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

Major

Trauma

Centre RehabMajor

Trauma

Centre Rehab

Trauma

Centre Rehab

Trauma

Centre RehabTrauma

Centre Rehab

Trauma

Centre Rehab

Trauma

Centre

Rehab

Rehab

Rehab

Rehab

Network

Director

Non-

London

Rehab

Major

Trauma

Centre RehabMajor

Trauma

Centre Rehab

Trauma

Centre Rehab

Trauma

Centre Rehab

Trauma

Centre Rehab

Trauma

Centre Rehab

Trauma

Centre

Rehab

Rehab

Rehab

Network

Director

Rehab

Special.

Rehab

London

Director

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 4th 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

LKG LKGF LKGM

Coverage

Quality

Score

1465

By 2010

1323

By 2010

1227

By 2010

1465

By 2010

1323

By 2010

1227

By 2010

1143

By 2012

1465

By 2010

1323

By 2010

1227

By 2010

1143

By 2012

% MT

incidents

in area

46% 29% 25% 38% 20% 21% 21% 42% 20% 21% 17%

Number of

Trauma

Centres

20 7 11 12 5 7 13 16 5 7 9

Havering

Bromley

Greenwich

Barnet

Hillingdon

Enfield

Barking and

Dagenham

City and

Hackney

Tower

Hamlets

Newham

Haringey

Ham

mersm

ith an

d F

ulh

am

Ealing

Hounslow

Brent

Harrow

Camden

Islington

Croydon

Ken

singto

n an

d C

helsea

Westminster

Lambeth

Southwark

LewishamWandsworth

Richmond and

Twickenham

Sutton and Merton

Waltham Forest

Bexley

ROYAL LONDON

HOSPITAL

KINGS COLLEGE

HOSPITAL

Kingston

ST GEORGE’S

HOSPITAL

Redbridge

Havering

Bromley

Greenwich

Barnet

Hillingdon

Enfield

Barking and

Dagenham

City and

Hackney

Tower

Hamlets

Newham

Haringey

Ham

mersm

ith an

d F

ulh

am

Ealing

Hounslow

Brent

Harrow

Camden

Islington

Croydon

Ken

singto

n an

d C

helsea

Westminster

Lambeth

Southwark

LewishamWandsworth

Richmond and

Twickenham

Sutton and Merton

Waltham Forest

Bexley

ROYAL LONDON

HOSPITAL

KINGS COLLEGE

HOSPITAL

Kingston

ST GEORGE’S

HOSPITAL

ROYAL FREE

HOSPITAL

Redbridge

Havering

Bromley

Greenwich

Barnet

Hillingdon

Enfield

Barking and

Dagenham

City and

Hackney

Tower

Hamlets

Newham

Haringey

Ham

mersm

ith an

d F

ulh

am

Ealing

Hounslow

Brent

Harrow

Camden

Islington

Croydon

Ken

singto

n an

d C

helsea

Westminster

Lambeth

Southwark

LewishamWandsworth

Richmond and

Twickenham

Sutton and Merton

Waltham Forest

Bexley

ROYAL LONDON

HOSPITAL

KINGS COLLEGE

HOSPITAL

Kingston

ST GEORGE’S

HOSPITAL

ST MARY’S

HOSPITAL

Redbridge

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:

No Factor Original Viability N&NW ProcessPreferred option

assessment

1 Clinical quality

2 Critical mass

3 Travel time / Coverage

4 Major incident compatibility

5 Reconfiguration alignment

6 Ease of deliverability

7 MTC capacity

8 Deliverability 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

An option of 3 would be more rapidly implementedSpeed of implementation9

A 4 network model is easier to implement and

produces networks of manageable size

Deliverability and sustainability of

networks8

A configuration of 4 MTNs has better resilience in

delivering the MTC capacity neededMTC Capacity7

A model based on 3 MTNs would be easier to

deliverEase of deliverability6

No differenceReconfiguration alignment5

4 MTNs provides better coverage and resilience

than 3 MTNsMajor incident compatibility4

4 MTNs provides better and more even coverage

than 3 MTNsTravel time / Coverage3

The higher number of patients per MTC will result

in better outcomesCritical mass2

3 MTNs provides higher clinical quality as the

N/NW bidders scored lower on clinical qualityClinical quality1

RationaleFactorNo

An option of 3 would be more rapidly implementedSpeed of implementation9

A 4 network model is easier to implement and

produces networks of manageable size

Deliverability and sustainability of

networks8

A configuration of 4 MTNs has better resilience in

delivering the MTC capacity neededMTC Capacity7

A model based on 3 MTNs would be easier to

deliverEase of deliverability6

No differenceReconfiguration alignment5

4 MTNs provides better coverage and resilience

than 3 MTNsMajor incident compatibility4

4 MTNs provides better and more even coverage

than 3 MTNsTravel time / Coverage3

The higher number of patients per MTC will result

in better outcomesCritical mass2

3 MTNs provides higher clinical quality as the

N/NW bidders scored lower on clinical qualityClinical quality1

RationaleFactorNo 3 MTNs 4 MTNs

3 MTNs 4 MTNs

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.

LKGM would deliver high quality of care for a

larger number of patients from April 2010Speed of implementation9

LKGM provides better resilience for delivering and

sustaining the networks

Deliverability and sustainability of

networks8

LKGM provides better resilience in delivering the

MTC capacity needed across LondonMTC capacity7

It is difficult at this stage to differentiate the

challenges facing LKGF and LKGMEase of deliverability6

LKGF and LKGM have a similar impact on

reconfiguration alignmentReconfiguration alignment5

LKGM offers a moderate advantage to delivery of

the Major Incident plan due to St Mary’s locationMajor incident compatibility4

LKGM provides marginally better coverage than

LKGFTravel time / Coverage3

Critical mass cannot be used to differentiate

between options with an equal number of networksCritical mass2

No demonstrable difference between the clinical

quality of LKGF and LKGMClinical quality1

RationaleCriterionNo

LKGM would deliver high quality of care for a

larger number of patients from April 2010Speed of implementation9

LKGM provides better resilience for delivering and

sustaining the networks

Deliverability and sustainability of

networks8

LKGM provides better resilience in delivering the

MTC capacity needed across LondonMTC capacity7

It is difficult at this stage to differentiate the

challenges facing LKGF and LKGMEase of deliverability6

LKGF and LKGM have a similar impact on

reconfiguration alignmentReconfiguration alignment5

LKGM offers a moderate advantage to delivery of

the Major Incident plan due to St Mary’s locationMajor incident compatibility4

LKGM provides marginally better coverage than

LKGFTravel time / Coverage3

Critical mass cannot be used to differentiate

between options with an equal number of networksCritical mass2

No demonstrable difference between the clinical

quality of LKGF and LKGMClinical quality1

RationaleCriterionNo LKGF LKGM

LKGF LKGM

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