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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

DISCUSSION DOCUMENT MAY 2003

STRATEGIC FRAMEWORK FOR MODERNISATION OF TERTIARY SERVICES

2

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

7

8

9

10

11

12

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

23

26

30

34

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



4

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.



5

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



6

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



7

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.



14

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



15

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.



16

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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



17

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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



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.



19

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



20

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,



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.



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-



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



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:



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



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



27

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



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



29

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



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



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


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



31

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



Neonatology Neonatal Intensive Care Unit Nephrology Acute renal failure / clinical nephrological problems /

dialysis complication Obstetrics & Gynaecology Service


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


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



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


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



33

Model B Central Referral Units (“Add on” to a National Referral

Hospital)

Specialist Service Available On-Site Specific Components Explicitly Included:


Lung volume reduction, Lung Transplant Maxillofacial Surgery National Referral Centre

{ { {







{ {



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 Rheumatology Bone Marrow Transplant, DEXA scans, Interleukin levels, joint replacement



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





Neonatology Neonatal Low & High Care, Neonatal Intensive care Obstetrics & Gynaecology Service



Paediatrics Service


Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry Acute Rehabilitation Team



35

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)


Neonatology Neonatal Intensive Care Unit Nephrology Acute renal failure / clinical nephrological problems / dialysis

complication Obstetrics & Gynaecology Service


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


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


(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



36

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


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



37

Model C Central Referral Units (“Add on” to a National Referral

Hospital)



Lung volume reduction, Lung Transplant Maxillofacial Surgery National Referral Centre

{ { {







{ {



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 Rheumatology Specialised Paediatric Rheumatology including Bone Marrow Transplant, DEXA scans, Interleukin levels, joint replacement



38

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



Mental Health services (Psychiatry & Psychology)


Neonatology Neonatal Low & High Care, Short stay ventilatory support

Obstetrics & Gynaecology Service



Paediatrics Service


Rehabilitation Centre Physiotherapy, OT, Orthotics & Prosthetics, Speech Therapy, Dietetics, Podiatry Acute Rehabilitation Team



39

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



Neonatology Neonatal Intensive Care Unit Nephrology Acute renal failure / clinical nephrological problems /

dialysis complication Obstetrics & Gynaecology Service


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


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


(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



40

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


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



41

Model D Central Referral Units (“Add on” to a National Referral

Hospital)



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




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 Rheumatology Specialised Paediatric Rheumatology including Bone Marrow Transplant, DEXA scans, Interleukin levels, joint replacement



42

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



43

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:



44

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



45

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


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


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


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Clinical Immunology


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


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


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


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


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


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


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


49

Endocrine Surgeon, Neurosurgery, Vascular Surgery, Obstetrics, Dialysis, Transplant Surgery, Radiation Oncology

Gastroenterology & Hepatology


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


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


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


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


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


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


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?)


51

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


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


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


52

Also On-Site

General Medicine, Neurology (?), Paediatrics

All Specialties

Neonatology


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


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


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


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


Regional Nuclear Medicine Specialised Radiographer only

Tertiary Nuclear Medicine Centre Specialist Nuclear Physician, Specialised Radiographers,

PET or gamma-PET As Tertiary


53


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


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


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


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


54

Also On-Site

Orthopaedics


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


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


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


M O with (Diploma in Allergy), Trained nurses

Specialist, M O with Dip. in Allergy, specialist nurse,

Specialists


55


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


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


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


56

Paediatric orthopaedics, Paediatric nuerosurgery, ICU, Playrooms and observation rooms.

Paediatric Critical Care (ICU)


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


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


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


57

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



Paediatric Nephrology and Transplant


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


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


General Paediatric Medicine General Paediatricians

Tertiary Paediatric Respiratory & Allergology Service Specialist Paediatric Pulmonologists & Allergologists,Specialist Nursing

Not Envisaged


58

specialties suggested as the only overlap between them is asthma management)


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


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)


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


Regional Plastic Surgery Service Specialist Plastic Surgeon, Rotating Registrars, MOs

Tertiary Plastic & Reconstructive Surgery Specialist Plastic Surgeon, Registrars, MOs, S

Mentioned but not Elaborated


59


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


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?)


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


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


60

Also On-Site

Radiology

Radiology, MRI, Pulmonology, Nephrology, Neurology, Dermatology and Haematology, Orthopaedics

Spinal Injury Rehabilitation & Management


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


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


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


Regional Vascular Surgery Service Specialist Vascular Surgeon, General Surgeon

Tertiary Vascular Surgery Service Specialist Vascular Surgeons

Not Envisaged


61


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

APPENDIX 3 ORGANISATIONAL MODELS – PESSIMISTIC SCENARIO

62

Regional Hospital Tertiary Hospital National Referral Centre

Anaesthetics

Not Specified

Not Specified

Not Specified

Burns


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?)


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?)


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


63

Clinical Immunology (No alternative scenarios offered; main difference probably in number of units affordable?)


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?)


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


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?)


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


Regional General Medicine Service General Physician, MOs, Specialist Nurse

Tertiary Dermatology Service Specialist Dermatologists, Regs, Specialised Nursing

None


64

feasibility of “ideal” specialist regional service?)


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)


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?)


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


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


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,


65

(No alternative scenarios offered; MTS team proposes smaller number of Tertiary and National units under this scenario)


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)


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)


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)


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


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?)


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?)


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?)


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


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


67

this scenario)


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?)


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)


Neonatal Low & High Care Unit Specialist Paediatricians, MOs, Nurses with specific training

Neonatal Intensive Care Unit Specialist Neonatologists, Paediatricians, MOs, Specialist Nursing

Not Envisaged


68


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)


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?)


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?)


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


None Tertiary Nuclear Medicine Centre Specialist Nuclear Physician, Specialised Radiographers, Medical Physics, Technologists Diagnostic and Therapy Nuclear Medicine

None


69

Also On-Site

Not Stated in Report

Obstetrics and Gynaecology (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)


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?)


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


Regional dental services Not specified Not Specified Not Specified

Not Envisaged

Not Envisaged

Orthopaedics

Description

General Orthopaedics

Sub-Specialty Orthopaedics

Orthopaedic Oncology Centre


70

(No alternative scenarios offered; main difference probably in number of tertiary and national units affordable?)


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?)


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?)


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


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


71

probably in number of tertiary units affordable?)


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


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?)


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)


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


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Paediatric Gastroenterology (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)


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)


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




Paediatric Nephrology and Transplant (n.b. fewer national centres under this scenario)


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


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(No alternative scenarios offered; main difference probably in number of tertiary units affordable and scope of activity at national referral centre?)


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?)


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?)


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


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,


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offered; main difference probably in number of tertiary and national units affordable?)


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


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)


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?)


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


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services, and Physiotherapy

Rheumatology (No alternative scenarios offered; main difference probably in number of tertiary units affordable?)


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)


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?)


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


Regional General Surgery Service Specialist General Surgeon

Tertiary Urology Service Specialist Urologists, Registrars, MOs

Not Envisaged


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offered; main difference probably in number of tertiary units affordable, plus no rotation of registrars to regional hospitals?)


Basic urology service Radiology

Comprehensive Urology Service and outreach to regional hospitals Not Specified

Vascular surgery


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

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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


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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


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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


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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


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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


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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


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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


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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


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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


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)

strategic framework for the modernisation of tertiary hospital … · 2015-05-19 · discussion...

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