Simon Robbins Senior Responsible Office, Major Trauma Project 4 February 2009

2 Project objective To design and implement an inclusive trauma system that assures the care of all injured patients and ensures that optimal care is provided at all stages of the patient journey

3 Case for change Poor co-ordination across London means the time to definitive care is unacceptably long The standard of care delivered to the majority of trauma patients across the UK has been shown to be sub-standard Governance and accountability are poor in London centres treating severely injured patients

4 International experiences should be used In a regionalised system, trauma patients are triaged to the most appropriate centre according to protocol: – Chicago: reduction in mortality of 25% when care is provided in a level 1 trauma centre – Florida: Trauma centre counties had significantly lower MVC death rates (50%) Regionalised trauma systems show a continuous improvement in results over time – Quebec: Integrated trauma system showed a reduction in mortality from 52% to 19% – Orange County: reduction in preventable deaths – US-wide study: mortality falls when volumes increase

5 Scope of the Project - three phases Phase 1 – Exploration – Until August 2008 Design a trauma system and optimal care pathway for London Run a preliminary phase to determine provider interest Develop designation criteria and process Phase 2 – Preparation – August 2008 – Summer 2009 Run designation process Public Consultation on options Implementation planning Phase 3 – Implementation – Summer 2009 onwards If the response to the proposals in the consultation is positive, implement the trauma plan and commission agreed trauma care pathways

6 Phase 1 – A trauma system made up of networks

7 Benefits of a London trauma system Improved patient outcomes A system-wide prevention strategy to reduce the number of people suffering severe injury 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 to optimum social and economic functioning Costs per life saved and per life-year saved are very low compared with other comparable medical interventions

8 Clinical Expert Panel (monthly) –20+ clinicians from trauma specialities including rehabilitation, LAS, public health, social services Patient Panel (monthly) –PPAG member –Relevant charities e.g. Headway, Spinal Injuries Association Commissioning Panel (monthly) –PCT representatives in and adjoining areas of London Stakeholder event – 120 attendees Focus group with the public to test proposals Linkage with NHS London Department of Emergency Preparedness (monthly) On-going conversations with surrounding PCTs and SHAs Gateway Review cited an ‘outstanding level of clinical engagement’ Stakeholder engagement

9 Phase 2 - Bid evaluation outcome An exhaustive set of designation criteria drawn up and agreed by all the expert panels supporting the project Site visits were conducted as part of the bid evaluation, to meet with bidding Major Trauma Networks (MTNs) 3 bids demonstrated the ability to deliver the required level of service by April 2010: –East London & Essex Trauma Network – MTC: Royal London Hospital –South East London Trauma Network – MTC: King’s College Hospital –South West London & Surrey Trauma Network –MTC: St George’s Hospital An additional designation process was run and completed in January 2009 to assess the viability of a 4 th MTN to cover North and North West London The 2 bids received demonstrated the ability to deliver the required level of service for North and North West London by April 2012 – MTC: Royal Free – MTC: St Mary’s

10 The MT project board has recommended to JCPCT ruling out –2-MTN systems because of –High risk that MTCs would not be able to cope with demand. This would have a significant negative impact on clinical quality and potentially destabilise other services –Low coverage of incidents and population –5-MTN system because of –Significant risk of poorer clinical outcomes compared to a 3- or 4-MTN system –Increased incremental cost compared to a 3- or 4-MTN system, it would not significantly improve journey time or coverage. The JCPCT have agreed three options for consultation –3-MTN system based on Royal London, King’s and George’s (LKG) –4-MTN system based on Royal London, King’s and George’s and Royal Free (LKGF) –4-MTN system based on Royal London, King’s and George’s and St Mary’s (LKGM) Potential configuration options

11 Summary of possible options LKGLKGFLKGM Coverage Quality Score 1465 By By By By By By By By By By By 2012 % MT incidents in area 46%29%25%38%20%21% 42%20%21%17% Number of Trauma Centres

12 The MT project team has developed nine factors to assess configuration options through the: Original options development process (patient and clinical expert Panel) Viability testing of the outcome of the first clinical evaluation stage The evaluation criteria from the additional designation process for N & NW London The factors that the MT Board recommended to use to inform the choice of a preferred option were: NoFactorOriginalViabilityN&NW Process Preferred option assessment 1Clinical quality 2Critical mass 3Travel time / Coverage 4Major incident compatibility 5Reconfiguration alignment 6Ease of deliverability 7MTC capacity 8Deliverability and sustainability of networks 9 Speed of implementation Factors to differentiate between options These factors have been applied to each of the options to identify a preferred option

13 3-MTN vs 4-MTN: summary of assessment against the 9 factors Although a 3-MTN system is stronger in terms of clinical quality (as measured by the designation criteria) and critical mass, there is considerable concern over MTC resilience in delivering MTC capacity and network size above that described in their original bids The MT Board considers factors 7 and 8 compelling enough to recommend a 4-MTN system, which could be implemented with support from the London trauma system for less developed networks

14 LKGF vs LKGM: summary of assessment against the 9 factors Of the 4-MTN systems, LKGM gives a greater proportion of London’s population covered by April 2010, creates a more sustainable system with networks’ capacity aligned to MT incidence and provides a better fit with London’s major incident planning It is acknowledged that alternative ways of redistributing PCTs to St George's or King’s exist, which would change MT incidence and number of TCs in the Royal Free network and could affect the assessment of criteria 7, 8 and 9.

15 A trauma system using the LKGM networks is preferred because: There is concern in a 3-MTN system, over MTC resilience in delivering capacity above that described in their original bids A 4-MTN system addresses this concern and gives better coverage, major incident compatibility, and networks of a more sustainable size Of the two possible 4-MTN systems, LKGM gives a greater proportion of London’s population covered at the earlier implementation date (April 2010) LKGM creates networks of more sustainable size LKGM provides a better fit with London’s major incident planning Conclusion