Loss associated with subtractive health service change: The case of specialist cancer centralization in England

Georgia B Black¹, Victoria J Wood², Angus I G Ramsay³, Cecilia Vindrola-Padros⁴, Catherine Perry⁵, Caroline S Clarke⁶, Claire Levermore⁷, Kathy Pritchard-Jones⁸, Axel Bex^{9

10}, Maxine G B Tran^{11

12}, David C Shackley¹³, John Hines^{9

14}, Muntzer M Mughal¹⁵, Naomi J Fulop¹⁶

Affiliations

¹ Principal Research Fellow, Department of Applied Health Research, 4919University College London, London, UK.
² Research Associate, Department of Applied Health Research, 4919University College London, London, UK.
³ Senior Research Fellow, Department of Applied Health Research, 4919University College London, London, UK.
⁴ Senior Research Fellow, Department of Targeted Intervention, University College London, London, UK.
⁵ Research Fellow, Applied Research Collaboration Greater Manchester/Division of Population Health, Health Services Research and Primary Care, 5292University of Manchester, Manchester, UK.
⁶ Senior Research Fellow, Research Department of Primary Care & Population Health, University College London, London, UK.
⁷ Executive Director of Operations, North Central London Cancer Alliance, 8964University College London Hospitals NHS Foundation Trust, London, UK.
⁸ Professor of Paediatric Oncology, North Central London Cancer Alliance, University College London Hospitals NHS Foundation Trust, & University College London Partners, London, UK.
⁹ Department of Urology, 4965Royal Free London NHS Foundation Trust London, London, UK.
¹⁰ Consultant Clinical Lead Specialist Centre for Kidney Cancer, Division of Surgery and Interventional Science, University College London, London, UK.
¹¹ Senior Lecturer in Renal Cancer Surgery, Division of Surgery and Interventional Science, University College London, London, UK.
¹² Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK.
¹³ Director & Medical Lead, Greater Manchester Cancer; Clinical Lead Manchester Academic Health Science Centre, 5292University of Manchester, Manchester, UK.
¹⁴ Consultant Urological Surgeon and Urology Pathway Director, Division of Surgery and Interventional Science, University College London, London, UK.
¹⁵ Honorary Clinical Professor, Division of Surgery and Interventional Science, University College London, London, UK.
¹⁶ Professor of Health Care Organisation and Management, Department of Applied Health Research, 4919University College London, London, UK.

PMID: 35471103
PMCID: PMC9548928
DOI: 10.1177/13558196221082585

Loss associated with subtractive health service change: The case of specialist cancer centralization in England

Georgia B Black et al. J Health Serv Res Policy. 2022 Oct.

. 2022 Oct;27(4):301-312.

doi: 10.1177/13558196221082585. Epub 2022 Apr 26.

Authors

Affiliations

¹ Principal Research Fellow, Department of Applied Health Research, 4919University College London, London, UK.
² Research Associate, Department of Applied Health Research, 4919University College London, London, UK.
³ Senior Research Fellow, Department of Applied Health Research, 4919University College London, London, UK.
⁴ Senior Research Fellow, Department of Targeted Intervention, University College London, London, UK.
⁵ Research Fellow, Applied Research Collaboration Greater Manchester/Division of Population Health, Health Services Research and Primary Care, 5292University of Manchester, Manchester, UK.
⁶ Senior Research Fellow, Research Department of Primary Care & Population Health, University College London, London, UK.
⁷ Executive Director of Operations, North Central London Cancer Alliance, 8964University College London Hospitals NHS Foundation Trust, London, UK.
⁸ Professor of Paediatric Oncology, North Central London Cancer Alliance, University College London Hospitals NHS Foundation Trust, & University College London Partners, London, UK.
⁹ Department of Urology, 4965Royal Free London NHS Foundation Trust London, London, UK.
¹⁰ Consultant Clinical Lead Specialist Centre for Kidney Cancer, Division of Surgery and Interventional Science, University College London, London, UK.
¹¹ Senior Lecturer in Renal Cancer Surgery, Division of Surgery and Interventional Science, University College London, London, UK.
¹² Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK.
¹³ Director & Medical Lead, Greater Manchester Cancer; Clinical Lead Manchester Academic Health Science Centre, 5292University of Manchester, Manchester, UK.
¹⁴ Consultant Urological Surgeon and Urology Pathway Director, Division of Surgery and Interventional Science, University College London, London, UK.
¹⁵ Honorary Clinical Professor, Division of Surgery and Interventional Science, University College London, London, UK.
¹⁶ Professor of Health Care Organisation and Management, Department of Applied Health Research, 4919University College London, London, UK.

PMID: 35471103
PMCID: PMC9548928
DOI: 10.1177/13558196221082585

Abstract

Objective: Major system change can be stressful for staff involved and can result in 'subtractive change' - that is, when a part of the work environment is removed or ceases to exist. Little is known about the response to loss of activity resulting from such changes. Our aim was to understand perceptions of loss in response to centralization of cancer services in England, where 12 sites offering specialist surgery were reduced to four, and to understand the impact of leadership and management on enabling or hampering coping strategies associated with that loss.

Methods: We analysed 115 interviews with clinical, nursing and managerial staff from oesophago-gastric, prostate/bladder and renal cancer services in London and West Essex. In addition, we used 134 hours of observational data and analysis from over 100 documents to contextualize and to interpret the interview data. We performed a thematic analysis drawing on stress-coping theory and organizational change.

Results: Staff perceived that, during centralization, sites were devalued as the sites lost surgical activity, skills and experienced teams. Staff members believed that there were long-term implications for this loss, such as in retaining high-calibre staff, attracting trainees and maintaining autonomy. Emotional repercussions for staff included perceived loss of status and motivation. To mitigate these losses, leaders in the centralization process put in place some instrumental measures, such as joint contracting, surgical skill development opportunities and trainee rotation. However, these measures were undermined by patchy implementation and negative impacts on some individuals (e.g. increased workload or travel time). Relatively little emotional support was perceived to be offered. Leaders sometimes characterized adverse emotional reactions to the centralization as resistance, to be overcome through persuasion and appeals to the success of the new system.

Conclusions: Large-scale reorganizations are likely to provoke a high degree of emotion and perceptions of loss. Resources to foster coping and resilience should be made available to all organizations within the system as they go through major change.

Keywords: Major system change; centralization; leadership; organizational loss.

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Conflict of interest statement

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MMM was Director of the OG Cancer Pathway Board (later joint Chief Medical Officer) for London Cancer and Consultant Upper GI surgeon at UCLH. JH was urology pathway lead for London Cancer, and CL was a pathway manager on the London Cancer centralizations. They therefore have an interest in the successful implementation of MSC; none of them had financial interests. DS is the Director of Greater Manchester Cancer and Clinical Lead; he was involved in the engagement and design aspects of the Greater Manchester proposals working for Commissioners and he has no financial interests.

Figures

**Figure 1.**
Relationships between subtractive change, emotional repercussions and support offered.

See this image and copyright information in PMC

References

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Loss associated with subtractive health service change: The case of specialist cancer centralization in England

Affiliations

Loss associated with subtractive health service change: The case of specialist cancer centralization in England

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical