decentralising nhs radiotherapy services

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Over the past three decades capacity

developers and commissioners of NHS

radiotherapy services have used the

mantra of safety for not commissioning

radiotherapy services outside of cancer

centres. In 1991, a Royal College of

Radiologists (RCR) working party report

concluded that non-surgical cancer ser-vices to district general hospitals should

be based at cancer centres. Furthermore,

the working party soundly condemned

any organisation of satellite radiother-

apy treatment facilities. However, more

recently there has been an NHS strategic

shift towards decentralising radiotherapy

services using the hub-satellite model,

also known as the hub and spoke model

and the linked unit model.

This article examines the events and

potential impact of this change in thinking

by investigating whether the hub-satel-

lite model is an appropriate and feasible

method for improving NHS radiotherapy

capacity, reducing inequity of access, and

providing safe and cost effective service.

Several pressures have contributed

to the reshaping of NHS radiotherapy

services over the past 20 years. These

forces can be classied into three main

categories: epidemiological, technolog-

ical and organisational. The timing and

weight exerted by each of these forces on

the service varies. However, they have

consistently posed a challenge to health-

care strategists, managers and medical

professionals. In addition, the centralised

delivery model has contributed to the

substantial under-provision of services

and has been unable to improve the under-

capacity issue. The impotency of this

model stems from a number of reasons.

First, the space constraints of existing

facilities are preventing any horizontal

expansion; second, this model has been

associated with an increase in inequity

of access causing substantial differences

in the level of service across the United

Kingdom; third, historically the model does

not provide an incidence-based service.

Epdemologal hallenge

The epidemiological changes in

cancer that have occurred over the past

40 years have exerted huge pressures on

NHS radiotherapy and cancer services.

In England, the total cancer incidence

continues to rise at a rate of 1.4% per

annum. This growing cancer burden has

been attributed to three main reasons: the

ageing baby boom population born during

the 1960s, the introduction of a number of

NHS screening programmes such as those

for breast, cervical and bowel cancers, and

the use of non-invasive blood tests such

as the prostate-specic antigen (PSA) test

to diagnose a large number of prostate

malignancies. Another epidemiological

change is the improvement in the cancer

survival rates in England. As a result the

number of patients living with cancer

who may require radiotherapy treatment

during their lifetime has also increased.

Radiotherapy contributes to the cure

of approximately 40% of the total number

of cancer patients who become diseas

free. It is predominantly prescribed i

combination with surgery and/or chemo

therapy and/or hormone therapy with

medical intention to cure. In addition to it

radical role, radiotherapy has a mainsta

in the palliation of cancer where it is give

to patients with advance stage, secondarmetastases or relapse primaries. Th

overall percentage of cancer patients wh

require radiotherapy treatment durin

the course of their illness is estimated t

range from 50% to 60%.

inequty n serve provson

A further challenge is the star

regional variations in the proportion o

patients receiving radiotherapy or th

variation in rate of use of radiotherapy

which ranges between 22% and 58%

These variations in radiotherapy us

are a direct result of the differences i

capacity level of radiotherapy services

In 2007, a report published by th

RCR, assessing radiotherapy capacity

highlights the issue of inequitable distri

bution of radiotherapy resources betwee

different regions in the United Kingdom

For instance, the number of radiotherap

treatment machines or linear accelerator

(linacs) per million of population varie

by nearly a factor of 3 (2.13 per millio

in the North of England and Norther

Ireland compared with 6.02 per millio

in the South of England). More recently

a survey carried by the National Cance

Services Analysis Team (NATCANSAT

to assess the United Kingdom radio

therapy infrastructure shows that inequit

still remains a major issue for NHS rad

otherapy services. The RCR recommen

6 linacs per million of population.

Decentralising NHS

radiotherapy services

ISSUE 1 FEbRUARy 2011NEWS

Inequity remainsa major issue for

NHS radiotherapy

services in the

United Kingdom


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impat o normaton tehnology

Radiotherapy in the early 1990s

entered the information technology era

and was the real driving force behindthe fast and continuous development in

radiotherapy, and a number of other inno-

vations in medical imaging.

One important milestone was the

introduction of digital imaging acquisition

and management technology. The picture

archiving and communication system

(PACS) is an information technology

system that handles electronically diag-

nostic images of all imaging modalities in

a hospital. The radiotherapy community

soon discovered that to reap the benet of

this new innovation in medical imaging

technology, the radiology tailored PAC

system needed to be modied to meet the

different imaging requirements in radia-

tion therapy. As a result, a separate branch

of PACS was developed: the radiotherapy

picture archival and communication

system (RT-PACS).

However, functionally the RT-PACS

was an information island. It was neither

linked or interfaced to the radiotherapy

treatment planning system (TPS) nor

linked to the linac treatment machines. The

reason for the lack of interface between

the RT-PACS and the multi-vendor equip-

ment within radiotherapy was due to the

absence of any internationally agreed

computer communication standard among

medical imaging and radiotherapy equip-

ment manufacturers that would facilitate

the ow and exchange of information

between the equipment. In other words,

no common computer language existed to

allow safe and accurate ow of medical

information between different computer

systems and medical equipment.The solution to the lack of interop-

erability between different information

systems within medical imaging came

from diagnostic radiology. In 1983, the

American College of Radiology along

with the National Electrical Manufacturers

Association (NEMA) approved the rst

common standard for digital communi-

cation of medical images. The approved

digital imaging and communications in

medicine (DICOM) version 1.0 was super-

seded by version 2.0 in 1988, and the

current version 3.0 was approved in 1993.

The compound PACS and DICOM-

radiotherapy protocols and standards

have created a digital environment in radi-

otherapy. Lack of systems connectivity

and interoperability within radiotherapy

has been improved tremendously

with the development of this specic

DICOM extension for radiotherapy.

The DICOM-radiotherapy extension

was developed to establish a standard

for the handling and transference of

imaging and non-imaging radiotherapy-

specic information objects denitions

(IOD), the latter highly important for

radiotherapy processes. The exten-

sion in 1997 consisted of four DICOM

objects including: radiotherapy image,

radiotherapy structure set, radio-

therapy plan and radiotherapy dose

(DICOM, 1997). In 1999, three addi-

tional record keeping IODs were

created: radiotherapy beams treatmen

record, radiotherapy brachytherap

treatment record and radiotherap

treatment summary record. ThesDICOM-radiotherapy extensions facili

tated the ow of image and non-imag

based IODs between different system

Thus, these developments made

possible for image and non-imag

base-data to ow between the lin

machine, TPS, the virtual simulatio

(VS) software, conventional simulato

(CS) and radiotherapy-PACS. The inter

face capabilities coupled with advance

in telecommunication facilitated th

collaboration between different radio

therapy centres.

The advent of information technolog

innovations affected fundamental radio

therapy work processes by transformin

many clinical practices and ultimatel

re-engineering the workow in radio

therapy services. Our position is tha

the electronic radiotherapy environmen

enables most radiotherapy processe

to take place outside the traditiona

centralised model while maintaining

or even increasing, quality outcomes i

patient care.

Organsatonal hanges

Radiotherapy workow consists o

several interdependent processes. From

a management organisation perspectiv

these processes, or work, can be groupe

into three main parts or sections: pre

treatment, planning and treatment. Thes

sections have been transformed by th

1st consultation& consenting

ConventionalStimulation (CS)

CT Scanning

Plan Verificationon CS

Pretreatment

Data input on TPS

Produce TPCarry necessary checks

Plan sent to CS

Planning

Data input ofmachine parameters(Full course or Daily)

1st day machineCheck X-ray films

Treatment

A typal radotherapy workfow durng the early 1990s

Hard copy Envronment (X-ray/Douments)

TPS: Treatment Plannng SystemcT: computed Tomography

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advancement in information technolog

and telecommunication.

Eonom evaluaton

In recent years, a number of studie

have been carried out to evaluate theconomical benet of different radio

therapy service delivery models i.e

centralised, fully decentralised an

outreach (H&S). In 2000, a Canadia

study by Dunscombe and Roberts drew

the following conclusions: rst, th

outreach radiotherapy service mode

is the economically superior servic

delivery model for separations betwee

30km and 170km, from a societa

prospective; second, the outreac

stafng model offers cost saving as uses the existing management and super

visory personnel, stationed at the centra

facility or hub; third, in the context o

cost to the health system the H&S servic

model was found to be more economica

compared with a fully decentralise

model in such a small catchment area

This is owing to the saving achieved b

eliminating duplications and under-us

of equipment, such as CT scanners an

TPS. Furthermore, some have argue

that the traditional centralised mode

imposes a higher nancial burden o

both urban and rural radiotherapy popu

lations when compared with the H&S.

The road ahead

Finally, it is worth noting that an

radiotherapy service provision mode

whether centralised, fully decentralise

or H&S, which is commissioned based o

non-scientic or subjective methods wi

inevitably lead to either under- or over

capacity issues. Scientic forecastin

of future radiotherapy needs has to b

the corner stone that enables plannin

of adequate radiotherapy resources an

insure the delivery of high-quality radio

therapy services.

SIMULATOR

RTTPSPHYSICS

PLANCHECKS

PHYSICS

PLANCHECKS

DAILY LINAC

TREATMENT

PLANNING

CHECKS

RADIOGRAPHERS

CHECKS & DATA

ENTRY

LINAC

1ST DAY

PORTAL

FILMS

WEEKLY

TX CARD

CHECKS

A typal radotherapy workfow n the early 1990s

Pre-treatment Proess Plannng Proess

Davd Shahata MS BS, imperal collegLondon. Wth thanks to Dr Benta cox

Treatment Proess

A typal radotherapy workfow n 2010 ndatng the mpat o radotherapy-PAcS andDicOM-radotherapy

NEWSISSUE 1 FEbRUARy 2011

RTTPS

DAILY

LINAC

TREATMENT

CT

PHYSICS

PLAN

CHECKS

RADIOGRAPHERS

CHECKS & DATA

ENTRY

PHYSICS

PLAN

CHECKS

WEEKLY

EPI & IGRT

VIRTUAL

SIMULATION

decentralising nhs radiotherapy services

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