Everyone should have ready access to a competent service

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I Agree
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Dear Editor

Aggarwal and colleagues[1] are correct to argue against promoting “shopping around” to address the issue of backlogs of patients requiring specialist cancer care. It is especially important to emphasise that using individual choice to allocate patients will increase inequalities in the way they describe.

The documented issue of “distance decay,” whereby patients are less likely to receive a timely diagnosis and treatment when the relevant facilities are located at increased distance from the residence, applies to primary care[2] and to all treatment modalities[3]. This is especially so for socioeconomically disadvantaged patients.

The poor cancer survival statistics, relative to similar European economies, which characterise the UK suggest that access is historically poor and the fact that a backlog for treatment has developed so quickly shows that cancer services are undersized. The reduced rate of diagnosis in 2020 has not alleviated the pressure, which emphasises the capacity issue[4].

There has been emphasis on the concept of improving cancer services by centralising specialised services to guarantee quality. Given the fact that many patients to not get timely access to services, the question arises: does the increment in quality from centralisation outweigh the decrement in receipt of service due to distance decay?

A further point is that the receipt of a specialised service requires both presentation of the patient to a diagnostic service which needs to be local enough to be readily accessed by people who might have cancer and accurate selection of those who may benefit from specialised surgery and appropriate management of those who will not so benefit. This is where multidisciplinary discussion involving the diagnostic team, the specialist surgeon and other therapeutic specialists is necessary. There is also a need to ensure that patients with recurrence gain rapid access to further care, especially as new systemic approaches emerge. A high quality local service is needed.

Aggarwal has carefully evaluated the mechanisms of delivering specialist surgery[5] This also depends on accurate evaluation of the benefits of centralisation and that includes establishing that such a benefit exists. Much of the argument comes from comparison between low- and high-volume hospitals in the United States. A first point to make is that a lowly NHS district general hospital has the workload of the workload of a medium to large American institution. As has been pointed out in Aggarwal’s section on inequalities, quoting Sajid Javed MP, choosing to travel for care is characteristics of residents of “leafy suburbs.[1]” Similarly in the USA, the large-volume hospitals attract well-favoured patients from a very wide area; these cannot be realistic examples of optimal care[1]. Even in the US, concern has been expressed over the adverse consequences of a pledge to eliminate low-volume surgery [7] Even when the volume pledge is in place for lung cancer resection, patients operated on in hospital that miss the criteria do not seem to be disadvantaged. Thoracic surgery was the first specialty to be centralised in the UK 60 years ago.

There will be many more cases of cancer in the coming years. Policy in the UK must ensure that potential cancer patients have ready and timely access to competent diagnostic and therapeutic services with sufficient capacity to avoid backlogs and efficient communication between the various components.

References
1] Aggarwal A, Walter F M, Sullivan R, van der Meulen J. “Shopping around” for treatment is not a solution to cancer backlog BMJ 2022; 379 :e071967 doi:10.1136/bmj-2022-071967
2] Murage P, Bachmann MO, Crawford SM, McPhail S, Jones A. Geographical access to GPs and modes of cancer diagnosis in England: a cross-sectional study. Family Practice. 2019;36:284-90.
3] Murage P, Crawford SM, Bachmann M, Jones A. Geographical disparities in access to cancer management and treatment services in England. Health & place. 2016;42:11-8.
4] https://digital.nhs.uk/data-and-information/publications/statistical/can… accessed 7/11/22. Highlighted in Seven Days in Medicine BMJ 2022;379:o2546.
5] Aggarwal A, Han L, Van Der Geest S, et al. Health service planning to assess the expected impact of centralising specialist cancer services on travel times, equity, and outcomes: a national population-based modelling study. The Lancet Oncology. 2022;23:1211-20.
6] Crawford SM How to provide specialist services: how do we know when centralisation is a good idea? Postgraduate Medical Journal 2021;97:69–7 doi: 10.1136/postgradmedj-2020-138151
7] Schwartz DM, Fong ZV, Warshaw AL et al, The Hidden Consequences of the Volume Pledge: “No Patient Left Behind”?. Annals of Surgery: February 2017 – Volume 265 – Issue 2 – p 273-274 doi: 10.1097/SLA.0000000000001833
8] Farjah F, Grau-Sepulveda MV, Gaissert H et al. Volume pledge is not associated with better short-term outcomes after lung cancer resection. Journal of Clinical Oncology. 2020;38:3518-27.

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The following competing Interests: 
Electronic Publication Date: 
Monday, November 7, 2022 – 17:39
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Everyone should have ready access to a competent service

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Last Name: 
Crawford
First name and middle initial: 
S. Michael
Address: 
Airedale General Hospital, Skipton Road, Steeton, Keighley, West Yorkshire BD20 6TD
Occupation: 
Clinical Lead for Research
Affiliation: 
Airedale NHS Foundation Trust
BMJ: Additional Article Info: 
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