How very specialist cancer services currently provide care for children living in south London and much of the south east

Children’s cancer centres (known as Principal Treatment Centres) are responsible for making sure every child with cancer gets the expert care they need. They are mainly for children aged 15 and under with cancer. (They can carry on caring for older children if that is best for individual patients.) 

This consultation is about the centre for children with cancer living in Brighton and Hove, East Sussex, Kent, Medway, south London and most of Surrey. We describe this as “south London and much of the south east.” It is what we mean when we say “the catchment area.”

Current service

The Principal Treatment Centre for south London and much of the south east is currently provided in partnership between The Royal Marsden NHS Foundation Trust and St George’s University Hospitals NHS Foundation Trust. (Trusts are NHS organisations that run services for patients.)

The teams leading and coordinating specialist care for children with cancer, including diagnosis, chemotherapy, conventional radiotherapy, bone marrow transplants, and many late-effects clinics (for managing longer-term impacts on patients) are based at The Royal Marsden’s site in Sutton. Life-saving intensive care, most children’s cancer surgery, and other specialist services needed by children with cancer are led and coordinated by the teams at St George’s Hospital eight miles away in Tooting.

The Royal Marsden has a Good rating for children’s services from the Care Quality Commission (from 2017), St George’s is rated Outstanding for children’s services (from 2019).

The Royal Marsden

The Royal Marsden is a specialist cancer hospital and has two sites in Chelsea and Sutton. Children’s and Young People’s Cancer Services are based at the 31-bedded Oak Centre for Children and Young People on the Sutton site. This purpose-built centre, which opened in 2011, has two inpatient wards, one for children mainly aged one to 15 and the other for teenagers and young adults aged 16 to 24. It also has a dedicated outpatient and day care unit, schoolroom, activity room and three play areas for children, as well as other facilities for teenage and young adult patients.

Inpatient care for children with cancer is on McElwain ward, which has 18 beds including a dedicated room for radioisotope therapy.  Eight of them are single ensuite rooms that are HEPA-filtered and so are suitable for children having bone marrow transplants and are used for other children as well. Each bed space has facilities that enable parents to stay on the ward with their child and there is a kitchen and lounge area for patients and families. The Royal Marsden also provides accommodation for families with four properties located within half a mile of the hospital so that those who have to travel long distances to the hospital can stay close by.   

Inpatient care for 16 to 24 year olds is on the Teenage Cancer Trust Unit which has 13 beds including five single ensuite rooms alongside a dedicated day care facility. Teenage and young adult services are not part of this consultation.

The Oak Centre has its own front entrance, specially designed garden space, roof terrace and outdoor spaces, and eight dedicated car parking spaces, free of charge, for children and young people attending day care appointments. All Royal Marsden staff working in the centre are experts in children’s and young people’s healthcare and in cancer. The Royal Marsden’s children’s cancer consultants lead the overall care for children with cancer who are receiving treatment from the Principal Treatment Centre, even when they are on another site, such as at St George’s Hospital or a shared care unit. When admitted to St George’s Hospital the Paediatric Intensive Care Unit team or surgical team will lead those episodes of care with daily input from The Royal Marsden paediatric cancer team.

In 2019/2020 (the year we are using as the reference year for the consultation, as it was the last full year pre-Covid[1]), 456 children received cancer care as an inpatient at The Royal Marsden. These children received admitted patient care as 4,137 day (or regular day) cases, 412 planned and 50 unplanned stays. 41 children received photon radiotherapy. This radiotherapy is delivered on site at The Royal Marsden. There were also almost 8,000 outpatient appointments for 1,354 children. Many children had more than one type of care. Children also accessed other specialist care and facilities as part of the integrated service provided including psychological support services, play therapists, social workers.

The Royal Marsden undertakes research into children’s cancer in partnership with the Institute of Cancer Research[2], one of the world’s most influential cancer research organisations. Together, both organisations form a National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC), one of 20 in the UK.

The Royal Marsden and Institute of Cancer Research jointly run a joint Paediatric and Adolescent Oncology Targeted Drug Development Programme. This helps turn discoveries made by scientists into new treatments for patients. Its aim is to accelerate the development of new drugs for children and young people with cancer.

The programme includes drug discovery, pre-clinical evaluation, early clinical trials and the Oak Paediatric and Adolescent Oncology Drug Development Unit at The Royal Marsden for children and young people, which is an NIHR clinical research facility. The drug development unit oversees early clinical trials – a way for children to get new or innovative treatments that might not otherwise be available.

The Royal Marsden attracted £38 million of funding for research in 2019/20, including £1 million for children’s cancer research. The hospital is consistently among the top three centres in Europe (in terms of numbers of trials available and numbers of patients recruited) in the Innovative Therapies for Children with Cancer (ITCC) European early phase trials consortium[3], Between 2017 and 2021[4], 32 per cent of all UK children recruited to trials by the 12 UK sites which are members of the consortium were recruited by The Royal Marsden.

The Oak Paediatric and Adolescent Oncology Drug Development Unit sits within the wider Royal Marsden Paediatric Clinical Research Team. This team carries out many other clinical trials and research studies, including other large trials of cancer treatments, supportive care studies and research into improving symptoms and palliative care. Some of these are carried out in collaboration with The Royal Marsden Children and Young People’s Symptom and Palliative Care Team.

The clinical trials are run by more than 25 Royal Marsden staff who are part of the clinical research team. They include children’s cancer consultants, drug development clinical fellows, research nurses, trial coordinators, data managers, a tissue collector, an assistant practitioner, and a research administrator for the team. Employment costs for half of these staff, including some doctors, a nurse, and some trials managers, are funded by The Royal Marsden Cancer Charity (RMCC). Some staff in the core clinical team are also funded by RMCC.

The Royal Marsden and Institute of Cancer Research jointly have an Experimental Cancer Medicine Centre for children as well as for one for adults. Experimental Cancer Medicine Centres have world-leading expertise in early phase clinical research. They work together in a UK-wide network to generate new treatments for cancer[5].

The Institute of Cancer Research’s Paediatric Oncology Experimental Medicine (POEM) Centre has six research teams working on children’s cancer. Five of these teams research solid tumours, including brain tumours, and one researches blood cancers. They are also one of the leading sites for development of imaging technology.

The Royal Marsden also hosts the children’s cancer network, which coordinates and develops care provided in children’s cancer shared care units at more local hospitals across the Principal Treatment Centre’s catchment area. These provide supportive care and, where agreed, specific chemotherapy treatments, as close to home as possible.

St George’s Hospital

St George’s Hospital is a large teaching hospital and provides many tertiary (specialist) services for adults and children. It is the largest healthcare provider in south west London and provides NHS services to Surrey, Sussex and beyond. 

It is one of six major providers of children’s care in London and one of three providers of children’s intensive care in south London.

St George’s Hospital provides intensive care services and support for children with cancer in south London and much of the south east. Some children are transferred to St George’s children’s intensive care unit from The Royal Marsden, others from shared care units, and others may need intensive care as part of their treatment at St George’s Hospital.

St George’s Hospital also undertakes about three quarters of all surgical procedures for children with cancer, and provides other specialist children’s services for them. It has four beds for children with cancer on the children’s ward, and two on the intensive care unit, as well as surgical beds in the children’s surgical and neurosurgical ward.

In 2019/20, 210 children received Principal Treatment Centre level cancer care as an inpatient at St George’s Hospital: these included 84 children who were there for intensive care, 72 children who had a planned stay and 93 who had an unplanned stay.  There were also 275 outpatient appointments for 72 children. Many children had more than one type of care. The 84 children there for intensive care had 1,451 critical care bed days at St George’s Hospital.

In addition to these services, St George’s Hospital also provides neurosurgery for children with cancer and children’s cancer care as a paediatric oncology shared care unit. These services are not part of the proposed reconfiguration.

St George’s has undertaken joint research with The Royal Marsden (as part of the current Principal Treatment Centre), mainly in the area of supportive care trials, for instance, in infectious diseases and antifungal studies. At the time the consultation launched, St George’s Hospital was preparing to become one of the sites taking part in the ALLTogether trial which tests anti-cancer therapy for children with leukaemia. Since 2023, the children’s cancer clinical research team at The Royal Marsden includes a post for a Research Nurse Specialist for Paediatric Oncology, employed by St George’s, who works cross-site with The Royal Marsden to support joint trials and tissue studies.

How the Principal Treatment Centre sites work together to provide children’s cancer services

The Royal Marsden provides most inpatient and outpatient care for children with cancer in the Principal Treatment Centre catchment area. Chemotherapy is given to a small number of children at St George’s if it is needed while the child is an inpatient there. The Royal Marsden also gives conventional (photon beam) radiotherapy, using x-rays, at its Sutton site. Some children need proton beam and other specialist forms of radiotherapy which is delivered at University College Hospital for all children in London and the south of England

As the Sutton site has no children’s intensive care unit, the children’s team at The Royal Marsden follows strict guidelines when a child may need intensive care treatment. Conversations with other professionals start at an early stage. Staff call the South Thames Retrieval Service (which is provided by Evelina London Children’s Hospital) to transfer the child to St George’s Hospital in a specially equipped children’s ambulance[6]. In 2019/20:

• 35 children were transferred from The Royal Marsden to St George’s Hospital because they needed or might need intensive care
• 15 of them were treated in the intensive care unit
• 23 were treated on the children’s ward
• some children were transferred more than once.  

The teams on the two sites work very hard to make sure children with cancer get safe, joined-up care. The service they provide is safe and high quality. A children’s cancer consultant and a doctor from The Royal Marsden are at St George’s every day, including at weekends. The Royal Marsden’s children’s cancer consultants provide 24/7 cover for both sites and will attend at any time, if needed in an emergency.

St George’s surgeons carry out some surgical procedures at The Royal Marsden, and complex surgery and surgery on children at higher risk of complications at St George’s Hospital.

A range of other specialists at St George’s Hospital contribute to children’s cancer care. For instance:

• a consultant paediatric endocrinologist (a doctor who specialises in hormones) from St George’s Hospital runs a clinic twice a week at The Royal Marsden.
• genetics clinics run jointly by teams from St George’s Hospital and The Royal Marsden look after children who may have a genetic link to cancer. The clinics offer surveillance/screening for earlier diagnosis of future cancers in patients and/or relevant family members.
• diagnosticians (such as pathologists) from St George’s Hospital contribute to joint team meetings to consider the best course of treatment
• a range of other specialists (for example, in infection and gastroenterology) are available on site at St George’s Hospital to input into the care of children with cancer.

Specialists at other hospitals also contribute to the care of children with cancer under the care of the Principal Treatment Centre. Evelina London Children’s Hospital staff run a fortnightly clinic at The Royal Marsden for children who need heart checks. Children with cancer may also require tertiary (specialist) heart and kidney services which are provided at Evelina London. Children with bone cancer, eye cancer and liver cancer have their surgery at national specialist hospitals such as the Royal National Orthopaedic Hospital, the Royal London Hospital, and King’s College Hospital, usually in partnership with the Royal Marsden.

Staff who are in scope from The Royal Marsden (and, if the future centre was at Evelina London, staff in scope from St George’s) would transfer under the transfer of undertakings and protection of employment regulations to the future centre. A staff consultation will be carried out ahead of transfer as part of a comprehensive transfer plan to ensure legal compliance and awareness of individual needs. Supporting as many as possible of the experienced and expert staff who provide the current service to move to the future Principal Treatment Centre will be a priority for NHS England.

NHS England hopes most staff will transfer to the new location.

Why The Royal Marsden is not an option for the proposed future Principal Treatment Centre

Since November 2021, it has been a national clinical requirement for very specialist cancer treatment services for children to be on the same site as a children’s intensive care unit and other specialist children’s services. As a specialist cancer hospital, The Royal Marsden does not have a level 3 children’s intensive care unit (which can give life support) on site. Children’s intensive care units are always on sites used by tens of thousands of children every year because intensive care teams need to see high volumes of very sick children to maintain their specialist skills and expertise. This wouldn’t be possible at The Royal Marsden due to the smaller number of children who need treatment there.

It is the view of NHS England’s London regional team, shared by The Royal Marsden, that it would not be clinically or financially sustainable for it to establish a children’s intensive care unit, in the absence of the other specialist children’s services needed on the same site as a children’s intensive care unit. The South Thames Paediatric Network (of children’s specialists across Kent, Medway, south London, Surrey and Sussex who work together to improve children’s care) agreed. It therefore will not be possible for The Royal Marsden to meet this national requirement.  

[1] A check in 2021/22 showed numbers were still very similar

[2] The Institute of Cancer Research, London (icr.ac.uk)

[3] The Innovative Therapies for Children with Cancer (ITCC) European early phase trials consortium is made up of 63 early phase clinical trials units and 25 paediatric cancer research laboratories

[4] The most recent period for which reports are available

[5] Experimental Cancer Medicine Centre Network for paediatrics has 12 participating centres in the UK, Great Ormond Street is the other one in London. In the adult network there are 15 centres, with those in London being Barts, Imperial, Institute of Cancer Research, King’s Health Partners and University College London Hospitals

[6] On occasion, the London Ambulance Service will provide the transfer instead.