19th and 20th September 2002, Kopanong Hotel, Benoni
Note
This report was compiled by representatives from the universities of Cape
Town, Free State, Natal and Stellenbosch. No inputs had been received from Medunsa,
Pretoria and Wits.
CURRENT ORGANISATION OF HAEMATOLOGY SERVICES IN RSA PUBLIC SECTOR
Pop 10,5 million and northern half of Transkei
2 hospitals King Edward with 6 beds
IALCH hospital 13 beds for Haematology and a new 5 bed transplant unit and 5
plasmapheresis beds for apheresis, TTP, GBS etc.
About 20 patients in hospital, in spite of only 6 haematology beds
Clinics: Twice a week at King Edward and daily clinics at IALCH Hospital.
Also a weekly regional hospital clinic in Durban
No overtime pay in Clinical Haematology
Personnel: (Combined Clinical and Laboratory Dept.)
6 consultants
4 Registrars
1 Medical registrar
Nursing staff is Inadequate
Draining Area:. (Half of Cape Metro and Half of WC and Eastern Cape 7,5 Million.)
Both haematopathology and clinical haematology are under one head but there
is a division in labour.
Clinics. Various focus clinics: including Lymphoma and Myeloma and Transplants
clinics
General haematology clinics as well
Clinics: 60 patients a day (general haematology and myeloma)
2 Day wards for chemo, transfusions etc. 12 beds in total
Apheresis section with 2 machines and hyperlipidaemia section (10 patients)
Cytopheresis: only for stem cell collection and lymphophoresis
Beds: Protected enviroment, with 14 beds in total but only 8 active of which
6 have laminar flow. Also 4 beds in general medicine.
Staff: The nursing staff is the backbone but is suffering, presently 60% are
agency staff in the Unit.
Medical Staff (17 total):
3 x clinical consultants
2 x pathology consultants
1 x medical registrar (rotating)
2 x haematology registrars
2 x senior house officers
1 x 5/8 post.
x haemato-pathology registrars and 2 x foreign registrars
Population served about 3 million
Drainage: Free State and Northern Cape. (Sparsely populated and large distances
- less than 10% of the population inhabiting 40% of the country's surface).
(Lesotho is a budget-wise unaccounted source of patients!)
Outpatients
Haematology Clinic Mondays (Clinics consist of general Haematology, Leukaemia
and Myeloma. Lymphoma falls under Dept. of Oncotherapy)
Hypercoagulability Clinic Wednesdays
Haemophillia Clinic Thursday (1/month)
Outreach Clinics Bethlehem and Welkom once a month
(15 –20 patients/clinic)
Inpatients
Beds belong to Internal Medicine. Care taken by the Internal Medicine registrars
but under haematology consultants’ supervision
Beds: Leukaemia Unit with 6 isolation beds for BM/stem cell transplantation
plus 12 haematology beds in General Internal Medicine wards
Day care
A blood cell separator available for plasma-apheresis requirements in hospital.
Cytopheresis procedures are rarely performed.
Personnel (10 doctors)
2 x Clinical Haematologists (Haematology and Cell biology)
4 x Registrars (Haematology and Cell biology)
1 x MO for Haematology (Internal Medicine)
1 x Physician specialising in Clinical Haematology (laboratory component)
1 x Rotating Registrar (Internal Medicine)
1 x Private physician with an interest in haematology (sessions). (Internal
Medicine)
Population served 3.5 to 4 million (an undeterminable number of patients), and overspill from Eastern Cape
Outpatients:
4-5 x/week:
1 lymphoma clinic Wednesday
1 lymphoma and myeloma clinic Monday
2 general haematology clinics Tuesday and Thursday
Occasionally haemophiliacs are seen on a Friday
20 to 30 patients /day
Inpatients:
At the present moment we treat a maximum of 4 acute leukaemia patients
at one time, no dedicated haematology beds at the moment.
Medical beds are used for haematology patients all over Internal Medicine (lymphoma,
myeloma, general haematology)
ICU: no beds yet, but 4-6 isolation beds are in the pipeline
Personnel: (7 doctors)
Nursing: rely on general medicine nurses in a 28-patient ward
Clinicians: (3)
1 senior registrar
1 rotating registrar from Internal Medicine
1 SHO rotating (no overtime)
2 unfilled (clinical haematology) specialist posts
Pathology: (4)
2 consultants
2 registrars
Facilities: no apheresis, no transplant facilities
Radiotherapy will only care for the lymphoma patient when undergoing RT treatment
2.1 Clinical Haematology at a Tertiary and Quaternary Level
There is no uniformity in the various tertiary centres because malignant and clonal disorders constitute about 70% of all haematological disorders seen at a tertiary level. With the result that at some centres haematological malignancies are to a varying degree treated by Medical Oncology and not Haematology. The issue of who must treat haematological malignancies is therefore unresolved and should be sorted out.
2.1.1 Malignant haematological and clonal disorders
Acute Leukaemias
Chronic Leukaemias (especially the initial assessment)
Multiple Myeloma, symptomatic or young
Non-Hodgkin's lymphoma
Hodgkin lymphomas
Patients needing a stem cell transplantation
Complications of oncological treatment for non-haematological malignancies
Non-malignant stem cell clonal disorders (MDS, MPD, PNH).2.1.2 Non-malignant haematological disorders
Aplastic anaemias
Hereditary anaemias
Thrombotic thrombocytopenic purpura
Autoimmune conditions: autoimmune haemolytic anaemia, ITP.
Immuno-deficiency syndromes: congenital and acquired
Various disorders requiring stem cell transplants
Iron overload
Coagulation disorders
Haemophiliacs: complicated cases
Thrombophiliacs: complicated cases2.1.3 Haematology at Tertiary level.
High dose chemotherapy can be given
Autologous stem cell transplantation can be given
Comprehensive haemophiliac management for complicated cases
Specialized haematological diseases treatment /management2.1.4 Haematology at a Quaternary level
Allogeneic Bone Marrow transplantation. Ideally at four centres, i.e. North, South, East and Central.
Likely Technical Developments and Changes in Clinical Practice
2.2.1 Advances in the field of Molecular Biology
This is likely to have a major impact on the diagnosis and treatment of haematological disorders in the future. Molecular and/or immunologically targeted therapy is already being successfully implemented. Gleevec for the treatment of chronic myelogenous leukaemia is one example.
It is also envisaged that gene therapy will become a reality in the near future. A severe haemophiliac can be changed to a moderate form of the disease by simply increasing the factor VIII level by 1-2%. This will have a major effect on the quantity of factor VIII concentrate used and will also have a major impact on the health budget. Clinical trials are already underway.
Insertion of modified genes into haematopoietic stem cells is another example of potential synergy between the laboratory (molecular manipulation of stem cells) and the clinic (transplantation).
Investment in molecular technology is therefore essential in preparation for these developments.
2.2.2 Laboratory Haematology
Near patient testing
Epidemiological, demographic and socio-economic impacts on need and demand for services in haematology
HIV/AIDS will certainly have a major impact on the need and demand for services in haematology. These needs and demands will to a large extent depend on the following:
the development made in the treatment of HIV/AIDS,
the availability of treatment for HIV/AIDS patients, and
Government’s policy towards treatment of HIV/AIDS.Many patients with late stage HIV infection or AIDS and acute leukaemia currently do not receive intensive chemotherapy due to a dismal prognosis. If the long-term prognosis of these patients should improve, a more curative approach to the treatment of their acute leukaemia will follow.
The lymphoproliferative disorders associated with HIV also poses a potentially enormous problem. None of the units in this country will be able to cope with the expected increases (10 times) in the incidence of these disorders with the HIV epidemic maturing into full AIDS. There is an apparent lack in any planing to boost groups or units who deal with lymphomas. Perhaps this needs to be identified as a single most important area where resources need to be channelled to.
Shortcomings and Limitations
The overall quality of tertiary care in haematology is currently inadequate
due to:
Lack of human resources
- A shortage of clinical haematologists
- A shortage of properly trained nursing staff
A shortage of allied health workers
Insufficient beds for patients with blood disorders on secondary and tertiary
level.
Insufficient and outdated equipment
Unavailability of modern drugs
3.1.1 How to address shortcomings
Increase in training of clinical haematologists
Clinical haematologists are extremely versatile and can be very useful at secondary level hospitals. A clinical haematologist, together with a clinical pathologist, would be able to run a comprehensive laboratory, take care of haemophilia and haematology clinics and look after patients with lymphoproliferative disorders.
Increase resources
Accreditation of institutions on all levels.
Independent clinical audits according to accepted international standards
Practice according to good evidence-based-medicine.
Participation in well conducted clinical trials to obtain new drugs.
4.1 Disparities in Access to Services
There are several barriers that impinge upon access to services
Policy:
Patients have to go through the system to get tertiary care and the system on primary and secondary level is not always in place.
Often a delay in diagnosis and referral because of a restriction on basic tests such as full blood countsGeographical
Provincial boundaries (patient may live 200km from a tertiary centre but has to travel 800km).Economic
The poorest are dependent on public transport that is often inadequate.4.2 Suggested improvements
Funding to expose malfunctioning of the services
Regular transport for rural patients
Beneficial to have good secondary and primary services.
5.1 Obstacles
The quality of expected good overall tertiary care in Haematology is lacking in the whole country
The most serious obstacle to maximise the efficient use of the resources at present seems to be the failure of the Administrative and Financial authorities to realise the need of the tertiary level services. Furthermore, it seems as if the authorities' concept of a good doctor is one who comes out with a very limited budget regardless of what the effect on patient care might be.”5.2 Suggestions
Improvement of Human resources
Acute need for good nursing care:
Too few nurses: - need to recruit more nurses
Need for adequately trained nurses at tertiary level
Acute need for trained Clinical Haematologists
Too few trained Clinical Haematologists in South Africa
Laboratory services
More trained pathologistsAttracting long term pathologists is problematic due to remuneration and other reasons.
Molecular techniques should be available on short notice in the immediate neighbourhood of such centresPhysical and technical resources also require improvement
The following should be available at all tertiary services:
Apheresis equipment,
Isolation rooms and protected environment wards,Adequate equipment to provide high dose chemotherapy/stem cell support services. Other support services:
Pharmacies, Drugs, coagulation factors
Blood transfusion services,
Allied services such as Radiology and Radiotherapy.
Consumables, disposable bone marrow needles, etc
There is a major shortage of Clinical Haematologists in South Africa. Tertiary Care Clinical Haematologists are urgently needed.
There is also a need for Clinical Pathologists in secondary care centres for timely diagnosis.
Need for more physicians for follow-up of haematology patients at secondary care level. (This already starts at primary care level in training primary care doctors /GP’s, i.e. medical students at pre-graduate level to recognise serious haematology problems and refer them in good time and to manage the anticoagulant therapy of uncomplicated patients).
Training of highly specialised nurses at tertiary and quarternary care level, starting from basically qualified Oncology nursing sisters.
Paramedical and other support services to be dedicated in the management of haematological patients.
7.1 Suggestions
Private-public interaction is a problematic issue due to different visions: private sector is profit driven while the public sector is service driven. Therefore the ideal situation would be one where the public sector is totally self-sufficient.
Possible areas of interaction
The public sector should draw expertise from the private sector especially as far as training is concerned.
Because bed utilisation in private sector is in some instances only 40%, overflow from state to private hospitals should be considered. This should be based on clearly spelt out contracts to safeguard the focus on service provision within the public sector.
Similarly should under-utilised modern equipment in the private sector be accessible to highly trained specialists from the public sector.
Private sector should not be setting standards because their goal is maximum profit.
Is there a place for outsourcing in clinical haematology in the public sector? This issue seems problematic and many problems are foreseen.
All tertiary centres should be affiliated to a University
Tertiary medicine is totally dependent on and fed by secondary and primary medicine. The latter also serve as step-down facilities from tertiary care. Therefore, communication links between the different levels should be improved.
All provinces should be catered for.
The development of Outreach Clinics should be considered.
Local tertiary laboratories supporting specialised clinical services need to be protected and mechanisms to maintain and improve the current repertoire of specialised and unique services should be entrenched. This means that the interaction between the NHLS and tertiary clinical services needs to be defined.
Prof. Philip Badenhorst (Free State) (Facilitator)
Prof. Vinod Joggesar (Kwazulu Natal)
Dr. Neil Littleton (Tygerberg)
Prof. Erna Mansvelt (Tygerberg)
Dr Vincent Naicker (Kwazulu Natal)
Prof. Nicholas Novitzky (UCT)