Developing new, high-quality major trauma and stroke services for London Joint Committee of PCTs Meeting in public Monday 20 July 2009.

Developing new, high-quality major trauma

and stroke services for London

Joint Committee of PCTs Meeting in public Monday 20 July 2009

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Agenda item 5 Introduction – Case for Change

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Presentation on the case for change and model of care for major trauma services

Matt Thompson, Clinical Director, Major Trauma Project

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Case for change

• ‘Major trauma’: most severe life-threatening injuries or multiple injuries - arm or leg amputations, severe knife and gunshot wounds, major spinal or head injuries.

• 0.1% of all A&E cases: estimated 1,600 major trauma patients per year treated in London - most injuries occurring in central London.

• Quality of care delivered to most patients is poor in London and the UK.

• Few hospitals are set up to provide highly specialised care and services are often poorly co-ordinated:

– patient transfers take on average 6 hours; – longer travel times to specialised centre have minimal effect on

mortality or morbidity.

• London is lagging behind other major international cities in its treatment of trauma patients.

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Model of care

Trauma system covers:– triage– transfers– acute care and rehabilitation

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Model of care

• Limited number of trauma networks in London.

• Each network would have:

– a major trauma centre (MTC) - immediate treatment for severely injured - 24 hours a day - seven days a week.

– local trauma centres (TCs) - at A&E departments - less severe injuries - high-quality ongoing treatment and rehabilitation for all patients.

– a continuous process of system evaluation, governance and performance improvement across the network.

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Model of care

Major trauma pathway

• By ambulance to nearest MTC, located no more than 45 minutes away.

• Immediate diagnosis and treatment by consultant-led multi-disciplinary team.

• Transfer to a local TC for rehabilitation as soon as clinically appropriate.

• Seamless transfer to MTC if patient in TC has suspected major trauma.

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Benefits

Anticipated benefits include:

• improved patient outcomes;

• improved education and training of those delivering trauma care;

• increased ability to deliver a pan-London major incident plan;

• more people surviving injury and returning work, society and a better quality

of life;

• costs per life saved and per life-year saved are very low compared with

other comparable medical interventions.

Presentation on the case for change and model of care for acute stroke services

Nicholas Losseff, Interim Stroke Clinical Director

Case for change

• Stroke is a brain injury, caused either by a reduction of the blood supply to the brain or bleeding within the brain causing nerve cells to die. Quick action is needed.

• More than 11,000 Londoners suffer a stroke each year.

• One person every hour admitted to a London hospital – one in five dies.

• Second-highest cause of death in London.

• Most common cause of adult disability in London.

Case for change

• UK and London has a significant excess mortality following stroke– both “standardised mortality” and across hospitals

• Variation in rates of death in different London hospitals – and people in outer London have most limited access to high-quality stroke services

• Evidence shows patients have reduced death and disability if treated in specialist centres.– thrombolysis / hyperacute / multidisciplinary

Model of care

Facilities

‘Hyper-acute stroke units’ (HASU)• Eight units proposed, open 24/7;• Immediate response to stroke: through appropriate critical mass of staff• Stabilisation and physiologic interventions;• Thrombolysis if appropriate; • Length of stay usually less than 72 hours.

‘Stroke units’ (SU)• 20+ units proposed;• Inpatient care following a patient’s hyper-acute stabilisation;• Multidisciplinary goal orientated rehabilitation; • Varied length of stay (until appropriate discharge from SU).

Model of care

Pathway

• By ambulance to nearest HASU, located no more than 30 minutes away.

• Assessment by specialist, access to a CT scan and thrombolysis (if appropriate), all within 30 minutes.

• Admission to a HASU bed: high-dependency care for the first 72 hours following admission.

• Once stabilised, transfer to a local stroke unit for rehabilitation and discharge into appropriate community care.

Model of care

TIA Services

• A transient ischaemic attack (TIA) is a temporary lack of blood to part of the brain.

• Sometimes called a ‘mini-stroke’ but unlike stroke, symptoms do not last.

• Risk of stroke much higher following a transient ischaemic attack.

• TIA will therefore be treated as an emergency.

• TIA services will provide rapid access to clinical expertise, imaging and treatment within:

• 24 hours of symptom onset for high-risk patients; • seven days for lower risk patients.

Potential benefits

• Population based hyperacute care

• Provide population based stroke unit care

• Emergency access for TIA patients

• Improved outcomes – less death and less dependency

Developing new, high-quality major trauma

and stroke services for London

Joint Committee of PCTs Meeting in public Monday 20 July 2009

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Agenda item 8 Report from the Clinical Advisory Group

Andy Mitchell, Clinical Director for NHS London and Commissioning Support for London

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Clinical Advisory Group (CAG)

• The Clinical Advisory Group (CAG) informs the development of the Healthcare for London programme.

• The CAG chair is a member of both the Commissioning Support for London and NHS London boards.

• The CAG has 32 members from a broad mix of professions, specialties, care settings and geography to ensure it can speak with authority, knowledge and expertise on an appropriate breadth of health issues.

• The CAG has advised the stroke and major trauma project boards throughout the consultation.

• Lessons have been learnt from specialist care for heart attacks in London.

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Clinical Advisory Group (CAG)

• The CAG received and discussed an assessment of responses made to the consultation on key clinical themes.

• The CAG:

– supports proposals to improve stroke and trauma care;

– agrees validity of case for change and model of care for major trauma;

– supports proposal to designate four major trauma centres;

– agrees validity of case for change and model of care for stroke;

– supports the proposal to designate eight hyper-acute stroke units;

– also agrees with the proposals for local stroke units and TIA services.

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Agenda item 9 Decision on the future delivery of major trauma and stroke services

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Recommendations for major trauma services

Simon Robbins, Senior Responsible Officer, Major Trauma Project

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Assessment of consultation responses

• Consultation created a strong response.

• We thank the public and stakeholders for their engagement.

• We have listened carefully to the issues raised.

• Overall support for our proposals.

• Helpful recommendations will inform our future plans.

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Consultation responses on the case for change

• Respondents accepted need to improve trauma services in London.

• Major trauma project board has not seen evidence of a substantial challenge.

• Major trauma project’s clinical expert panel agreed no new evidence had emerged in recent months to affect the case for change.

• Major trauma project board agreed that the case for change remains valid.

• CAG also agreed with this view.

Recommendation: agree that the case for change for major trauma is valid

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Consultation responses on the model of care

• Respondents agreed better treatment if taken immediately to a specialist trauma centre, at the centre of a trauma network, rather than to nearest hospital.

• Major trauma project board - no evidence of a substantial challenge to the model of care.

• National Clinical Advisory Team (NCAT): “clear evidence that dedicated major trauma teams with a higher patient throughput save lives compared with smaller units”.

• Clinical expert panel noted emerging evidence from Australia: reduction of in-hospital death rate in major trauma patients over 5 years.

• Major trauma project board agreed that the proposed model of care remains valid.

• CAG also agreed with this view.

Recommendation: agree that the proposed model of care for major trauma is valid

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Consultation options for major trauma

Option 1 Our preferred optionFour trauma networks

Major trauma centres at:• Royal London Hospital• King’s College Hospital• St George’s Hospital• St Mary’s Hospital

Option 2

Four trauma networks

Major trauma centres at• The Royal London Hospital• King’s College Hospital• St George’s Hospital• Royal Free Hospital

Option 3

Three trauma networks

Major trauma centres at:• Royal London Hospital• King’s College Hospital• St George’s Hospital

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Consultation responses on the number of major trauma centres

• Majority of responses to consultation supported the designation of 4 MTCs (consultation options 1 and 2).

• Small number of responses to consultation in favour of 3 MTCs (consultation option 3) or 5 MTCs:

– Model of care and affordability considerations favour fewer MTCs;

– Concerns over the resilience of a 3-MTC trauma system, echoed by NCAT

– Trauma system with 5 MTCs not considered by the JCPCT to be viable consultation option;

– Risk of poorer clinical outcomes;

– Increased cost but no improvement in journey time.

• Major trauma project board agreed 4 major trauma centres remains the best option for London.

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Number of major trauma centres - summary

Recommendation: agree that a four-network major trauma system should be designated

3 MTCs

100% of major trauma incidents in London would be covered within 45 minutes for both the 3-MTC and 4-MTC options. More patients would have shorter journeys in a 4-MTC system.

Access to MTC in 45 minutes

Strategic coherence

Both 3- and 4-MTC configurations would enable the consolidation of specialised services.

Enables colocation of MTC and HASU

The baseline costs for the new model of care are affordable at 0.1% of PCT allocations. The estimated recurrent cost of a 3-MTC configuration is estimated to be £2.5m lower than that of a 4-MTC configuration.

Affordability and efficient use of resources

All potential MTC sites could be significant providers of specialist acute services.

Ensures MTCs are located on hospital sites which could be significant

providers of specialist acute services

Equitable access to specialist services

A 4-MTC system is easier to implement and produces networks of manageable size in relation to the number of trauma centres.

Network effectiveness

Critical mass is more favourable for a 3-MTC system, but there are significant concerns over resilience. A 4-MTC system would create more manageable capacity in each MTC and increased ability to respond to major incidents.

Capacity and resilience

Implementation plans and monitoring against progress are in place for all potential MTCs.

Implementation plans

Potential MTCs in the North and North West scored lower in the bid evaluation than the other three potential MTCs in Option 3.

Outcomes of the external evaluation

3 MTCs would best comply with the model of care advocating a small number of specialised units to improve clinical outcomes.

Compliance with the agreed model of care

Sustained and optimal quality of provider services

Rationale4 MTCsJCPCT criterion 3 MTCs

100% of major trauma incidents in London would be covered within 45 minutes for both the 3-MTC and 4-MTC options. More patients would have shorter journeys in a 4-MTC system.


Strategic coherence

Both 3- and 4-MTC configurations would enable the consolidation of specialised services.


The baseline costs for the new model of care are affordable at 0.1% of PCT allocations. The estimated recurrent cost of a 3-MTC configuration is estimated to be £2.5m lower than that of a 4-MTC configuration.


All potential MTC sites could be significant providers of specialist acute services.




A 4-MTC system is easier to implement and produces networks of manageable size in relation to the number of trauma centres.


Critical mass is more favourable for a 3-MTC system, but there are significant concerns over resilience. A 4-MTC system would create more manageable capacity in each MTC and increased ability to respond to major incidents.


Implementation plans and monitoring against progress are in place for all potential MTCs.


Potential MTCs in the North and North West scored lower in the bid evaluation than the other three potential MTCs in Option 3.

Outcomes of the external evaluation

3 MTCs would best comply with the model of care advocating a small number of specialised units to improve clinical outcomes.

Compliance with the agreed model of care


Rationale4 MTCsJCPCT criterion

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• Majority of responses to consultation supported preferred option: 4 MTCs at the Royal London, King’s College, St George’s and St Mary’s hospitals (option 1).

• Strong support from outer north London for 4 MTCs at the Royal London, King’s College, St George’s and the Royal Free hospitals (option 2).

• Integrated impact assessment considered option 1 most likely to result in positive impacts.

• Differences between options 1 and 2 relate to geographical location of MTC in north west London.

• Major trauma project board agreed option 1 remains the best option for London.

Consultation responses on the location of major trauma centres and networks

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Location of major trauma centres - summary

Recommendation: agree that major trauma centres should be commissioned at the Royal London, King’s College, St George’s and St Mary’s hospitals

4 MTCs inc. St Mary’s

100% of major trauma incidents in London would be covered within 45 minutes for both 4-MTC options. Marginally more patients would have shorter journeys with the 4th MTC at St Mary’s.


Strategic coherence

Both options would enable the consolidation of specialised services. Colocation would be easier to realise for the configuration with the Royal Free as the 4th MTC.


Commissioning costs to PCT costs are the same for both optionsAffordability and efficient use of resources

All potential MTC sites could be significant providers of specialist acute services




The 4th MTC at St Mary’s would produce a network of more manageable size in north west London, by allocating the greatest number of TCs to the Royal London


The 4th MTC at St Mary’s would have a more manageable number of patients than the Royal Free due to a smaller catchment area and offers moderately increased ability to respond to major incidents


Implementation plans and monitoring against progress are in place for all potential MTCs


St Mary’s and the Royal Free obtained the same score in the bid evaluationOutcomes of the external evaluation

Both configurations would equally comply with the model of careCompliance with the agreed

model of care


Rationale4 MTCs

inc. Royal Free

JCPCT criterion4 MTCs inc. St Mary’s

100% of major trauma incidents in London would be covered within 45 minutes for both 4-MTC options. Marginally more patients would have shorter journeys with the 4th MTC at St Mary’s.


Strategic coherence

Both options would enable the consolidation of specialised services. Colocation would be easier to realise for the configuration with the Royal Free as the 4th MTC.


Commissioning costs to PCT costs are the same for both optionsAffordability and efficient use of resources

All potential MTC sites could be significant providers of specialist acute services




The 4th MTC at St Mary’s would produce a network of more manageable size in north west London, by allocating the greatest number of TCs to the Royal London


The 4th MTC at St Mary’s would have a more manageable number of patients than the Royal Free due to a smaller catchment area and offers moderately increased ability to respond to major incidents


Implementation plans and monitoring against progress are in place for all potential MTCs


St Mary’s and the Royal Free obtained the same score in the bid evaluationOutcomes of the external evaluation

Both configurations would equally comply with the model of careCompliance with the agreed

model of care


Rationale4 MTCs

inc. Royal Free

JCPCT criterion

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Implementation and transition

• The proposal is for the London trauma system to go live in April 2010.

• We have developed the following aspects to provide assurance that the proposals can be delivered:

– Implementation and transition – Workforce – Finance and commissioning – IT – Whole pathway - prevention and rehabilitation – Evaluation assurance plan

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Future of major trauma care in London

By end 2010:

• Pan-London system

• High-quality specialist services – Major trauma networks

• Major trauma centres• Trauma centres

• Equality of access: all Londoners within 45 minutes by ambulance

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Recommendations for stroke services

Rachel Tyndall, Senior Responsible Officer, Stroke Project

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Assessment of consultation responses

• Consultation created a strong response.

• We thank the public and stakeholders for their engagement.

• We have listened carefully to the issues raised.

• Overall support for our proposals.

• Helpful recommendations will inform our future plans.

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Case for change: responses to consultation

• General improvements in services between the Sentinel Audits of 2006 and 2008

• London still failing to provide high quality specialist care for all stroke patients.

• Need to improve stroke services accepted by many respondents.

• Project board has not seen evidence of a substantial challenge.

• Clinical expert panel agreed no new evidence to affect case for change.

• Project board therefore agreed that the case for change remains valid.

• Clinical Advisory Group also agreed with this view.

Recommendation: agree that the case for change for stroke is valid

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Key issues raised:

• Should all patients should be transported to a HASU if only those suitable for thrombolysis would benefit?

Clinical advisers to project board advised that HASUs will benefit all patients, not just those receiving thrombolysis.

• Could telemedicine be used in order to offer facilities at more hospitals?

Clinicians have advised that face-to-face care from a clinical expert represents best practice.

Model of care: response to consultation

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Model of care: response to consultation• Model of care proposed received considerable support and is endorsed by the

project board.

• NCAT stated that proposals, “if implemented appropriately and adequately resourced, will undoubtedly greatly improve stroke care for the people of London”.

• Proposals in line with those set out in National Stroke Strategy.

• Alternative models considered by stroke project board and an independent panel.

• Both consider the proposed model of care the best solution for London.

• Analysis indicates that proposed model of care is affordable, cost effective and offers a net economic benefit.

Recommendation: agree that the model of care for stroke is valid.

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Number of HASUs: response to consultation

• A small number of suggestions for fewer than 8 HASUs.

• A number of respondents suggested more, smaller HASUs.

• Majority of responses, the project board, the clinical advisory group and the independent review all affirmed support for 8 HASUs.

• A number of respondents and key stakeholders suggested 8 was a minimum and more should be considered if appropriate.

• Evaluation plan suggested regular monitoring of HASUs to quickly address issues that might arise.

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Assessment of number of HASUs

• HASU care should be delivered in no more than 8 sites. This would:– Optimise the number of patients being treated at each site– Ensure that expert teams are available 24 hours a day – Ensure that all Londoners were within a 30-minute blue light ambulance drive of a

HASU

• Fewer than 8 HASUs not able to meet the specified requirements of capacity and travel times.

• More than 8 HASUs:- Less critical mass - Harder to staff with

specialist staff - Small benefit in travel

times - Economies of scale will be

achieved in a lower number of HASUs

JCPCT criterion



Strategic coherence

8 HASUsMore than 8 HASUs


JCPCT criterion



Strategic coherence

8 HASUsMore than 8 HASUs


Recommendation: agree to commission 8 hyper-acute stroke units in London.

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Preferred option of HASU location

We recommended the creation of 8 new HASUs at:

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Several other hospitals showed they could also meet future standards and were put forward as alternatives to the preferred configuration.

Consultation options for HASU location

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HASU location: response to consultation

• 61% of respondents in favour of the proposed configuration of HASUs.

• A number of respondents supported alternative locations outlined in consultation:

– Barnet Hospital – Chelsea and Westminster Hospital– Mayday University Hospital – St Thomas’ Hospital – The Royal Free Hospital

• Some other locations were supported.

• Key issue for respondents was a local unit, whether in place of a preferred provider or additional to the preferred option.

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HASU location: issues taken into account

• Project board weighed these views and evidence, and recommends that the preferred options remain as described in the consultation document.

• This recommendation is made in the context of:

– A pan-London approach;

– The need for high-quality hyper-acute services – Equality of access for all Londoners within a 30-minute ambulance journey.

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Location of Hyper Acute Stroke Units

Recommendation: the JCPCT agree that eight hyper-acute stroke units should be

commissioned at:

Charing Cross Hospital, Hammersmith

King’s College Hospital, Denmark Hill

Northwick Park Hospital, Harrow

Queen’s Hospital, Romford

St George’s Hospital, Tooting

The Princess Royal University Hospital, Orpington

The Royal London Hospital, Whitechapel

University College Hospital, London

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Proposals for location of SUs & TIA services

We recommended the creation of 21 SUs and TIA services at:

Excluding north east London due to general review of acute services.

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SU & TIA location: response to consultation

• 75% of respondents were in favour of the proposed configuration of stroke units and TIA services.

• A number of respondents said they would prefer more local stroke unit services:

– Ealing Hospital– Chase Farm Hospital– The Whittington Hospital– Queen Mary’s Hospital, Sidcup

• A number of respondents said they would prefer more local TIA services: – Ealing Hospital

• Key issue for respondents was local stroke unit and TIA services.

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Sector specific arrangements

Sector specific arrangements in place in the following sectors:

• North east London

• North west London

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Configuration of Stroke Units & TIA services

Recommendation: agree that stroke units should be commissioned at:

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Stroke: implementation and transition

Phased approach:

– Full SU capacity in place before expanding HASU bed numbers;

– SU opening planned to commence in October 2009 – full SU capacity planned to be available from end of January 2010;

– TIA service ‘go-live’ date synchronised with SU opening;

– Opening of hyper-acute beds is planned to take place in phases;

– Services at Queens Hospital and Princess Royal University Hospital will develop at a different speed;

– Proposed that in addition to the HASUs in the preferred option, additional transitional capacity for south east London is provided by St Thomas’ Hospital;

– All stroke services will be operational by Apr 2012.

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Stroke: implementation and transition

• We have developed the following aspects to provide assurance that the proposals can be delivered:

– Deliverability – Implementation and transition assurance – Workforce assurance – Finance and commissioning assurance – IT assurance – Whole pathway assurance (prevention, rehabilitation) – Evaluation assurance plan

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Future of stroke care in London

By April 2012:

• Pan-London system

• Specialist services – Hyper-acute stroke unit care– Local stroke unit care – TIA services

• Equality of access: all Londoners within 30 minutes by ambulance

Developing new, high-quality major trauma and stroke services for London Joint Committee of PCTs Meeting in public Monday 20 July 2009.

Documents

major trauma patients

major trauma project

outer london

central london

treatment of trauma

changemajor trauma

different london hospitals

major spinal