SPINAL CORD INJURY: THE NEW POLITICAL PERSPECTIVE

SPINAL CORD INJURY – WHO CARES? Asking the right questions

IN THE BEGINNING 1948 – NHS created by Health Act 1948 – NHS created by Health Act 1952 – Health Act amended to allow development of ‘specialist’ services providing for less than 1 million UK citizens each year 1952 – Health Act amended to allow development of ‘specialist’ services providing for less than 1 million UK citizens each year 2003 – Review of ‘Specialist Services’ 2003 – Review of ‘Specialist Services’ 2006 – Parliamentary Investigation 2006 – Parliamentary Investigation (Carter Report) (Carter Report)

THE FINDINGS ‘Specialities’ listed on NHS website for reference purposes ‘Specialities’ listed on NHS website for reference purposes Specialist Commissioners for strategic services (pan-regional) at mercy of Regional bodies, PCTs and individual trusts Specialist Commissioners for strategic services (pan-regional) at mercy of Regional bodies, PCTs and individual trusts Some specialist funding being diverted by PCTs and hospital trusts Some specialist funding being diverted by PCTs and hospital trusts Specialist services often isolated or bypassed by expansive generalist services Specialist services often isolated or bypassed by expansive generalist services Misperception of ‘care closest to home’. Misperception of ‘care closest to home’.

PARLIAMENTARY GROUP SIA, MASCIP, BASCIS & Parliamentary Disability Group SIA, MASCIP, BASCIS & Parliamentary Disability Group 3-year project funded in 2006 ‘Preserving & Developing National SCI Service’ 3-year project funded in 2006 ‘Preserving & Developing National SCI Service’ New group, has cross-party support New group, has cross-party support 2009 Secretary of State accepts findings, and agrees initial action plan 2009 Secretary of State accepts findings, and agrees initial action plan Action Plan to commence in 2010/2011 Action Plan to commence in 2010/2011

THE NEW AGENDA Confirm Government support for ‘National SCI Service’ Confirm Government support for ‘National SCI Service’ Streamline Specialist Commissioning for strategic services at national level Streamline Specialist Commissioning for strategic services at national level Audit use of specialist funding Audit use of specialist funding Define ‘Spinal Cord Injury’ for purposes of creating an NHS Pathway Define ‘Spinal Cord Injury’ for purposes of creating an NHS Pathway Define and develop a ‘Model’ service. Define and develop a ‘Model’ service.

New Commissioning Pathway

THE NEW AGENDA Define a ‘Model’ SCI Centre Define a ‘Model’ SCI Centre Audit current SCI Centres against this model and plan for future development Audit current SCI Centres against this model and plan for future development Calculate accurate annual incidence of SCI using NHS codes Calculate accurate annual incidence of SCI using NHS codes Fund the development of a national SCI database and reporting centre Fund the development of a national SCI database and reporting centre Consider additional SCI Centre beds Consider additional SCI Centre beds

WHAT IS A SPINAL CORD INJURY? NHS Definition Set Audit Criteria 2010/2011

ACTUAL SCI  Spinal cord injury worthy of referral to a specialist SCI Service is defined when one of the following ICD-10 codes is recorded in primary diagnosis field (ie first 10 documented problems):  5140 Concussion and oedema of cervical spinal cord; 5141 Other and unspecified injuries of cervical spinal cord; 5142 Injury of nerve root of cervical spine; 5240 Concussion and oedema of thoracic spinal cord; 5241 Other and unspecified injuries of thoracic spinal cord; 5242 Injury of nerve root of thoracic spine; 5340 Concussion and oedema of lumbar spinal cord; 5341 Other injury of lumbar spinal cord;

ACTUAL SCI  5342 Injury of nerve root of lumbar and sacral spine; 5343 Injury of cauda equina; 5344 Injury of lumbosacral plexus; T060 Injuries of brain and cranial nerves with injuries of nerves and spinal cord at neck level; T061 Injuries of nerves and spinal cord involving other multiple body regions; T093 Injury of spinal cord, level unspecified; T094 Injury of unspecified nerve, spinal nerve root and plexus of trunk.   Statement to the House on behalf of DoH in response to Parliamentary Question ‘How does DoH define ‘Spinal Cord Injury’ July 2009

New SIA Publication

SCI Incidence Update England & Wales admissions to SCI Centres 71% male 71% male Average age at injury 44 years old Average age at injury 44 years old Range: 3 – 103 years old Range: 3 – 103 years old Largest group (20%) aged years old Largest group (20%) aged years old ~ 20% of traumatic SCI not referred to SCI Centre ~ 20% of traumatic SCI not referred to SCI Centre C1 - 4 C5-8T1-12L1-5S1-5 Not Given 24%26%37%11%0.1%1.9%

SCI Incidence Update England & Wales % of SCI due to trauma 27% due to Moving Vehicle Collision 27% due to Moving Vehicle Collision 26% due to Falls 26% due to Falls Non-traumatic patients significantly older than traumatic cases (P<0.01) Non-traumatic patients significantly older than traumatic cases (P<0.01)

ADMISSION POTENTIAL  ~450 SCI centre beds, ~300 dedicated beds for ‘first-time’ admissions  Increased length of stay  Increased discharge delays  Immediate need for additional beds in Southern England  ‘Preventable’ complications linked to admission delays

SCI Incidence Update England & Wales % of traumatic SCI cases sustained accompanying trauma Chest injuries (39%) Upper limb injuries (30%) Pelvis and lower limb injuries (28%) Head injury (19%)

SCI Incidence Update England & Wales % of the patients were reported to have significant pre-existing medical conditions: Cardiovascular (26%) Respiratory (16%) Neurological (12%) Diabetes (13%) Mental health problems (9%)

SECONDARY SCI Secondary neurological deterioration can occur due to: Secondary neurological deterioration can occur due to: natural pathological processes natural pathological processes inappropriate moving and handling inappropriate moving and handling surgical interventions surgical interventions poor systems management post- trauma poor systems management post- trauma Inappropriate early mobilisation Inappropriate early mobilisation

THE UK SCI CARE PATHWAY

NHS COMMISSIONERS SERVICE REVIEW 2003  A coordinated care pathway from A&E  Early recognition of SCI*  Referral to SCI Centre within 24 hours*  Transfer to SCIC if appropriate  SCI Centre liaison if transfer delayed  Support and education for PTH staff  Referral to SCIC if patient readmitted

WHO INFORMS SCI CARE   Department of Health   NHS Specialised Services Commissioners   Local Commissioning Groups   Multidisciplinary Association of SCI Professionals (MASCIP)   British Association of SCI Specialists (BASCIS)   Spinal Injuries Association (SIA)   Spinal Injuries Scotland (SIS)   International Spinal Research Trust (Spinal Research)   International Spinal Cord Society (ISCoS)   Parliamentary All-Party Working Party on Spinal Cord Injury* *work under development   National Patient Safety and Modernisation Agency   Joint Royal Colleges Ambulance Liaison Committee   British Trauma Society   British Orthopaedic Association   Royal College of Nurses   Royal College of Physicians   Royal College of Surgeons   British Society for Rehabilitation Medicine   Intensive Care Society*   British Association of Neuroscience Nurses*

DELAYS IN TRANSFER  Critically Unstable for Transfer  Mental Health / Self-Harm Risk  Needing Mechanical Ventilation  Lack of Specialist Bed in SCIC  Post-Admission Complications!

SCI CENTRE DEVELOPMENT 1  Map activity to capacity and admission criteria  All Acute SCI Centres to be on site of University Teaching Hospital with Level 1 Trauma Centre  ? Separate acute and rehabilitation capacity  ? Expand ventilator beds and dedicated ICU beds in parent trust (M’bro Model)  Plan to provide ideal number of SCI beds per capita against current regional populations

SCI CENTRE DEVELOPMENT 2  Consider separate paediatric SCI service  Audit outcomes of older patients against care pathway options available  Expand SCI Liaison Service  Expand OPD for Outreach Services  Invest in Hospital and Community Link- Workers  Develop collaborative care guidelines with key professional bodies  Invest in telemedicine and new health support technologies

READMISSION TO SCIC Most appropriate for the assessment or treatment of SCI-related problems and complications, where the appropriate clinical expertise and experience is not available in a local hospital.

READMISSION POTENTIAL  3 days per patient per year after discharge  More frequent for patients with early ‘preventable’ complications  303 bed nights per year needed  150 SCI centre readmission beds  Currently 42% of these episodes admitted to local general hospital

READMISSION TO DGH Most appropriate for the assessment or treatment of problems /complications unrelated to SCI, where appropriate clinical expertise and experience is not available in a SCI Centre

READMISSION POTENTIAL  5 days per patient per year after discharge  More frequent for patients with early ‘preventable’ complications  500 bed nights per year needed  150 SCI centre readmission beds  At least 30% of these episodes admitted to SCI Centre instead

Any Questions?