Title: Reorganising specialist cancer surgery for the 21st century: a mixed methods evaluation (RESPECT-21)
Funder: Department of Health and Social Care

Abstract: There are longstanding recommendations to centralise specialist healthcare services, reducing the number of centres providing specialist care[1-3]. It is argued that such changes support increased patient volume, and that this increases patient access to appropriate procedures and, for some procedures, better clinical outcomes. However, little is known about: the impact of such changes on clinical outcomes, organisation and provision of care, patient experience, or costs and cost-effectiveness[4,5]; how such changes are planned and implemented[5]; and patient, public and professional preferences[6,7]. London Cancer (3.2 million people in North Central and North East London, and West Essex) and Manchester Cancer (3.1 million people in Greater Manchester and East Cheshire) plan to centralise specialist surgical services separately for four cancers (prostate, bladder, kidney, and oesophago-gastric), to be provided through a smaller number of centres. Full implementation is anticipated by December 2015[8,9]. The study will use a framework combining an analysis of 'what works' with the 'how' and 'why' of change, based on the following interrelated components: 1) decision to change; 2) developing the new service models; 3) implementation; 4) adherence to the new models; 5) impact on provision of care; and 6) impact on outcomes (e.g. mortality, patient experience, costs). RESEARCH QUESTIONS RQ1. What were the key processes in centralising specialist cancer surgery services in London Cancer and Manchester Cancer? RQ2. What is the impact of the centralisations on provision of care, in terms of clinical processes and outcomes? RQ3. What are the cost and cost-effectiveness of the changes? RQ4. What is the impact on patient experience, including choice and continuity of care? RQ5. What is the impact on staff and healthcare provider organisations, including ways of working, skill mix and approaches to collaboration? RQ6. What are patient, public and professional preferences in relation to these centralisations? RQ7. How might lessons from centralising specialist cancer surgery services be applied in future centralisations of specialist cancer services and other specialist settings? We propose a mixed methods evaluation of these centralisations, using a controlled before and after design. Methods include: documentary analysis (RQ1) and stakeholder interviews (RQ1,4,5); analysis of local and national data on clinical processes and outcomes (RQ2), costs and cost-effectiveness (RQ3), and patient experience (RQ4). We will conduct a Discrete Choice Experiment[10, 11] to examine patient, public and professional preferences for changes of this kind (RQ6). Finally, we will hold a workshop for people planning to centralise specialist cancer and other specialist services, to discuss how our lessons might apply more widely. We will incorporate feedback into our final conclusions (RQ7). Centralising specialist services will remain a priority in the English NHS in the coming years[12,13]. This study will address gaps in the evidence related to such changes, including processes of change, their impact and cost-effectiveness, and stakeholder preferences. It will be of considerable value to those who commission, organise and manage specialist services. The team includes clinicians, researchers and patient representatives from London and Manchester with the knowledge and expertise necessary to conduct an evaluation of this scale and complexity.

Lay abstract: There is evidence to suggest that for some types of operation, hospitals carrying out more cases of that operation may have better results (e.g. better patient outcomes). It has been recommended that cancer surgery services should be provided in fewer hospitals (centralised), because this would make it more likely that patients are treated in a unit by surgeons and other healthcare staff who are expert in treating their condition, with access to the technology needed to provide the most appropriate care. However, little is known about whether and how centralisation of cancer surgery services affects patient outcomes, patient experience, the ways in which care is organised and provided, and the cost of services. There is also little evidence about how changes of this kind are planned, put into practice, and how they are kept going. Finally, we know little about what patients, members of the public, and healthcare professionals think is most important in changes like this. We want to study changes in specialist cancer surgery services across North Central and North East London and West Essex (covering 3.2 million people) and across Greater Manchester (3.1 million people). Both areas are currently working to reduce the number of hospitals providing specialist surgery for prostate, bladder, kidney, and oesophagus and stomach cancers. We will address several questions: did the changes improve provision of care, patient outcomes and patient experience? How were the changes planned and applied? Were the changes good value for money? What do patients, members of the public, and healthcare professionals (doctors, nurses, therapists) think are the most important factors to take into account when considering changes like this? How might lessons from this study be applied in other settings? We will look at hospital data from across the country to see whether changes reduced deaths , length of hospital stay and improved other outcomes, whether patients received the clinical care they should have done, and we will look at a national patient survey to see whether patient experience improved. We will examine service plans and meeting minutes, and we will interview people associated with cancer services, including surgeons, nurses, managers, patients, and carers. We will also survey patients, members of the public, and healthcare professionals, about their preferences for changes of this kind. We will identify the effect changes like this have on patients, carers, professionals and services, and how such changes are planned, applied, and kept going, and how local factors influence this. The lessons learned will help healthcare managers, clinicians, and patient and carer groups who are involved in planning and applying similar changes, including how to get patients and carers, members of the public, and healthcare staff involved. We want our research to be useful to a wide range of people, so we will hold a workshop for people who want to change specialist cancer services elsewhere, and other types of specialist service, so that they can tell us how to make our findings helpful to them. The research team includes experts in specialist cancer surgery from London and Manchester, and academics who are experienced in studying changes of this kind, working with clinicians and patient experts. The team’s contributions have been fully costed. Before embarking on our study it will be reviewed by an NHS Research Ethics Committee.

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