Case Studies

Malta was recording delays at various junctures of the cancer care pathway, such as delays between the first referral and the first hospital consultation or waiting times for diagnostic tests and treatment initiation (Attard et al., 2020). Furthermore, coordination of care was limited due to limited communication among multidisciplinary teams and patients frequently expressed facing difficulties navigating the system.

To address challenges in cancer care, the Directorate for Cancer Care Pathways (DCCP) was established in 2014 to promote advancement in quality cancer care and enhance support, advice, timely access, coordination, and continuity of care for cancer patients. Prompted by the National Cancer Plan for the Maltese Islands 2017-2021 developed by the Ministry of Health (Government of Malta, 2017; Ministry for Health and Active Ageing, 2024), and with the collaboration of public health agencies, health professionals, IT system designers, and civil society representatives, the DCCP introduced several key actions:

• Research & Innovation: introduction of a Research Unit to promote innovation and national projects in cancer care (2023).
• Prevention, Early Detection, & Diagnostics: introduction of an online GP fast-track e-referral system to reduce waiting times for first hospital consultation (2019); and active participation of DCCP in developing more educational initiatives during the annual national Pink Oct-Movember Campaign, including television and radio programmes, as well as school visits (2014).
• Cancer care: introduction of a Nurse Navigation System (WHO, 2022; Zammit, 2022), along with nurse-led clinics (e.g., follow-up clinics), which now includes 12 navigators covering nine cancer types and consists of navigators that provide (in-person and over the phone) expert advice and person-centred care support (2017); and introduction of ambulatory services, consisting of home cancer care through the dispensation of chemotherapy portable pumps, and outreach services, dedicated to training outreach nurses to extend home care services, including the training of an outreach team to provide cancer-related interventions and deliver home-based chemotherapy regimes for increased comfort for patients and reduced access barriers (Public Service, 2024) (2024).
• Quality of Life: introduction of a Survivorship Unit to support patients in the post-treatment phases (2019).
• Digital solutions: enhanced digitalization of the care pathway and development of various IT systems for oncology centres or nurse navigation.

The COVID-19 pandemic contributed to accelerating the uptake of these various initiatives, with, for example, fast-track e-referrals for suspected cancers reaching a total of 3 379 since the start of the service, 8 536 patients benefiting from Nurse Navigation Services, and over 47 000 patients who received a one-to-one call with the Survivorship Unit.

Enablers: Enablers include a strong government funding, as DCCP funds these various initiatives through the government’s annual budget for health (Financing); as well as a solid governance framework, aligned with the National Cancer Plan and the EBCP, which includes policies and standard operating procedures (SOPs) for most services, conduct regular audits, as well as the recent recruitment of a Quality Assurance Manager (Governance).

Barriers: These include the lack of essential health workers, including nurses, pharmacists, psychologists, and other health professionals, which challenges the effective expansion of certain services and reinforces the need for better integration of digital tools (Resources); as well as the resistance of some health professionals towards digital tools, even though it is a decreasing issue (Service delivery).

Through the various initiatives implemented, the DCCP is contributing to the health system’s goals of equity and access, with more equitable access to cancer care for all; efficiency, with more coordinated and timely care; people-centredness, with care organised around a more holistic and person-centred approach; and quality and safety, with the development of policies and audits

Lessons learned: While the implementation of the various initiatives by the DCCP has been successful, learning how to make the case for investment in human resources is still needed. Lessons learned since 2014 include the importance of starting with a base-line patient needs analysis to identify care gaps and needs; meticulous planning of achievable goals with reasonable timeframes, including the gradual introduction of each initiative through pilots prior to scaling up; being aligned with both National Cancer Plans and the EBCP; securing sustainable funding; involving all stakeholders, including patients; capitalising on ‘champions’, such as health ministers, directors, or leaders, to advocate for the initiative; and designing clear and transparent policies and SOPs, as well as conducting regular audit of the implemented changes. 

For more information

https://health.gov.mt/public-bodies/cancer-care-pathways

Contact

For further details on this case study, please reach out to obs-pace@obs.who.int.