Specialist Service Available On-Site Specific Components Explicitly Included: Anaesthetics Burns Unit Specialised Burns ICU & Theatre Clinical Pharmacology Specialist Critical Care & ICU Full ICU Service Dermatology Specialist Service Inpatient & ambulatory Diagnostic Radiology
X-Ray, Multi-slice CT Scan, Ultrasound, Fluoroscopy, Mammography, Colour Doppler US, Interventional Radiology, Angiography
ENT Surgery Specialised Service General ENT Surgery Gastroenterology Tertiary GIT Service General Medicine Service
Coronary Care Echocardiography, Stress ECG Endoscopy, proctoscopy, sigmoidoscopy, colonsocopy (with Gen Surg) Genetic Nurse & Counselling Oncology palliation and basic care
General Surgery Service Complex & High Acuity Care Infectious Diseases Tertiary Infectious Diseases Service, Pathology
Services, Infection Control, Dietician, Counselling Services, Social Worker
Mental Health Services (Psychiatry & Psychology)
Child and adolescent psychiatry; Old-age psychiatry; Forensic psychiatry; Substance abuse; Liaison psychiatry; Eating disorders; Inpatient psychotherapy; Social psychiatry; Acute psychotic (complicated); Acute non-psychotic (complicated)
Neonatology Neonatal Intensive Care Unit Nephrology Acute renal failure / clinical nephrological problems /
dialysis complication Obstetrics & Gynaecology Service
As Regional plus: Fetal / Maternal Medicine
Ophthalmology General Ophthalmology Service Orthopaedic Surgery Sub-Specialty Orthopaedics Paediatric Medicine Specialist General Paediatricians with special interest Paediatric Surgery Specialist Paediatric Surgery Service Paediatric ICU Full Paediatric ICU Service Paediatrics Service
Neonatal Low & High Care General Paediatric Medicine Service General Paediatric Surgery
Plastic & Reconstructive Surgery Specialist Service General Plastic & Reconstructive Surgery Rehabilitation Centre
Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry, Audiology Acute Rehabilitation Team Stroke Unit
Respiratory Medicine Comprehensive Pulmonology Service Trauma Tertiary Major Trauma Centre
(n.b. protocol-based transfer only, no walk-in A&E service)
Urology Specialist Service General Urology Service Vascular Surgery Specialist Service General Vascular Surgery Service
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Model D National Referral Hospital Services (“Adds on” to a Tertiary Hospital) Specialist Service Available On-Site Specific Components Explicitly Included: Cardiology Angiography, Echocardiography, Ultrasound,
Electrocardiography, Stress Testing, ECG Holter Pacemaker follow-up, Cath Lab, Electrophysiology Ablation
Cardiothoracic Surgery Full Cardiothoracic Service Clinical Immunology Tertiary Clinical Immunology Craniofacial Surgery Critical Care & ICU Additional ICU Capacity Diagnostic Radiology MRI, Interventional Neuroradiology Endocrinology Tertiary Endocrinology Service ENT Surgery Specialised ENT Service Geriatrics Specialised Geriatric Service Haematology Tertiary Haematology Service Human Genetics Tertiary Genetics Service Infectious Diseases Clinical Research Capacity Medical & Radiation Oncology Tertiary Oncology Centre Neurosurgery Tertiary Specialist Neurosurgery Service Nuclear Medicine Tertiary Nuclear Medicine Centre Obstetrics & Gynaecology Service
Oncology Urogynaecology Reproductive Medicine
Ophthalmology Specialised Ophthalmology Service Orthopaedic Surgery Orthopaedic Oncology Plastic & Reconstructive Surgery Tertiary Plastic & Reconstructive Surgery Rehabilitation Spinal Injury Unit Renal Transplant Renal Transplant Unit Rheumatology Tertiary Rheumatology Service Urology Tertiary Urology Service Vascular Surgery Tertiary Vascular Surgery Service Paediatric Cardiology Paediatric ICU Additional Paediatric ICU Capacity Paediatric Endocrinology Paediatric Gastroenterology Paediatric Haematology & Oncology Paediatric Infectious Diseases Paediatric Nephrology Dialysis & Renal Transplant Paediatric Neurology Paediatric Respiratory Medicine & Allergology
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Model D Central Referral Units (“Add on” to a National Referral
Hospital)
Specialist Service Available On-Site Specific Components Explicitly Included:
{ Cardiology Cardioverter Defibrillator & LV Assist Devices Unit { Cardiothoracic Surgery Heart & Lung Transplant Unit { Respiratory Medicine National Pulmonology Referral Centre:
Lung volume reduction, Lung Transplant
{ {
Diagnostic Radiology Interventional Neuroradiology Cardiac Imaging
{ { { {
Medical & Radiation Oncology National Oncology Referral Centre: Bone Marrow Transplant, Stereotactic Radiation; laminar flow, cryopreservation, T-cell depletion facilities
{ Haematology Bone Marrow Transplantation Unit
{ Hepatology Specialist Liver Unit { Liver Transplant Liver Transplant Unit { {
General Surgery National Surgical Referral Centre: Liver and major pancreatic resections, TME
Maxillofacial Surgery National Referral Centre Clinical Immunology National Referral Centre Clinical Pharmacology National Policy Support Unit Dermatology National Referral Centre Endocrinology National Endocrinology Referral Centre ENT Cochlear Implant
Skull Base Surgery Human Genetics National Genetics Centre Ophthalmology Super-Specialist Ophthalmology Services Infectious Diseases National Institute for Communicable Diseases National Paediatric Referral Centre:
{ { {
Paediatric Medicine & Surgery Organ transplantation, epilepsy surgery, craniofacial surgery; certain high-cost / complexity medical interventions
{ Paediatric Gastroenterology Transplant Surgery, Metabolic Laboratory { Paediatric Haematology & Oncology Bone Marrow Transplant { { { {
Paediatric Neurology Complex epileptic surgery, complex neuromuscular patients, neurodegenerative and metabolic patients, Video telemetry, intracranial mapping, neuro-metabolic lab.
{ {
Paediatric Rheumatology Specialised Paediatric Rheumatology including Bone Marrow Transplant, DEXA scans, Interleukin levels, joint replacement
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Overview of Models
Clearly, each of Models A to D reflects a slightly different resource scenario, but also a different
emphasis in the balance of service delivery across levels. Model A reflects a very optimistic
resource scenario, in which sufficient funds and skills are available to achieve a significant
deepening of specialist services at regional hospital level, so that all regional hospitals could have
basic specialist services such as Dermatology, ENT, Ophthalmology, Urology and Vascular
Surgery, as well as comprehensive radiology services up to and including single-slice CT scanners.
Once consequence of Model A would be the need to have relatively fewer tertiary hospitals – on the
grounds that regional hospitals are significantly stronger in this model than in others. Model B also
reflects an optimistic scenario – but one in which it is not feasible to have such a wide range of
specialist skills at regional hospital, and which rather seeks to offer a larger number of concentrated
tertiary hospitals. Model C reflects a rather more resource-constrained scenario. Under this model,
a number of services have to confine their tertiary presence to entry-level specialist services, with
complex activities only affordable at national referral level. Model D then offers the most pessimistic
view, requiring a further degree of concentration and foregoing a number of significant investments
(e.g. no CT at regional hospital level, no PET centre nationally etc.).
Readers should also note that, in all these models, Regional Hospitals offer the highest level of
access to health care at which the public can directly “walk in” without referral (i.e. via A&E or open
access out-patients clinic). From the tertiary level upwards, models A to D all clearly assume that
patients will arrive at their doors following referral or transfer, and that tertiary and national referral
hospitals would be physically configured to prevent walk-in access by unreferred patients (e.g. by
not providing ambulatory A&E facilities, but a Major Trauma facility for EMS-delivered casualties
only). This does not preclude offering regional hospital services on site – but there would always
need to be a significant degree of physical separation of regional and tertiary facilities on the same
campus.
While the precise number of hospitals affordable under each model and scenario is itself a critical
output of the modelling which will shortly be undertaken, it is probably helpful to readers to have
some illustration of how these models might translate into numbers of hospitals by type. Please do
not construe these numbers as in any way a “plan” or an intention – their purpose is simply to help
readers to visualise the models. Currently, there are 45 public regional hospitals, and 26 “tertiary”
hospitals – the ten “central” hospitals (in Gauteng, Western Cape, KwaZulu Natal and Free State)
plus another 16 across the country offering a significant level of more specialised services, and
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receiving funding under the National Tertiary Services Grant. Compared to this baseline, it might be
helpful to imagine Models A to D looking something like this:
Model Regional Hospital Tertiary Hospital Combined Tertiary and National Referral Hospitals
Central Referral Units (by type of unit)
A 45 14 to 16 5 or 6 1 or 2B 45 18 to 22 5 or 6 1 or 2C 45 16 to 20 4 or 5 1D 45 14 to 20 4 or 5 1
Next Steps
Over the coming months, the MTS Project Team will be using the concepts and service models
developed in this document as the basis for a substantial quantitative modelling exercise. We will
use cost and activity data, and the information generated by specialties on optimal unit sizes, to
develop costed scenarios for the future configuration of tertiary hospital services. These data will be
combined with the outputs of a spatial model (which considers the costs of patient travel between
hospitals, and uses GIS software to model alternative hospital and service location scenarios), and
a review of the evidence on hospital efficiency and quality of care, to generate and evaluate specific
options for the configuration and distribution of tertiary hospital services across the country. The
best options will be presented to health decision makers in the form of an option appraisal and plan
for the modernisation of tertiary services. It is anticipated that this plan would probably take up to
ten-years to implement, to ensure that essential human resources can be developed and nurtured to
match the required expansion and reconfiguration of services in key areas, and to ensure that
capital investments are matched by the human resources required to make them work effectively.
We anticipate that the plan itself would be subject to detailed consultation before its final adoption.
In the meantime, the MTS Project Team is eager to receive feedback and comments from anyone
who has not participated in the MTS workshop process – be they patients, carers, health care
professionals, academics, or simply concerned members of the public. If you would like to submit
comments or suggestions to the team, please provide them in written form to the individuals
overleaf:
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MTS Project Team Contact Details
Ms. Matsie Seritsane, MTS Project Manager
Email: [email protected]
Ms. Rolize Kruger, MTS Administrator
Email: [email protected]
Fax:
012 312 0552
Post:
MTS Project Team
Civitas Room 2420
Department of Health
Private Bag X828
Pretoria 0001
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Appendix 1 – Specialty Focus Groups Held and Reports Received Reports Received Anaesthetics Burns Cardiology Cardiothoracic surgery Clinical Immunology Clinical pharmacology Craniofacial Surgery Critical care / ICU Dermatology Diagnostic Radiology Endocrinology Ear, Nose & Throat Surgery Gastroenterology & Hepatology General Medicine General Surgery Geriatrics Haematology Human Genetics Infectious Diseases Medical & Radiation Oncology Neonatology Neurosurgery Nephrology Neurology Nuclear Medicine Obstetrics and Gynaecology Opthalmology Orthopaedics Other Rehab Specialists Oral and Maxillofacial Surgery Paediatric Surgery Paediatric Medicine (incl. Infectious Diseases) Paediatric Cardiology Paediatric Critical Care (ICU) Paediatric Endocrinology / Diabetes Paediatric Gastroenterology Paediatric Haematology/ Oncology Paediatric Nephrology and Transplant Paediatric Neurology Paediatric Respiratory Medicine & Allergology Paediatric Rheumatology Plastic & Reconstructive Surgery Mental Health Services Renal / Liver transplantation Respiratory Medicine Rheumatology Spinal Injury Rehabilitation & Management Trauma Urology Vascular surgery
APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO
46
Regional Hospital Tertiary Hospital National Referral Centre
Anaesthetics
Not Described
Not Described
Not Described
Burns
Description Personnel Resources & Activities Also On-Site
General Burns Service General Surgeon, MOs, Nursing Dedicated burn care facility for minor and moderate burns, Telemedicine link High care, general or plastic surgery
Specialised Burns Unit Specialist Burn Care Surgeons, Specialised Nursing Dedicated Burns ICU and Theatre Trauma, Plastic & Reconstr Surgery, Rehabilitation Team, Dietician, Social Work
Possible Future Development Not described in detail
Cardiology
Description Personnel Resources & Activities Also On-Site
General Physician Service with Cardiology Training General Physicians, Technologists, General Nursing Echocardiography, Ultrasound, Electrocardiography, Stress Testing ICU, Internal Medicine
Specialist Cardiologist Service Cardiologists, Snr. Registrars, Radiographers, Cardiac / Cath Lab Technologists, ICU staff, Dietician, OT, Physio, Other Rehab Echocardiography, Ultrasound, Electrocardiography, Stress Testing, ECG Holter Pacemaker follow-up, Cath Lab, Electrophysiology Ablation, Cardiac Surgery, MRI, Nuclear Medicine, ICU, Respiratory Med, Diabetes care, Dialysis, Neurology, Vascular Surgery, Anaesthetics, Paediatrics, Full Rehabilitation Service
As Tertiary plus: Heart Transplant, Cardioverter Defibrillators, LV assist devices
Cardiothoracic surgery
Description Personnel Resources & Activities Also On-Site
Not Described / Required Specialised Cardiothoracic Surgery Centre Specialist Cardiothoracic Surgeons, Registrars, MOs, Nursing Full Cardiothoracic service ICU, Radiology, Cardiology & Paediatric Cardiology, Respiratory Medicine
National Cardiothoracic Hub As Tertiary As Tertiary plus heart / lung transplant ICU, Radiology, Cardiology & Paediatric Cardiology, Respiratory Medicine
APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO
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Clinical Immunology
Description Personnel Resources & Activities Also On-Site
Regional Immunology Services General Physician, MOs, Specialist Nurse Diagnosis and basic treatment Laboratory
Tertiary Clinical Immunology Specialist Clinical Immunologist, MOs Advice centre, Inpatient beds, Immunotherapy modalities, Research & Teaching, Preventative Immunology Access to all major disciplines, Laboratory
National Referral Centre Specialist Clinical Immunologists & Scientists As Tertiary plus gene sequencing, sophisticated and innovative immunotherapy As Tertiary plus Technical College
Clinical pharmacology
Description Personnel Resources & Activities Also On-Site
Regional Clinical Pharmacology Service Clinical Pharmacologist (or trainee) Training and advice for regional and PHC service providers Basic assays / laboratory
Tertiary Clinical Pharmacology Service Clinical Pharmacologists, Specialised Laboratory Scientists Training and advice, patient-level consultation, laboratory support and advice Forensic Laboratories
National Policy Support Unit As Tertiary Support for Government policy and regulation of pharmaceuticals and traditional medicines As Tertiary
Craniofacial
Description Personnel
Not envisaged Not envisaged National referral centre with 2 units nationally Neurosurgeon, plastic surgeon, MFOS, ENT, Audiologist, Dietician, OT, Orthodontist, Paed. Dentist, Social Worker, Physiotherapist, Paed. Anaesthetist
Critical care / ICU
Description Personnel Resources & Activities Also On-Site
Regional ICU Service Medical ICU Director (general specialist with ideally 6 months experience in Intensive Care), 24 hr availability medical cover provided by a doctor with advanced life support skills. Nurse Manager (Critical Care Trained), Medical & Nursing Support, Professions allied to medicine services Int. care for patients with not more than 1 organ failure & not expected to require >3 days ventilation 24-hour lab & radiology services
Tertiary ICU Service 24 hr on-site cover by dedicated medical staff (MO/ Registrar) in addition to 24 hour cover by trained intensivists (not necessarily on site) ICU trained nurses, ICU Technologists and dedicated professions allied to medicine services Full ICU services includes both intensive care and high care beds 24-hour lab & radiology services
ICU Support for Quaternary Services As Tertiary but larger, sub-specialty training for ICU nurses, 24 hour ICU Technologists Additional support for transplantation and cardiac surgery and certain other quaternary services As Tertiary
Dermatology
Description
Regional Dermatology Service
Tertiary Dermatology Service
National Dermatology Referral Service
APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO
48
n.b. only 20 dermatologists in public sector today
Personnel Resources & Activities Also On-Site
Specialist Dermatologist, Specialised Nursing Ambulatory Dermatology Service, Telemedicine link to Tertiary Not stated
Specialist Dermatologists, Regs, Specialised Nursing Full dermatology inpatient service and specialised clinics Not stated
Specialist Dermatologists, Regs, Specialised Nursing As Tertiary plus super-specialists for ‘hi-tech” and rare conditions Not stated
Diagnostic Radiology
Description Personnel Resources & Activities Also On-Site
General Radiology Service Radiologist, Radiographers, Ultrasonographer, Nursing, Technical X-Ray, Fluoroscopy, Ultrasound, Single-slice CT Scan & telelink to tertiary centre General Surgery
Specialised Radiology Service Radiologists, Radiographers, Ultrasonographer, Nursing, Technical, Medical Physics, IT X-Ray, Fluoroscopy, Ultrasound, Multi-slice CT Scan, MRI, Mammography, Colour Doppler US, Gamma cameras Anaesthetics, Clinical Engineering
Specific High-Cost Facilities As Tertiary PET Scan, Interventional Neuroradiology, Cardiac Imaging
Ear, Nose & Throat Surgery
Description Personnel Resources & Activities Also On-Site
General ENT Service ENT Specialist, MOs Basic ENT surgical equipment, Audiometry / Audiology Radiology
Specialised ENT Service ENT Specialists, Registrars, MOs ENT Surgery, Bone Laboratory, Vestibular Studies, Laser Endoscopic Surgery, Audiometry / Audiology MRI, ICU, Neurosurgery, Oncology, Radiology (and access to all other tertiary depts as required)
Super-Specialist Service attached to Tertiary ENT Specialists with specific expertise Cochlear Implants, Skull Base Surgery
Endocrinology
Description Personnel Resources & Activities Also On-Site
General Medical Endocrinology General Physician, MOs and Nurses with specific training Type 2 Diabetes and common thyroid disorders Dietician, General Surgery, Ophthalmology
Tertiary Endocrinology Service Specialist Endocrinologists, Registrars, MOs and Nurses with specific training All diabetes requiring referral, all other endocrine (incl. Metabolic, bone, lipid disorders) and thyroid disorders and dyslipidaemia Sonar, CT, Nuclear Medicine, Ophthalmology, Dietician, Podiatrist, General Surgery, Chemical Pathology MRI, bone density, Invasive Radiology,
National Endocrinology Referral Centre Adult and Paediatric Specialist Endocrinologists, Registrars, MOs, Nursing All endocrine conditions, including transplants and fertility management , . pancreatic islet cell transplantation and or highly specialised services like proton beam radiotherapy
APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO
49
Endocrine Surgeon, Neurosurgery, Vascular Surgery, Obstetrics, Dialysis, Transplant Surgery, Radiation Oncology
Gastroenterology & Hepatology
Description Personnel Resources & Activities Also On-Site
Level II GIT Service Specialist General Physician or Surgeon (with GIT training), GIT Nurses, Registrars on rotation Upper GI endoscopy, Proctoscopy, sigmoidoscopy and colonoscopy, acute GIT emergencies Not stated
Tertiary GIT Service Specialist Medical and Surgical Gastroenterologists, Registrars, MOs, Specialised Nursing, Technicians Super-specialist activities: Upper GIT, hepatico-pancreatic-biliary diseases, colon diseases Virology, Immunology, CT, ICU
Specialist Liver Unit Specialist Clinical Hepatologists, Hepatic Surgeons, Pathologist MARS machine, bioartifical liver support devices Liver Transplant Unit
General Medicine
Description Personnel Resources & Activities Also On-Site
General Medicine Service Generalist Specialist Physician, Visiting Sub-Specialists, Registrars, MOs, Nursing Coronary care, ICU, Haemodialysis, Echocardiography, Scopes, Sonar CT Scan, Radiology, General Surgery, Obs & Gynae, Paediatrics, Allied Health Professionals e.g. Physiotherapy, Nutrition, OT.
General Medicine & Sub-Specialist Medicine Service Generalist Specialist Physicians, Sub-Specialist Physicians, Registrars, MOs, Nursing Coronary care, ICU, Haemodialysis, Echocardiography, AT Scan, Angiography, Scopes, Sonar, Outreach to Regional Hospitals MRI, CT Scan, Radiology, General Surgery, Obs & Gynae, Paediatrics, Allied Health Professionals e.g. Physiotherapy, Nutrition, OT.
No difference from Tertiary
General Surgery
Description Personnel Resources & Activities Also On-Site
Regional General Surgery Service Specialist General Surgeons, Registrars, MOs, Nursing, Anaesthetists “All general surgery” All general disciplines, Radiology, Allied Health Disciplines incl. Stoma therapists and Nutrition Units.
Tertiary General Surgery Specialist General Surgeons with special interests, Registrars, MOs, Nursing, Anaesthetists Complex and high acuity Anaesthetists, Radiology with CT and interventional capability, ICU
National Surgical Referral Centre Super-Specialists, Registrars, MOs, Nursing, Anaesthetists Specific procedures e.g. liver and major pancreatic resections, TME As Tertiary
Geriatrics
Description Personnel
General Medicine for Geriatric Patients General Physicians, MOs, Nursing, Physio, OT, S S
Specialised Geriatric Service Specialist Geriatricians, Registrars, MOs, Nursing,
O S S
No Quaternary Level Envisaged
APPENDIX 2 ORGANISATIONAL MODELS – IDEAL SCENARIO
50
Resources & Activities Also On-Site
Speech Therapist, Social Worker, dietician and chiropodist. Integrated General Medical Unit and Rehabilitation Service CT, Radiology, Echocardiography, ICU, General Surgery, Urology, Gynaecology, Psychiatry, Orthopaedics
Physio, OT, Speech Therapist, Social Worker dietician, clinical psychologist and chiropodist. Acute Geriatric Care, Stroke Unit, Psycho geriatric Care, Rehabilitation Service MRI, CT, Radiology, Echocardiography, ICU, All Other Adult Tertiary Specialties especially Neurology, Cardiology, Orthopaedics, Urology
Haematology
Description Personnel Resources & Activities Also On-Site
Consultation Services Part time haematologist MO with interest, Haematology trained nurses Possible Outreach Activities (not specified) Palliation and supportive services e.g. Medicine
Tertiary Haematology Service Specialist Clinical Haematologists, Pathologists with special interest, Registrars, MOs, Nursing, Min. 3 consultants Malignant haematological, lymphoproliferative and clonal disorders, non-malignant haematological disorders; Apheresis, isolation, stem cell harvesting and storage facilities Oncology (Medical & Radiation), Radiology,
Bone Marrow Transplantation Unit Linked to a Tertiary unit Allogeneic Bone Marrow Transplantation Research facilities
Human Genetics
Description Personnel Resources & Activities Also On-Site
Genetic Diagnosis & Counselling Service Genetic Nurse, Regional Coordinator (nurse) for district hospital genetic services Basic diagnostic, counselling and therapeutic support (incl. Amniocentesis) Radiology, Obs & Gynae, Paediatrics, Gen. Med., Gen. Surg., Social Workers
Tertiary Genetics Service Specialist Medical Geneticists, Genetic Nurses / Counsellors, Medical Technologists Diagnostic services and complex counselling and care As regional plus Ultrasound
National Genetics Centre As Tertiary Specialised molecular diagnostic tests, Inborn Error of Metabolism screening & diagnosis As Tertiary
Infectious Diseases
Description Personnel Resources & Activities
Regional General Medicine Specialist General Physician, Registrars, Nurses with specific training, infection control, microbiologist and virologist. Complex conditions not manageable at Level I; endoscopy bronchoscopy isolation facilities HIV
Tertiary Infectious Diseases Specialist Infectious Diseases, Registrars, MOs, Specialist Nursing, infection control, microbiologist and virologist. Unusual infections, complicated malaria and HIV, HAART isolation facilities complicated TB novel
Not Envisaged however, there is a need for a National Centre for Communicable Diseases. (n.b. no mention of containment facilities?)
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Activities Also On-Site
endoscopy, bronchoscopy, isolation facilities, HIV, HAART and expanded antibiotic formulary. Radiology, CT, ICU, microbiology, virology, immunology, social work
HAART, isolation facilities, complicated TB, novel antibiotics and training in infectious diseases Radiology, CT, MRI, ICU, dialysis, microbiology, virology, immunology, social work
Medical & Radiation Oncology
Description Personnel Resources & Activities Also On-Site
Regional General Medicine MO with oncology diploma, Oncology Nurses Basic medical oncology: basic care, follow-up, palliation, Laminar Flow, Basic Laboratory and R-ray services Radiology, Laboratory, Chemotherapy, General Surgery, Obs & Gynae, Dietician, Psychiatry, Social Work, Pharmacists
Tertiary Oncology Service Specialist Medical and Radiation Oncologists, Therapy Radiographers, Oncology Nurses, Research Coordinators, Medical Physicists, Pharmacists, Social Workers, Mould room Technicians Linear Accelerator, CT scan planning, Brachytherapy Cobalt Isolation facilities, Single bed units, Most standard chemotherapy and biological drugs, Monoclonal antibody therapy Radiology, CT, ICU, Surgical Oncology, Gynaecological Oncology, Neutropenic isolation areas for chemotherapy patients, Therapeutic Isolation areas for patients receiving radioactive isotopes
National Oncology Referral Service As Tertiary Bone Marrow Transplant, IMRT, Intraoperative Radiation, Stereotactic Radiation, PET Scan planning; laminar flow, cryopreservation, stem cell harvesting, T-cell depletion facilities, inter operative radiation, autologous and allogeneic stem cell transplant units and further development of the South African Bone Marrow Transplant Registry to obtain volunteer unrelated donors for stem cell transplant patients. As Tertiary plus Nuclear Medicine & PET, Haematology
Mental Health Services
Description Personnel Resources & Activities
Regional Mental Health Service Specialist Psychiatrist, Clinical Psychologist, Registrars, Psychiatric Nurses, OT, Social Work, Psychiatry interns. Acute inpatient, outpatient; child and adolescent psychiatry, ECT, liaison, satellite clinics
Tertiary Mental Health Service Specialist and sub-specialist Psychiatrists, Clinical Psychologists, Registrars, Psychiatric Nurses, OT, Social Work, Psychiatry interns. Child and adolescent psychiatry; Old-age psychiatry; Forensic psychiatry; Substance abuse; Liaison psychiatry; Eating disorders; Inpatient psychotherapy; Social psychiatry; Acute psychotic (complicated); Acute non-psychotic (complicated)
Not Envisaged
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Also On-Site
General Medicine, Neurology (?), Paediatrics
All Specialties
Neonatology
Description Personnel Resources & Activities Also On-Site
Neonatal Low & High Care Unit Specialist Paediatricians, MOs, Nurses with specific training Low and high care; short-term ventilation awaiting transfer, Kangaroo care Radiology, CT, Ultrasound, Physio, OT, Dietician, Speech Therapist, Social Work, Technical Support
Neonatal Intensive Care Unit Specialist Neonatologists, Paediatricians, MOs, Specialist Nursing Intensive and high care, obstetric and perinatal services, Kangaroo care As Regional plus MRI; access to all Paediatric Sub-Specialties
Not Envisaged
Nephrology
Description Personnel Resources & Activities Also On-Site
Regional Dialysis Service Specialist General Physician and nurses with renal training, dialysis therapists, clinical technologist Haemodialysis & peritoneal dialysis for stable chronic patients, primary prevention, organ donation Social worker, dietician
Tertiary Nephrology Service Specialist Nephrologists, Registrars, Spec. nurses, dialysis therapists, clinical technologists, social worker Haemodialysis & peritoneal dialysis chronic & acute, primary prevention, organ donation, referral for transplant Radiology, Dietician
National Referral Centre As tertiary plus psychologist Haemodialysis & peritoneal dialysis chronic & acute, renal, pancreas-kidney, liver-kidney transplantation As Tertiary; Transplant Surgery
Neurology
Description Personnel Resources & Activities Also On-Site
Regional General Medicine Physician with Neurology Diploma Not specified Radiology, CT
Tertiary Neurology Service Specialist Neurologists, Registrars, MOs, Specialist Nurses, Technologists Neurology, EEG, Stroke Unit Rehabilitation Team, Radiology, MRI, CT, ICU
Not Envisaged
Neurosurgery
Description Personnel Resources & Activities Also On-Site
General Surgeon / Trauma Service General Surgeon, Rehab staff Trauma and Neuro-rehabilitation CT Scan, ICU, Rehab Team, Telemedicine
Only two levels envisaged “National Tertiary” Specialist Neurosurgeon Service Neurosurgeons, Registrars, MOs, nursing Neurosurgical theatres & equipment for full range of neurosurgical operations and management CT & Neuroradiology, Neurology, Full Rehabilitation team, ICU
Nuclear Medicine
Description Personnel
Regional Nuclear Medicine Specialised Radiographer only
Tertiary Nuclear Medicine Centre Specialist Nuclear Physician, Specialised Radiographers,
PET or gamma-PET As Tertiary
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Resources & Activities Also On-Site
Limited equipment, telemedicine link to tertiary Not Stated in Report
Medical Physics, Technologists Diagnostic and Therapy Nuclear Medicine Not Stated in Report
Positron Emission Tomography or gamma-PET Adequate Cyclotron capacity for isotope production
Obstetrics and Gynaecology
Description Personnel Resources & Activities Also On-Site
Regional Obstetrics & Gynaecology Service Specialist General Obstetricians & Gynaecologists, Registrars, MOs, Nursing Basis and Emergency obstetrics, ultrasound, prenatal diagnosis, Kangaroo care, Basic and Emergency. Gynaecology, diagnosis, basic urogynaecology mid trimester abortions or adequate systems for pain relief, basic menopause and screening programmes, preliminary investigations for infertility Anaesthesiology, High Care / ICU (adult and baby) basic oncology
Tertiary Obstetrics & Gynaecology Service Specialist & Sub-Specialist Obstetricians & Gynaecologists, Registrars, MOs, Nursing As regional plus: Fetal / Maternal medicine, Oncology, Urogynaecology, Reproductive Medicine Anaesthetics, Radiology, ICU, Neonatology, Human Genetics, All Medical Sub-Specialities, Paediatric Surgery, Radiation Oncology, Colorectal Surgery, Urology, Endocrinology, Plastic Surgery, Physio, Pathology, Psychology
Not Envisaged
Opthalmology
Description Personnel Resources & Activities Also On-Site
General Ophthalmology Service Specialist Ophthalmologist, Registrars / MOs, Nursing Operating Room & Microscope, Argon & Yag Lasers, routine ophthalmic surgery Anaesthetics, Radiology, Maxillo facial, Plastic Surgery and Pathology
Specialised Ophthalmology Service Specialist Ophthalmologists, Registrars and MOs, Orthoptist, Nursing Complex surgery, B Scan Ultrasound & imaging, Electro diagnostics Neurology, Neurosurgery, Radiology, Anaesthetics, Oncology, Paediatrics, Physicians Maxillo facial, Plastic Surgery and Pathology
Super-Specialist Ophthalmology Service As Tertiary Oncological surgery, Genetics, Specialised paediatric, Photodynamic therapy As Tertiary plus MRI, Human Genetics Maxillo facial, PlasticSurgery and Pathology
Oral and Maxillofacial Surgery
Description Personnel Resources & Activities
General MFOS services Part or Full time specialist assisted by MO or dentist Oral Sepsis, Basic Trauma, Dento-alveolar surgery Radiology, laboratories, Anaesthetics
Full Spectrum of MFOS Services Specialists or Academic Appointments
Non e envisaged
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Also On-Site
Orthopaedics
Description Personnel Resources & Activities Also On-Site
General Orthopaedics General Specialists, MOs, Nursing All general orthopaedic surgery High Care, X-Ray, Ultrasound, General Medicine, General Surgery, Rehabilitation Team, Orthotics, Prosthetics
Sub-Specialty Orthopaedics Specialists with special interests, Registrars, Nursing Arthroplasty, Spinal Surgery, Hand and Upper Limb Surgery, Spinal Surgery, Athroscopic Surgery (revision surgery) Paediatrics, Foot and Ankle, Chronic Sepsis and Oncology As regional plus MRI, CT, ICU, access to all other tertiary specialties
Orthopaedic Oncology Centre Super-Specialists Orthopaedic Oncology, Spinal, Tissue Engineering e.g. Limb Salvage As tertiary (n.b presumably close link to Oncology)
Other Rehab Specialists
Description Personnel Resources & Activities Also On-Site
Regional Rehabilitation Centre Physiotherapy, Occupational Therapy, Orthotics & Prosthetics, Speech therapy, Dietetics, Podiatry Combined Rehabilitation Team & Facility to provide integrated rehabilitation All Regional Hospital Services
Tertiary Rehabilitation Centre Physiotherapy, Occupational Therapy, Orthotics & Prosthetics, Speech therapy, Dietetics, Podiatry, Audiology Combined Rehabilitation Team & Facility to provide integrated rehabilitation (excl. spinal injury unit) All Tertiary Hospital Services
Not Envisaged
Paediatric Medicine
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Medicine Service Specialist General Paediatrician, MOs, Nursing General & emergency paediatrics, neonatology, child abuse, child health service Radiology, Neonatal High Care, Isolation facilities, Anaesthetics, Obs & Gynae, Paed Surgery, Rehabilitation Team, Social Work
Tertiary Paediatric Medicine Service Specialist General and Sub-specialist Paediatricians, Registrars, MOs, Specialist Nursing General Paediatrics plus Genetics, Child Psychiatry & Behavioural Paediatrics, Infectious Diseases and full range of Paediatric Sub-Specialties As Regional plus all surgical sub-specialties, Oncology, Nuclear Medicine, ICU, NICU
National Paediatric Referral Centre Super-specialist Paediatricians / Surgeons, Registrars, MOs, Specialist Nursing Organ transplantation, epilepsy surgery, craniofacial surgery; certain high-cost / complexity medical interventions As Tertiary
Paediatric Allergology
Description Personnel
M O with (Diploma in Allergy), Trained nurses
Specialist, M O with Dip. in Allergy, specialist nurse,
Specialists
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Resources & Activities Also On-Site
Clinic facilities with resuscitation, skin tests, spacers, basic spirometry Expertise in immunotherapy, allergy and asthma education
dietician Spirometry, skin pricks tests (titrated). Spacers, radiology Laboratory able to determine Specific IgE, nasal eosinophils, tryptase, immunotherapy clinics (bee, venom and inhalant, double blind placebo controlled food challenges
Full diagnostic allergy clinic able to develop in house indigenous allergen Specific IgE tests, Western blotting, lymphocyte proliferation and cytokine assays, Aerobiology asthma education, epidemiological surveillance, clinical trials, Double blind placebo controlled food challenges Full lung function facilities, radiology and immunology clinics, drug desensitisation expertise
Paediatric Cardiology
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Medicine Service Specialist General Paediatrician with cardiology training Echocardiography Not specified
Tertiary Paediatric Cardiology Service Specialist Paediatric Cardiologists & Cardiac Surgeons, Cardiac Anaesthetists, Clinical Technologists, ECG Technicians Echocardiography, Cardiac Cath & Cardiac Surgery Paediatric ICU, MRI, CT, Nuclear Medicine
National Paediatric Cardiology Referral Centre As Tertiary As Tertiary plus Transplants, Electrophysiology As Tertiary
Paediatric Child development
Description Personnel Resources & Activities Also On-Site
Paediatric Medicine Services General Paediatricians, Nurses, Physiotherapist, Occupational therapist, Speech Therapist, Dietician, Social Worker Basic paediatric development screening e.g. vision, hearing and addressing rehabilitation of chronic/static conditions. Radiology (CT Scan) Vision and hearing screening.
Child Development Services Specialist Child Developmentalist, Nurses, Physiotherapist, Occupational therapist, Speech Therapist, audiologist (specialised for child development) Dieticians, Pharmacist (paediatric trained), Clinical Geneticists, Social Worker Full developmental services with outreach programmes. Telemedicine may play a role. Neurophysiology (e.g. BAER, EEG, EIMG). Relevant laboratory services (e.g. genetics) Radiology: CT, MRI. Neuropsychology, Paediatric Psychiatry, P di t i th di P di t i
National referral services As Tertiary No quaternary services exist yet. PET Scan? ƒMRI
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Paediatric orthopaedics, Paediatric nuerosurgery, ICU, Playrooms and observation rooms.
Paediatric Critical Care (ICU)
Description Personnel Resources & Activities Also On-Site
Critical Care of Children Paediatricians, MOs and nurses with paediatric resuscitation skills Recognise critically ill children, resuscitate and stabilise for transfer, telemedicine link to tertiary Radiology, Paediatric Surgery & Medicine
Paediatric ICU Service Paed. Intensivist as Medical Director, Paed ICU-trained Nurse as Nursing Director, Paed ICU nurses, ICU technologist Full Paediatric ICU Service 24-hour Lab & Radiology, access to all Paeds
ICU Support for Quaternary Paediatric Services As Tertiary, but with personnel possessing sub-specialty skills Support to e.g. transplant, cardiac surgery, neurosurgery etc. As Tertiary
Paediatric Endocrinology / Diabetes
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Medicine Service Specialist General Paediatrician, Trained Nurses andMOs Diagnosis, early referral, emergency care Telemedicine, Social Work, Social Services, laboratories
Tertiary Paediatric Endocrinology Service Specialist General Paediatrician with interest in Endocrinology, Staff & Patient Educators Comprehensive Endocrinology Service, outreach, screening Psychology, Paediatric Surgery, Paediatric Radiology, Genetics, Social Services, Genetics, Lab
National Paediatric Endocrinology Referral Unit Specialist Paediatric Endocrinologist, Molecular Laboratory Complex and rare metabolic disorders, advanced investigations As Tertiary
Paediatric Gastroenterology
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Medicine Service Specialist General Paediatrician Diagnosis, basic treatment, follow-up management of tertiary cases Radiology, Counsellors, Social Work, Paed Surgery
Tertiary Paediatric Gastroenterology Service Specialist Paediatric Gastroenterologists Clinical, endoscopic and lab evaluation, treatment As Regional plus: ICU, Other Paediatric Sub-specialties, Dietetics, Infectious Diseases, Adult GIT
National Paediatric Referral Centre Super-specialist Transplant Team Transplant Surgery, Metabolic laboratory As Tertiary plus Pharmacology lab
Paediatric Haematology/ Oncology
Description Personnel Resources &
Regional Paediatric Medicine Service Specialist General Paediatrician / Visiting Consultant Palliative care and identification for possible
Tertiary Paediatric Medicine Service Specialist General Paediatrician Chemotherapy under guidance, palliative care,
National Referral Paediatric Haematology & Oncology Centres Sub-Specialist Haematologist / Oncologists, Specialist Nurses Full diagnostic and treatment services with autologous
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Activities Also On-Site
diagnosis Radiology, Ultrasound, Social Worker
diagnosis Radiology, CT, High Care, Social Worker, Physio, Paediatric Surgery
and allogeneic Bone Marrow Transplant at selected site(s) Radiology, CT, Radiation Oncology, ICU, High Care, Hospital School, Paediatric Surgery and Surgical Sub-specialties
Paediatric Infectious diseases
No Separate Report – See Paediatric Medicine
No Separate Report – See Paediatric Medicine
No Separate Report – See Paediatric Medicine
Paediatric Nephrology and Transplant
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Medicine Service Specialist General Paediatrician, MOs Screening and treatment of basic conditions, Telemedicine link to referral unit Radiology, Social Work
Characterised as Quaternary Service Quaternary Paediatric Nephrology Service Specialist Paediatric Nephrologists, Specialist Nurses, Technologists, Specialist Paediatric Surgeons Biopsies, Peritoneal and Haemodialysis, Renal Transplant Radiology, Sonar, ICU, Nuclear Medicine, Psychology,Social Work
Paediatric Neurology
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Medicine Service General Paediatricians, Nursing, Physio, OT, Speech Therapy Basic paediatric care e.g. epilepsy, CPs, chronic rehabilitation Radiology
Paediatric Neurology Service Specialist Paediatric Neurologists, Developmental Paediatricians, Nursing, Physio, OT, Speech Therapy Full paediatric neurology services and telemedicine support to regional CT, MRI, spectroscopy, ICU, Neurosurgery, Radiology, EEG & EMG, Psychology, Psychiatry, Social Work
National Referral Service As Tertiary Complex epileptic surgery, complex neuromuscular patients, neurodegenerative and metabolic patients, Video telemetry, intracranial mapping, neuro-metabolic lab. As Tertiary plus histopathology, molecular genetics, metabolic specialists
Paediatric Respiratory Medicine & Allergology (Spit between the two sub
Description Personnel
General Paediatric Medicine General Paediatricians
Tertiary Paediatric Respiratory & Allergology Service Specialist Paediatric Pulmonologists & Allergologists,Specialist Nursing
Not Envisaged
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specialties suggested as the only overlap between them is asthma management)
Resources & Activities Also On-Site
Spacer devices for infants, peak flow metres, pulse oximetres and X-rays Physiotherapy, Microbiology laboratory and Radiology.
Spirometry, skin prick testing, spacers, histamine challenges, bronchoscopy, Lung function facilities Radiology, Spiral CT, Paediatric ICU, NICU, Paediatric Cardiothoracic Surgery, Dieticians, Physio, Psychology
Paediatric Rheumatology
Description Personnel Resources & Activities Also On-Site
General Paediatric Medicine, continuation of therapy General Paediatricians Screening, follow-up and step-down of tertiary cases Radiology, Phsyio, OT, Orthopaedics, step down facilities
Tertiary Paediatric Rheumatology Service Registered Specialist Paediatric Rheumatologist, Dedicated Specialist Nurse Practitioner Diagnosis and treatment: lupus, dermatomyositis all vasculitides, problem JCA and systemic onset disease. All connective tissue diseases and immunomodulatory therapy. Radiology, MRI, Paed ICU, Rehabilitation Team, Adult Rheumatology, Nephrology, Ophthalmology, Paed Orthopaedics
National Paediatric Referral Centre As Tertiary Bone Marrow Transplant, DEXA scans, Interleukin levels, joint replacement As Tertiary plus: Laminar Flow unit, Haematology, Infectious Diseases, Immunology and BMT
Paediatric Surgery (including the cardiothoracic surgery, general paediatric surgery, neurosurgery, ophthalmology, orthopaedics, plastic & reconstructive surgery, ENT, urology subspecialties)
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Surgery Service General surgeon with paediatric interest, or an MO with general and paediatric surgical experience. Basic paediatric surgery Specialist Anaesthetics, Radiology, General Paediatrics, Care, Physiotherapy, Laboratory Services
Tertiary Paediatric Surgery Service Specialist Paediatric Surgeons and other subspecialties i.e. cardiothoracic and general paediatric surgery, ophthalmology, neurosurgery, orthopaedics and plastic and reconstructive, ENT, urology, Registrars, MOs, Specialist Nursing Comprehensive paediatric surgery – general and sub-specialties As regional, All Paediatric disciplines, ICU, Paediatric Anaesthetics, Oncology, Radiology, Pathology
National Paediatric Referral Centre Super-specialist Paediatric Surgeons and sub specialists , Registrars, MOs, Specialist Nursing Organ transplantation, epilepsy surgery, craniofacial surgery, cochlear implants, laryngeal reconstruction, limb salving oncology, eye salvaging oncology. As Tertiary
Plastic & Reconstructive Surgery
Description Personnel
Regional Plastic Surgery Service Specialist Plastic Surgeon, Rotating Registrars, MOs
Tertiary Plastic & Reconstructive Surgery Specialist Plastic Surgeon, Registrars, MOs, S
Mentioned but not Elaborated
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Resources & Activities Also On-Site
Secondary plastic surgery; Dermatome, Osteotomy, Microscope Radiology, CT, Anaesthetics, General Surgery, Rehabilitation Team
Specialist Nurses All services: Dermatome, Osteotomy, Microscope, Laser, Endoscopy Radiology, CT, MRI, Anaesthetics, ICU, Rehabilitation Team
Renal / Liver transplantation
Description Personnel Resources & Activities Also On-Site
See General Medicine and Nephrology Renal Transplant Unit Specialist Surgeon, Specialist Nephrologist, Specialist Nursing, Transplant Coordinator, Registrars Dedicated renal transplant unit Dialysis, Radiology, Anaesthetics, ICU, Immunology Lab, Pharmacology, Bacteriology
Liver Transplant Unit As Renal Unit plus Specialist Hepatologists Dedicated Liver Transplant Unit As Renal Unit plus Virology
Respiratory Medicine (n.b. No mention of specialist MDR TB facilities?)
Description Personnel Resources & Activities Also On-Site
Regional General Medicine Service Specialist General Physician and MOs , Technologists Diagnosis, acute care and referral, spirometry, oximetry, outreach from referral centre ICU (?) Radiology
Tertiary Pulmonology Service Specialist Pulmonologists, Registrars, MOs, Pulmonology Technologists Comprehensive Pulmonology service, including Respiratory ICU Radiology, CT, Nuclear Medicine, Thoracic Surgery, Occupational Health, Tuberculosis Control Program, Infectious disease specialities, Radiation Oncology services, and Physiotherapy
National Pulmonology Referral Centre As Tertiary As Tertiary plus: lung volume reduction surgery, lung transplantation (with Thoracic Surgery) As Tertiary
Rheumatology
Description Personnel Resources & Activities
Regional General Medicine Service Specialist General Physician and/or MOs with Rheumatology diploma Uncomplicated rheumatoid arthritis, gout, osteoarthritis, follow-up of tertiary cases
Tertiary Rheumatology Service Specialist Rheumatologists, Registrars, MOs, Specialist Nursing All Rheumatology, DEXA scans
Not Envisaged
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Also On-Site
Radiology
Radiology, MRI, Pulmonology, Nephrology, Neurology, Dermatology and Haematology, Orthopaedics
Spinal Injury Rehabilitation & Management
Description Personnel Resources & Activities Also On-Site
Acute Rehabilitation Service “Acute Care team” (composition not specified) Theatres, Spinal Beds, Turning Teams / Beds ICU, CT, Anaesthetics, General Surgery, Orthopaedic Surgery, Psychology, Physician
Acute Rehabilitation Service “Acute Care team” (composition not specified) Theatres, Spinal Beds, Turning Teams / Beds ICU, CT, MRI, Anaesthetics, General Surgery, Orthopaedic Surgery, Urology, Neurosurgery, Plastic Surgery, Psychology, Physician
No Quaternary Level (n.b. Strong focus on strengthening PRIMARY rehabilitation services in report, requiring a comprehensive PHC rehab centre)
Trauma
Description Personnel Resources & Activities Also On-Site
Level II Trauma Services Specialist General Surgeons & Physicians, SpecialistOrthopaedic Surgeons 24 hour initial definitive trauma care regardless of severity of injury, stabilisation for transfer of complex trauma (coordinated by General Surgery) Anaesthetics, Radiology, High Care
Tertiary Major Trauma Centre Specialist Trauma Surgeons (sub-specialist General Surgeons) Comprehensive care for all trauma in coordination with other specialties Anaesthetics, Radiology, ICU, All other major specialties and surgical sub-specialties
Not Envisaged
Urology
Description Personnel Resources & Activities Also On-Site
Regional General Surgery Service Specialist General Surgeon, Urology Registrar rotated from tertiary centre Basic urology service Radiology
Tertiary Urology Service Specialist Urologists, Registrars, MOs Comprehensive Urology Service and outreach to regional hospitals Not Specified
Not Envisaged
Vascular surgery
Description Personnel
Regional Vascular Surgery Service Specialist Vascular Surgeon, General Surgeon
Tertiary Vascular Surgery Service Specialist Vascular Surgeons
Not Envisaged
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Resources & Activities Also On-Site
Majority of Vascular Surgery cases Anaesthetics, Radiology, Duplex Doppler, General Medicine, ICU
All Vascular Surgery Anaesthetics with special interest, Radiology (incl. Interventional), Duplex Doppler, General Medicine, ICU, Cardiology, Neurology, Endocrinology
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Regional Hospital Tertiary Hospital National Referral Centre
Anaesthetics
Not Specified
Not Specified
Not Specified
Burns
Description Personnel Resources & Activities Also On-Site
Burns Service at Selected Regional Hospitals Only General Surgeon, MOs, Nursing Dedicated burn care facility for minor and moderate burns, Telemedicine link High care, general or plastic surgery
Specialised Burns Unit Specialist Burn Care Surgeons, Specialised Nursing Dedicated Burns ICU and Theatre Trauma, Plastic & Reconstructive Surgery, Rehabilitation Team, Dietician, Social Work
None
Cardiology (No alternative scenarios offered; main difference probably in number of units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional General Medicine Service General Physicians with Cardiology Training, Technologists, General Nursing Echocardiography, Ultrasound, Electrocardiography, Stress Testing ICU, Internal Medicine
Specialist Cardiologist Service Cardiologists, Snr. Registrars, Radiographers, Cardiac / Cath Lab Technologists, ICU staff, Dietician, OT, Physio, Other Rehab Echocardiography, Ultrasound, Electrocardiography, Stress Testing, ECG Holter Pacemaker follow-up, Cath Lab, Electrophysiology Ablation, Cardiac Surgery, MRI, Nuclear Medicine, ICU, Respiratory Med, Diabetes care, Dialysis, Neurology, Vascular Surgery, Anaesthetics, Paediatrics, Full Rehabilitation Service
As Tertiary plus: Heart Transplant, Cardioverter Defibrillators, LV assist devices
Cardiothoracic surgery (No alternative scenarios offered; main difference probably in number of units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional General Medicine & Surgery Specialised Cardiothoracic Surgery Centre Specialist Cardiothoracic Surgeons, Registrars, MOs, Nursing Full Cardiothoracic service ICU, Radiology, Cardiology & Paediatric Cardiology, Respiratory Medicine
National Cardiothoracic Hub As Tertiary As Tertiary plus heart / lung transplant ICU, Radiology, Cardiology & Paediatric Cardiology, Respiratory Medicine
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Clinical Immunology (No alternative scenarios offered; main difference probably in number of units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional General Medicine Service General Physician, MOs, Specialist Nurse Diagnosis and basic treatment Laboratory
Tertiary Clinical Immunology Specialist Clinical Immunologist, MOs Advice centre, Inpatient beds, Immunotherapy modalities, Research & Teaching, Preventative Immunology Access to all major disciplines, Laboratory
National Referral Centre Specialist Clinical Immunologists & Scientists As Tertiary plus gene sequencing, sophisticated and innovative immunotherapy As Tertiary plus Technical College
Clinical pharmacology (No alternative scenarios offered; MTS team queries feasibility of regional service under this scenario?)
Description Personnel Resources & Activities Also On-Site
None (Group please comment, especially how many regional specialists outside tertiary centres at present?)
Tertiary Clinical Pharmacology Service Clinical Pharmacologists, Specialised Laboratory Scientists Training and advice to all levels of care, patient-level consultation, laboratory support and advice Forensic Laboratories
National Policy Support Unit As Tertiary Support for Government policy and regulation of pharmaceuticals and traditional medicines As Tertiary
Craniofacial Surgery
Description Personnel Resources & Activities Also On-Site
Not Envisaged Not specified Not specified Not specified
Not Envisaged Not specified Not specified Not specified
1 National Referral Centre Not specified Not specified Not specified
Critical Care / ICU (No alternative scenarios offered; main difference probably in number of tertiary and national referral units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional ICU Service Medical ICU Director, Nurse Manager (Critical Care Trained), Medical & Nursing Support Int. care for patients with not more than 1 organ failure & not expected to require >3 days ventilation 24-hour lab & radiology services
Tertiary ICU Service 24 hour cover by trained intensivists and ICU trained nurses, ICU Technologists Full ICU services 24-hour lab & radiology services
ICU Support for Quaternary Services As Tertiary but larger, sub-specialty training for ICU nurses, 24 hour ICU Technologists Additional support for transplantation and cardiac surgery and certain other quaternary services As Tertiary
Dermatology (No alternative scenarios offered; MTS team queries
Description Personnel
Regional General Medicine Service General Physician, MOs, Specialist Nurse
Tertiary Dermatology Service Specialist Dermatologists, Regs, Specialised Nursing
None
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
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feasibility of “ideal” specialist regional service?)
Resources & Activities Also On-Site
Full dermatology inpatient service and specialised clinics Not stated
Diagnostic Radiology (No alternative scenarios offered; MTS team proposes no PET under this scenario, smaller number of tertiary centres)
Description Personnel Resources & Activities Also On-Site
General Radiology Service Radiologist, Radiographers, Ultrasonographer, Nursing, Technical X-Ray, Fluoroscopy, Single-slice CT, Ultrasound, Telelink to tertiary centre General Surgery
Specialised Radiology Service Radiologists, Radiographers, Ultrasonographer, Nursing, Technical, Medical Physics, IT X-Ray, Fluoroscopy, Ultrasound, Multi-slice CT Scan, MRI, Mammography, Colour Doppler US Anaesthetics, Clinical Engineering
Specific High-Cost Facilities As Tertiary Interventional Neuroradiology, Cardiac Imaging
Ear, Nose & Throat Surgery (No alternative scenarios offered; MTS team proposes General ENT service at only selected Regional hospitals e.g. 1 in 3 under this scenario; plus fewer tertiary centres?)
Description Personnel Resources & Activities Also On-Site
Supra-regional General ENT Service ENT Specialist, MOs Basic ENT surgical equipment, Audiometry / Audiology – Selected Hospitals Only Radiology
Specialised ENT Service ENT Specialists, Registrars, MOs ENT Surgery, Bone Laboratory, Vestibular Studies, Laser Endoscopic Surgery, Audiometry / Audiology MRI, ICU, Neurosurgery, Oncology, Radiology (and access to all other tertiary depts as required)
Super-Specialist Service attached to Tertiary ENT Specialists with specific expertise Cochlear Implants, Skull Base Surgery
Endocrinology
Description Personnel Resources & Activities Also On-Site
Regional General Medicine Service MOs and Nurses with specific training Type 2 Diabetes and common thyroid disorders Dietician, General Surgery, Ophthalmology
Tertiary General Medicine Service Specialist General Physicians, Registrars, MOs and Nurses with specific training Thyroid and Type 1 & 2 Diabetes, all complex diabetics, all other endocrine disorders (incl. Metabolic, bone and lipid disorders) Sonar, CT, Nuclear Medicine, Ophthalmology, Dietician, Podiatrist, General Surgery, Chemical Pathology
National Endocrinology Referral Centre Adult and Paediatric Specialist Endocrinologists, Registrars, MOs, Nursing All highly complex metabolic / endocrine conditions, including transplants and fertility management As Tertiary plus MRI, bone density, Invasive Radiology, Endocrine Surgeon, Neurosurgery, Vascular Surgery, Obstetrics, Dialysis, Transplant Surgery, Radiation Oncology
Gastroenterology & Hepatology
Description Personnel
Level II GIT Service Specialist General Physician or Surgeon (with GIT
) G
Tertiary GIT Service Specialist Medical and Surgical Gastroenterologists,
O S
Specialist Liver Unit Specialist Clinical Hepatologists, Hepatic Surgeons,
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
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(No alternative scenarios offered; MTS team proposes smaller number of Tertiary and National units under this scenario)
Resources & Activities Also On-Site
training), GIT Nurses, Registrars on rotation Upper GI endoscopy, Proctoscopy, sigmoidoscopy and colonoscopy, acute GIT emergencies Not stated
Registrars, MOs, Specialised Nursing, Technicians Super-specialist activities: Upper GIT, hepatico-pancreatic-biliary diseases, colon diseases Virology, Immunology, CT, ICU
Pathologist MARS machine, bioartifical liver support devices Liver Transplant Unit
General Medicine (Smaller number of tertiary centres, reduced capability for outreach to regional under this scenario)
Description Personnel Resources & Activities Also On-Site
General Medicine Service Generalist Specialist Physician, Visiting Sub-Specialists, Registrars, MOs, Nursing Coronary care, ICU, Haemodialysis, Echocardiography, Scopes, Sonar CT Scan, Radiology, General Surgery, Obs & Gynae, Paediatrics, Allied Health Professionals e.g. Physiotherapy, Nutrition, OT
General Medicine & Sub-Specialist Medicine Service Generalist Specialist Physicians, Sub-Specialist Physicians, Registrars, MOs, Nursing Coronary care, ICU, Haemodialysis, Echocardiography, AT Scan, Angiography, Scopes, Sonar, Outreach to Regional Hospitals MRI, CT Scan, Radiology, General Surgery, Obs & Gynae, Paediatrics Allied Health Professionals e.g. Physiotherapy, Nutrition, OT.
No difference from Tertiary
General Surgery (Smaller number of tertiary and national centres under this scenario)
Description Personnel Resources & Activities Also On-Site
Regional General Surgery Service Specialist General Surgeons, Registrars, MOs, Nursing, Anaesthetists “All general surgery” All general disciplines, Radiology, Allied Health Disciplines incl. Stoma therapists and Nutritional units
Tertiary General Surgery Specialist General Surgeons with special interests, Registrars, MOs, Nursing, Anaesthetists Complex and high acuity Anaesthetists, Radiology with CT and interventional capability, ICU
National Surgical Referral Centre Super-Specialists, Registrars, MOs, Nursing, Anaesthetists Specific procedures e.g. liver and major pancreatic resections, TME As Tertiary
Geriatrics (Smaller number of tertiary centres under this scenario)
Description Personnel Resources & Activities Also On-Site
General Medicine for Geriatric Patients General Physicians, MOs, Nursing, Physio, OT, Speech Therapist, Social Worker, dietician and chiropodist. Integrated General Medical Unit and Rehabilitation Service CT, Radiology, Echocardiography, ICU, General
Specialised Geriatric Service Specialist Geriatricians, Registrars, MOs, Nursing, Physio, OT, Speech Therapist, Social Worker, , dietician, clinical psychologist and chiropodist. Acute Geriatric Care, Stroke Unit, Psycho geriatric Care, Rehabilitation Service
No Quaternary Level Envisaged
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
66
Surgery, Gynaecology, Psychiatry, Orthopaedics andold age psychiatry with suitably trained nursing staff.
MRI, CT, Radiology, Echocardiography, ICU, All Other Adult Tertiary Specialties especially Neurology, Cardiology, Orthopaedics, Urology
Haematology (No alternative scenarios offered; main difference probably in number of tertiary and national referral units affordable?)
Description Personnel Resources & Activities Also On-Site
No Regional Service Possible Outreach Activities (not specified)
Tertiary Haematology Service Specialist Clinical Haematologists, Pathologists with special interest, Registrars, MOs, Nursing Malignant haematological and clonal disorders, non-malignant haematological disorders; Apheresis, isolation, stem cell harvesting and storage facilities Oncology (Medical & Radiation), Radiology,
Bone Marrow Transplantation Unit Linked to a Tertiary unit Allogeneic Bone Marrow Transplantation Not specified
Human Genetics (No alternative scenarios offered; main difference probably in number of tertiary and national referral units affordable?)
Description Personnel Resources & Activities Also On-Site
Genetic Diagnosis & Counselling Service Genetic Nurse, Regional Coordinator (nurse) for district hospital genetic services Basic diagnostic, counselling and therapeutic support (incl. Amniocentesis) Radiology, Obs & Gynae, Paediatrics, Gen. Med., Gen. Surg., Social Workers
Tertiary Genetics Service Specialist Medical Geneticists, Genetic Nurses / Counsellors, Medical Technologists Diagnostic services and complex counselling and care As regional plus Ultrasound
National Genetics Centre As Tertiary Specialised molecular diagnostic tests, Inborn Error of Metabolism screening & diagnosis As Tertiary
Infectious Diseases (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional General Medicine Specialist General Physician, Registrars, Nurses with specific training, infection control, microbiologist and virologist. Complex conditions not manageable at Level I; endoscopy, bronchoscopy, isolation facilities, HIV, HAART and expanded antibiotic formulary. Radiology, CT, ICU, microbiology, virology, immunology, social work
Tertiary Infectious Diseases Specialist Infectious Diseases, Registrars, MOs, Specialist Nursing, infection control, microbiologist and virologist. Unusual infections, complicated malaria and HIV, HAART, isolation facilities, complicated TB, novel antibiotics and training in infectious diseases. Radiology, CT, MRI, ICU, dialysis, microbiology, virology, immunology, social work
National Institute for Communicable Diseases. (n.b. no mention of containment facilities?)
Medical & Radiation Oncology (n.b. fewer tertiary centres under
Description Personnel
Regional General Medicine Service MO with oncology diploma or Mos working under the
Tertiary Oncology Service Specialist Medical and Radiation Oncologists,
National Oncology Referral Service iThemba Labs. As Tertiary
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
67
this scenario)
Resources & Activities Also On-Site
supervision from a major centre. Social workers and oncology nurses with necessary onsite training, as technicon training alone is insufficient. Basic medical oncology: basic care, follow-up, general palliative therapy and terminal care. No radiation oncology on site. Radiology, basic laboratory and X-ray services, Luminar flow and pharmacists, basic chemotherapy, General Surgery, Obs & Gynae, Dietician, Psychiatry, Social Work
Therapy Radiographers, Oncology Nurses, Clinical Research Coordinators, medical physicists, pharmacists, social workers, mould room technicians, radiation laboratory technicians and radiobiologists Linear Accelerator, CT scan planning, Brachytherapy Cobalt Isolation facilities, Single bed units, Most standard chemotherapy and biological drugs, monoclonal antibody therapy, neutropenic isolation areas for patients receiving chemotherapy esp. leukaemias and lymphomas, and therapeutic isolation areas for patients receiving radioactive isotopes. Radiology, CT, ICU, Surgical Oncology, Gynaecological Oncology, MRI scanning, nuclear medicine, laboratories, general surgery, gynaecology, central venous access facilities and research laboratories.
Bone Marrow Transplant, Stereotactic Radiation, laminar flow, cryopreservation, T-cell depletion facilities, inter operative radiation, autologous and allogeneic stem cell transplant units and further development of the South African Bone Marrow Transplant Registry to obtain volunteer unrelated donors for stem cell transplant patients. As Tertiary plus Nuclear Medicine, Haematology
Mental Health Services (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional Mental Health Service Specialist Psychiatrist, Clinical Psychologist, Registrars, Psychiatric Nurses, OT, Social Work Acute inpatient, outpatient; child and adolescent psychiatry, ECT, liaison, satellite clinics General Medicine, Neurology (?), Paediatrics
Tertiary Mental Health Service Specialist and sub-specialist Psychiatrists, Clinical Psychologists, Registrars, Psychiatric Nurses, OT, Social Work Child and adolescent psychiatry; Old-age psychiatry; Forensic psychiatry; Substance abuse; Liaison psychiatry; Eating disorders; Inpatient psychotherapy; Social psychiatry; Acute psychotic (complicated); Acute non-psychotic (complicated) All Specialties
Not Envisaged
Neonatology (n.b. fewer tertiary centres under this scenario)
Description Personnel
Neonatal Low & High Care Unit Specialist Paediatricians, MOs, Nurses with specific training
Neonatal Intensive Care Unit Specialist Neonatologists, Paediatricians, MOs, Specialist Nursing
Not Envisaged
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Resources & Activities Also On-Site
Low and high care; short-term ventilation awaiting transfer, Kangaroo care Radiology, CT, Ultrasound, Physio, OT, Dietician, Speech Therapist, Social Work, Technical Support
Intensive and high care, obstetric and perinatal services, Kangaroo care As Regional plus MRI; access to all Paediatric Sub-Specialties
Nephrology (Dialysis offered only at selected regional hospitals, fewer tertiary centres, only renal transplant under this scenario)
Description Personnel Resources & Activities Also On-Site
Supra-Regional Dialysis Service Specialist General Physician and nurses with renal training, dialysis therapists, technologist Haemodialysis & peritoneal dialysis for stable chronic patients, primary prevention, organ donation Social worker, dietician
Tertiary Nephrology Service Specialist Nephrologists, Registrars, Spec. nurses, dialysis therapists, technologists, social worker Haemodialysis & peritoneal dialysis chronic & acute, primary prevention, organ donation, referral for transplant Radiology, Dietician
National Referral Centre As tertiary plus psychologist Haemodialysis & peritoneal dialysis chronic & acute, renal transplantation As Tertiary; Transplant Surgery
Neurology (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional General Medicine Service Physician with Neurology Diploma Not specified Radiology, CT
Tertiary Neurology Service Specialist Neurologists, Registrars, MOs, Specialist Nurses, Technologists Neurology, EEG, Stroke Unit Rehabilitation Team, Radiology, MRI, CT, ICU
Not Envisaged
Neurosurgery (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
General Surgeon / Trauma Service General Surgeon, Rehab staff Trauma and Neuro-rehabilitation CT Scan, ICU, Rehab Team
Only two levels envisaged “National Tertiary” Specialist Neurosurgeon Service Neurosurgeons, Registrars, MOs, nursing Neurosurgical theatres & equipment for full range of neurosurgical operations and management CT & Neuroradiology, Neurology, Full Rehabilitation team, ICU
Nuclear Medicine
Description Personnel Resources & Activities
None Tertiary Nuclear Medicine Centre Specialist Nuclear Physician, Specialised Radiographers, Medical Physics, Technologists Diagnostic and Therapy Nuclear Medicine
None
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
69
Also On-Site
Not Stated in Report
Obstetrics and Gynaecology (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional Obstetrics & Gynaecology Service Specialist General Obstetricians & Gynaecologists, Registrars, MOs, Nursing Emergency obstetrics, ultrasound, prenatal diagnosis, Kangaroo care, Emerg. Gynaecology, diagnosis, basic urogynaecology, mid trimester abortions or adequate systems for pain relief, basic menopause and screening programmes, preliminary investigations for infertility Anaesthesiology, High Care / ICU (adult and baby) basic oncology
Tertiary Obstetrics & Gynaecology Service Specialist & Sub-Specialist Obstetricians & Gynaecologists, Registrars, MOs, Nursing As regional plus: Fetal / Maternal medicine, Oncology, Urogynaecology, Reproductive Medicine Anaesthetics, Radiology, ICU, Neonatology, Human Genetics, All Medical Sub-Specialities, Paediatric Surgery, Radiation Oncology, Colorectal Surgery, Urology, Endocrinology, Plastic Surgery, Physio, Pathology, Psychology
Not Envisaged
Opthalmology (No alternative scenarios offered; Ophthalmology only at selected Regional Hospitals, fewer tertiary centres under this scenario?)
Description Personnel Resources & Activities Also On-Site
Supra-Regional General Ophthalmology Service Specialist Ophthalmologist, Registrars / MOs, Nursing Operating Room & Microscope, Argon & Yag Lasers, routine ophthalmic surgery Anaesthetics, Radiology
Specialised Ophthalmology Service Specialist Ophthalmologists, Registrars and MOs, Orthoptist, Nursing Complex surgery, B Scan Ultrasound & imaging, Electro diagnostics Neurology, Neurosurgery, Radiology, Anaesthetics, Oncology, Paediatrics, Physicians
Super-Specialist Ophthalmology Service As Tertiary Oncological surgery, Genetics, Specialised paediatric, Photodynamic therapy As Tertiary plus MRI, Human Genetics
Oral and Maxillofacial Surgery
Description Personnel Resources & Activities Also On-Site
Regional dental services Not specified Not Specified Not Specified
Not Envisaged
Not Envisaged
Orthopaedics
Description
General Orthopaedics
Sub-Specialty Orthopaedics
Orthopaedic Oncology Centre
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
70
(No alternative scenarios offered; main difference probably in number of tertiary and national units affordable?)
Personnel Resources & Activities Also On-Site
General Specialists, MOs, Nursing All general orthopaedic surgery High Care, X-Ray, Ultrasound, General Medicine, General Surgery, Rehabilitation Team, Orthotics, prosthetics
Specialists with special interests, Registrars, Nursing Arthroplasty, Spinal Surgery, Hand Surgery (?) As regional plus MRI, CT, ICU, access to all other tertiary specialties
Super-Specialists Spinal, Tissue Engineering As tertiary (n.b presumably close link to Oncology?)
Other Rehab Specialists (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional Rehabilitation Centre Physiotherapy, Occupational Therapy, Orthotics & Prosthetics, Speech therapy, Dietetics, Podiatry Combined Rehabilitation Team & Facility to provide integrated rehabilitation All Regional Hospital Services
Tertiary Rehabilitation Centre Physiotherapy, Occupational Therapy, Orthotics & Prosthetics, Speech therapy, Dietetics, Podiatry, Audiology Combined Rehabilitation Team & Facility to provide integrated rehabilitation Spinal Surgery, Arthroplasty Surgery, Arthroscopic Surgery (including revision surgery) Paediatrics, hand and Upper Limb Surgery, Foot and Ankle, Chronic Sepsis, oncology All Tertiary Hospital Services
Paediatric Medicine (Main difference probably in number of tertiary and national units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Medicine Service Specialist General Paediatrician, MOs, Nursing General & emergency paediatrics, neonatology, child abuse, child health service Radiology, Neonatal High Care, Isolation facilities, Anaesthetics, Obs & Gynae, Paed Surgery, Rehabilitation Team, Social Work
Tertiary Paediatric Medicine Service Specialist General and Sub-specialist Paediatricians, Registrars, MOs, Specialist Nursing General Paediatrics plus Genetics, Child Psychiatry & Behavioural Paediatrics, Infectious Diseases and full range of Paediatric Sub-Specialties As Regional plus all surgical sub-specialties, Oncology, Nuclear Medicine, ICU, NICU
National Paediatric Referral Centre Super-specialist Paediatricians / Surgeons, Registrars, MOs, Specialist Nursing Organ transplantation, certain high-cost / complexity medical interventions As Tertiary
Paediatric Cardiology (No alternative scenarios offered; main difference
Description Personnel
Regional Paediatric Medicine Service Specialist General Paediatrician with cardiology training
Tertiary Paediatric Cardiology Service Specialist Paediatric Cardiologists & Cardiac Surgeons, Cardiac Anaesthetists, Clinical T h l i t ECG T h i i
National Paediatric Cardiology Referral Centre As Tertiary
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
71
probably in number of tertiary units affordable?)
Resources & Activities Also On-Site
Echocardiography Not specified
Technologists, ECG Technicians Echocardiography, Cardiac Cath & Cardiac Surgery Paediatric ICU, MRI, CT, Nuclear Medicine
As Tertiary plus Transplants, Electrophysiology As Tertiary
Paediatric Child Development
Description Personnel Resources & Activities Also On-Site
General Paediatric Medicine Service General paediatrics, Nurses, Physiotherapy, OT, Speech Therapy Basic paediatric development, screening e.g. vision and hearing Vision and hearing screening
Child Development Services Specialist child developmentalist, Nurses, Physiotherapy, OT, Speech Therapy, Audiology, Dieticians, Social Workers Full developmental service. Neurophysiology (BAER, VER, EEG, EMG) Basic laboratory services, Radiology: CT and MRI, Psychology, Paediatric Psychiatry, Orthopaedics, Neurosurgey, ICU, General out patient facilities.
As Tertiary None None None
Paediatric Critical Care (ICU) (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
Critical Care of Children Paediatricians, MOs and nurses with paediatric resuscitation skills at least 1 specialist with post graduate paediatric resuscitation and stabilisation training Recognise critically ill children, resuscitate and stabilise for transfer, telemedicine link to tertiary Radiology, Paediatric Surgery & Medicine
Paediatric ICU Service Paed. Intensivist as Medical Director, Paed ICU-trained Nurse as Nursing Director, Paed ICU nurses, ICU technologist Full Paediatric ICU Service 24-hour Lab & Radiology, access to all Paeds
ICU Support for Quaternary Paediatric Services As Tertiary, but with personnel possessing sub-specialty skills Support to e.g. transplant, cardiac surgery, neurosurgery etc. As Tertiary
Paediatric Endocrinology / Diabetes (n.b. fewer tertiary centres under this scenario)
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Medicine Service Specialist General Paediatrician, Trained Nurses andMOs Diagnosis, early referral, emergency care Telemedicine, Social Work
Tertiary Paediatric Endocrinology Service Specialist General Paediatrician with interest in Endocrinology, Staff & Patient Educators Comprehensive Endocrinology Service, outreach, screening Psychology, Paediatric Surgery, Radiology, Genetics
National Paediatric Endocrinology Referral Unit Specialist Paediatric Endocrinologist, Molecular Laboratory Complex and rare metabolic disorders, advanced investigations As Tertiary
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
72
Paediatric Gastroenterology (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Medicine Service Specialist General Paediatrician Diagnosis, basic treatment, follow-up management of tertiary cases Radiology, Counsellors, Social Work, Paed Surgery, Chemical pathology, haematology
Tertiary Paediatric Gastroenterology Service Specialist Paediatric Gastroenterologists Clinical, endoscopic and lab evaluation, treatment As Regional plus: ICU, Other Paediatric Sub-specialties, Dietetics, Infectious Diseases, Adult GIT, Full laboratory service, including histopathology, EM, microbiology, endoscopy theatre
National Paediatric Referral Centre Super-specialist Transplant Team, Transplant Surgery, Metabolic laboratory, complex liver and intestinal surgery As Tertiary plus Pharmacology lab, interpreters, child mental health services, social workers, paediatric surgery
Paediatric Haematology/ Oncology (n.b. fewer national centres under this scenario)
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Medicine Service Specialist General Paediatrician / Visiting Consultant Palliative care and identification for possible diagnosis Radiology, Ultrasound, Social Worker
Tertiary Paediatric Medicine Service Specialist General Paediatrician Chemotherapy under guidance, palliative care, diagnosis Radiology, CT, High Care, Social Worker, Physio, Paediatric Surgery
National Referral Paediatric Haematology Sub-Specialist Haematologist / Oncologists, Specialist Nurses Full diagnostic and treatment services with autologous and allogeneic Bone Marrow Transplant at selected site(s) Radiology, CT, Radiation Oncology, ICU, High Care, Hospital School, Paediatric Surgery and Surgical Sub-specialties
Paediatric Infectious diseases
No Separate Report – See Paediatric Medicine
No Separate Report – See Paediatric Medicine
No Separate Report – See Paediatric Medicine
Paediatric Nephrology and Transplant (n.b. fewer national centres under this scenario)
Description Personnel Resources & Activities Also On-Site
Regional Paediatric Medicine Service Specialist General Paediatrician, MOs Screening and treatment of basic conditions, Telemedicine link to referral unit Radiology, Social Work
Characterised as Quaternary Service Quaternary Paediatric Nephrology Service Specialist Paediatric Nephrologists, Specialist Nurses, Technologists, Specialist Paediatric Surgeons Biopsies, Peritoneal and Haemodialysis, Renal Transplant Radiology, Sonar, ICU, Nuclear Medicine, Psychology,Social Work
Paediatric Neurology Description Regional Paediatric Medicine Service Paediatric Neurology Service National Referral Service
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
73
(No alternative scenarios offered; main difference probably in number of tertiary units affordable and scope of activity at national referral centre?)
Personnel Resources & Activities Also On-Site
General Paediatricians, Nursing, Physio, OT, Speech Therapy Basic paediatric care e.g. epilepsy, CPs, chronic rehabilitation Radiology
Specialist Paediatric Neurologists, Developmental Paediatricians, Nursing, Physio, OT, Speech Therapy Full paediatric neurology services and telemedicine support to regional CT, MRI, spectroscopy, ICU, Neurosurgery, Radiology, EEG & EMG, Psychology, Psychiatry, Social Work
As Tertiary Complex epileptic surgery, complex neuromuscular patients, neurodegenerative and metabolic patients, Video telemetry, intracranial mapping, neuro-metabolic lab. As Tertiary plus histopathology, molecular genetics, metabolic specialists
Paediatric Respiratory Medicine & Allergology (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
General Paediatric Medicine General Paediatricians No specific activities described
Tertiary Paediatric Respiratory & Allergology Service Specialist Paediatric Pulmonologists & Allergologists,Specialist Nursing Spirometry, skin prick testing, spacers, histamine challenges, bronchoscopy Radiology, Spiral CT, Paediatric ICU, NICU, Paediatric Cardiothoracic Surgery, Dieticians, Physio, Psychology
Not Envisaged
Paediatric Rheumatology (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
General Paediatric Medicine General Paediatricians Screening, follow-up and step-down of tertiary cases Radiology, Phsyio, OT, Orthopaedics
Tertiary Paediatric Rheumatology Service Specialist Paediatric Rheumatologist, Specialist Nurse Practitioner Diagnosis and treatment: lupus, dermatomyositis all vasculitides, problem JCA and systemic onset disease. All connective tissue diseases. Radiology, MRI, Paed ICU, Rehabilitation Team, Adult Rheumatology, Nephrology, Ophthalmology, Paed Orthopaedics
No National Referral Centre
Paediatric Surgery (No alternative scenarios
Description Personnel
Regional Paediatric Surgery Service Specialist General Surgeon, MO with Diploma in
Tertiary Paediatric Surgery Service Specialist Paediatric Surgeons, Registrars, MOs,
National Paediatric Referral Centre Super-specialist Paediatric Surgeons, Registrars,
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
74
offered; main difference probably in number of tertiary and national units affordable?)
Resources & Activities Also On-Site
Surgery Basic and general paediatric surgery Anaesthetics, Radiology, General Paediatrics, ICU
Specialist Nursing Comprehensive paediatric surgery – general and sub-specialties As regional, All Paediatric disciplines
MOs, Specialist Nursing Organ transplantation, epilepsy surgery, craniofacial surgery As Tertiary
Plastic & Reconstructive Surgery
Description Personnel Resources & Activities Also On-Site
None Tertiary Plastic & Reconstructive Surgery Specialist Plastic Surgeon, Registrars, MOs, Specialist Nurses All services: Dermatome, Osteotomy, Microscope, Laser, Endoscopy Radiology, CT, MRI, Anaesthetics, ICU, Rehabilitation Team
Mentioned but not Elaborated
Renal / Liver transplantation (Fewer renal transplant units under this scenario)
Description Personnel Resources & Activities Also On-Site
See General Medicine and Nephrology Renal Transplant Unit Specialist Surgeon, Specialist Nephrologist, Specialist Nursing, Transplant Coordinator, Registrars Dedicated renal transplant unit Dialysis, Radiology, Anaesthetics, ICU, Immunology Lab, Pharmacology, Bacteriology
Liver Transplant Unit As Renal Unit plus Specialist Hepatologists Dedicated Liver Transplant Unit As Renal Unit plus Virology
Respiratory Medicine (n.b. fewer tertiary centres under this scenario) (n.b. No mention of specialist MDR TB facilities?)
Description Personnel Resources & Activities Also On-Site
Regional General Medicine Service Specialist General Physician and MOs , Technologists Diagnosis, acute care and referral, spirometry, oximetry, outreach from referral centre ICU (?), Radiology
Tertiary Pulmonology Service Specialist Pulmonologists, Registrars, MOs, Pulmonology Technologists Comprehensive Pulmonology service, including Respiratory ICU Radiology, CT, Nuclear Medicine, Thoracic Surgery, Occupational Health, Tuberculosis Control Program, Infectious disease specialities, Radiation Oncology
National Pulmonology Referral Centre As Tertiary As Tertiary plus: lung volume reduction surgery, lung transplantation (with Thoracic Surgery) As Tertiary
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
75
services, and Physiotherapy
Rheumatology (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
Regional General Medicine Service Specialist General Physician and/or MOs with Rheumatology diploma Uncomplicated rheumatoid arthritis, gout, osteoarthritis, follow-up of tertiary cases Radiology
Tertiary Rheumatology Service Specialist Rheumatologists, Registrars, MOs, Specialist Nursing All Rheumatology, DEXA scans Radiology, MRI, Pulmonology, Nephrology, Neurology, Dermatology and Haematology, Orthopaedics
Not Envisaged
Spinal Injury Rehabilitation & Management (n.b. fewer tertiary centres under this scenario)
Description Personnel Resources & Activities Also On-Site
Acute Rehabilitation Service “Acute Care team” (composition not specified) Theatres, Spinal Beds, Turning Teams / Beds ICU, CT, Anaesthetics, General Surgery, Orthopaedic Surgery, Psychology, Physician
Acute Rehabilitation Service “Acute Care team” (composition not specified) Theatres, Spinal Beds, Turning Teams / Beds ICU, CT, MRI, Anaesthetics, General Surgery, Orthopaedic Surgery, Urology, Neurosurgery, Plastic Surgery, Psychology, Physician
No Quaternary Level (n.b. Strong focus on strengthening PRIMARY rehabilitation services in report, requiring a comprehensive PHC rehab centre)
Trauma (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)
Description Personnel Resources & Activities Also On-Site
Level II Trauma Services Specialist General Surgeons & Physicians, SpecialistOrthopaedic Surgeons 24 hour initial definitive trauma care regardless of severity of injury, stabilisation for transfer of complex trauma (coordinated by General Surgery) Anaesthetics, Radiology, High Care
Tertiary Major Trauma Centre Specialist Trauma Surgeons (sub-specialist General Surgeons) Comprehensive care for all trauma in coordination with other specialties Anaesthetics, Radiology, ICU, All other major specialties and surgical sub-specialties
Not Envisaged
Urology (No alternative scenarios
Description Personnel
Regional General Surgery Service Specialist General Surgeon
Tertiary Urology Service Specialist Urologists, Registrars, MOs
Not Envisaged
APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO
76
offered; main difference probably in number of tertiary units affordable, plus no rotation of registrars to regional hospitals?)
Resources & Activities Also On-Site
Basic urology service Radiology
Comprehensive Urology Service and outreach to regional hospitals Not Specified
Vascular surgery
Description Personnel Resources & Activities Also On-Site
Regional General Surgery Service Specialist General Surgeon Trauma without ICU need Anaesthetics, Radiology, Duplex Doppler, General Medicine
Tertiary Vascular Surgery Service Specialist Vascular Surgeons Majority of Vascular Surgery Anaesthetics with special interest, Radiology (incl. Interventional), Duplex Doppler, General Medicine, ICU, Cardiology, Neurology, Endocrinology
National Vascular Surgery Referral Centre Specialist Vascular Surgeons with special interests Thoracic-abdominal aneurysms, Endovascular AArepair As Tertiary
APPENDIX 4 IDEAL / MINIMUM UNIT SIZES
77
Minimum Staffing Requirements for an Ideal Unit – as per specialty reports Anaesthetics Report not submitted
Cardio thoracic surgery Not specified
Cardiology Not specified
Clinical immunology 1 clinical immunologist/medical school
2 specialist scientists
1 MO/hospital
1 clinical immunology trained nurse/referral centre
Use NHLS for personnel issues
Clinical pharmacology Not specified
Dermatology National referral centre Super specialists with expertise e.g. gene therapy
Tertiary hospital Adequate ratio of specialists and registrars (numbers and type not
specified)
Regional hospitals
Full time specialists (numbers and type not specified)
Diagnostic radiology Number of staff will depend on the size of department and work load
Baseline 24 hr busy general X-ray unit:
7 radiographers
2 radiologists who could cover a group of hospitals
3 nurses
2 typists
2 cleaners
1 regional clinical engineer (to be shared with other centres)
3 darkroom staff
3 clerks
3 porters
Low-activity unit without after hour cover:
3 radiographers
Central hospital
2 Medical Physicists
Radiology workload calculation
0.45 FTE radiologist / 1,000 examinations / month
0.25 FTE radiologists / additional service point added e.g. 0.25 FTE for
1 mammographic unit, 0.25 FTE for 1 fluoroscopic unit
1 FTE / CT scanner in use to be added. If ≥ 1,000 CT examinations are
performed / month and additional 1 FTE radiologist to be added
APPENDIX 4 IDEAL / MINIMUM UNIT SIZES
78
0.5 FTE should be added if the radiology department performs images
for full radiotherapy / oncology departments
2 FTE added / MRI
For registrars a factor of 1.5 registrars / consultant
Radiographers: ≈ 2.7 radiographers / doctor (registrar and consultant)
Endocrinology Requirements for 200 out patients and 15 inpatients/week: Endocrinologist 3 (ideal) 1 (minimum)
Specialist physician 2 (ideal) 1(min)
MO/registrars 3 (ideal) 2 (min)
Trainee 1
Diabetes nurse educators 4 (ideal) 2 (min)
Other sisters 2 (ideal) 1 (min)
Nurses in training 2 (ideal) 1 (min)
Clerks 2 (ideal) 1 (min)
Secretary 1 (ideal) 1 (part-time)
Dietician 2 (ideal) 1 (min)
Podiatrist 1 (ideal) 1 (part-time)
Biokineticist 1 (ideal)
Ophthalmologist (ideal) 1 (part-time)
ENT 1 x Chief Specialist
2 x Specialists
8 x Registrars
2 x Medical Officers
1 x Research assistant
1 x Secretary
Gastroenterology and hepatology
Tertiary Liver Units:
It was felt that at this stage, two liver units were enough. Each centre
should have at least 3 clinical hepatologists, 2 hepatic surgeons and
one pathologist whose main pathological interest should be the liver. All
Liver Transplant Units should be attached to a Liver Unit.
Acceptable Norms regarding tertiary GIT Units:
It was necessary to obtain figures as to what are acceptable norms as
regards the number of the population needed for one gastroenterologist
or one tertiary GIT unit or one tertiary Liver unit. It was noted that these
would be figures derived in Western countries and it needed to be
decided whether these would be appropriate for South Africa or not.
Each of the present GIT units should have 3 medical and 3 surgical GIT
consultants. It is hoped that both the Department of Health and the
clinicians should try and obtain these figures.
It would appear that we are short of the British norms as regards
APPENDIX 4 IDEAL / MINIMUM UNIT SIZES
79
endoscopy units.
General medicine In-patient:
60 patients / specialist physician
2 interns and 2 MO or registrars / specialist
General surgery At least two sub-specialists, or the equivalent FTE’s.
A norm of specialist per beds for tertiary general surgery should be
about one-specialist/ 12 beds. It should however be noted that all
tertiary units must have a training responsibility; some will be for
generalist specialists and other for subspecialty training. Therefore a
system providing for academic increments must be incorporated. The
norm for specialists at LII one specialist for 15 – 20 beds is appropriate.
To determine unit sizes by patient volumes will lead to many of the
inequities that have given rise to this process. We should rather be
developing our own South African norms for the number of specialists
per 100 000 population. Based on this and the available human
resources one can then start to allocate units. This however cannot
ignore the historically developed units, which have shown proven
sustainability. These units must be incorporated into any new system
where appropriate. (e.g. don’t close down three of the four
gastroenterology units in Johannesburg, rather shrink to two and ensure
better referral patterns from nearby surrounding provinces)
Geriatrics For 100 patients / week
In-patient services:
Acute beds: 24 beds
Stroke unit: 10 beds
Psycho geriatrics beds: 24 managed with psychiatrists
Rehabilitation services
Out patient services;
Multi disciplinary assessment clinics
Specialised clinics e.g. dementia, osteoporosis, falls etc.
1 Chief specialist
1 Principal specialist
1 Specialist
2 Career registrars
1 Medical officer
1 Rotating registrars
1 Secretary
Trained nurses, PT, OT, speech therapists, social worker, dietician,
clinical psychologist, chiropodist (to be shared with other subspecialties)
Haematology Not specified
APPENDIX 4 IDEAL / MINIMUM UNIT SIZES
80
Human genetics Four medical geneticists and 16 Genetic Nurses/counsellors
20 Scientists/medical technologists for laboratory testing
ICU/ Critical care Full range of medical and surgical subspecialties (especially paediatric
subspecialties for paediatric intensive care. For adult women full time
obstetrics and gynaecological services. Physiotherapy and pharmacy
services.
Regional hospitals Minimum 6-bed high care with capacity for ventilation for 24-48 hours.
Provincial tertiary hospitals 8-12 beds (minimum)
12 bed (ideal)
High care beds
National referral centre 12 ICU beds (minimum)
20 ICU beds (ideal)
High care beds (overall 4-8% of hospital beds)
Ideal ICU nurse: patient ratio
1 ICU trained staff: 2 (preferably) 1 patient
1 non ICU trained RN: 1 patient
Ideal high Care Unit nurse: patient ratio
1 RN: 1-2 patients depending on severity of illness and turnover
Infectious diseases Sizes of units should be estimated using the number of Infectious
diseases physicians looking after them and the rest of the staff should
be in proportion.
For every infectious disease physician the unit should manage eight to
ten patients.
Medical and radiation oncology
Not specified
Mental health Not specified
Neonatology Level III (NICU) facilities should have a minimum of 4-6 beds per unit.
Given the low birth weight rates, high sepsis rates and the need for
neonatal surgery, the requirements for NICU beds appropriate for South
Africa should not less than 1 to 1,5 per 1000 annual delivery.
Nurses: baby ratio:
Neonatal ICU care unit 1:1
Neonatal High Care unit 1:3
Neonatal Low Care unit 1:5
APPENDIX 4 IDEAL / MINIMUM UNIT SIZES
81
Nephrology All dialysis units should be supervised or serviced by a registered
nephrologist and managed on a day-to-day basis by a specialist
physician with recognised expertise in dialysis.
Medical staff should be readily available to deal with emergencies and
review chronic patients every 3 months (min) and 1 month (ideal).
Staff: patient ratio for chronic dialysis should be 1:4 (including nurses
and clinical technologists): Expanded care 1:2, Basic care 1:3
Acute dialysis; special care 1:1
A registered nurse with haemodialysis experience should be present at
all times in the unit.
Neurology Not specified
Neurosurgey 1 HOD,
2 Principal Specialists
4 Specialists
6 Registrars minimum
2-4 Medical Officers (Alternatively, a minimum of 8
registrars).
Rotating interns for teaching (currently no rotating
interns are present).
Nuclear medicine Difficult to state however, the international guide is 1000-1200
studies/camera/year.
Also, the minimum size of a unit in terms of patient work load depends
on the kind of service the unit is expected to deliver (e.g. limited or
comprehensive)
Obstetrics and gynaecology Generic criteria (HPCSA)
Sub specialty requirements (College of Medicine)
Ophthalmology 2-4 Ophthalmologists per million population,
4-8 MO/Registrars,
1 x orthoptist,
2 x nurses/ OMA per doctor
Nursing staff (registered, enrolled and OMA) for theatre and ward
Orthopaedics Regional level 1 specialist
4 MOs
APPENDIX 4 IDEAL / MINIMUM UNIT SIZES
82
Tertiary and National referral units (not specified) Dependent on size of institution and services rendered
Other Rehabilitation specialties
Not specified, however should be based on patient classification
systems, workload measurement systems and or patient needs.
Paediatric Allergology 1 Specialist
1 Medical Officer (Diplomate in Allergy)
Specialised Nurse
Dietician
Paediatric Cardiology Minimum
2 paediatric cardiac surgical operations/surgeon/week
> 500 echocardiographic studies p.a. (most units are performing 1000-
2000 paediatric cardiac echo studies p.a.
≥ 50 cardiac catheterisation procedures/cardiologist p.a.
Ideal
2 Trained Paediatric Cardiologists
1 Fellow
1 Registrar
≈ 100 congenital heart operations/mil needed p.a.
10 operations/mil for acquired valve disease
Paediatric Critical Care/ICU National referral centres
Minimum: 4 intensivists/18-20 beds/unit
Tertiary Hospitals
24 hrs intensivist to cover ICU @ all times, this is 4-5 intensivists on site
Smaller centres e.g. Bloemfontein
Minimum: 1 Full time intensivist as unit director
Paediatric intensivists to coordinate regional critical care services
Nurse: patients ratio
1 sister and 1 nurse: 2 patients
8 –10 PICUs needed in the country
Maximum size of unit
20- 25 beds, 4 – 5 step down beds 20 ICU
APPENDIX 4 IDEAL / MINIMUM UNIT SIZES
83
Paediatric Child Development Minimum
1 General specialist and 1 career MO at regional level
2 sub specialist at supra regional level
1 sub specialist and 1 training post (Snr. Registrar) at supra provincial
level
1 sub specialist at quaternary level
Ideal
3 skilled generalists and 1 career MO at regional level
3 sub specialists and 1 career MO at supra regional level
2 sub specialists, 2 training posts (snr. Registrars) and 1 career MO at
supra provincial level
1 sub specialist, 1 career MO at quaternary level
Paediatric Endocrinology Establish ”joint” multi disciplinary clinics.
Each teaching hospital should have a paediatrics endocrinology unit
(with support staff and other sub specialist services including radiology
and surgery). Unit size and staffing requirements not specified.
Paediatric Gastroenterology Minimum
At least 2 specialists and a senior registrar for training per unit.
Paediatric Haematology/Oncology
Minimum
2 full time sub specialists / unit
Specialty nurses
Ideal
2–5 dedicated consultants and sub specialists depending on size of unit
1-2 training posts per registered unit
Dedicated nursing staff trained in Haematology/oncology/paediatrics
Higher nurse: patient ratios (as most is HC)
Outreach and home visiting nurse
Paediatric medicine Regional Hospital:
3 Paediatrician
6 Registrar / MO
Paediatric Nephrology and transplantation
Minimum:
2 consultants/unit
ICU back up
GIT team
Transplant surgeons (number not specified)
Transplants: 50 kidneys p.a. and liver 15-20 p.a.
Paediatric Neurology Not specified
Paediatric Respiratory medicine
2 Pulmonologists
Auxiliary staff
Radiology
APPENDIX 4 IDEAL / MINIMUM UNIT SIZES
84
Cardio thoracic
Paediatric Rheumatology 1 specialist rheumatologist
1 dedicated rheumatology nurse practitioner
Paediatric surgery Ideal
Each province to have at least 1- 2 specialised units
At least ≥3 regional paediatric surgery units to be developed
Plastic surgery Ideal norm
1 plastic surgeon per 250 000 patients
Academic Centre
1 Principal Specialist
1 Senior Specialist
2 Registrars
1 MO
Metro Supra Regional
1 Principal Specialist
1 Senior Specialist
2 Registrars
1 MO
Peripheral Supra Regional
1 MO
Renal/ Liver transplant Minimum size: (all personnel P/T = full-time practitioner but part-time
commitment to transplantation)
1 Surgeon
1 physician
1 general anaesthetist
1 nurse for each of the following, ward, theatre and ICU/HC
1 coordinator
1 registrar/MO/intern
Infrastructure: Radiology
Pharmacology
Bacteriology
General ward Ideal size (F/T)
1 specialist surgeon
1 nephrologist
1 expert anaesthetist
3 nurses for each of the following, ward, theatre and ICU/HC
3 coordinator
3 registrar/MO/intern
APPENDIX 4 IDEAL / MINIMUM UNIT SIZES
85
Infrastructure: Radiology
Pharmacology
Bacteriology
2 dedicated wards
Respiratory medicine Tertiary Units
The numbers of equivalents required depend upon the patient load in
tertiary hospitals, the number of extension programmes and additional
administrative and clinical responsibilities. For most provinces at least 5
full-time equivalents are required. At least one dedicated sub-speciality
trainee in pulmonology and another in critical care are required (see
Critical Care document). One training registrar/community medical
officer for Pulmonology.
The absolute minimum requirements for critical mass and cross-cover in
the ICU and extension services are 3 full time individuals in
pulmonology. This does not take into account any clinical work in
general medicine, teaching, training, administrative duties and
University responsibilities or research. There is also a need for trainee
posts and junior staff posts as indicated above.
Regional Units
A Specialist in General Medicine with many special interests but at least
a minor interest in Pulmonology who will liase with the visiting
Pulmonologist and select cases for additional specialist opinion and
referral to the Tertiary Hospital.
In provinces where Pulmonology Units are unlikely to be affordable, a
general physician may be trained in bronchoscopy. However the poor
cost efficiency of trying to maintain optimal equipment and its use
without the support of an effective microbiological service, cyto-
pathologist, quality assure for handling cleaning and sterilisation of the
bronchoscopy equipment and surgical backup for emergencies severely
limit the practicalities of this option (which has been tried in several
regions).
Medical Officers including community service doctors who would have
the opportunity for regular supervision and teaching from a visiting
pulmonologist. Medical officers will be encouraged to take the Diploma
in Pulmonology on a part time basis to enhance their skills
Rheumatology 3 or 4 Consultants
2 to 3 Registrars
1 to 2 Nursing Sisters
1 part-time Medical Officer
Specialist sessional posts should be available. However, these
APPENDIX 4 IDEAL / MINIMUM UNIT SIZES
86
numbers would vary based on the service volumes and the demand for
services in the different areas.
Spinal injury and rehabilitation Minimum:
Spinal TB: 500 beds
Rehabilitation: 12 beds/ million population
Units should be attached to regional hospitals with dedicated staff and
access to other specialised services e.g. urology, surgery etc.
Urology Ideal unit
Academic head
Consultants
Registrars
Ideal staff establishment
Chief specialist
Principal specialist
2 senior specialists
8 registrars
4 medical officers
Ideal number of beds: 70 –100
This ideal unit will be responsible for Urological service to a region
including one or more regional hospitals (level II). Urology Registrars
would rotate to the regional hospital supervised by an urologist e.g.
Durban metropolitan service.
Vascular surgery Minimum:
400 operations p.a. (minimum)
2 vascular surgeons
2 registrars
Sufficient nurses, beds, high care and ICU beds, secretaries, duplex
Doppler
Minimum size vascular training unit:
1 000 operations p.a. (minimum)
2 vascular surgeons
2 registrars
Sufficient nurses, beds, high care and ICU beds, secretaries, duplex
Doppler
2 vascular surgery fellows (post general surgical training who are
vascular surgery trainees for a two year period)