For the first time an analysis of the impact of NHS patient choice and competition on the reorganisation of surgical cancer services and investment in high cost medical technologies published in The Lancet Oncology has revealed that retaining competitive edge through new technology investment, rather than quality improvement, appears to be a powerful driver in the reconfiguration of surgical cancer centres in England.
Of the 16 prostate cancer surgical centres that closed between 2010 and 2017, none had done so because of explicit evidence of poor quality care. Instead, patients often travelled to alternative centres that provided robotic surgery, leaving other centres that couldn’t attract the same level of patients faced with the threat of closure.
Between 2010 and 2017, the number of robotic centres has more than tripled – increasing from 1 in 5 (12/65) centres providing the technology in 2010 to over three quarters (42/49) in 2017. This has occurred despite a lack of evidence of improved outcomes in terms of survival and side effects for robotic surgery compared to open surgery.
The authors say that better regulation is needed to assess technology delivery in the NHS, and that quality indicators should be made available to inform patient choice.
The study, led by the London School of Hygiene & Tropical Medicine and King’s College London (UK), included data from 19256 men in England who were diagnosed with prostate cancer and underwent radical prostatectomy between 2010 and 2014. It is the first analysis of the impact of patient choice and competition on the reorganisation of surgical cancer services in England.
“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,” explains Dr Ajay Aggarwal, London School of Hygiene & Tropical Medicine, UK.
“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,” he adds.
Previous research found that 1 in 3 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 (10/23 [43.5%], compared to 2/37 [5.4%]). Over this period, 16 (25%) of the initial 65 centres closed, none of which had introduced robotic prostatectomy.
“Even within publicly-funded systems like the NHS, competition policies have stimulated a form of centralisation through ‘natural selection’, as centres invest in unproven new technologies to protect their status, instead of services being regionally planned and coordinated. Similar patterns have been observed in other health-care markets such as the United States. Rapid adoption of high technology therapies is not unique to prostate cancer, and further research should look at other types of cancer where new types of treatment are increasingly available as well,” says Dr Aggarwal.