Offline: How HSE rules are blocking use of UHL's robot for treating prostate cancer

Fintan Walsh

Reporter:

Fintan Walsh

The Da Vinci robot at University Hospital Limerick is the only one of its kind in Irish public healthcare

The Da Vinci robot at University Hospital Limerick is the only one of its kind in Irish public healthcare Picture: Brian Arthur

MEN with prostate cancer are being denied life-saving surgery at University Hospital Limerick, as a result of a strict HSE regulation that has been in place for 11 years.

Findings in a Limerick Leader investigation show that an annual average of 30 men are forced to travel to Galway to undergo radical prostatectomies — a service prohibited in the Mid-West region.

This is despite the Dooradoyle complex having access to the most unique range of surgical equipment — for any public hospital in the country — to treat all ailments in the urinary tract and the most complex of cancer sites

One of the unique pieces of equipment includes the Da Vinci Xi Dual Console surgical robot, which was installed at UHL in 2016 and has operated on approximately 90 patients since. It is the only device of its kind in Irish public healthcare

And UHL is home to a number of surgeons who are trained to carry out Da Vinci operations, and three highly-skilled consultant urologists, who regularly perform surgeries on the kidney, bladder and prostate. 

11-YEAR-OLD RULE

However, radical prostatectomies have been out of the equation for more than a decade, since the HSE’s National Cancer Strategy in 2006. This was responsible for the formation of eight cancer centres at eight hospitals, including UHL.

The National Cancer Control Programme’s criteria for assigning types of cancer surgeries to the centres has been mainly based on the number of new cases per year presented to the hospital. The NCCP is run by the HSE.

A spokesperson for the Health Service Executive told this newspaper that it “more recently” reviewed international studies on the link between “caseload per hospital or surgeon and clinical outcomes”.

It said that, specifically for prostate cancer, the volume should be 50 cases or more, with each urologist operating on at least 20 men every year. The spokesperson added that it would be “preferably 40 to 50 cases per year”.

“Looking at the Irish prostatectomy data this would mean four or five cancer centres would perform this work.”

The spokesperson added that, in line with the new National Cancer Strategy 2017-2026, there needs to be “completion of centralisation of cancer surgery to the designated cancer centres”.

But the HSE has also said that “there is a requirement to optimise the number of designated cancer centres performing surgery for different cancer types to ensure the best possible outcome for patients”.

REVIEW REQUESTED

While UHL is just 10 Mid-West patients short of reaching the general NCCP target, if prostrate cancer surgery was made available at UHL it is likely a large number of patients from all over the country would avail of the Da Vinci keyhole surgery, following positive feedback from other patients on whom the robot was employed.

It is understood that if prostate cancer surgeries were to become available at UHL, patients from all over Ireland requiring radical surgery would be able to receive treatment in Limerick.

In December 2016, a spokesperson for the UL Hospitals Group confirmed that it was not a designated prostate cancer surgery hospital “as per NCCP policy”.

The spokesperson explained that the NCCP policy was put in place to “restrict the number of public hospitals doing prostate cancer surgery in order to centralise expertise for this procedure”.

The UL Hospitals Group said that patients’ requirements for prostate cancer surgery were “well provided for under the current arrangement”.

But then on July 21, the spokesperson stated it had “requested that the NCCP reviews the current situation to allow UL Hospitals to become a dedicated centre for prostatectomy surgery”.

81 MEN REFERRED

According to new data received by the Leader, through Freedom of Information, 81 men were forced to travel to Galway University Hospital between 2014 and 2016 for radical surgery. Thirty men were referred from the radical access prostate clinic (RAPC) in 2014. This dropped to 25 the following year, but increased by one patient in 2016.

“All patients that choose the surgical treatment option for the prostate cancer are referred to Galway University Hospital. This decision is a result of the recommendation for the NCCP on the surgical sites for prostate cancer treatments,” a HSE official said.

And while UHL refers an annual average of 30 men from the RAPC to Galway, the Dooradoyle clinic deals with 1,300 patients every year.

Of this huge number, there are approximately 300 prostate cancer diagnoses every year in the Mid-West, according to National Cancer Registry Ireland data.

Men are generally diagnosed and initially treated at the radical access clinic in Dooradoyle. If they require surgery, they are then referred onto Galway University Hospital.

The clinic is run by Garett Durkan, a consultant urologist based at GUH, on a weekly basis, while UHL’s three consultant urologists also assess patients at the clinic, a spokesperson stated.

SKILL AND TECHNOLOGY

The three highly-skilled urologists are each paid between €122,753 and €160,893, and the UL Hospitals Group has been looking to add a fourth to the team for a number of months.

In 2016, the JP McManus Benevolent Fund donated to UHL the Da Vinci surgical robot, worth €2.6m. This device provides minimally-invasive keyhole surgery, enabling largely improved recovery periods in comparison to regular laparoscopic [keyhole] operations.

Speaking about the Da Vinci Xi robot at a board meeting of the UL Hospitals Group on October 6, 2016, robotic surgeon Prof Calvin Coffey said that if UHL is to become a “centre of excellence for robotic assisted surgery”, more theatre access would be required.

This is according to minutes of that meeting, received through Freedom of Information from the UL Hospitals Group.

Prof Coffey also mentioned that the state-of-the-art machine can provide annual financial savings of €110,000 in equipment use.

Separate figures received through Freedom of Information show that there is an average cost-saving of four bed days per patient. UL Hospitals Group confirmed that one bed day equates to an expenditure of €1,456.

When asked if the NCCP will be reviewing the restriction on UHL, the HSE did not directly respond to the question. 

Comment: Can UHL be a centre of excellence without full spectrum of services?

SINCE the foundation of the UL Hospitals Group in 2013, multi-million euro investments into medical innovation have been rolling off the conveyor belt for Limerick.

While the €16m Leben building and €25m A&E have been applauded by health professionals, there is one string to UHL’s bow that has piqued greater interest — the Da Vinci surgical robot.

Not only has it immensely improved the patient experience at UHL, it has saved the taxpayer hundreds of thousands, and has contributed to surgeon upskilling.

It is the only one of its kind in Irish public healthcare, and has set the standard for treatment in colorectal, renal and adrenal cancer. But men with prostate cancer — the most common male cancer worldwide — are told to go to Galway instead, because of an archaic HSE policy based on quantity of patients and not on quality of services.

When this rule came into effect in 2006, UHL was the Mid-Western Regional Hospital with no comparable state-of-the-art tools or level of skill to treat prostate cancer, like it can today. There are three urologists at UHL who are trained to carry out world-class prostate cancer surgery, but red tape cordons off the theatre for this operation.

How can UHL be a centre of excellence if the full spectrum of urology surgeries are not available? UL Hospitals has recognised this problem as it is now seeking the National Cancer Control Programme to review the matter.

The NCCP wants to centralise expertise, a fair system that has been championed by the NHS. But already, patients from all over the country are availing of Da Vinci operations because the feedback is glowing. So if the HSE wants more numbers, the problem can be easily solved.

Parallel to that, if they want to turn a hospital into a centre for prostate cancer excellence, then why have they not invested in this crucial piece of infrastructure elsewhere?

In the meantime, UHL trains hundreds of medical students, but none of whom will be able to learn how to carry out prostate cancer surgery on-site.

UHL has a golden opportunity to be a champion in robotic surgery, but an anachronistic policy stands in its way.