London School of Hygiene & Tropical Medicine

Retaining competitive edge through technology investment, rather than quality improvement, appears to be a powerful driver in the reconfiguration of surgical cancer centres in England. These are the findings of a study published by researchers from the London School of Hygiene & Tropical Medicine in The Lancet Oncology.

The study was funded by the National Institute for Health Research and includes data from 19,256 men in England who were diagnosed with prostate cancer and underwent radical prostatectomy between 2010 and 2014. The paper presents the first analysis of the impact of patient choice and competition on the reorganisation of surgical cancer services and the adoption of technology.

The authors report that of the 16 prostate cancer treatment centres that closed between 2010 and 2017, none had done so because of explicit evidence of poor quality care. Instead, patients often travelled to centres that provided high technology treatments, leaving others who couldn’t attract the same level of patients faced with the threat of closure.

Dr Ajay Aggarwal, NIHR Doctoral Research Fellow in the Department of Health Services Research and Policy at the London School of Hygiene & Tropical Medicine, said:

“NHS choice and competition policy is based on the principle that patients will travel to centres they think will provide the best service. Closures were never intended to result from this, but the large number of patients deciding to receive treatment elsewhere meant some centres faced the risk of closures as they were no longer performing a sufficient number of procedures to sustain their service.

“However, since there are no publicly available indicators to help patients judge the quality of prostate cancer surgery, patients have to make their choices based on other factors. In this case, it appears that patients use the availability of robotic prostatectomy as an indicator of high quality care, despite a lack of evidence of its superiority compared with open surgery. NHS hospitals are subsequently investing millions of pounds into new and sometimes unproven technologies which has a direct impact on the type of care patients receive, but also the configuration of services as a whole.”

Previous research found that one in three men with prostate cancer who had a radical prostatectomy in the NHS between 2010 and 2014 travelled beyond their nearest prostate cancer treatment centre. Younger, fitter and more affluent men were more likely to travel, highlighting the risk of further increasing inequalities in access to care. Men were most attracted to centres offering robotic prostatectomy or who employed surgeons with a national reputation.

During the time of the study, 23 of the initial 65 prostatectomy centres gained patients, with some centres doing an additional 400-500 procedures as a result of people travelling to that centre. By comparison, 37 of the 65 centres lost patients, with some doing 200 fewer operations than expected based on where patients lived.

Centres that gained patients were eight times more likely to offer robotic surgery, compared to centres that lost patients. Over this period, 16 of the initial 65 centres closed, none of which had introduced robotic prostatectomy.

The researchers conclude that if quality performance and outcome indicators are not available to guide patient choice, competitive factors in addition to policies advocating centralisation may threaten the health services’ ability to deliver equitable and affordable cancer care.

Publication

Ajay Aggarwal, Daniel Lewis, Malcolm Mason, Arnie Purushotham, Richard Sullivan & Jan van der Meulen. Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery: a national, population-based study. The Lancet Oncology. DOI: http://dx.doi.org/10.1016/S1470-2045(17)30572-7