Introduction

We have two options for the proposed future Principal Treatment Centre that we are consulting on. These options are: 

• Evelina London Children’s Hospital, Lambeth, south London with conventional radiotherapy services at University College Hospital

and  

• St George’s Hospital, Tooting, south London with conventional radiotherapy services at University College Hospital

Under both of these options, we propose that conventional radiotherapy services for children move from The Royal Marsden to University College Hospital, near Euston station in central London. University College Hospital is part of University College London Hospitals NHS Foundation Trust.

The following section sets out how the current service is provided, the reasons for change, and how radiotherapy would be provided in the future.

1. Overview

Many children diagnosed with cancer receive external beam radiation therapy – radiotherapy – as part of their treatment. There are two main types of radiotherapy:

• conventional radiotherapy, which uses high-energy x-rays (photon beams),
• proton beam therapy, an advanced form of radiotherapy that uses beams of high-energy protons. 
  
  

There are other superspecialist radiotherapy services for children too:

• brachytherapy (a form of internal radiation therapy providing localised treatment using sealed radioactive sources)
• stereotactic radiosurgery and stereotactic radiation therapy (SRS/ SRT) (forms of radiation therapy that can precisely target high-dose radiation)
• molecular radiotherapy treatments (a form of radiotherapy which involves the use of radioactive medication to target specific conditions within the body). 

Clinical requirements for children’s conventional radiotherapy services are set by the national service specification for Paediatric Photon Radiotherapy Services. This was published by NHS England in June 2023. 

It specifies that each conventional radiotherapy service for children must serve a large enough population to support a big enough team with the knowledge, skills and equipment to deliver care to children with complex needs, and maintain sub-specialist experience, given how wide-ranging cancer diagnoses can be in children.

Among other things, the service specification details:

• how children must be referred to the service
• the membership and skills of the multidisciplinary team that must provide the service
• how the service will ensure children get the best form of radiotherapy for them, referring to proton beam and other specialist types of radiotherapy where appropriate.

The service specification also requires conventional radiotherapy services to be open 24 hours a day, 365 days a year.  

The service specification has been developed with input from patients, parents, clinicians and others, in the context of changing expectations of demand for conventional radiotherapy services. Currently, most children receive conventional radiotherapy but this is expected to change in favour of proton beam therapy. 

England has two proton beam centres: the first opened at The Christie NHS Foundation Trust in Manchester in 2019, and the second at University College Hospital (which is part of University College London Hospitals NHS Foundation Trust) near Euston, in central London, in 2021. 

Proton beam therapy limits the dose of radiation to the surrounding normal tissues, which means there is the potential for less damage to normal tissue. This is particularly advantageous in children who are still growing as it can potentially reduce long-term side effects.   

As the very specialist proton beam therapy service continues to be developed, it is anticipated that more children with cancer who require radiotherapy treatment will, in future, receive proton beam therapy instead of conventional radiotherapy. It is not suitable for treating all types of cancer.

As a result, there has been movement towards providing these services in a different way, including by consolidating children’s radiotherapy services. This increases the resilience of services, helping ensure they can be adequately staffed, and offering wider expertise in sub-specialties and opportunities for further research. A recent example of such consolidation is the transfer of children’s conventional radiotherapy from the Clatterbridge Cancer Centre NHS Foundation Trust in Liverpool to The Christie NHS Foundation Trust in Manchester, which is one of the largest children’s radiotherapy providers in England.

Conventional radiotherapy, as well as all other radiotherapy services, are already provided at University College Hospital for children using the Principal Treatment Centres for north London and the surrounding areas, Southampton, and some children from the Principal Treatment Centre in Oxford. 

2. Current service

Most children with cancer under the care of the current Principal Treatment Centre for south London and much of south east England who need conventional radiotherapy have it at The Royal Marsden, where it is delivered by a highly specialist and integrated multidisciplinary team. Children travel to University College Hospital for all other types of radiotherapy such as proton beam therapy.

Our data shows that 41 children had conventional radiotherapy treatment at The Royal Marsden in 2019/20, delivered in 700 hospital sessions.

Seven of these children had a particular type of radiotherapy called total body irradiation which is given in preparation for a bone marrow transplant. These patients usually need to have this delivered over up to four days as part of a hospital inpatient stay. 

In 2019/20, 20 children from The Royal Marsden were referred for proton beam therapy.  Modelling undertaken by NHS England with clinical teams at The Royal Marsden expects that in the future the proportion of children who have proton beam therapy could increase to about 60% (equivalent to about 35 children). Fewer children are expected to have conventional radiotherapy in comparison. Demand will vary from year to year. There will also be changes in clinical practice.

The Royal Marsden service is provided by a highly specialist and integrated multidisciplinary team including specialist radiographers, physicists, a clinical nurse specialist, anaesthetists, allied health professionals (including physiotherapists and speech and language therapists), social workers and play specialists, all based at The Royal Marsden and supporting the care of children with cancer.

The radiotherapy services at The Royal Marsden and University College Hospital work very closely together. A small number of patients from The Royal Marsden have their conventional radiotherapy at University College Hospital – for example, patients with more complex airway issues who would benefit from the specialist infrastructure University College Hospital has on-site.

Neither Evelina London nor St George’s has a children’s conventional radiotherapy service.  This is a highly specialist service that is only provided in around 10 sites across the country.

3. Reasons for change 

While The Royal Marsden currently provides high quality conventional radiotherapy treatment for children as part of their care, the proposed move of specialist children’s cancer services to either Evelina London or St George’s Hospital, alongside advances in radiotherapy treatment, means it is proposed this service is provided differently in the future.  This is because:

1. It would be difficult to sustain the conventional radiotherapy service for children at The Royal Marsden without the staff and facilities of the Principal Treatment on site:
   • staff who currently play an important role in providing care would no longer be at The Royal Marsden, as most members of the multidisciplinary team are part of the Principal Treatment Centre and would move when it moves
   • the facilities needed to treat children would no longer be available, as some children who need radiotherapy require an inpatient bed. Funding and specialist workforce for current inpatient beds would transfer to the future provider of the Principal Treatment Centre   
   • it could be harder to recruit and retain staff for a standalone service – specialist staff needed to provide children’s radiotherapy might not want to work at a centre that undertakes no other children’s work. Given the reduced number of children requiring conventional radiotherapy, it could also be more challenging for staff to maintain their skills and experience to a sufficient degree. 
2. With the proportion of children expected to receive proton beam therapy expected to increase, we expect the number of children requiring conventional radiotherapy services in the future to fall. This would make it even harder to sustain a high-quality service.

Alongside the reasons above, providing conventional radiotherapy at two different sites, neither of them on the same site as the future Principal Treatment Centre, would create the need for additional journeys and add complexity. Under this scenario, clinical (radiation) oncologists at the future Principal Treatment Centre would need to work with both University College London Hospitals and The Royal Marsden to coordinate, make decisions, and provide care to children, as well as spending time at the future centre. Patients could need to find their way to both University College Hospital and The Royal Marsden, depending on their radiotherapy needs. This complexity would impact patient experience and, without careful coordination and planning, potentially their care.  

4. How would radiotherapy be delivered in the future  

In both options, we propose that, as part of the change for specialist children’s cancer services, conventional radiotherapy for children moves from The Royal Marsden to University College Hospital, on Euston Road in central London. This would mean that all radiotherapy (conventional radiotherapy as well as proton beam and other types) rather than some, as now, would then be provided at University College Hospital [1].  

University College Hospital is the largest centre for children’s conventional radiotherapy in the UK. As well as being one of two centres in the UK to provide proton beam therapy, University College Hospital is the only centre in the UK providing brachytherapy for children. It provides the stereotactic radiosurgery and stereotactic radiation therapy (SRS/ SRT) service for the south of England and is one of two UK centres providing molecular radiotherapy treatments for children. Its specialist multidisciplinary staff support treatment of these patients while they are receiving their care on-site.  

The full range of radiotherapy commissioned treatments for both adults and children and young people can be found on the NHS England Cancer Radiotherapy Clinical Reference Group here.

The service is supported by a children’s radiotherapy multidisciplinary team and has an established role in all children’s cancer multidisciplinary teams in the Principal Treatment Centres located in north London and Southampton, and links to children’s cancer multidisciplinary teams for the Oxford Principal Treatment Centre. Most children with cancer travel from home for their radiotherapy. Children with cancer who are inpatients at those Principal Treatment Centres are transferred to University College Hospital for their radiotherapy. The radiotherapy service works in partnership with these centres, as it would plan to do with the future Principal Treatment Centre for children with cancer who live in south London and much of the south east. 

[1] Our proposals do not affect radiotherapy services for patients aged 16 to 24 , or adult services, which are both provided at The Royal Marsden.

5. Benefits of the proposed change

There would be significant potential benefits for patients of the proposed future Principal Treatment Centre if conventional radiotherapy services were to be at University College Hospital. This service would be provided as part of a larger children’s radiotherapy service which would offer the full range of radiotherapy treatments and support a larger number of patients. Potential opportunities to improve future care for children with cancer would include:   

• more opportunities for doctors and other professionals delivering radiotherapy for children to work together in one place, allowing them to develop greater expertise and specialist knowledge in treating children’s cancers by sharing and growing their knowledge and skills. This would offer the potential to improve the treatments provided and, with that, achieve even better patient outcomes  
• more opportunities to develop clinical and lab-based research (including opportunities for collection of real-world data) that could help to improve care for children in years to come 
• the provision of all radiation treatment types to children by a specialist team could be highly attractive to staff, supporting recruitment and retention of very skilled staff, giving stability and resilience within the service, and ensuring the service could be provided to children when they need it, even when some staff required time away from work. 

These benefits are consistent with the national service specification for radiotherapy. They would allow for increased uptake of proton beam therapy while ensuring that children who need it continue to receive high quality conventional (photon) radiotherapy.

6. Impacts of proposed change

Travel

Proton beam patients would continue to travel to University College Hospital’s Grafton Way building, near Euston, central London irrespective of the location of the proposed future Principal Treatment Centre. However, the move of conventional radiotherapy would introduce the need for planned travel to University College Hospital for children in the future.  

• Up to 10 [2] children a year who have radiotherapy ahead of a bone marrow transplant (total body irradiation, which often needs to be provided during a hospital stay) would have a planned transfer from the proposed future Principal Treatment Centre to University College Hospital for this treatment. This would be scheduled in line with each patient’s treatment plan.  
• About 25 other children with cancer a year would require conventional radiotherapy. These children would travel to University College Hospital for conventional radiotherapy as outpatients or day cases, travelling from home to University College Hospital and back instead of, as currently, from home to The Royal Marsden and back. Some children stay in the hospital if they are too unwell to travel and/or family circumstances determine this is best [3]. Around 35 other children would travel (as they do now) for proton beam therapy and other types of radiotherapy [4].  

The delivery of conventional radiotherapy services at University College Hospital would result in longer journeys for some children and their families.  If needed, they could make use of accommodation that is already available for children with cancer and their families close to University College Hospital while they are having radiotherapy treatment.  

Analysis of travel times for patients across the catchment areas who would need to attend University College Hospital as outpatients or day cases is set out below. 

Travel time modelling software was used to generate public transport and car journey travel times for all children living in the Principal Treatment Centre catchment area to University College Hospital and The Royal Marsden’s site in Sutton [4].

The table below shows the average (median) travel times when travelling by road or by public transport, from where a patient may live to each location. The analysis found travel time by road will increase on average by 22 minutes to University College Hospital (as compared to The Royal Marsden) whilst the same journey by public transport will reduce by 27 minutes.

	The Royal Marsden	University College  Hospital
Average (median) driving time	52 minutes	74 minutes
Percentage of people living within the catchment area for whom driving time is 60 minutes or less	66%	27%
Average (median) journey time by public transport	97 minutes	70 minutes
Percentage of people living within the catchment area for whom public transport travel time is 60 minutes or less	21%	35%

For those living in areas categorised as the most deprived, journey times to University College Hospital (as compared to The Royal Marsden) would increase on average by 20 minutes by road and reduce by an average of 40 minutes by public transport.

Recommendations that have been developed as part of the Interim Integrated Impact Assessment for the service reconfiguration would support the future Principal Treatment Centre to work with University College Hospital (part of University College London Hospitals NHS Foundation Trust) to help mitigate travel impacts on patients and their families. We would also learn from arrangements that are currently in place for patients who travel to University College Hospital from the catchment areas of the other Principal Treatment Centres. 

[2] In 2019/20, 7 children from the current Principal Treatment Centre had total body irradiation as part of their treatment.

[3] Numbers are estimates and would vary year on year.

[4] Please see the Factsheet “How travel times were assessed” for further information on the underlying methodology.

Resilience 

While there are many potential benefits from the proposal to provide services for patients at University College Hospital, including greater resilience and specialism in the workforce, there are also potential downsides of consolidation. As the single provider of conventional radiotherapy services for London and the south east, a problem with University College London Hospitals’ estates or equipment could impact on the ability to provide care for patients across a wide area. Some of the associated risks are mitigated by the fact that University College Hospital has a number of different machines for both conventional and proton beam therapy in the event of any problem with a particular piece of equipment. In addition, conventional radiotherapy and proton beam therapy are provided in different buildings on the University College Hospital campus, giving some resilience against any building issue.  University College London Hospitals has business continuity plans in place for radiotherapy services including further mitigations for these types of risks. NHS England, nationally and regionally, would continue its existing work with the Trust to support ongoing review and management of risks.   

Capacity

NHS England will work with stakeholders including University College London Hospitals to ensure that there is the necessary capacity to treat patients from The Royal Marsden should the services transfer. Building on work to date, detailed planning work would be undertaken to agree the best way to provide care for children that need to have treatment after a decision is made.  This would determine the specific details of how much capacity would be needed so that plans can be finalised and implemented ahead of the proposed move of services.  

Teenage and Young Adult radiotherapy services at The Royal Marsden

The radiotherapy service provided by The Royal Marsden for teenagers and adults is not expected to be impacted by proposed changes to the Principal Treatment Centre. It would continue to see a large number of patients every year and has the workforce to sustain this.

Other radiotherapy service considerations

University College Hospital already provides photon and proton radiotherapy services for the Principal Treatment Centre at Southampton, as well as some children from the Principal Treatment Centre in Oxford.

Services providing radiotherapy for patients in other parts of the country will not form part of this consultation. 

As noted below, NHS England is committed to securing the ongoing provision of high-quality radiotherapy services for children with cancer.

Other patients who currently access radiotherapy services at The Royal Marsden

There are a very small number of children who do not have cancer who require conventional radiotherapy as part of their treatment.  Where there is an impact on these children as a result of the proposal, we would work with relevant organisations, including University College London Hospitals to support the ongoing delivery of their treatment.

7. Enabling this change to take place 

University College London Hospitals NHS Foundation Trust provided letters of support to both Guy’s and St Thomas’ NHS Foundation Trust, which submitted its proposal for the future Principal Treatment Centre to be at Evelina London Children’s Hospital, and to St George’s University Hospitals NHS Foundation Trust, which submitted its proposal for the future Principal Treatment Centre to be at St George’s Hospital.

The letters included the following: 

University College London Hospitals NHS Foundation Trust also set out some considerations around the way in which the service would be provided and the clinical model developed, drawing on its experience of becoming the provider of conventional radiotherapy services for the Principal Treatment Centres in Southampton as well as some children from Oxford.

8. Implementation

Detailed planning for the proposed move of children’s radiotherapy would follow a decision about the location of the proposed future Principal Treatment Centre and subsequent discussion between The Royal Marsden, University College London Hospitals and the future centre, with support from NHS England. This would include specific details of the patient pathway which would draw on existing arrangements for children under the care of the Principal Treatment Centres located in north London, Southampton and Oxford, and be developed further through detailed discussion between clinicians in light of the needs of this specific patient group and pathways at the future Principal Treatment Centre. 

The radiotherapy service is a key part of the service for children with cancer. NHS England would work to support the transition arrangements, including the agreement of funding to ensure that the future service had sufficient capacity and was sustainably resourced. Discussions to support the development of the funding model are underway including with University College London Hospitals, NHS England London, NHS England South East and NHS England nationally.