Published: 18 Dec 2023

St George’s Hospital has formally set out why #KidsDeserveStGeorge’s in its response to an NHS England Consultation on the future of children’s cancers services.

St George’s is home to a large children’s hospital with expert doctors, nurses and other clinicians who already provide specialist services to children with cancer.

The St George’s proposal is to consolidate the primary treatment centre onto the St George’s site in a new, state-of-the-art children’s cancer wing – delivering outstanding facilities to match the outstanding care already provided.

St George’s has 25 years’ experience of delivering cancer care and believes Kids Deserve St George’s because this expertise – built up over these years, and the professional relationships between different clinical specialists as they collaborate to treat children with cancer – cannot be easily or quickly replicated overnight if the service was moved to a hospital with no experience of treating children with cancer.

The services that matter most for children with cancer are available on site at St George’s and for 80 per cent of children with cancer, St George’s can offer or is poised to offer key treatments that the Evelina will not or will have to develop.

Many parents have said they would prefer the children’s cancer centre to be outside of central London, with good parking provision so they don’t have to use public transport with an immunosuppressed child. St George’s offers this, with dedicated parking spaces and a drop-off zone for the families of children with cancer, directly outside the entrance of our proposed new, state-of-the-art children’s cancer centre.

Consolidating the children’s cancer centre at St George’s will also be easier and less costly for the NHS to deliver.

St George’s Consultation Response

You can read our full response to the consultation below.

Response to the public consultation on the future of the children’s cancer Principal Treatment Centre (PTC) in the South Thames region.

Please accept this as St George’s response to the public consultation on the future of the children’s cancer Principal Treatment Centre (PTC) in the South Thames region.

St George’s is home to a large children’s hospital, with dedicated paediatric capacity and an extensive range of tertiary paediatric subspecialties. We are rated outstanding for paediatrics by the CQC, and have been delivering the PTC in partnership with the Royal Marsden for decades. Our proposal is to consolidate the PTC onto the St George’s site in a new, state-of-the-art children’s cancer wing – delivering outstanding facilities to match the outstanding care we already provide.

Our view is that the best option for children is for the PTC to be consolidated onto the St George’s site. We believe this is the best option because:

• Unlike the Evelina, St George’s has 25 years’ experience of delivering paediatric cancer care. The expertise built up over these years, and the professional relationships built up between different clinical specialists as they collaborate to treat children with cancer, cannot be easily or quickly replicated overnight. See annex A for more detail.
• The services that matter most for children with cancer are available on site at St George’s.
  • 15% of children with cancer will have a neuroblastoma, renal tumour, or germ cell tumour, and these children will often require major surgery performed by a paediatric oncology surgeon to remove or reduce their tumour. This expertise is rare: there are 20 such surgeons in the country, three of whom are at St George’s. The Evelina does not have this expertise, and would need either to rely on surgeons from St George’s going to work at the Evelina, or to build a new surgical team to cater for these children.
  • 25% of children with cancer have a brain or spinal tumour, many of whom will need neurosurgery. Some other children with cancer will also need neurosurgery as a result of their treatment. Sometimes this neurosurgical input is needed in an emergency. Along with King’s, St George’s provides neuro-oncology surgery and acute neurosurgery, but the Evelina does not.
  • 32% of children with cancer will have leukaemias or other blood cancers, and a further 10% will have a lymphoma. For these children, bone marrow transplants and increasingly CAR-T are key treatments for the PTC to be able to deliver. These are complex, high-risk, heavily regulated treatments. St George’s has a bone marrow transplant programme for adults and is accredited to provide CAR-T for adults, and so is well placed to extend the offer to children. GSTT does not have a bone marrow transplant programme, and is not accredited to deliver CAR-T. These highly regulated and complex clinical and laboratory services are difficult to set up without past experience.
  • The services available at the Evelina and not St George’s (inpatient cardiology and nephrology) are important, but required for much smaller numbers of children with cancer (see Annex B for more detail). On the other hand, the commonly used aspects of these specialties are delivered at St Georges or could be through tele-medicine. Patient transfers would not be required.
  • Taken together, this means that for some 80% of children with cancer, St George’s can offer or is poised to offer key treatments that the Evelina will not, or will have to develop. To my mind this calls into question why the NHS has embarked on a competitive process, bringing in providers without experience of children’s cancer, rather than working with the existing providers to meet the new service specification as has been done in North London.
  • Looking further to the future, St George’s, University of London is an international leader in research in vaccines, infection studies and clinical trials, a key strategic asset given the long-term potential for vaccine technology to be developed to support the treatment of cancer.
• St George’s can deliver what parents of children with cancer say they want. Above all, expertise and experience. But parents have also said that when you have a child with cancer, potentially on immunosuppressants, you take them to hospital by car not on public transport. Parents have consequently said they would prefer the children’s cancer centre to be outside of central London, with good parking provision. St George’s will and does offer this, with dedicated parking spaces and a drop-off zone for the families of children with cancer, directly outside the entrance of our proposed new, state-of-the-art Children’s Cancer Centre.
• Consolidating the children’s cancer centre at St George’s will be easier and less costly for the NHS to deliver. A large part of the service is already at St George’s, and at St George’s, an existing non-clinical space can, at relative speed, be transformed into a new state-of-the-art cancer centre. It will also be less disruptive for staff, and cost the NHS less, when compared with trying to move more services and more staff to central London. See annex C for detail.
• If children’s cancer services are transferred from St George’s to the Evelina London Children’s Hospital, this will have an impact on other children’s services at St George’s. Children’s cancer services are not neat, stand-alone services. For instance, the surgeons at St George’s who operate on children with cancer also operate on other children from across South West London and Surrey. In some cases, St George’s will have to retain these staff but lose the income associated with children’s cancer care. In other cases, the expert staff supporting children with cancer could leave St George’s. This would weaken other services provided to children in South West London and Surrey, particularly surgery and pathology. See Annex D for more detail.

Since submitting our proposals, our position with regards to research and education has also grown stronger. We already support more children into trials of medicinal projects than any other provider in South London, and are uniquely placed to support the PTC’s ongoing partnership with the ICR, given our proximity and the Government’s support to build a new hospital in Sutton that would see the St George’s, Epsom and St Helier Group co-located with the ICR. Now, with City University of London and St George’s, University of London exploring a merger and developing ambitious plans to invest in the St George’s campus, the opportunities are stronger still.

I know many of these arguments will be familiar to NHS England, as we have made them consistently over the past 3 years. Nevertheless, I believe that together they make a compelling case for keeping the PTC at St George’s, and I hope you will feel able to consider them as you make your decision.

Annex A – St George’s Paediatric Cancer Experience

The current PTC service at St George’s and the Royal Marsden has been built up over 25+ years.

In many cases, it is reliant on the experience of individuals with extremely rare expertise. For instance:

• Paediatric oncology surgery requires surgeons with uncommon skill and expertise. There are only around 20 in the country, of whom 3 are at St George’s. St George’s is the only hospital in South London with such expertise.
• Paediatric oncology surgeons work with a small number of highly specialised paediatric anaesthetists for complex cancer cases – St George’s is unique in South London in having such experts supporting children’s cancer care.
• Pathologists – there is a national shortage of paediatric pathologists, and very few with paediatric oncology skills. In South London, outside St George’s no other paediatric centre’s pathologists routinely undertake oncology pathology

It cannot be assumed that these individuals will move if the children’s cancer service moves – and since most of them provide care to children with cancer but also to other children, most will not qualify for automatic transfer under TUPE regulations.

If the individuals do not move, developing the expertise in new staff takes a long time. For instance:

• Advanced nurse practitioners in oncology take 4+ years of training and supervised practice before they can practise independently
• It takes between 5 and 8 years post completion of paediatric surgical training for a surgeon to develop competence in paediatric oncology surgery
• It takes 1 year to train nursing staff with oncology specific skills such as administration of chemotherapy and High Dependency Unit level competencies, and another 1-2 years for consolidation of skills

The importance of experience is also not just about individuals, but about multi-disciplinary teams building up years of experience and trust working together to provide patients with seamless care. For instance:

• Paediatric oncology surgery requires a whole team approach, involving surgeons, nurses, diagnosticians, anaesthetists, theatre staff, intensive care clinicians. This has developed over years at St George’s
• The surgical service is highly integrated into a multi-disciplinary team, alongside pathology, diagnostic radiology, interventional radiology, paediatric intensive care and oncologists. At St George’s this team benefits from years of mutual trust in each other’s competence and knowledge.
• Some paediatric tumours are seen rarely in children – joint working with adult specialist surgeons is well established for these.
• The medical oncology service is similarly integrated with other medical and diagnostic services, particularly critical specialties like infectious diseases and microbiology.

Annex B – important services for children with cancer, including neurosurgery

Because children with cancer can need care from a wide range of paediatric specialists, the national service specification for PTCs sets out a number of service which, while they do not need to be on the same site, must be ‘readily accessible’. Most of these services are available on site at both St George’s and the Evelina, but the key differences between the two relate to neurosurgery, kidney care, and cardiology.

	Available at St George’s?	Available at Evelina?	Scale of need
Neurosurgery (for cancer-related problems affecting patients’ brains, nervous systems or spines)	Yes. Neurosurgery for children with cancer is delivered at St George’s (the smaller service) and King’s (the larger service)[1], primarily depending on which part of London/the South East the child is from.	No – patients would go to King’s or St George’s for surgery. In exceptional circumstances, emergency neurosurgery could be carried out on site at Evelina London by a neurosurgeon from King’s.	Approximately 25% of children with cancer have a brain/spinal tumour. In 19/20, 86 children had cancer-related neurosurgery. Sometimes this is needed in an emergency.
Paediatric oncology surgery	Yes. Of the c. 20 paediatric oncology surgeons in the country, three are at St George’s.	No – either surgeons from St George’s would need to go to the Evelina to undertake the surgery, or the Evelina would need to develop the expertise.	Approximately 15% of children with cancer have a solid tumour of the type where a major paediatric oncology surgical operation may be needed.
Inpatient nephrology (for patients with kidney disorders)	No – outpatient clinics and dialysis available on site, but for other inpatient care children would go to the Evelina.	Yes	In 19/20, 6 children with cancer who were treated at The Royal Marsden also received inpatient care at Evelina London for kidney care. 3 of them had to stay overnight in hospital.
Inpatient cardiology (for patients with defects and diseases of the heart and blood vessels)	No – outpatient clinics and diagnostics available on site, but for inpatient care children would go to the Evelina.	Yes	In 2019/20, 25 children with cancer who were treated at The Royal Marsden also received inpatient care at Evelina London for heart care. All were seen as day cases (i.e. did not stay overnight in hospital), mostly for diagnostic tests which St George’s can deliver on site.

Sources: NHSE Pre-Consultation Business Case, National Disease Registration Service (NDRS)

 

Annex C – finances

 

NHSE have assessed the St George’s proposal as involving lower capital costs, representing better value for money, and having a better revenue impact (see table below).

 

	St George’s	Evelina
Capital costs	£30.8m	£44.3m
–          Funded by charitable donation	–          £0m	–          £10m
–          Funded by NHS	–          £30.8m	–          £34.3m
Value for money ratio The VfM ratio shows the relationship between a project’s costs and benefits. If the ratio is greater than 1, the benefits outweigh the costs. If the ratio is less than 1, the costs outweigh the benefits.	1.5	1.3
Adjusted financial performance of the service – retained surplus / (deficit) by 2030/31	-£0.018m	-£1.9m

Source: NHSE Pre-Consultation Business Case, finance section, available here.

Beyond the financial impact on each individual institution, there will be wider costs to the NHS as a whole. This includes stranded costs at St George’s if the children’s cancer service moves to the Evelina. St George’s has estimated these costs at c. £2.5m in the first year if the service moved.

Annex D – impact on St George’s other paediatric services if children’s cancer moves

Paediatric cancer care at St George’s is delivered by a wide range of specialties, as part of their broader caseload, including paediatric surgery, paediatric intensive care, paediatric acute medicine, gastroenterology, haematology, infectious disease, neurology, paediatric neurosurgery, and clinical support services such as paediatric pathology and radiology. There are few tertiary paediatric specialties at St George’s whose work would not be affected by moving the children’s cancer service to central London.

For most of these services, the Trust believes it would be able to mitigate the impact over time. But for some services (particularly paediatric surgery, paediatric intensive care, and paediatric pathology) the impact would be much more significant.

1. Paediatric surgery. Transferring the PTC would mean the service losing 20% of its elective caseload, and the element of its case load that makes it most attractive to current and future surgical staff – paediatric oncology cancer is complex, rewarding work for our surgeons. St George’s view is that it is highly likely that in time it would result in some of the service’s most experienced and capable surgeons leaving, and make the service a less attractive prospect for surgeons that the Trust would need to seek to replace them. This includes surgeons that the Trust currently relies on to deliver general and specialist paediatric surgery for children from across South West London and Surrey..
2. Paediatric pathology. Paediatric cancer constitutes a significant proportion of the total number of specimens examined by the Trust’s paediatric pathology department, and an even more significant proportion of the department’s workload (because cancer cases tend to be more complex and time consuming). It is also, as with surgery, the element of the caseload that makes the department attractive to current and future staff. The loss of cancer work would therefore significantly impact on the attractiveness of the department, at a time when paediatric pathologists are in short supply across the country. The Trust’s view is that it would threaten the viability of the service. This would in turn impact on other services in South West London catered to by St George’s paediatric pathology department, including perinatal post-mortems, and paediatric and maternity services.
3. Financial impact – particularly for intensive care. Paediatric oncology is an integral part of a range of paediatric services at St George’s, rather than a stand-alone service. Clinical staff care for children with cancer but also children without cancer. Consequently, if the service were transferred to the Evelina, St George’s would lose the associated income but not be able to cut all the costs associated with the staff and facilities. St George’s currently estimates that the resultant financial gap would be c£2.5m in the first year after any move of the cancer service, reducing over time. The impact is particularly significant for paediatric intensive care, where just under £1m of these costs sit.

[1] Depending on the data source and year in question, St George’s provides c.20-30% of neurosurgery for children with cancer in the region, and King’s 70-80%.

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