Over the past couple of decades, the centralisation of services has been a universal trend across healthcare, both geographically and across the full spectrum of provision. Yet despite public health providers the world over widely buying into the its supposed benefits, the shift in focus away from local provision towards the concentration of specialist expertise and resources in a few dedicated centres has remained controversial.
With so much surgical practice classified as specialist, i.e. specific, sometimes complex procedures to treat a narrow range of conditions, surgery has been particularly affected by the move towards rationalisation. No doubt this has been driven by the perception that, at some point in the planning and provision of surgical services, there are advantages to be gained.
But that raises the question of the nature of these advantages, and who exactly benefits from them. It also obliges hospitals, clinicians and administrators to question, if there are winners in service centralisation, whether or not there are losers too, and if so, query whether the balance between the two is correct.
In this article, we will argue that, far from delivering de facto advantages, centralisation has been a prudent response to resource shortages. By focusing the expertise available in specialist areas in fewer dedicated centres, providers have been able to make efficiency gains which have created better outcomes compared to what has gone before.
However, by extending the pathways from diagnosis and primary care to surgery, patients have lost out, through the simple fact of having to travel to get access to the procedures they need. Added to that, with resources being concentrated in a handful of specialist ‘hubs’, provision for aftercare back in the local hospitals has been reduced, to the detriment of patients’ interests in the longer term.
At Proximie, we don’t believe this is the best possible situation for anybody. Centralisation may have had its place 10 or 20 years ago. But in the age of remote surgery, the need to focus resources physically in fewer centres has been removed. In terms of available expertise, resources can now be shared and indeed multiplied via real-time digital communications. In other words, rather than making the patient go to where the resources are, we now have the opportunity to take the resources back out to where the patients need them.
A summary of the case for centralisation
The main argument in favour of centralising specialist surgical services centres around what is known as the volume-output relationship. In short, due to efficiency gains and economies of scale, it is argued that there is a positive correlation between the volume of patients undergoing a particular procedure at a single centre and their outcomes.
So, for example, based on a number of studies, the Vascular Society for Great Britain recommends that centres for specialist vascular surgical services should be in urban areas with a population of no less than 800,000. This it is because key regional hospitals of this type ensure a flow of patients which ensures the most efficient use of resources, including staff, facilities and equipment, and that the expertise which comes from increasing caseloads leads to better patient outcomes.
One of these studies makes the specific point that centralisation increases the number of consultants working in larger vascular surgery teams, and suggests that this concentration of expertise leads to better service organisation and quality of care.
However, evidence in favour of these sorts of conclusions is far from universal. A more recent regional study into vascular surgical provision in the UK concludes that “centralisation has not significantly impacted the overall efficiency of the carotid endarterectomy pathway.” The reference to the pathways to and beyond surgery itself is significant, as it takes into account the fact that surgical provision is much more than the delivery of the procedures themselves. Other factors aside from the availability and use of resources in theatre need to be considered.
Who loses out
A worldwide metastudy into the impact of centralisation on surgical services for gynaecological cancer concludes that, while there may be evidence that it increases survival rates for ovarian cancer in particular, more research is needed into the impact on patients’ quality of life.
This gets to the heart of why centralisation has remained controversial. The added efficiency streamlined services bring certainly benefits providers, while arguments about improving standards and outcomes have never been clear cut. But what is certainly true is that it makes lives harder for patients, who are expected to travel to receive care they need, often as a matter of life and death, away from the support structure of their families and friends.
There is also the suggestion that centralisation creates the conditions for its own justification by weakening the ability of local hospitals to deliver the care patients need. A 2016 study from the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland acknowledges that centralisation “dilutes” the presence of GI expertise in district hospitals.
Similarly, a British Journal of Healthcare Management study into vascular surgery reports that the switch of tariff funding to the major hubs where procedures are performed impacts on the ability of district hospitals to provide aftercare. When the patient goes back to their local hospital for rehabilitation, so funding comes with them. Both the patient and the hospital lose out.
Another way forward
In a major review of the reconfiguration of service provision in the UK, The King’s Fund acknowledges that centralisation alone cannot solve the many dilemmas and complexities associated with public healthcare delivery, and that the main consideration must be to “ensure that patients receive the right care, in the right place, at the right time.” That includes reversing the dominant policy towards centralisation, and looking instead at how local service provision can be sustained and supported, with better integration with primary and tertiary care.
The key factor here is again resourcing, and the argument can be made that centralisation only appears to be beneficial when resources are scarce. In the best of possible worlds, all healthcare provision would be available at the point where a patient first accesses care, i.e. on a local level. If this sounds utopian, it is surely the direction healthcare services should be pulling in.
In surgery, expertise in specialist areas is always raised as a key resource shortage. But perhaps it is really a question of distribution. One US study into surgical services makes the point that specialist provision tends to be concentrated around medical schools and teaching hospitals, i.e. where the expertise is nurtured and where it often remains. The challenge, then, is how to distribute it more equitably and in response to demand.
Technology provides us with the solution. Telemedicine is already being widely used to assist diagnosis in local hospitals, with consultants based in the central hubs using available platforms to consult with both patients and local doctors. This is seen as a positive for patients, reducing the need to travel back and forth for appointments.
The next step is to see this technology used enable surgical procedures to be performed locally. Platforms like Proximie make virtual surgery possible, with a distant consultant guiding and overseeing an operation from afar via a tablet and a piece of AR software. Watching a live video stream of the procedure, they can use the AR tools to provide rich multimedia instruction to the surgeon in situ, the equivalent of a consultant overseeing an operating team directly in theatre.
The direct benefit is that this reduces the need for patients to travel. The more the virtual distribution of expertise can facilitate procedures at a local level, the better quality of life patients will enjoy. Indirectly, this will also start to reverse the whole process of centralisation. Local surgeons will be supported in performing a wider variety of procedures, building up expertise in a wider range of disciplines. It will be easier for a surgeon to become a registrar with a specialist focus without moving to a specific hub.
Eventually, there will be no resource shortage in specialist expertise at all, and the need to rationalise and centralise what is available will be removed.