Title: Delivering integrated care systems and patient choice for specialist cancer treatments in the NHS: impact on access, equity and outcomes of care.
Funder: Department of Health and Social Care

Abstract: Research Question What is the optimum organisation of specialist cancer treatment services in the NHS, which supports both patient choice of treatment provider and the continued centralisation of specialist services? Background The NHS long term plan supports the centralisation of specialist services into fewer larger units, supported by networking between hub and spoke hospitals. However, current evidence demonstrates variation in the quality of treatment across specialist cancer hubs, with centralisation associated with inequities in access and inferior outcomes for more vulnerable groups. At the same time, the NHS plan remains committed to patient choice of treating hospital to enable patients to shape the service and improve their experience. However, my previous NIHR funded research has demonstrated a negative impact of choice policies on the equity and efficiency of service delivery. Up to one in three prostate cancer patients bypass their nearest surgical or radiotherapy centre, especially younger, more affluent patients, with unintended consequences on the design of the service and high-cost technology adoption. Aim The 4-year project will investigate the impact of patient choice and service centralisation policies on equity in access to specialist services and patient outcomes across four cancer types. Objectives To investigate whether patients with different cancers bypass their nearest specialist treatment service and to understand the patient and service characteristics associated with this mobility. To understand what patient mobility means for patterns of hospital service utilisation. To investigate the impact of hub-and-spoke centralisation of cancer services on access to specialist cancer treatments and outcomes. To model what impact different configurations of specialist cancer treatment services would have on travel burden, equity in access to services and patient outcomes to inform service design.Methods The study will use national datasets including Hospital Episode Statistics and Cancer Registry data. The study population includes all breast, bowel, prostate and oesophageal cancer patients, newly diagnosed between 2013-2018 across the English NHS (estimated 900,000 patients). 40 men and women treated for cancer in the NHS will be interviewed as part of the study. The study will use an interdisciplinary mixed methods approach in addition to a detailed knowledge of clinical pathways of care and the configuration of services through my expertise as a Consultant Oncologist. Methods will include qualitative interviews, geographic mobility mapping, conditional logistic regression analyses, kernel density estimation, multi-level regression, location allocation modelling and patient demand simulation. Anticipated impact It will inform commissioners, and cancer alliance boards of the current utilisation of cancer services, and specific gaps with respect to access and outcomes. It will develop a methodological approach that will support health care planners to investigate the service and audit the impact of potential changes in the configuration of cancer (or non-cancer) specialist services on access and outcomes, to inform service re-design. It will build capacity and capability in health services research (HSR) amongst PPI representatives and the publicDissemination will be achieved through academic publications, policy briefings and direct engagement with NHS policymakers, patients, charitable, and academic communities through the project Steering committee and planned policy workshops.

Lay abstract: Aims of the research This 4-year project will examine from the perspective of patients, hospitals and policymakers how best to organise specialist cancer services to improve the quality of treatment delivered and ensure that the most vulnerable patients groups are able to access good quality care. It will aim to: 1. Understand the patient and hospital factors which influence where patients with different cancer types receive their treatment. 2. Investigate the impact of centralisation of cancer services in England on access and outcomes from specialist cancer treatments for breast, bowel, prostate and oesophageal cancer. 3. Investigate how closures of cancer treatment services might be undertaken in a way that improves patient outcomes and minimises the burden of travel for the sickest, elderly and most socially deprived patient groups. Background The NHS is centralising cancer services to fewer centres, either by closing smaller specialist cancer units or limiting the types of treatments they offer in order to improve patient outcomes and use limited resources more effectively. It is expected that networking between referring hospitals and specialist cancer centres will guarantee access to all evidence-based treatments. However, these models of care delivery have been associated with difficulties in access to treatment for cancer patients, which has had a worsening effect on their health outcomes. In addition, variation in the quality of treatment persists across specialist NHS cancer centres.The NHS also continues to support patients to have a choice of treating hospital. Through their choices, it is expected that patients will shape the service to improve their experience and reduce waiting lists. This is important given the findings from my previous NIHR funded research which demonstrated that up to one in three prostate cancer patients travel beyond their nearest surgical or radiotherapy centre for treatment, especially younger, healthier and more affluent patients. This movement of patients had unintended consequences on the number of cancer centres performing surgery and the use of high-cost technologies, with no evidence this has improved the quality of care. Design and methods used The study will use patient information collected by NHS hospitals and approaches to the analysis of information from the fields of geography and economics. It will include all patients diagnosed and treated for breast, bowel, prostate and oesophageal cancer in the English NHS between 2013 and 2018 (approximately 900,000 patients). These cancers have been chosen as they present different challenges in defining how best to organise services as they vary in their presentation and treatments. 40 men and women treated for these cancers in the English NHS will be interviewed as part of the study. Patient and public involvement (PPI) PPI has informed the scope, objectives and design of the study. Patients expressed concerns around the continued lack of transparent information on why NHS cancer services are continually changing; expecting some patients to travel further for care with no clear evidence of quality improvement. Following their recommendations, four cancer types will be investigated, and interviews undertaken with patients diagnosed with these cancers. The written proposal has been reviewed by four PPI groups and feedback regarding the lay summary, methods and dissemination strategy incorporated. A six-person PPI Advisory Panel will feed into the work packages, guide the dissemination strategy, and co-design planned engagement activity. Dissemination Research publications and policy briefings to hospitals and NHS Cancer Alliances will be used to disseminate the research findings. Engagement with NHS policymakers, clinicians, charitable and academic communities will take place through the Steering Committee and planned policy workshops. A debate will be organised to engage with the public regarding the implications of NHS hospital closures, guided by my findings.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: CANCER AND NEOPLASMS