When most of us consider the Health Service it is the institutions ? GP practices, district general and teaching hospitals ? which come to mind. Yet any ambition to place the patient at the centre of health care must stand in their shoes and consider their experience. This relates to the interface with individuals rather structures. For cancer patients it means their ordeal from the suspicion of cancer through to its diagnosis and treatment and, sadly for many, the care offered when cure is no longer achievable and treatment ineffective. Cancer networks, with their focus on clinical issues and the patient pathway, enable services to be considered in this horizontal way.

Cancer networks were the first managed clinical networks to emerge in the United Kingdom. The re-organisation of cancer services ? initiated through the Calman-Hine report in 1995 ? was developed further with the advent of the National Cancer Plan in 2000. The initial organisation around a hub (cancer centre) and spoke (cancer unit) model has now developed into care being based across the patient pathway from primary care through the secondary (unit) tertiary (centre) and ultimately to palliative care as appropriate.

The vast majority of cancer patients in the UK are now managed on the basis of discussions which take place in a multidisciplinary team. There is evidence that the quality of decisions made in this setting is better and as a result patient outcomes improve. The National Cancer Plan objective of improved survival rates from cancer is as likely to be met from improvements in the organisation of cancer care as they are from increased investment in expensive technology and buildings. Decisions made in these MDTs take into account the views of a range of professionals including surgeons, physicians, oncologists, specialist nurses and many others. It is a productive forum focusing on the real life needs of the patient.

The basic building block is the multidisciplinary team, which extends to involve the tumour site-specific groups that have developed across a wide range of tumour types in the 34 cancer networks in England. This builds a structure within the network in which a critical mass of clinicians can influence resource allocation by managers who are usually represented at the level of the policy board of the cancer network. In my own network the leaders (both clinicians and managers) have emerged and enabled teams to improve the delivery and quality of care across the network which usually covers a population of 1-2 million people. Improvements include closer working between primary and palliative care in the training of staff. For example, district nurses are now trained with palliative care skills, and in the development of strategies for the reconfiguration of services so that a larger number of patients with a condition are treated with appropriate expertise ? rather than smaller units treating small volumes of patients and being unable to afford or sustain the appropriate infrastructure.

Networks provide a number of advantages to both patients and doctors. They can be grouped according to their function ? for instance pathology (such as emergency medicine), client group (children or the elderly), disease (cancer or cardiac) or speciality (vascular surgery). They facilitate innovation, the spreading of best practice and a broadening input of expertise so that an entire population can access a highly specialised team based at a reasonable geographical distance. Such access is often improved by a matrix of care where the specialist team visits cancer units but performs complex difficult tasks such as surgery or radiotherapy at one site. Networks are also able to foster effective patient and user involvement which is more difficult in the silos which acute hospitals often become. As a result they can respond more promptly to the ever-changing environment of the Health Service.

One of the success stories of the cancer networks has been the National Cancer Research Network. More patients are now entering clinical trials of cancer than before and the NCRN has exceeded its target of 7.5 per cent of patients entering trials six months ahead of schedule. This enhanced research culture must bring benefits to both staff and patients by improving both the morale of the team and perception of those people they serve. Team working and building relationships across organisations enables a less hierarchical culture which (I can attest from my own experience as Macmillan Network Lead Clinician in Surrey, West Sussex and Hampshire) improves the quality of care but also enhances staff recruitment and retention. This is a very real challenge in the Health Service.

So how do we measure success? Relatively little is published on the effectiveness of managed clinical networks and there can be no doubt that they are challenged by the pre-existing hierarchical structures of the NHS and the number of recent reorganisations. Now that Shifting the Balance of Power has bedded down, the real challenge for networks will be in effective commissioning and performance measurement.

One of the major controversies surrounding cancer networks has been the inability to track the money reaching the front line. However any comparison of investment across different health economies with widely varied infrastructure is artificial and makes no allowance for the existing baseline or competing demands. A more constructive approach is to emphasise our successes. The best clinical networks offer effective communication, trust and the development of long-standing relationships, all of which contribute to progress. It is the fostering of these relationships and the understanding and affinity which they cultivate ? the unquantifiable softer edges ? where clinical networks really add value and are very well suited to placing the patient at the heart of the Health Service.

One danger is that they may be seen as a structural panacea and turned into NHS organisations. There may be advantages in shifting the management focus from institutions towards services for patients but it could undermine the creativity and fleetness of foot which networks can offer.