Reorganising specialist cancer surgery for the 21st century: a mixed methods evaluation (RESPECT-21)

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.