Subspecialisation in neurosurgery—does size matter?

Abstract

In this issue Solheim et al. [15] present data from the Norwegian Cancer Registry looking at the 5-year survival for children with brain tumours in relation to centre volume and outcome. As these authors indicate, centralisation of services is very topical at the present time. Certainly in England paediatric craniofacial services have been largely centralised for many years and there is presently a review of how best to deliver the rest of paediatric neurosurgery [14]. Likewise, in Holland there are discussions over centralisation of paediatric brain tumours (and there has already been centralisation of craniofacial and epilepsy surgery), and centralisation of paediatric neurosurgery has already begun in France [9]. In countries without socialised medicine, there is a move by insurance companies to seek treatment for their patients in accredited centres. The driver for these changes is a desire to improve the quality of care. In their study, Solheim et al. [15] did not observe a relationship between centre volume and outcome in Norway and they raised concerns over the use of centre volume as a proxy for quality. Comparing the results from one “large” unit with those from three “small” centres, the authors found no overall difference in survival between the centres and children with primitive neuroectodermal tumour (PNET)/ medulloblastomas treated in the larger centre fared worse. The authors draw two main conclusions: