London Eye: The end of the capital's cancer networks

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The end is nigh

So farewell then, London Cancer and London Cancer Alliance – the two confusingly named organisations charged with improving cancer treatment in the world’s greatest city.

Both bodies were offshoots of functions of the now-defunct NHS London strategic health authority, and are themselves now being wound up or absorbed by other organisations.

London Cancer covered north central and north east London, plus the part of Essex near London – the same footprint as that of UCL Partners, the academic health science network with which it worked and which will now take it over. It will retain its name and staff.

London Cancer Alliance covered all of south London and north west London, and was funded by membership dues paid by the trusts in its patch. It will be replaced by a vanguard centred around specialist cancer trust the Royal Marsden, dubbed RM Partners.

The vanguard will cover trusts in north west and south west London, while those in south east London will now make their own arrangements, under the leadership of Guy’s and St Thomas’ Foundation Trust.

Why the split? And, more importantly, what will the recent organisational changes mean for future attempts to coordinate cancer provision in London?

Because despite the public-facing happy-clappiness of the successor bodies, rivalries between the teams in different hospitals can make centralising services difficult.

London Cancer can claim some past success on this front.

Prostate cancer surgery is moving from King George Hospital in Ilford to University College London Hospital Foundation Trust.

Haematology cancer services are now provided from two sites rather than three (the Royal Free’s services are moving to UCLH). Next year some brain cancer services are moving from the Royal London to UCLH.

Falling performance

This is all laudable work but no one can seem to explain why cancer performance in the LC patch is the worst in London, and has declined over the past four years.

Considered on the 62-day target (85 per cent of patients to be seen within 62 days of referral), Camden, Havering, Barnet, Enfield and Haringey boroughs have seen steeper falls in performance since 2012-13 than any other London boroughs.

Over the same period, UCLH and the Royal Free have moved from performances of 89 per cent and 93 per cent respectively, to 65 per cent and 74 per cent.

Of course central London providers do more-complex work and this affects their waiting times. They also get late patient referrals which show up on their waiting times. They also treat patients from all over the country (London fact of the week: According to NHS England London boss Anne Rainsberry, the capital’s trusts do £2bn of non-London work a year).

But none of these are new factors and none of them explain the falls in performance for London Cancer’s boroughs.

London Eye spoke to some senior people on the network and provider side and they didn’t volunteer a theory. Overall capacity is not the issue, so what is? (Send your facts/theories gratefully received and anonymity preserved – ben.clover@emap.com.)

Hopefully LC initiatives like stepping up straight-to-test schemes and centralising prostate work will start to improve these figures, but the trajectory at the moment is pointing the other way.

Meanwhile, to the west and south, London Cancer Alliance’s 17 staff will be transferred to RM Partners.

The LCA was largely funded by its members, the provider trusts of south and north west London.

What happens when it is taken over by a vanguard run by cancer specialist the Royal Marsden? There is the risk that the voice of no-brand outer London trusts, which nonetheless serve large populations, will go unheard.

LCA had been working on a system for attributing waiting time breaches more clearly; the future of this work under the new arrangements is also unclear.

Splitting up

And why the split?

Spokespeople have not been forthcoming on motive, but there are some possible clues to be had from insiders and from the minutes of the LCA members’ board.

A meeting of this group in May 2015 now looks particularly pertinent.

The minutes show a consultant from Imperial presented a paper recommending the centralisation of specialised urological cancer surgery onto two sites, down from the four across on the work is currently performed.

Those four sites are run by the Royal Marsden, Imperial, Guy’s and St Thomas’ and St George’s.

So which hospitals stood to lose the work? The Royal Marsden, which did media on behalf of the LCA in its final days, said the paper made no recommendation as to where the services should be centralised.

However, the minutes do show Marsden chief executive Cally Palmer saying she could not back the two-site model. She said although her trust’s activity on this procedure was below recommended levels and its population catchment was too small, the assessment work did not reflect her trust’s strengths in research.

Later in the same meeting Ms Palmer made a similar argument on head and neck cancer surgery.

The minutes say “CP acknowledged that the RM surgery numbers were smaller than activity at the other providers. However, if this was addressed any change would require work to ensure that there was not a negative impact on non-surgical oncology or the current level of research.”

And: “Furthermore, CP referenced [the number of patients that surgeons treated privately] and the importance of including this when evaluating individual surgical expertise and safety. When looking at service configuration it must not be forgotten that the private patient activity makes an important financial contribution to NHS clinical practice.”

She was challenged on this by a consultant head and neck surgeon from St George’s, who said the LCA’s original memorandum of understanding was that “only NHS activity should be used when considering the reconfiguration of NHS services, namely that the future of private patient work for any institution was not guaranteed and as such it would be inappropriate to use in this circumstance.” (Although he conceded private work should be included in the assessment of how much activity each surgeon undertook.)

The Royal Marsden has the biggest private income of any trust in the NHS, earning £76.9m from private patients in 2014-15, more than a fifth of its turnover.

It’s not hard to imagine that the world famous London cancer specialist might not want to remain part of an organisation which kept making proposals that could see it losing work.

In the case of urological surgery, the centralisation proposals would definitely have seen at least one of the trusts now signed up to RM Partners lose out. More likely two as Guy’s and St Thomas’ is a big provider covering a large population.

Former LCA chair Neil Goodwin had sought to clarify the alliance’s role in contentious reconfiguration proposals at the April members’ board meeting.

The minutes record him saying: “There is no suggestion of LCA assuming the direct management of (significant) service reconfiguration. It has always been clear that it is not LCA’s role to undertake the leadership role of commissioners for service reconfiguration.”

It doesn’t sound like it was clear.

Figures close to the process have suggested to London Eye that, as evidenced by the end of LCA, the south east London trusts and those to the west of the patch - specifically Guy’s and St Thomas’ and the Marsden - wanted to go in different directions.

What does this mean for RM Partners and cancer provision across south west and north west London? One source suggested that, unless St George’s and the Marsden find a way to centralise their cancer surgery, Imperial and the Guy’s/King’s College Hospital alliance will always dominate.

Updated 2.30pm 31/3/2016: A reader gets in touch to point out that the likelihood of the Royal Marsden losing services is low given Ms Palmer’s new role as overall NHS England national cancer director.