Cancer workforce focus

As highlighted in the Health Status Report, cancer is the most common cause of death in Aotearoa New Zealand – accounting for 31% of all deaths in 2020. Age-standardised mortality rates from cancer are highest for Māori and Pacific peoples.

Over the past two decades, we have significantly reduced age-adjusted mortality rates from cancer. This owes in large part to improvements in our treatment of cancers, including new pharmaceuticals and technologies, and improved approaches to caring for people with cancer. We can expect to continue to see such improvements into the future.

But to make sure these improvements deliver on better care for New Zealanders, we need a sufficient cancer workforce. Several factors drive a need for growth in our cancer workforce:

• As New Zealanders get older on average, incidence rates of cancer are increasing.
• Improvements in technology, pharmaceuticals and cancer care models often require more workforce to deliver (or require new skills).
• Relatively low growth in some of our key medical cancer specialties – including both medical and radiation oncology, and gynaecological oncology.

Cancer isn’t a monolith – and our diagnostic and treatment pathways, and the workforces involved in cancer care, vary by cancer. For the purposes of this spotlight, we’ve divided our cancer workforce into four nominal groups based on the kinds of cancer care they provide.

Over the past five years we have made a lot of headway in understanding how we can improve cancer care – driven by exceptional clinical leadership, and by the role of the Cancer Control Agency | Te Aho o te Kahu in shaping a national approach to cancer care. This gives us significant opportunities to strengthen our cancer workforce over the next three years:

• Getting training volumes right for specialist workforces. As demand for cancer care has mounted, our training of specialists – including radiation and medical oncologists, gynaecological oncologists, and specialist cancer nurses – has failed to keep pace with service growth. By getting these volumes matched to future need, we can close the gap between what New Zealanders need and the workforce we have.
• Focusing on model of care change. Clinical networks and the Cancer Control Agency have outlined opportunities to shift the blend of workforces we use in cancer care – and moving towards these models over time will allow more of our people to work at the top of their scopes, and make better use of workforces which are faster to train (like radiation therapists, cancer nurses, and kaiāwhina).
• Supporting specialisation into cancer. For more generalist workforces where we have relatively good supply – nursing, healthcare assistants and kaiāwhina – we can make use of our strong workforce position to support more people to get involved in providing cancer care.

For this Plan, our focus is on non-regrettable investments in our cancer workforce – areas where we know we’re going to experience growth in future or changes to how we provide cancer care. Over the next three years we will likely see significant shifts in where and how we provide different kinds of cancer care, as we shape a national network of hospital and specialist provision – allowing for more people to get common cancer treatments closer to home, with more specialist centres to provide care for rarer, more complex cancers. 

Though very different specialties, our medical oncology, haematology and stem cell workforces have similar opportunities. Respectively:

• Medical oncology services care for people with cancers of the solid organs who could benefit from systemic therapies such as chemotherapy, immunotherapy and targeted therapies.
• Clinical haematology services care for people with blood and related cancer, as well as people with blood disorders that are non-cancerous such as haemophilia. People with blood cancer also benefit from a range of systemic therapy.
• Our long-term outlook for medical oncology is good, with a growing workforce – but this growth will be needed to manage a mounting burden of disease resulting from cancers, and continual improvements in the tools to treat them.

What it will take

We have shortages in our specialist medical workforces across these specialties which we need to address to make our cancer workforce sustainable. Short-term, our focus needs to be on:

• Right-sizing training, so we better match how many registrars we train and the number of specialists we need in future.
• Improving top-of-scope capacity by growing nursing and support workforces and changing our models of care – freeing up doctors’ time to focus on more complex work.
• Supporting training in private settings, particularly laboratories, to give our specialists the exposure they need to train.

Over the medium-term, new chemotherapies and improvements in cellular treatments are likely to put additional load on our medical oncology and haematology workforces – so sustaining growth, shifting models of care and attracting more junior doctors will be essential.

Unlike radiation and medical oncology, our surgical oncological workforce are spread across a range of surgical specialties and sub-specialties – and supported by the same clinical teams as other surgical care. This makes it challenging to isolate our “surgical oncology” workforce – and means that many of the opportunities for this workforce overlap with those on wider surgical workforces.

Surgical specialties are, overall, comparatively better staffed than our other oncology workforces. However:
Gynaecological oncology has acute workforce shortages, with insufficient SMO workforce across New Zealand.
We have a growing volume of surgeries occurring in the private system across our surgical workforce. We need to ensure that this outsourcing delivers value for New Zealand and doesn’t result in shortages in our public surgical workforces.

What it will take

Over the next three years we need to start by improving our data on surgical oncology workforces, so we can more readily map what we have today against anticipated demand. At the same time, we will have to focus on:

• Growth in gynaecological oncology, using international recruitment and right-sizing training to grow this small, specialist workforce.
• Using training in private settings to bolster public training capacity.

Medium-term, we will likely need shifts in how we deliver surgical oncology care. These shifts will need to be be clinically-led and aligned to how we plan operating theatre capacity across New Zealand, so that we have both the surgical workforces and surgical facilities needed for excellent cancer care.

Around a third of cancer patients receive at least one course of radiation therapy as part of their care. Demand for radiation therapies control to grow – and will be supported by new linear accelerators (LINACs) planned for Hawkes Bay, Taranaki and Northland.

We have relatively acute shortages of radiation oncologists – and while we have only moderate shortages of radiation therapists, we will need growth over coming years to meet demand for care, particularly in rural areas. We are also overreliant on international talent to staff workforces such as medical physicists.

What it will take

Changes to how we deliver radiation therapies offer significant opportunities to make better use of allied workforces, and provide better care for more New Zealanders as new LINACs come online. Short-term, this looks like:

• Growing specialist allied and nursing roles, including advanced scope radiation therapy and cancer nursing roles, so we make the most of our nursing and allied professionals.
• Strengthening local training pathways including getting our radiation oncology training numbers right, and training more medical physicists in New Zealand.

These shifts will help short-term, and help improve access to radiation therapies in rural communities. Medium-term, we will need continued work to get our professionals working at top-of-scope, including exploring new models of care that make better use of our nursing and allied workforces.

As highlighted above, nursing, allied and support workforces form a vital part of how we deliver all kinds of oncological care. While these are discussed to some extent in the three areas above, some opportunities for these workforces cut across cancer streams and care pathways.

At present, pathways to specialise in cancer for many workforces are relatively fragile or inconsistent across New Zealand. For example, there is no universal pathway for nurses to specialise as clinical nurse specialists in cancer care, and to then become cancer-specialist nurse practitioners; and we have few oncological nurse prescribers. Much of our allied cancer capacity is based in NGOs, meaning there are opportunities to make better use of allied workforces in public cancer care.

What it will take

Shifting models of care to make more use of nursing, allied and kaiāwhina capacity needs to be clinically-led, and will take some time. But we can make some safe assumptions about what the future will look like, which is the basis for our immediate focus on clearer cancer specialisation pathways particularly for nursing and kaiāwhina workforces, so we can begin building the specialist capabilities we’ll need in future to improve capacity for care.

At the same time, there are opportunities to better engage our people in service and quality improvement through implementation of decentralised trials, and capability-building so more of our people can deliver advanced therapies. These will give our people opportunities to expand scope across cancer specialisations – and deliver improved, expanded care to New Zealanders.