Centralisation of complex urological surgery and understanding the three Es: is it inevitable?

Many jurisdictions are grappling with health systems traditionally wanting to provide everything to everyone, everywhere: a truly universal health system. However, does a universal health system offer the best outcomes for patients or is it the best use of resources? Furthermore, training of surgeons has changed dramatically, to the point where generalists still exist but are an increasingly small pool as sub-specialisation has emerged, meaning technical skills are not evenly distributed. Against this background of organic change in skillsets is that centralisation of services has been discussed in the literature for decades, with a seminal review of three urological cancer procedures published in 2004 [1]. The goal of centralisation is to improve quality of care, directing cancer services to highvolume centres which should result in population-level improvements in cancer outcomes but also, increasingly, improvements in patient-reported outcome measures (PROMs).