Is it time for a global move towards the centralisation of surgery?

Insights from Dr Tomas Poskus’ ESCP2021 keynote lecture.

The European Society of Coloproctology’s (ESCP) 16th Annual Scientific Meeting – ESCP 2021 - gathered 1405 colorectal experts from all corners of the world to assess the latest research and insights on colorectal surgery. Attendees delved into wide-ranging topics and discussions, from how to pick the right operation for the patient, to gender and diversity in surgery, and new surgical techniques and guidelines.

As healthcare organisations assess their current practice and administrative set-ups in the wake of the COVID-19 pandemic, Tomas Poskus, Professor of Surgery at Vilnius University Hospital, delivered a timely keynote lecture that explored whether all rectal cancer care should be centralised.

In medicine, centralisation is a process whereby resources, infrastructure, staff, materials, knowledge and research are concentrated in order to improve quality of care and financial efficiencies.

Dr Poskus shared a number of studies from across Europe and the United States that demonstrated the benefits and potential pitfalls of centralisation.

For example, studies found that hospitals performing a higher volume of more challenging surgeries experienced lower rates of patient deaths in these procedures. In addition, centralisation appeared to significantly improved overall clinical outcomes, and resulted in lower rates of emergency surgeries, and more lymph nodes being examined and found.

But while centralisation has the potential to drastically transform surgical outcomes, it can impact patients and services in less positive ways, too. This can happen as the number of hospitals offering certain operations decreases, driving patients to travel further for treatment. Another consequence of there being fewer hospitals treating the same conditions is that there is less competition. One study shared by Dr Poskus found that patients were less likely to be offered new and innovative treatments. However, both these negative outcomes can be avoided with careful planning.

To ensure that both hospitals and patients experience the benefits of centralisation without the downfalls, Dr Poskus shared 12 recommendations for centralisation of services.

Dr Poskus’ 12 recommendations for centralisation:

  1. The definition should be based on the disease or on the organ system rather than the operation.
  2. Planning is based on minimal numbers of cases per centre and well distributed among various regions, considering population and cultural specificities.
  3. Planning should include at least two centres per country to allow for choice and competition.
  4. Appropriate resources must be secured with a proper evaluation of available infrastructure and personnel.
  5. Centres must offer fully functioning multidisciplinary teams of specialists capable of tackling all aspects of diseases all year round.
  6. Centres must be linked to hospitals to secure adequate referral and follow ups.
  7. Specifications of centralisation must be legally enforced.
  8. The process for centralisation must be accompanied by mainstream media activities to secure appropriate awareness of the population.
  9. Centres must have an externally audited database and must be actively involved in research.
  10. Quality control must be accompanied by international benchmark comparative studies.
  11. Equal accessibility to centralised healthcare should be monitored.
  12. Centres must be involved in surgical education and secure specialised training as well as allowing rotation of general surgery.
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