How can UK urologists justify the expense of using the latest technology within a nationally funded health system?
Introduction
Listening to leading robotic surgeon Ben Challacombe speak so passionately about the wonders of robotic surgery in excising prostates, kidney tumours, bladder cancers and more, one almost forgets that we live in an era where daily headlines warn of a funding crisis; “Patients denied key treatments due to NHS cost-cutting, surgeons warn”; “NHS facing year-round crisis, says BMA” (Guardian, 2011; 2018). Technology is known to be one of the reasons that health care costs are rising (Bodenheimer, 2005), and urology is at the forefront of technological innovation (Kekre, 2012). The question then arises: can one justify spending £1.7million on a new da Vinci Robot (Robotic Hysterectomy, 2018), or spending millions developing Versius, the new robot from CMR Surgical, when the NHS is cutting costs on all fronts? This essay contends that the United Kingdom has a moral obligation to explore the use of new technologies in surgery as the NHS is a key driver of innovations, bringing new technology to the forefront of surgical care across the globe. I will use Rogers’ (1962) Diffusion of Innovation Theory and the da Vinci Robot as an example to show that the UK is an “innovator” and that, ultimately, the benefits of investing in evidence-based technology in urology justify its high initial costs.
The Diffusion of Innovations Theory
Donald Berwick aptly uses the example of scurvy in his 2003 paper “Disseminating Innovations in Health Care” as an example of slow diffusion of a scientific discovery into the mainstream. Scurvy claimed the lives of many thousands of sailors for centuries, until Captain James Lancaster definitively proved in 1601 that “3 teaspoons of lemon juice a day” (Berwick, 2003;1969) prevented any of his men from succumbing to the disease. Despite this, the British Navy took an astounding 264 years (and thousands upon thousands more deaths) to implement a policy enforcing ships to take citrus fruits on all voyages. Some, such as explorer, innovator and visionary Captain James Cook, refused to sit back and let scurvy claim the lives of their men, and implemented measures before the British Navy declared them mandatory. Captain Cook made eating sauerkraut (also abundant in Vitamin C) compulsory on his ships, and in his whole career, lost only 3 sailors to scurvy. It is innovators like Lancaster and Cook that bring new ideas to the forefront of the scientific world, and without them, innovations disseminate slowly or not at all. Rogers’ (1962) Diffusion of Innovations Theory explains how and why new innovations spread through society and is particularly relevant in health care. The theory has at its heart the sigmoidal Diffusion Curve (Figure 1) which defines different groups that adopt innovations. The first group are the innovators, who make up the initial 2.5% of adopters, then comes the early adopters who are influenced by the innovators, and next the early majority. At this stage, an innovation reaches “critical mass” and is henceforth sustainable and adopted by the late majority then laggards, or traditionalists (Rogers, 2003). I contend that the NHS is an innovator on the global stage of health care. Like Lancaster and Cook, the NHS has a history of trialling and implementing innovations before other health care systems around the world. In doing so, it allows other countries to follow suit, and invest in new technologies that improve efficacy of procedures, reduce recovery times and, in the long term, save money.
Figure 1. Diffusion Curve adapted from Rogers (1962) “Diffusion of Innovations”
Berwick describes how innovators tend to be “wealthier than average” and able to “accept risks inherent in innovating.” (Berwick, 2003;1972) While the NHS is not awash with funding it is certainly leading the way in terms of investing in technology, and for good reason. A prime example is the work of John Wickham, the pioneer of minimally invasive surgery (particularly laparoscopic nephrectomy), PCNL and extracorporeal shockwave lithotripsy (ESWL) in the UK (BAUS, 2017). Wickham’s innovations led to a vast improvement in stone surgery success rates and a decrease in complication rates (Jones et al, 1990), as well as shortening recovery time for partial nephrectomy and much more besides (Aron & Gill, 2007). These procedures, which harboured criticism from traditionalist surgeons favouring large incisions and direct visualisation, were quickly implemented by the NHS and acted as a driver for early adopters, such as the USA, very quickly becoming the world standard in urology. The NHS is surveyed with interest from around the globe and can be considered both an innovator and opinion leader; in many ways, it sets the benchmark for good care. By investing in technology, it brings to the limelight new procedures that the “laggards” are less inclined to adopt but that may improve patient care. As a community, we can justify using the latest technology, despite the calls for cost-cutting, to make it more accessible, to push boundaries and create new norms in surgical care, just as John Wickham did for PCNL and minimally invasive surgery in the 1970s and 80s. I argue that we as a national health care system and country have a moral obligation to invest in technology in order to improve patient care not just in the UK, but around the world.
Tech success in urology: The da Vinci Robot
There are, however, inherent risks in investing in technological innovation, the most poignant being that there will be inevitable failures. Furthermore, when a new piece of technology arrives, a major challenge is overenthusiasm and its use without high-quality evidence (Kekre, 2012); surgeons “embrace new modes of treatment before their merits and weaknesses are assessed” (Barbash & Glied, 2010;701). So, how can UK urologists foster innovation and invest in technology without bankrupting the NHS? There is no easy answer to this question, but with robust cost-benefit analysis and relying on evidence-based use, it is possible to implement new technology; improving surgical outcomes while minimising financial risk.
A recent success story is shown by the most recent figures for robotic assisted radical prostatectomy (Figure 2). Of the 7,962 procedures, over 86% were robot assisted cases, and only 6.41% were open, with a similar number performed laparoscopically. This is compared to 2015 (Figure 3), where only 71.83% were robotic cases, 17.66% laparscopic and 10.43% open. The rapid diffusion of the da Vinci Surgical System, “the poster boy of technical advancement in surgery” (Kekre, 2018;376), into urological surgery is an example of the place of technology in surgery and the necessity for innovation to be trialled and adopted.
However, while the da Vinci Robot has been around for nearly two decades, it was initially slow to diffuse into the mainstream. It has been trialled in various surgical specialties, including colorectal, upper gastrointestinal and cardiothoracic surgery, yet has often been found to be of similar efficacy but greater financial burden compared to existing techniques (Ballantyne, 2007; Mirnezami et al, 2010). For some time, it had been suggested that robotics could have an application in urology, and Benway et al. (2009) seminal paper provided initial evidence of equivalent surgical outcomes associated with robotic assisted laparoscopic partial nephrectomy, shorter lengths of stay and lower intraoperative blood loss rates compared to “traditional” laparoscopic partial nephrectomy. Where laparoscopic procedures had taken over from open procedures previously (Gill et al, 2004), it looked like RALPN may have been able to improve the procedure yet further. With further evidence compiled in the following years from around the world (Mir et al, 2011; Zhang et al, 2013; Wu et al, 2015), NHS England acknowledged the place of robotics in urology and officially sanctioned RALPN to be routinely performed by 2016. In a nationally funded health care system, spending on technology is not always justified, but RALPN and RARP are key example of how technology can be integrated into the existing system using strong evidence and minimising risk. Indeed, initial BAUS national outcome data on RALPN has been positive, with 2111 cases performed in 2014-16 and a median length of stay of 3 days compared to 6 days for open surgery (BAUS, 2018). As more positive data arises for RALPN, the justification for its use rises. Both procedures, RALPN and RARP, are here to stay, and with further evidence, many more procedures will be performed robotically in the NHS.
Conclusion
There is no doubt that the NHS is in a time of financial distress, so funding expensive technology is often heavily criticised. However, when it comes to innovation, the UK is both an “innovator” on Rogers’ (1962) Diffusion Curve and an opinion leader that is watched and copied by health care systems around the globe. We therefore have a moral obligation to be innovative and to take the risk of investing in new technology so that not just the UK, but “laggards” around the world, can improve surgical outcomes and patient care. We must follow on from the work of John Wickham, by pioneering new techniques that may seem to go against the grain, such as using the da Vinci Robot for partial nephrectomies and radial prostatectomies. However, we must still proceed with caution; by combining our enthusiasm to embrace new technology with evidence-based practice, technology can continue to thrive in UK urology, despite the nature of its funding. As Berwick (2003) so poignantly states, “In health care, invention is hard, but dissemination is even harder”; using the latest technology in urology is not only justified, but necessary.
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