Evidence and impact of NHS choice and competition policies on the delivery of prostate cancer services : a national population based evaluation

Background: Policies encouraging patient choice and hospital competition have been introduced across several countries with the aim of improving the efficiency, equity and quality of health care services. The English National Health Service (NHS) is an example of a publicly funded health system in which hospitals are expected to compete on quality and not price to attract patients, who themselves are allowed to choose any hospital that best meets their needs. To date, there is limited evidence about the factors that influence patients’ decisions to choose a hospital other than their nearest (“patient mobility”) or the implications of these choices on the health system. Methods: In this thesis, national patient-level datasets and mixed quantitative and qualitative research methods were used to investigate the role of choice and competition policies on the delivery of specialist cancer services, using prostate cancer as a case study. This included an assessment of both the extent and drivers of patient mobility for curative prostate cancer treatment as well as the wider system impact of patient mobility and hospital competition on service capacity, service configuration, technology adoption and patient outcomes. Semi-structured interviews were undertaken with men previously treated for prostate cancer to provide further insight into the factors that inform and influence provider choice. Results: Patient mobility for cancer treatment far exceeds the 5-10% considered necessary to stimulate improvements in quality. One in three men and one in five men bypassed their nearest centres for prostate cancer surgery and radiotherapy respectively. Travel time was the dominant factor influencing location of care, but its impact was less strong for younger and more affluent socioeconomic groups. Men were attracted to centres offering innovative technologies and practices of care as well as centres that employed clinicians with a national reputation for prostate cancer. This has resulted in shifts in market share for individual cancer centres resulting in a net gain of patients for some centres - “winners” - and a net loss of patients for others - “losers”. Surgical centres classified as “losers” had a greater likelihood of closing their service. Competition between hospitals has contributed to the rapid adoption of costly technology for prostate cancer surgery. However, there is limited evidence to suggest that hospital competition improves patient outcomes. Conclusions: The thesis demonstrates unequivocally that patient mobility and hospital competition is occurring within the NHS. Choice and competition policies rather than a coordinated policy towards centralisation have been the most significant drivers in the reconfiguration of prostate cancer surgical services in the NHS. Indicators, which accurately reflect the quality of cancer treatment delivered, are needed to guide patients’ decision-making. In their absence, patient mobility may negatively affect the efficiency and capacity of a regional or national cancer service without improvements in patient outcome, and widen socioeconomic inequalities in access to care.