Programme, Discussion and Feedback Formats for Specialty

Focus Groups

MEETING OF UROLOGY GROUP

VENUE : KIEVITS KROON COUNTRY ESTATE

DATE : 1st and 2nd OCTOBER 2002

Attendance:

Prof. A M Segone
Prof. Z Berecky
Prof. S Reif
Dr. A Pontin
Dr. M Borkowski		 – Facilitator/Medunsa
- University of Natal
- University of Pretoria
- University of Cape Town
- university of Witwatersrand

The Universities of the Free State and Transkei did not send a representative.

FUTURE SCANNING (2002 to 2010)

Minimally invasive urological surgery:
Endourology: flexible ureteroscopy, laser urological surgery, ESWL, PCNL
Laparoscopy: diagnostic and therapeutic

Diagnostic Urology:
Spinal CT, MRI, Cystoscopy table with integrated C-arm and X-ray facilities
Urodynamic laboratory

Outcomes of the above:
Quicker diagnosis
Shorter hospital stay
Less morbidity
Cost effective
Efficient
More patients treated

Current situation:
Delayed diagnosis
Longer hospital stay
Less efficient
Higher morbidity

Resource requirements:
Equipment as stated above
Facilities including: - Theatres
Outpatient facilities
Medical staff commensurate with workload of the community

Epidemiological implications:

Prostate Cancer – African population (black)
- not preventable
Female incontinence – all population groups

- partially preventable,
- better ANC(anti natal care)
Infections

STD, - all groups
TB
 

Bilharzia

- regional
- clean water
- better sanitation
Trauma

– urethral strictures, all groups
– preventable
Stone disease:

- Indians and whites
- Increasing among blacks
- Prevent recurrence
TB:

Improve socio-economic status

Impact of HIV/AIDS
Varies in severity with region
Severe problem

Priorities:
Human resources;
Equipment

Quality of Care:

Shortcomings and limitations:
Delay in diagnosis and treatment
Lack of equipment
Poor ancillary services:-medical, paramedical, social

Problem solving:
Improve primary health care
See "outcomes"
Procurement of equipment
Improve ancillary services (e.g. Anaesthetic, Radiological service).

Highly specialised services:
Localised to Regional Centres:

Access to service:

Regional

- lack of Government Urologists in some provinces(public service)
 

Impoverished, mainly black rural people
All groups:

- Poor primary health care
- delay in referrals and inappropriate distribution of services
rural problem

Apparent refusal by the provinces to pay for tertiary services Influx of non-south African patients from surrounding countries Inadequate transport facilities

Problem solving:
Self evident from above

Efficient Use of Resources: serious obstacles

Lack of operating time
Too many bosses Province
University
Superintendent or CEO’s

High junior staff turnover (replacement difficult)

Lack of peripheral and step down facilities

Lack of support staff

Pathology
Radiology
Investigational
Lack of specialised nursing staff, eg. ICU, nurses trained on endoscopies etc.
Maintenance of specialised instruments

What needs to be done:

Amend above

Opportunities offered by restructuring

Increase "day case" surgery
Increase specialised clinics, e.g. prostate clinic, incontinence clinic etc.

What needs to be done?

See above

Education and training

Medical: - undergraduates: Concern about the insufficient undergraduate training in urology:- University
 

- interns and community service: rotation involving urology recommended – HPCSA
 

- postgraduates:- Minimum 4 years postgraduate training
 

- One year post qualification training in the public sector (CMSA)
Nursing: - undergraduates – (Nursing Council). Urology
: - Postgraduates - Specialist Nurses

Erectile dysfunction
    Stoma & Incontinence
    Oncology, Catheter
Others:

- undergraduate:
 

- postgraduates (combined interest e.g. interventional radiology).

Future spread of training;

  
Training:

- Community Hospital/Clinic

 – none
  - Regional Hospital: undergraduates
    interns &community service
    rotating registrars/senior registrars
  - Tertiary – under and postgraduates Nurses Specialist
   

Medical
   

other X-Ray
    interventional

Public and Private Interaction:

Interdependence:

MRI

 one way (private).
  ESWL  
 

Laser

  

- Creation of private wards within state hospitals
- Private practitioners doing sessions in state hospitals
Scope for expansion:    
Effective but expensive    

Organisation of Services:

There is virtually no urological service outside tertiary institutions throughout SA.

Strengths:

- Registrars see complete spectrum of Urological conditions in one hospital .
Weaknesses

– maldistribution of human resources
- Overloading of tertiary institutions
- Insufficient funding of tertiary institutions
- Long travelling distances for patients
- Failure to recognise Urological disease
- Long hospital stay due to inefficient transport

How to improve efficiency

Size of an "ideal" unit:

- A unit consists of:

Ideal staff establishment

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 a urologist e.g. Durban metropolitan service.

Outcomes: - Primary health care must improve in order to get more treatable patients in urology units to achieve better results.

Organisational models

Regional Hospitals: (Level II)

Service provided:

Personnel:

Resources required:

Other supporting services:

Referral system: see above

Teaching functions:

Tertiary Hospitals (Level III +)

Service provided: all cases referred

Personnel required: see " ideal unit"

Resources required: see " future scanning "

Supporting services: all specialities and facilities

Teaching functions: all teaching functions

National Referral Centre: N/A to Urology

Miscellaneous: