The right place for the right patient… at the right cost

Nicola Nicolai: Guest Editor

Urology surgeon Nicola Nicolai proposes key criteria for sustainable services that provide each patient with access to the level of specialist services that they need.

Debates about the benefits and drawbacks of centralising the planning and delivery of cancer services in a few large referral centres, such as featured in the March–April issue of Cancer World, are important in teasing out key challenges in balancing high quality with accessibility in cancer care. However, it is the economics of austerity that will determine how this debate evolves. Cancer survival varies not just between but also within countries. Poorer survival rates cannot simply be blamed on lack of referral centres, because the quality of referral centres varies according to the technical and scientific resources available. Centres should be funded according to how effectively they perform, taking into account measures such as length of hospitalisation, rates of complications, disease recurrence and re-admission.

Economic analysis should include costs of examinations and treatments, but also the cost of obliging patients to travel a long way (to both the patient and the economy in lost output), and the risk that barriers to travel may mean some people will not access facilities that could benefit them.

Effective community-based healthcare services are needed for early diagnosis, prevention and screening. Rather than concentrating all cancer care in a few large referral centres, it may be better to differentiate healthcare facilities according to the intensity of care, concentrating major medical and surgical procedures, with a high risk of complications, at a few hospitals with exceptional levels of expertise.

Minimum criteria are needed to ensure all cancer units and centres provide high-quality services in staging and treating cancer. These may include a critical mass of patients, a core team, a non-core team, non-medical healthcare professionals, systematic data collection, multidisciplinary management of patients, and educational activity. Patient advocates should be involved to promote education and empowerment of patients, focusing on their needs for logistical help and social support

Guidelines are very helpful in promoting knowledge, though they don’t always improve efficiency. IT systems are essential to support effective communication and allow clinicians to share information quickly. Out-sourcing certain facilities and treatments can work, but will be counterproductive without shared guidelines and patient pathways. Centres of expertise must be able to keep up their technical know-how of core clinical activities, as this is where practitioners develop their professional competencies and gain clinical experience.

The big challenge is first knowing how to get all these elements – effective preventive intervention and early detection, high standards of care, cost-effectiveness and better communication – to work together, and then building the political will to drive through the changes.

Modern organisational models can help create well-structured networks: national or regional interdisciplinary working groups that link primary care, hospitals, referral centres, health administrators, GPs and patient advocates. Key elements must include regular multidisciplinary meetings, shared guidelines, and agreements between centres for access to facilities that are not available locally.

Nicola Nicolai is a urology surgeon working with the Prostate Cancer Programme, Istituto Nazionale dei Tumori, Milan, Italy

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