What are we consulting on? We are consulting on hospital-based care in London for patients - with a major trauma, or - a stroke WE are Healthcare for London and we are consulting on behalf of the 31 London PCTs and South-West Essex PCT Primarily this is acute care but for stroke centres in particular (but also hyper-acute units and Transient Ischaemic Attack services) this includes some rehabilitation. We believe these proposals will save over 500 lives a year.

Major trauma Adult hospital-based care We expect to consider children’s services later in the year. These proposals could save 100 lives a year and save thousands from serious disability 3

What is major trauma? Major trauma – a limb amputation, severe gunshot or knife wounds, a spinal injury, open skull fracture, paralysis or multiple injuries e.g. a road traffic accident Trauma – fractured neck of femur, broken ankle, minor head injury Clinically a major trauma patient is one whose injuries are assessed as more than 16 on the Injury Severity Score diagnostic tool. However we can generally say major trauma patients have ‘immediate life-threatening injuries’. 4

The scale of the problem Around 1,600 major trauma cases per year About one case a week for most A&Es Most major trauma cases occur in central London Major trauma tends to occur in places where large number of people occur. The National Confidential Enquiry into Patient Outcome and Death in 2007 found that over half of patients receive sub-standard care. High incidence in central London is because most major trauma occurs where people gather. Major trauma accounts for 0.1% of most A&E cases. There are NO proposals in this consultation to close any A&E. 5

The case for change Current death rates are 40% higher in the UK than in parts of the US where there are effective trauma systems. In Quebec, Canada, death rates fell from over 50% to 19% when the province introduced a trauma system Two thirds of major trauma patients taken to a local hospital end up being transferred Royal London has 28% less deaths from major trauma compared with national average ‘Major trauma centres’ are needed because too many complex cases are going to local hospitals which do not have the specialist services required. These cases need specialised services. Royal London has 28% fewer deaths from major trauma than the national average, but there are many hospitals which are below the national average. This is unfair. Two thirds of respondents to Consulting the Capital supported fewer, more specialised centres Travel times are less of an issue that for stroke. Most major trauma patients die either at the scene or in a hospital. Going to a local hospital and then being transferred can add 6-12 hours of time (time to get into hospital, time to wait and be assessed, time to find out where a team can be assembled and time to get another ambulance) and this can mean patients spending far more time NOT being treated than a 45 minute ambulance ride. All patients in London would be no more than a 45 minute ambulance ride from a major trauma centre. There are examples around the world of 30 minute travel time for ambulances and up to 60 minutes. The UK is tending to model on a 45 minute travel time. 6

What a good major trauma service looks like New specialist centres of care which have: sufficient volumes of patients for clinicians to become skilled are open 24/7, and provide a complete range of specialist major trauma care to a defined high standard A good service needs: 24/7 Specialist services – with enough patients to treat for clinicians to gain and keep their skills. So, the best orthopaedic surgeon in the world, if put in a hospital that only deals with five patients a year – won’t be the best in the world by the end of the year. The best surgeon will be the one who is working in a hospital where there are 400 or more patients a year. So you cannot just spend more money and get good staff in all hospitals around London. National Clinical Assessment Team (who reviewed our clinical evidence) suggest a minimum of 250 patients a year. Healthcare for London’s clinical team suggested that best clinical outcomes come from at least 400 cases a year. Since we have around 1600 cases a year this suggests three (400 x 3 = 1200) or four (400 x 4 = 1600). However, please note, the information on numbers of major trauma patients is limited. Our estimates are between 1, 000 and 2, 200 patients a year. Three centres would give around 550 cases a year each (if spread equally) which could give better outcomes if we could be sure the units could cope with the volume and the organisation of the large networks. 7

What a good trauma network looks like Three or four networks with a major trauma centre leading and co-ordinating the service and clear transfer agreements Local trauma centres in all A&Es would improve, so thousands of patients would have better care Ability to cope with a major disaster Networks are needed because we have to drive up improvement in all trauma centres in A&Es across London. We need to ensure: That trauma centres and major trauma centres work together to share information and expertise so all centres can improve performance e.g. rotation of staff Major trauma centres become accountable for their networks. We should not have hospitals transferring patients that have been waiting in A&E for hours What is the difference between a trauma centre and an A&E? A&E departments will continue to provide the vast majority of emergency care. Trauma centres in A&Es provide more specialised care. However, services will be better organised and co-ordinated between hospitals. 8

Three networks – option 3 Three centres would give: More patients per major trauma centre – which in theory is good, but only IF each centre could cope. But three centres would also mean: each major trauma centre has more trauma centres to manage – which is cause for concern and there is less resilience if there is a major incident – especially if that major incident is at one of the hospitals

Four network alternative – Royal Free, option 2 In this option, The Royal Free manages more hospitals than St Mary’s did and Royal London manages fewer. Otherwise it is exactly the same Whilst we could ask St George’s to lead improvements in trauma in some hospitals north of the river (e.g. Charing Cross or Chelsea and Westminster), St George’s was the third weakest bid (King’s College was the second).

Four networks – St Mary’s, our preferred option 1 Our preferred option is for four networks (rather than three) because: Each major trauma centre has less trauma centres to manage We can be fairly sure that the major trauma centres will have sufficient numbers of patients but not be overwhelmed and unable to cope Four centres would have better capacity in a major incident (especially if the incident was at a hospital) Royal London Hospital, King’s College Hospital and St George’s Hospital are in each of the three options we propose because: All three supplied excellent bids to Healthcare for London on how they could meet the exacting clinical standards set as criteria by clinicians, patients and voluntary organisations by 2010 St Mary’s and Royal Free are our alternatives for a fourth major trauma centre. They supplied the only other two bids to become a major trauma centre. Both showed that they could meet the clinical standards (both received the same score but the bids were not as good as the other three) and both would need a longer time (until 2012) to become fully operational. St Mary’s is our preferred fourth site because: in the proposed configuration the Royal London (the best bidder and our only current major trauma centre) manages more hospitals than option 2. And St Mary’s (the weakest bid of the four shown here) has to manage fewer hospitals than The Royal Free does in option 2. The NHS London Department for Emergency Preparedness assesses St Mary’s as offering a moderate advantage over The Royal Free in dealing with major incidents due to transport and road access issues and its proximity to high risk areas such as central London and Heathrow

The balancing act Three networks More patients at major trauma centres Quicker to set up the networks (2010) Four centres Major trauma centres not overloaded Better for major incidents Smaller networks to manage This slide summarises the case for three or four centres: Three centres would give around 550 cases a year which could give better outcomes. However we need to be sure each major trauma centres could: cope with the volume of patients; manage the organisation of the large networks; and continue to be effective in the event of a major incident (especially if the incident was on one of the major trauma unit sites) On the plus side we think we could cover the whole of London a bit quicker (by 2010 rather than 2012) but remember that patients in NW London don’t currently have this service, so it is not ‘taking away’ anything Why isn’t travel on the balance? We have said that travel time is not one of the most important issues. There are examples around the world of 30 minute travel time for ambulances and up to 60 minutes. The UK is tending to model on a 45 minute travel time. But this is meaningless if patients are travelling to a hospital that cannot deal with the situation. Nevertheless we recognise that travelling quickly to a good quality service is better than travelling to one far away. And we also recognise that relatives and carers would wish to travel short rather than long distances (all other aspects of care being equal). Analysis of ambulance journey data suggests that, for the small number of major trauma patients which would be taken directly to one of the major trauma centres (as opposed to one of the thirty one A&E departments in the current system), the average scene to hospital journey time would increase from around 11.5 minutes to about 16 minutes. Please note: Although there needs to be enough centres to cope with a major disaster, actually a major disaster does not necessarily mean lots of major traumas. Mainly there are deaths, minor injuries, trauma and SOME cases of major trauma. We are currently analysing the 7/7 bombings to look at the numbers of each type of patient.

Stroke Adult hospital-based care We recognise that prevention and rehabilitation are essential to tackle the problems of stroke but this is about hospital-based care (which includes some rehabilitation). Almost a third of strokes are potentially preventable. The Healthcare for London team has produced prevention and rehabilitation strategies and is now working with PCTs to implement improved rehabilitation services such as community rehabilitation and early supported discharge services. Rehabilitation is essential. It is not good enough that people can ‘just about’ live their life. With good rehab people can live full and active lives. These proposals could save 400 lives a year and save thousands from serious disability 13

What is a stroke? A stroke is a type of brain injury. There are two types: – when blood vessels burst (haemorrhagic) – when blood vessels clot (ischaemic) Thrombolysis is treatment using a clot-busting drug that can only help ischaemic strokes. 15% of strokes are haemorrhagic 85% of strokes are ischaemic Of the 85% ischaemic strokes, around 30% of these are suitable for thrombolysis. Currently less than 10% receive thrombolysis. You cannot thrombolyse a haemorrhagic stroke as this will make matters worse. That is why you need a scan first. But thrombolysis is not the only treatment available. Hyper-acute stroke units also provide the most intensive monitoring, investigation and care for all stroke patients. On arrival to a hyper-acute stroke unit, a patient will be stabilised and a range of investigations carried out to determine the cause of the stroke and crucially prevent another from occurring. Expert monitoring by specialist stroke nurses will ensure any complications, such as chest infections and problems swallowing, are detected and given urgent medical attention. Therapy staff are also able to minimise the long-term impact of a stroke and begin intensive rehabilitation as early as possible. Some clinicians think that it is only worth going to a hyper-acute unit if the stroke has occurred within the last three hours (so that thrombolysis can be performed) but our panels believe that there are still benefits in all stroke patients being treated on a hyper-acute stroke unit. 14

Avoiding a stroke Many strokes are preventable, particularly by lowering blood pressure. Simple steps can help reduce your risk:  stop smoking – smoking can double your risk of having a stroke eat healthily – eat five portions of fruit and vegetables a day and reduce your salt intake drink alcohol sensibly – drinking too much alcohol raises your blood pressure exercise more – this lowers your blood pressure get your blood pressure checked. Whilst we are consulting on hospital-based care for stroke patients, we recognise that we could save many more lives by helping people to reduce their risk of a stroke., so we are taking this opportunity to promote healthier living.

The scale of the problem In complete opposite to major trauma, most cases of stroke occur in the suburbs – where older people tend to live. The next two most important factors in stroke are i) ethnicity (there is a 60% greater incidence of stroke within the black African and black Caribbean populations than the white population and ii) social deprivation. However the actual numbers of people from BME communities having a stroke are not as high as would be expected as there are fewer older black and minority ethnic people in London. Second biggest killer and most common cause of disability 11,500 strokes a year in London – 2,000 deaths 16

The case for change The UK is among the worst performers in Europe – you are almost twice as likely to die from stroke in the UK compared to France The Stroke Association support plans to create more specialised centres 25% more likely to recover and lead an independent life rather than die or be disabled if patients are treated on a specialist unit – could save 400 lives a year Some of the difference between France and UK is due to issues other than acute services – e.g. prevention – diet, incidence of obesity, ethnicity. We have some of the best hospitals in the UK and some of the very worst. This is unfair on many people in London. 67% of respondents to Consulting the Capital (including the Stroke Association) supported plans to create more specialised centres. Only about 50% of stroke patients are treated on a dedicated stroke unit.

What a good stroke service looks like • 24 hour, 7 days a week service. A scan as quick as possible – patients lose brain cells every second they are left untreated Modern treatments such as clot-busting drugs for those that need them Specialist centres of care which have sufficient numbers of patients, and expert staff Time to treatment is critical. BUT this is not just about ambulance time to a hospital, it is also about: Recognising stroke and dialling 999 (of which more later) Time for an ambulance to arrive at the scene Time to be treated. Specialist centres with greater numbers of patients are better. Hospitals need enough patients to treat so that clinicians gain and keep their skills. The best clinician in the world, if put in a hospital that only deals with five patients a year – won’t be the best in the world by the end of the year. The best clinician will be the one who is working in a hospital where there are 500, or 1, 000 patients a year. So you cannot just spend more money and get good staff all around London. Again, it may be worth reiterating that we recognise that prevention and rehab are vitally important but they are not the subject of this consultation. 18

Three hour window So, lets look at TIME TO CALL AN AMBULANCE. The reason we are using a ‘3 hour window’ is that thrombolysis is most effective within 3 hours of onset of a stroke. But in any event ‘every second counts’. First thing is to make sure that a stroke is recognised: we can use the FAST method.

Recognising the signs of stroke FAST

Three hour window Next, looking at TIME TO GET TO A HOSPITAL times, we need to consider: Time for an ambulance to arrive (these days far fewer ambulances are based at large ambulance stations – they are more spread out across London. We are even looking at basing some of them at new polyclinics). The average time for an ambulance to arrive is 13 minutes after the call. Next there is time for ambulance staff to assess the situation and assist the patient onto an ambulance. Average time is 23 minutes. Next we need to look at the time for the ambulance to transport the patient to the hospital - so we need enough hospitals so that travel times are short. Our calculations are that with our proposals all patients in London would be within 30 minutes ambulance journey of a hyper-acute (emergency) stroke unit. This is our estimate calculated after: analysing millions of actual journey times discussing the proposals with the London Ambulance Service, using modelling computer programmes. And the, looking at TIME IN A HOSPITAL, we need to consider: Some hospitals CT scan only 20% of patients within 24 hours – no hospital in London scans more than 84% of patients within 24 hours. Many hospitals do not have scanning facilities open overnight. Good processes must be in place so that when patients arrive they are treated! What is the point in being rushed to a hospital that then tells you to wait for a scan until the morning?

The proposals for stroke Eight hyper-acute units where all patients would go for very specialised treatment. No-one would be more than a 30 minute ambulance journey from a centre and would be scanned and (if appropriate) thrombolysed within 30 mins of arrival at the centre Over 20 local stroke units where people would go after the first three days – for ongoing care and rehabilitation Transient ischaemic attack centres providing rapid testing and specialist services for people who have suffered a ‘mini stroke’. All hyper-acute stroke units have an associated stroke unit. All stroke units have an associated TIA centre. All units are actually co-located except for the proposal from UCL (whose associated stroke unit is the nearby National Hospital for Neurology and Neurosurgery – however the independent assessors felt that there were good transfer arrangements put in place) Everyone would go to the hyper acute unit first as there are specialist skills needed for thrombolysis, to prevent another stroke and for early rehabilitation. After around three days patients would transfer to a local stroke unit which could be in the same hospital or in a more local hospital. TIAs – or mini-strokes – the symptoms do not last and the patient recovers. However 10% go on to have a large stroke within a week – need to diagnose high risk patients within 24 hours and low risk patients within 7 days. 22

Hyper-acute stroke units – our proposal All London hospitals were asked to submit bids to become a hyper-acute unit, a local stroke unit or a transient ischaemic attack unit. The exacting criteria were developed with clinicians, patients, carers and voluntary organisations. The bid evaluation was done by external assessors. The bids showed how they would meet challenging NEW standards of delivery in the future (not current standards). Hyper acute stroke units (HASUs) This map shows those units that are proposed: Whilst all hospitals would need to be supported in their planning and delivery, two hospitals (Royal London and Princess Royal) provided plans that the independent assessors judged to have very significant development needs and would need very strong and intensive support in order to be able to meet the high standards set. However these hospitals have been proposed to provide good geographical cover for East London and (in the case of Royal London) because we believe it would be good to base hyper-acute stroke units where there are proposed major trauma centres. This view is supported by the review of our proposals by the National Clinical Advisory Team. Queen’s Hospital’s plans for a hyper-acute stroke unit (HASU) did not need extra support, but its bid for a stroke unit did not meet the criteria, so because all HASUs need a stroke unit, technically it will need support to establish a stroke centre.

Hyper-acute stroke units However, we also think we need to NOT commission hyper-acute services in some units that were assessed to be able to meet the clinical quality targets without significant assistance. These are mainly in central London. NOT commissioning hyper-acute services in these units does not significantly increase travel times and will increase the number of patients being treated in other units and release some staffing expertise – thereby improving survival and reducing disability. We are recommending that these alternative sites continue to provide high-quality stroke unit and TIA services.

Stroke units and TIA services Stroke Units and Transient Ischaemic Attack services This map shows our proposed units and services (a stroke unit must have TIA services too – it would be possible to have a stand-alone TIA, but we are not proposing any) All of the proposed hospitals provided proposals that were independently assessed as being able to achieve the high standards without external support, but…. [go to slide 27]

HASU, Stroke and TIA Units The shape of things to come!

What are we asking? Do you agree with our proposal on HOW to treat stroke patients i.e. hyper-acute stroke units, stroke units and TIA services? Do you agree that eight hyper-acute units is right? Do you agree with our proposed sites for stroke services? Are there others that should be included / excluded? You need to consider: Whether all stroke patients should go to a hyper-acute stroke unit How much weight you are going to give to time to hospital compared to quality of service when you get there? How much support will those units that have been shown to require significant assistance need – and how easy will it be to achieve a first-class service? Whether we have a good spread of hospitals across London providing services Whether you would prefer any of the alternative hospitals to provide hyper-acute services 27

Heart attacks – a case study Since 2005 patients go to one of eight specialist hospitals They benefit from angioplasty – a balloon that opens up blocked arteries Reduced deaths by 40% The principle for specialisation is shown in this example of the services now provided for victims of heart attacks. 28

Location of heart attack centres I think you will agree that the units are far less dispersed than our proposed hyper-acute stroke units. However, even so … [Go to next slide]

London Ambulance Service ‘blue light’ journey times to heart attack centres 2007-08 The travel times recorded (and there are about 1, 000 trips shown here) show that very few are above 40 minutes. This shows travel times from scene of heart attack to heart attack centre.

Average journey times in ambulances 2005-2008 blue call vs other Points to note These are short times but just as important Rush hour variation for blue light conditions are much less marked than for normal ambulances

Workforce and next steps

More staff, better trained More training, especially of London Ambulance Service staff More staff (especially recognising stroke services as a specialty). Hospitals tell us they are planning to recruit: Need to develop services that are 24/7 Some staff will work from different locations Approximately 600 nurses 200 therapists (physiotherapists, occupational therapists, speech and language therapists) More consultants and junior medical staff a) Stroke is relatively straightforward - ambulance staff need to be able to recognise stroke b) Major trauma much more difficult. E.g. a patient may show signs of no injuries, but if he or she has fallen from a height, all the damage may be internal. The ambulance service is putting together guidance (called a sieve) on identifying major trauma as i) major acute hospitals do NOT want to be swamped with trauma patients and ii) trauma centres do not want to receive major trauma patients. Need for more staff – this is particularly true for stroke. We need specialist stroke consultants (but not many), stroke nurses, radiographers and radiologists. NHS London’s workforce strategy (published in sept 2008) maps how specific workforce plans and education and training plans will be developed. A significant challenge given the working time directive. Staff will work from different locations if some hospitals no longer provide services 33

Investment An additional £23 million to be invested in stroke services Major trauma services will cost an additional £9 - £12 million Four trauma centres would be a little more expensive to run than four centres (around £2-3million) The additional funding for the LAS is because ambulances are travelling greater distances, out of their area, so there will need to be more of them

Have your say We would like your comments and responses: Full and compact versions of the consultation document are available. The compact is available on CD, in Braille, as Easy Read and in 15 languages Background reports are available on request and on the website

The consultation will close on: 8 May 2009