A new way of managing colorectal cancer in the Southern District Health board population must urgently replace competition with co-operation, reviewers say.
It would also cost more, although how much is not spelled out in the review.
A leaked draft of a damning report on Southland access to the board's colonoscopy services says there is urgent need for a new approach to the disease.
Christchurch auditors, general surgeon Phil Bagshaw and gastroenterologist Steven Ding, want a new organisational plan (OP) which aims for the lowest possible incidence of the disease, earliest diagnosis and the best outcomes for established cases.
The board, which has the third-highest incidence of colorectal cancer (CRC) in the country, has too many of these cancers first diagnosed in the emergency department, and spread beyond the bowel at the time of diagnosis, yet one of the lowest colonoscopy rates, they said.
"These unfavourable standards indicate that there are serious problems with the control of CRC in the SDHB population.
"Inadequate resourcing appears to be a major impediment to the SDHB dealing with these problems."
They said access to colonoscopies in the SDHB has become too tightly controlled, with evidence for adverse consequences for patient care.
Auditors said this was apparent in some of 20 Southland cases they reviewed, verbal evidence presented to them, and a survey of senior doctors in 2017, in which 15 clinicians reported being aware of patients they thought had come to harm as a result of having a referral for endoscopy declined.
The report said evidence presented indicated dysfunctional relationships between the gastroenterology department and some other hospital service departments. Relationships with the departments of surgery and medicine at Southland Hospital were particularly strained and there were also concerns about serious staff disputes in the gastroenterology department, itself which might impact on the ability to recruit suitable senior specialist staff in future.
It recommended trauma counselling should be offered immediately to affected clinical and management staff at Southland Hospital. Counselling should also be offered to any members of the gastroenterology department who find the current situation stressful.
A claim of a state of inter-service warfare emerged in interviews with Southland Hospital staff. Staff said two serious attempts by management to resolve problems had failed and one interviewee said another attempt to cosy-up won't work.
Auditors said the OP would need to be organised and co-ordinated between the local community, local general practitioners and community health workers, relevant hospital clinical services and university departments.
Each would need to know how they were expected to function in the plan in an integrated way.
Greater access to elective operating theatre time and fully resourcing the board's second endoscopy room would be part of the plan.
Advocacy might be required to secure such investments. The approach would, however, be likely to receive wholehearted public support.
Changes to the leadership style and organisation of the department of gastroenterology would also be needed, involving mentoring of someone only identified as [G] in the report by a local retired specialist clinician, external help from an organisation such as the Cognitive Institute to work within the department to normalise interpersonal relationships and address communication issues with an established code of behaviour.
The draft report seeks a full review of SDHB endoscopy services by an external senior doctor in a year's time to ensure satisfactory progress is being made.
If progress is not adequate, consideration should be given to having a separate endoscopy service for Southland Hospital.
Auditors want the national guidelines, on which the local guidelines are based, to be subjected to a scientifically robust prospective study to determine the validity of their use as rationing tools.
They suggest the guidelines criteria which outline the conditions under which access to colonoscopy is granted might need extending, but acknowledged this could be a long process.
In the meantime, they want specialist physicians and surgeons with a particular interest in gastroenterology to be able to use their expert clinical judgement to override the local guidelines where they consider this is appropriate. At the moment, the guidelines are being applied to all requests for colonoscopies for symptomatic patients, regardless of who is referring them.
Board chief executive Chris Fleming, who did not wish to comment on the findings of the report before it is finalised, said action had been taken requiring an agreement to be put in place between the gastroenterology department and general surgery for a clear process to allow gastroenterologist specialist override of the referrals. He has not clarified if this is in place yet.
The auditors also recommended Southland clinicians with a gastrointestinal specialty interest and appropriate endoscopy skills should be allowed their own endoscopy lists.
It is not known when the report will be finalised. The draft, dated March 30, is being circulated to those who participated in the review for fact-checking and input.
