Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Recto Running Head: Lessons from the implementation of a cancer care network in Catalonia Verso Running Head: Josep M. Borras, Alan Boyd, Mercedes Martinez-Villacampa, Joan Brunet, Ramon Colomer and Josep Ramon Germa <cts>Lessons learned in the implementation of a cancer care network in Catalonia <rec>Received (in revised form): 3rd December, 2008 <aus>Josep M. Borras, Alan Boyd, Mercedes Martinez-Villacampa, Joan Brunet, Ramon Colomer and Josep Ramon Germa <abh>Abstract <abs>Cancer care across different levels of a health system is a key issue in planning cancer management. In Europe, cancer networks have been proposed as a model of care, thereby changing the traditional informal relationship between healthcare providers to formal coordination among professional organisations. This paper presents the experience of the Catalan Institute of Oncology (ICO), which began developing cancer care networks in two Spanish regions in 1998. The regions, which provide healthcare for about 2 million inhabitants, include 11 hospitals owned by different nonprofit providers of public healthcare. This paper discusses the value added by cancer networks in a Southern European healthcare context with a diverse range of hospitals. Establishing a shared model of care, based on multidisciplinary tumour committees and clinical guidelines, helped ICO to manage that diversity. An inclusive and cooperative approach, founded on personal contact, respect and understanding between different stakeholders was important, coupled with the flexibility to make agreements that suited local circumstances, while respecting the fundamental principles of the model. The importance of human factors is also highlighted by consideration of the boundary-spanning role of the medical oncologist. <bio>Josep M. Borras specialises in epidemiology. Formerly Director of the Catalan Institute of Oncology, he is now Director of the Regional Government of Catalonia’s Cancer Plan and Scientific Coordinator of the Spanish Ministry of Health’s Strategy on Cancer. <bio>Alan Boyd is a research associate. He has been at Manchester Business School since 2003, and previously worked in the health and social care sectors for over 15 years. His research interests lay in the organisation of local government and healthcare services, particularly the role of democratic governance in service improvement. <bio>Mercedes Martinez-Villacampa is a medical oncologist. She is the clinical coordinator for the oncologists working in the in the Costa de Ponent hospital network and responsible for medical oncology in one of these hospitals. <bio>Joan Brunet is a medical oncologist. He was formerly coordinator of the oncologists working in the Girona hospital network and responsible for medical oncology in one of these hospitals. He is now Head of the Medical Oncology Department at the Catalan Institute of Oncology Cancer Centre in Girona. <bio>Ramon Colomer is a medical oncologist and former Head of the Medical Oncology Department at the Catalan Institute of Oncology. He is now Medical Director of the MD Anderson Medical Centre in Madrid. He is also President of the Spanish Society of Medical Oncology. <bio>Josep Ramon Germà is a medical oncologist. He is the Head of the Medical Oncology Department in the Costa de Ponent Cancer Centre of the Catalan Institute of Oncology, and Past President of the Spanish Society for Medical Oncology. He is also Professor of Oncology at the University of Barcelona. <corres>Josep M. Borras <corres>Catalan Cancer Plan <corres>Av Gran Via s/n Km 2,7 <corres>08907-Hospitalet, Barcelona <corres>Spain <corres>Tel: +34 932 607 820 <corres>E-mail: [email protected] <key>Keywords: cancer, networks, health policy, organisation of cancer care, implementation <AS>Introduction <ful>One of the most important issues in planning resources for cancer care for a defined population in the context of a public healthcare system is how to organise the clinical journey of the cancer patient between different physicians and levels of care. Two or more levels of care are usually involved in cancer treatment and follow-up, ranging from primary healthcare to university teaching hospitals. Some components of the treatment for common cancers are usually carried out in community or intermediate hospitals, while others, such as radiotherapy, are usually centralised in more specialist hospitals, for reasons of quality and efficient use of resources. There is some evidence that treatment within specialist teams is associated with better outcomes for low-incidence cancers or where highly-specific therapies are used.1–3 On the other hand, centralisation of cancer care might make services less accessible to patients, and has been associated with a more advanced stage at diagnosis and poorer survival.4 While the debate between centralisation and decentralisation has been predominant in cancer policy in recent years, as exemplified by the report by the Institute of Medicine and the literature reviews produced for that report,5–7 several cancer plans have also recognised the importance of coordinating cancer care among different hospitals and levels of care.8–10 The policy framework outlined in the Calman-Hine report,11,12 for example, both defined specific roles for hospitals providing different levels of cancer care and proposed multidisciplinary care with tumour specialisation; it has also been associated with improved cancer outcomes.13–15 Networks in cancer care have tended to evolve from the ‘hub and spoke’ model towards a more integrated 16 model. Healthcare has traditionally been based on networks of informal relationships between professionals,17 and managed clinical networks, such as those for cancer care in Scotland,18–20 aim to build on existing referral patterns and professional relationships in order to organise cooperation more formally. These networks are intended to facilitate ‘working in a coordinated manner unconstrained by existing professions and health board boundaries’.21 This is easier said than done because such boundaries are often deeply embedded in institutions, cultures and individual professional identities.22 A similar approach has been developed in France with the aim of promoting equity of access to cancer care, involving different hospitals and physicians in a region with an emphasis in promoting multidisciplinary care and implementation of clinical guidelines.23,24 Research on the organisation and functioning of cancer care networks has largely been focused on Northern Europe and the UK in particular, so it is important that conclusions based on that research are tested by considering experiences from other countries and organisational contexts. This paper does this by presenting a case study of two related networks of cancer care, organised among hospitals in two healthcare regions in Catalonia, Spain by the Catalan Institute of Oncology (ICO). The paper focuses on the lessons learned in implementing those networks from an organisational perspective. <AS>The study <ful>In 2004, one of the authors (AB), undertook semi-structured face-to-face interviews with network staff, including the then Director of ICO (JMB), managers of each network (RC and JRG), and an oncologist from one of the networks, as part of a larger research project investigating ways of organising cancer services. The interviews were taped and transcribed, and a thematic analysis was performed and presented back to the interviewees in the form of a report. Subsequent feedback and reflection by all of the participants identified their theories about the causal mechanisms that were at play, and these were compared and contrasted with theories generated by previous research on managed clinical networks, drawn from a literature review. This paper first gives an overview of the Catalan health system in order to provide a context for the description of the objectives and organisation of the networks that follows. It then discusses the outcomes of the networks for the hospitals involved, for patients, and for staff, particularly medical oncologists. The paper ends by identifying what network participants believe to be the key success factors, highlighting what learning may be transferable to cancer networks elsewhere. <AS>The networks <bs>Overview of the Spanish healthcare system <ful>The 17 regions of Spain are autonomous with regard to healthcare, each deciding their expenditure priorities within the common framework established in the country’s constitutional right to universal access to care and a common basket of health services.24 In Catalonia, it was decided to build community hospitals so that every citizen would be no more than 30 minutes away from a hospital. As a result, there are now 68 publicly funded hospitals for a population of 7 million people, of which 14 are university teaching hospitals. Municipalities own most hospitals; consortia of municipalities and other institutions own some, and voluntary organisations such as the Church own the rest. The makeup of the boards of directors depends on the ownership, but typically involves representatives of the municipality, community organisations and Catalan Health Service officials. The Catalan Health Service pays hospitals prospectively, through contracts that take into account overall activity and case-mix complexity. ICO is a nonprofit public hospital, which offers specialised cancer care, including medical oncology, radiotherapy, clinical haematology and palliative care for three healthcare subregions with a total population of about 3 million people. In each subregion, cancer surgery is offered in partnership with a neighbouring university teaching hospital. ICO’s first network, in the Costa de Ponent subregion on the southern edge of the city of Barcelona, was established in 1996 and covers 1.4 million people. A second network, covering 0.6 million people, was established in 2001 in the Girona subregion in the northern area of Catalonia. A third network, covering the 0.8 million inhabitants of the Barcelones Nord-Maresme subregion on the northern edge of the city of Barcelona, was established in 2003, but was still in process of being developed at the time of the study, and is not covered by this paper. The Costa de Ponent network comprises six community hospitals and a cancer centre. One hospital is about 10 km from the centre, while the others are between 30 and 60 km away. The Girona network comprises five community hospitals and a cancer centre. One hospital is about 5 km from the centre, while the others are about 40 km away. All except one of the community hospitals in both regions have between 125 and 250 beds. <bs>Objectives and organisation of the networks <ful>The networks aim to provide high-quality care as close as possible to where patients live, in line with the Cancer Plan of Catalonia. In isolation, community hospitals find it difficult to provide high-quality care: there is an insufficient volume of patients (and thus accompanying resources) to enable staff to develop specialist expertise, and the lack of such opportunities can lead to a vicious circle of high staff turnover and workforce shortages. In addition, without some centralisation, costly new technologies and treatments become prohibitively expensive. The networks are seen as a way of addressing these issues while also maintaining person-centred care and facilitating research (enrolment of patients in clinical trials), principally through improved communication. The hospitals seek to share a common, multidisciplinary approach to cancer care based on tumour committees26,27 and clinical guidelines, as per the Cancer Plan of Catalonia.28,29 This approach was established at the outset as an essential component of the network agreement between ICO and each community hospital. A medical oncologist and a radiotherapy oncologist from the cancer centre attend the committees, which have two different roles: to develop and review protocols, and to discuss the new cases diagnosed in the hospital, including whether treatment should take place in the hospital or at the cancer centre. Relatively simple treatments, follow-up and uncomplicated palliative care are provided in the community hospital, with more complex treatments and most acute inpatient care in the cancer centre. Patients included in clinical trials are usually treated centrally during the study protocol. The community hospitals do however vary greatly in terms of their catchment area, capacity and infrastructure. This means that the cancer centre needs to make specific arrangements with each community hospital. There are hospitals that for reasons of funding, or difficulties in managing adverse effects, have decided to restrict themselves to specific chemotherapies, and in three cases, it is not still possible to give chemotherapy. Information systems are not connected between hospitals, and in several cases there is no computerised database available for the clinical record. Ideally, the multidisciplinary tumour committee discussion should take place at the very beginning of a patient’s treatment, but some surgeons (generally those operating on urological cancers) present their cases only after surgery. ICO and medical directors of the community hospitals are working to change this practice. The Costa de Ponent network organises a monthly meeting (which lasts two hours on average) of specialists and doctors from community hospitals, where cancer cases, clinical protocols and the new clinical trials that have started are presented, together with any results that may be of interest. Clinical guidelines shared between hospitals have been discussed in an annual meeting with all physicians of every hospital involved in the multidisciplinary cancer treatment. Every year the meeting is focused on a particular tumour and takes place in a different hospital. Each network now also has a drug committee, with participation from key clinicians and hospital pharmacists, to consider every new cancer drug in the hospital-approved drug list. A key element of the network relationship is that a medical oncologist from the cancer centre spends part of their time (typically two or three days per week) working at a particular community hospital, and the rest of their time working at the cancer centre. On the days when the oncologist is in the cancer centre, they focus on a single type of patient or tumour, so that they have continuous access to up-to-date oncology research and practice. In the community hospital, the oncologist does ‘a bit of everything’, seeing all types of cancer patients in an outpatient clinic, as well as administering chemotherapy (eg adjuvant therapy for colon and breast cancer), and participating in tumour committee meetings. A nurse who works with the medical oncologist in the community hospital acts as a ‘navigator’, guiding patients through the whole cancer care system.30 To maintain the integrity of the model, it is important that the oncologist’s workload is commensurate with their allocation of days at the community hospital, and that they can spend at least two days each week at the cancer centre, doing more specialised work and facilitating communication between the community hospital and cancer centre in order to prepare specialised surgery. Relationships developed through the network have facilitated the introduction of an extra oncologist shared between five hospitals. This arrangement has provided necessary additional oncologist time at those hospitals and helped with staff cover, while still allowing oncologists to spend sufficient time at the centre. This has been beneficial overall, but there has been some loss of the continuity for patients and staff in the community hospitals. Management of each network is based on the clinical leadership of the departmental heads of medical oncology and radiotherapy oncology in the corresponding cancer centre. The medical and radiotherapy oncologists working with community hospitals are drawn from and are managed through these departments, but they liaise directly with the medical director of the community hospital when working there. An annual meeting of the medical director and executive manager of the community hospital, and from ICO the manager responsible for the network (nowadays, the head of the medical oncology department) and the director, reviews the agreement between the community hospital and ICO, including any changes that could result in improvements, and the financial arrangements. The results of these meetings are communicated to the relevant Catalan Health Service executive to consider when setting the prospective payments for the coming year to the community hospital and to ICO. <AS>Discussion <bs>Outcomes <ful>The cancer networks have benefited the healthcare system by facilitating the provision of higher-quality, evidence-based care, being instrumental in trying to reduce inappropriate variation in oncological practice by using clinical guidelines, and in making better use of scarce expertise.31 Community hospitals benefit from economies of scale, access to expertise, and learning from others in the network, via the cancer centre; cancer centres reduce inappropriate referrals, streamline referral processes, and increase recruitment into clinical trials.32 The ratio of follow-up visits to new patients has tended to increase over time as the relationship with oncologists from the cancer centre has developed. The networks also have several strengths from a patient perspective. First, patients wait for a shorter time when being referred for an appointment with the medical oncologist or the multidisciplinary care team at the cancer centre, because the medical oncologist takes the referral in person at the community hospital and feeds it directly into ICO’s appointment system, cutting out a layer of bureaucracy. In addition, patients have better access to any special diagnostic or therapeutic procedures. There is also greater continuity of care, as it is generally the same oncologist who sees patients both in the community hospital and in the cancer centre. This can be a big relief for patients, particularly from rural areas, who are faced with a diagnosis of cancer and having to visit a large hospital in the city. When the patient comes to the cancer centre for the first time, they already have some idea of what is going to happen, and the doctor already knows something about that patient. There can be benefits for staff too. The common early career pattern of an oncologist gaining broad experience and then specialising is facilitated by the network arrangement, but without the disruption arising when oncologists move on from one hospital to another to follow their career. There may also be longer-term issues, however, that need to be considered with regard to career planning and manpower planning. The work environment for the oncologist varies radically between the cancer centre and the community hospital (see Table 1). There are opportunities for both organisations to learn from such insights if they can put in place suitable feedback mechanisms to facilitate constructive discussion about doing things differently. The table also emphasises that spanning the boundary between two organisations is demanding and requires particular skills. Such individuals need support and commitment from the organisations, to ensure that they are not disadvantaged,33,34 particularly during the early days of working in a new organisation when they may feel isolated both in the community hospital and in the cancer centre. <bs>Success factors <ful>The Catalan experience reinforces previous research suggesting that successful networks have at their foundation good personal relationships characterised by trust and reciprocity,35,36 yet do not rely overly on a small number of particular individuals.37 From the outset, ICO sought to promote trust and a long-term relationship among all hospitals joining the networks. One key aspect of this has been to make it explicit that referrals are twoway: whenever patients no longer need specialist care, the centre refers them back to the community. This has helped the network to gain acceptance from the directors of community hospitals, because they no longer ‘lose’ patients, and the accompanying funding, to the centre. ICO has also stressed that costs should not be shifted between hospitals through, for instance, changing the place to administer high-cost chemotherapy due to budgetary instead of clinical reasons. The focus is on ensuring that everybody sees benefits from the arrangement — community hospitals gain access to an experienced oncologist, the cancer centre coordinates its area of influence, and each level of care is focused on what can be done better. In order to achieve this, a flexible approach has needed to be taken to the different organisation and priorities of each community hospital.38 A culture of cooperation has been emphasised through consistent application of cooperative and inclusive 39 norms, and by including in the network agreement a procedure to discuss problems in the relationship either at hospital or clinician level. Active involvement and hence ‘ownership’ of key personnel has been sought, particularly from medical directors in community hospitals, who provide valuable support to ICO oncologists working in the hospital through regular meetings, where they discuss both particular and more strategic issues, such as developing protocols. The annual meeting between senior managers of each hospital and their cancer centre counterparts also provides a mechanism for constructive development of the network. Additionally, by involving officials from the funding body, the Catalan Health Service, the initiative has been instrumental for the expansion of the networks. Professionals from different hospitals have regular opportunities for interaction, either focused on a clinical case, as in tumour committees; on guidelines for tumour therapy, presented in an annual meeting; or on pathways, new protocols or trials, in monthly meetings. This sharing of experiences has helped to build a common understanding of cancer care across organisational and professional boundaries. Pre-existing professional relationships have been instrumental in building the network; most important was the fact that many surgeons and internal medicine physicians in community hospitals were trained as specialists in the tertiary university teaching hospital with which ICO is associated, facilitating professional relationships and clinical leaderships. This inclusive and cooperative approach, which consciously attempts to manage internal and external stakeholder relationships from the inside out and from the outside in40 appears to have established, or at least reinforced, a culture and ‘organisational field’41 that has helped to overcome some of the organisational and professional barriers that have inhibited cancer networks elsewhere.42–45 A fundamental difficulty is that different organisations or professions brought together through the network may have different priorities, cultures and working practices, and it may not be straightforward to bridge these differences and facilitate constructive working. This can further complicate the logistical problems of coordinating the inputs of a large number of different professionals, and of maintaining expertise as oncologists no longer have so much contact with one another. <AS>Conclusion <ful>The ICO experience shows that cancer networks can add value in a healthcare context that involves a diverse range of hospitals. Establishing common systems across a network, such as tumour committees and clinical guidelines, can help to manage that diversity, but requires genuine, ongoing involvement of the managers and clinicians of each hospital, which may not be easy to achieve. An inclusive and cooperative approach, based on personal contact, respect and understanding between different stakeholders (particularly managers and clinicians in different organisations) is important, coupled with the flexibility to make arrangements that suit local circumstances, while respecting the fundamental principles of the model.46 In Catalonia, this was facilitated to some extent by preexisting clinical relationships and a supportive regional health body, but it may well be achievable even in less auspicious circumstances if time is taken to build constructive relationships at the outset. Finally, the boundary spanning medical oncologist role is a complex one, with concomitant opportunities and dangers, which may not be recognised without suitable feedback mechanisms. Organisational networks need to pay as much attention to human factors as to structures and processes. <AS>Conflicts of interest <ful>The authors declare no conflicts of interest. <AS>Acknowledgments <ful>The authors would like to thank to all the physicians (medical oncologists, radiotherapy oncologists and clinical haematologists) and nurses involved in the networks. This paper was partially supported by the Cancer Research Network of the ‘Instituto Carlos III’, Spain (RD06/0020). A preliminary version of this project was presented at the ‘Improving cancer services’ conference, organised by ESO/EHMA, in Milan, March, 2005. <refh>References <ref>1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Birkmeyer, J. D. (2002) ‘Hospital volume and surgical mortality in United States’, New England Journal of Medicine, Vol. 346, pp. 1128–1137. Halm, E. A. (2002) ‘Is volume related to outcome in health care? A systematic review and methodological critique of the literature’, Ann Intern Med, Vol. 137, pp. 511–520. Pla, R. (2004) ‘Does volume influence outcomes in cancer surgery? An analysis based on clinicaladministrative data [in Spanish]’ Cir Esp, Vol. 75, pp. 179–188. Campbell, N. C. (2001) ‘Rural and urban differences in stage at diagnosis of colorectal and lung cancers’, British Journal of Cancer, Vol. 84, pp. 910–914. Hewit, M. and Simone, J. (eds) (1999) Ensuring Quality Cancer Care, National Academy Press, Washington. Hillner, B. E. (2000) ‘Hospital and physician volume or specialisation and outcomes in cancer treatment: importance in quality of cancer care’, Journal of Clinical Oncology, Vol. 18, pp. 2327–2340. National Cancer Policy Board (2001) Interpreting the Volume-Outcome Relationship in the Context of Cancer Care, National Academy Press, Washington. Department of Health (1995) A Policy Framework for Commissioning Cancer Services: A Report by the Expert Advisory Group to the Chief Medical Officers of England and Wales, Stationery Office, London. Kerr, D. J. (1996) ‘Delivering cancer care: a model from the West Midlands’, British Journal of Cancer, Vol. 74, pp. 667–669. National Health Priority Council (2006) National Service Improvement for Cancer, Australian Government Department of Health and Ageing, Canberra. Department of Health, ref. 8 above. Haward, R. (2006) ‘The Calman-Hine report: a personal retrospective on the UK’s first comprehensive policy on cancer services’, Lancet Oncol, Vol. 7, pp. 336–436. Haward, R. (2003) ‘Breast cancer teams: The impact of constitution, new cancer workload and methods of operation on effectiveness.’ British Journal of Cancer, Vol. 89, pp. 15–22. Houssami, N. (2006) ‘Breast cancer: multidisciplinary care and clinical outcomes’, European Journal of Cancer, Vol. 42, pp. 2480–91. Morris, E. (2006) ‘The impact of Calman-Hine report on processes and outcomes of care for Yorkshire’s colorectal cancer’, British Journal of Cancer, Vol. 95, pp. 979–985. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. Edwards, N. (2002) ‘Clinical networks’, British Medical Journal, Vol. 324, p. 63. Southon, G. (2005) ‘Networks: a key to future health services’, Australian Health Review, Vol. 29, pp. 317– 326. Wood, K. (2001) ‘The development of integrated health care models in Scotland’, Int J Integrated Care, Vol. 1: e41, available at: www.ijic.org (accessed 6 May 2007). Gregor, A. (2003) ‘Managed clinical networks in practice: is it working?’ Clinical Oncology, Vol. 15, p. 16971. Livingston, M. and Woods. K. (2003) ‘Evaluating managed clinical networks for cancer services in Scotland’, Int J Integrated Care, Vol. 3, pp. 1–16, available at: www.ijic.org/portal/publish/articles/co0026/articleprint.html (accessed 22 December, 2007). Scottish Executive (2003) ‘Promoting the development of managed clinical networks in NHS Scotland’, Health Department, Circular HDL, 69, Edinburgh. Mur-Veeman, I. (2003) ‘Development of integrated care in England and the Netherlands — Managing across public-private boundaries’, Health Policy, Vol. 65, pp. 227–241. Farsi, F. (2002) ‘Cancer networks [in French]’, Bull Cancer, Vol. 89, pp. 197–206. Ray-Coquard, I. (2006) ‘Medical practices and cancer care networks: examples in oncology’, Bull Cancer, Vol. 93, pp. E13–E20. Duran, A. (2006) ‘Spain: Health system review’, Health Systems in Transition, Vol. 8, No. 4, pp. 1–2008. Department of Health, ref. 8 above. Fleissig, A. (2006) ‘Multidisciplinary cancer care: are they effective in the UK?’, Lancet Oncol, Vol. 7, pp. 935–943. Vidal, J. (2003) ‘The clinical practice guidelines in cancer — OncoGuidelines. Catalan Agency Health Technology Assessment Research’, Newsletter, Vol. 31, pp. 3–5, available at: www.aatrm.net/infpdf/en/but31eng.pdf (accessed 22 December 2007). Autonomous Government of Catalonia (2001) Cancer Plan for Catalonia, Department of Health and Social Security, Barcelona. Dohan, D. (2005) ‘Using navigators to improve care of the underserved patients. Current practices and approaches’, Cancer, Vol. 104, pp. 848–855. Edwards, ref. 16 above. Brunet, J. (2006) ‘Access to specialized cancer care and clinical trials for cancer patients from non-urban areas is facilitated by a cancer network’, Journal of Clinical Oncology (ASCO Part I), Vol. 24, 18S, pp. 16006. Conner, M. (2001) ‘Developing network-based services in the NHS’, Int J Health Care Quality Assurance, Vol. 14, No. 6, pp. 237–244. Norris, E. (2005) ‘Multidisciplinary perspectives on core networking skills. A study of skills: and associated training needs, for professionals working in managed clinical networks’, Journal of Interprofessional Care, Vol. 19, No. 2, pp. 156–163. Ferlie, E. and McGivern, G. (2003) Relationships between Health Care Organisations. NCCSDO, London. Godwin, N. (2006) Leadership in Health Care, Routledge, London. Colomer, R. (2004) ‘Cancer care in rural areas [letter]’, British Journal of Cancer, Vol. 90, p. 1688. Ibid. Fenton, E. (2001) ‘Reflections from organization science on the development of primary health care research networks’, Family Practice, Vol. 18, pp. 540–544. Savage, G. T. (1997) ‘Governance of integrated delivery systems/networks: a stakeholder approach’, Health Care Management Review, Vol. 22, No. 1, pp. 7–20. Currie, G. and Suhomlinova, O. (2006) ‘The impact of institutional forces upon knowledge sharing in the UK NHS: The triumph of professional power and the inconsistency of policy’, Public Administration, Vol. 84, No. 1, pp. 1–30. Ferlie and McGivern, ref. 35 above, Addicott, R. (2006) ‘Networks, organizational learning and knowledge management: NHS Cancer Networks’, Public Money & Management, Vol. 26, No. 2, pp. 87–94. Ferlie, E and Addicott, R. (2004) The Introduction, Impact and Performance of Cancer Networks: A Process Evaluation, Imperial College, London. McCallum, A and Brommels, M. (2004) ‘How do clinical networks and organisational approaches to integrate care impact on access to health care?’, available at: www.integratedcarenetwork.org/publish/articles/000051/article_print.html (accessed 22 December 2007) Mur-Veeman, I. (2008) ‘Comparing integrated care policy in Europe: Does policy matter?’ Health Policy, Vol. 85, pp. 172–183. Table 1: Comparison between working in the cancer centre and the community hospital from the perspective of a medical oncologist Aspect of work Cancer centre Subspecialisation Developing expertise in one tumour area Experts in other tumours can always be asked if appropriate Resources Any test can be done, although the process may be bureaucratic and time-consuming Community hospital Using general concepts and ‘common sense’, with no specialists to call on Fewer resources (eg CT scan, ultrasound), but results may be obtained within the same day Multi-disciplinary working Accessibility to/for patients Responsibility Discussions are between clinicians with similar subspecialisations, and the outcomes tend to be predictable Patients tend to interact with different members of the team, with fewer opportunities for personal communication between patient and doctor Discussions are with surgeons and pathologists, who may have a general perspective, requiring the oncologist to talk in ‘another language’ Doctor, patient and sometimes the family, meet in person more often The patient can talk about problems from their perspective (ie the practical implications for them as a family member, employee, community member etc); although this can take time, the oncologist gets extra information, helping decision making Large team, with the danger that some Smaller team (eg doctor, nurse and outpatient problems may not be addressed because assistant), which functions more as a team, nobody takes ownership of them with clear responsibilities for each member