Making it safe / better / sound / work / happen

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1 Betsi Cadwaladr University Health Board Board Paper Item 12/52.3 Subject: Summary or Issues of Significance Strategic Theme / Priority / Values addressed by this paper Legislation or Healthcare Standard: Evidence base or other relevant information to inform decision (e.g risks) Consultation with others: Equality Impact Assessment (EqIA) Major Trauma Services This report describes the outcome and recommendations following a review process undertaken within BCU Health Board as a result of changes to major trauma services in England. The report makes recommendations for the provision of specialist trauma services to the Board. Making it safe / better / sound / work / happen Welsh Government Annual Quality Framework 2012/13 The National Audit Office report Major Trauma Care in England (February 2010) Recommendations have been informed by a formal evaluation process with detailed criteria covering; Safety of care, Standards of care, Accessibility of Service, Sustainability of Service and Acceptability. North West and West Midlands Commissioners / service providers and Community Health Council have been engaged with review. Has EqIA screening been undertaken? Y Has a full EqIA been undertaken? N Recommendations: It is recommended that the Board support University Hospital North Staffordshire (Stoke) as the provider of major trauma services for the North Wales population. Author(s) Presented by Sue O Keeffe, Critical Care Network John Darlington Neil Bradshaw Date of report 11 th June 2012 Date of meeting 24 th May 2012 Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

2 Betsi Cadwaladr University Local Health Board Major Trauma Centre Recommendations Situation The national Audit office report Major trauma care in England (February 2010) concluded that major trauma care in England does not represent value for money because the service is not being delivered efficiently or effectively. Subsequently, the NHS Clinical Advisory Group s report of September 2010, Regional Networks for Major Trauma, led to the establishment of Major Trauma Centres (MTCs) in England. Two MTC s were identified in the regions adjoining North Wales; one at Liverpool and the other in Stoke. This provided Betsi Cadwaladr University Health Board (BCUHB) with the ideal opportunity to review which MTC is best suited to provide tertiary level trauma services for the North Wales population. This report describes the process that has been undertaken in this review and makes recommendations for the provision of specialist trauma services to the Health Board. It recommends to the Health Board for the selection of the University Hospital of North Staffordshire as the provider of tertiary level specialist trauma services Background Most patients with traumatic injuries require care that can be provided effectively and efficiently within the three BCUHB hospitals. Historically, each year around 40 seriously injured adult patients are transferred out of BCUHB to England for specialist tertiary care. This care includes the management of complex orthopaedic trauma, traumatic brain injury, cardiothoracic injury and, spinal injury but excludes burn injury patients who will continue to go to Whiston Hospital and children treated at Alderhey. Such life-threatening and life-changing injuries are fortunately uncommon but place a heavy demand on acute care specialties and on the rehabilitation services. These injuries are complex and expensive to treat; the cost of rehabilitation and long-term disability is greater still. In light of this, the provision of high quality trauma services was identified as a priority for BCUHB. Assessment A working group was established in autumn 2010 and reporting to BCU Board of Directors. The NHS Clinical Advisory Group s (CAG) report Regional Networks for Major Trauma was used as the basis for developing a Service Specification for evaluation of the two MTCs offering tertiary level trauma services. A Management of the Seriously Injured Patient in North Wales Information Sharing Event was held on 9th December Senior clinical and managerial teams from both potential Major Trauma Networks, i.e. the North West and the University Hospital North Staffordshire, presented their proposals. The aim of the event was to share information with BCUHB staff not previously 1

3 directly involved in the discussions; an open questions session enabled BCUHB staff, clinicians and managers, to raise questions about the service models. Each provider completed a self assessment evaluation template. The evaluation template was taken from the key elements of the BCUHB s Major/Poly Trauma Service Specification document. In addition, the evaluation template took into account additional and key factors identified by Clinicians at the clinical event held in December To see the provider s full self assessment submissions against the Major/Poly Trauma Service Specification please visit On February 20 th 2012 senior clinical and managerial teams from the MTC providers were interviewed by a panel of senior BCUHB clinicians and managers. The Community Health Council has been apprised of the process throughout and have considered our recommendations using the agreed protocol for determining substantial change. To enable recommendations regarding the Major Trauma service provider to be made to the Board of Directors and Health Board a formal evaluation assessment process was undertaken by the panel. Key to this process was strong clinical engagement in decision-making. This was supported by a robust and transparent assessment framework with benefits criteria identified by the panel to support the assessment of options. The assessment framework took into account the previously agreed key criteria of safety, standards of care, accessibility and sustainability. An additional criterion was added in relation to acceptability as it was considered essential that the recommended options are considered acceptable to all stakeholders, staff and the local community. The recommendations resulting from the above non financial benefits criteria were tested against the key criterion of affordability. The key criteria were ranked in order of importance by informed personnel on the panel. Descriptors were identified to define each criterion and to guide the weighting and scoring process. Each option was examined in turn against the agreed criteria and a brief description of how that option meets the criterion was considered and recorded. Each member of the panel scored each option, a consensus score was recorded. The figures from both the weighting and scores were multiplied together to provide a total weighted score for each option. This enabled the panel to rank each option in terms on non-financial benefits and to identify the preferred option on the basis of these benefits only (see appendix 1). Two options were considered against the Key Criteria; Option 1 - North West Trauma collaborative only (i.e. Aintree, RLUH, WCFT, LHCH etc) Option 2 - University Hospital North Staffordshire (UHNS) only Summary The preferred option is Option 2: University Hospital North Staffordshire in Stoke. The rationale is that through submission of evidence and interviews the senior team were able to clearly demonstrate and provide assurance that they are in a position to immediately respond and deliver the Major/Poly Trauma Service Specification and benefit the population of North Wales. The panel concluded that Liverpool has not yet established an MTC that meets these specifications and will require major capital investment and a couple of years work before it can offer a service comparable to that which already exists in Stoke. 2

4 Whilst there was a robust clinical rationale for recommending University Hospital North Staffordshire further financial discussions were required. These have now concluded and the overall the financial conclusion is that UHNS costs are lower than Walton. On the 7 th March 2011 a SBAR including an Equality Impact Assessment was submitted to the Board of Directors (BoD) regarding recommendations for Major Trauma Centre care for the population of North Wales. BoD members agreed, in principle, that the preferred provider for Betsi Cadwaladr University Health Board s (BCUHB) patients for major trauma would be University Hospital North Staffordshire (UHNS). This was however subject to the following; o o o o Development of an Operational Protocol (clarifying which patients would be referred to UHNS and those who would not, including appropriate age range governance) see appendix 2. Concluding detailed financial assessment including affordability and value for money comparisons. Further engagement with Community Health Council (CHC) and assessment against our Protocol for Managing Substantial Change Image transfer capability In addition, it was agreed rehabilitation services would be made a priority for further phase of work, linked to the now established Neurosciences Network. This review will consider existing patient pathways across all CPGs and make recommendations for future service provision. The following further detailed work was undertaken and supported by Board of Directors at 9 th May meeting: Operational Protocol: The Operational Protocol cited in appendix 2 describes the referral pathways for seriously injured patients, those with an isolated traumatic brain injury, spontaneous non-traumatic intracranial bleeds and burn injuries. It also confirms the maximum age range for referrals to Alder Hey as substantiated by Dr Bimal Mehta, Consultant in Paediatric Emergency Medicine and Trauma Lead, Emergency Department, Alder Hey Children's NHS Foundation Trust. Community Health Council: The Executive Committee of the Community Health Council (including CHC members of the Services Planning Committee) considered the health board s review of major trauma services at its meeting 1 st May. The Committee discussed in particular the potential shift of the services to be provided for North Wales patients from the current provider in North West England to the University Hospital of North Staffordshire in Stoke and whether this would constitute a substantial change and therefore require a period of consultation. Members discussed the following aspects: Major trauma services are already provided outside of Wales in a number of centres in North West England and, in some instances, beyond. The number of patients per year from North Wales needing the service Concerns regarding travel times for carers/families to the current provider and to the centre in Stoke were addressed in discussion to the satisfaction of those present. Priority from the patients' perspective was quality and safety of treatment in the most appropriate location, provision in a single site with effective follow up. It was resolved by the Executive Committee and members of the Services Planning Committee present that a potential shift of provider would not constitute a substantial change. 3

5 To comply with due processes and for completeness the CHC substantial change protocol template has been completed and be submitted for the attention of the Services Planning Committee. Image Transfer: Images are currently transferred to the Walton Centre (and elsewhere) via a PACS point to point link. UHNS will be using an Image Exchange Portal (IEP) to share images between sites. At present BCUHB can transfer images to IEP from all sites, However, until the autumn, for Wrexham and Glan Clwyd images would need to be sent to Bangor, and then from Bangor on to IEP. The Health Board are planning to connect the new PACS to IEP as it is deployed, timescales planned are July/August in Bangor, August/September in YGC and September/October in Wrexham. In the interim period, if necessary it is possible to transfer images point to point. Financial assessment: The overall financial assessment of current costs payable under mandatory PbR tariffs and local critical care prices at The Walton Centre and other Liverpool NHS providers is estimated to be 0.24m p.a. higher than the likely costs for the same activity and case mix at UHNS. Major Trauma for Injury Severity Scores (ISS) greater than 15 is currently provided under contracts managed by Welsh Health Specialist Services Committee (WHSSC), by NHS Trusts in Liverpool. The Walton Centre NHS Foundation Trust currently provides the majority of ISS >15 activity for BCUHB (over 95%). The initial emergency admission is funded via the non specialist BCUHB managed contracts for Aintree Hospitals University NHS Foundation Trust or Royal Liverpool and Broadgreen University Hospitals NHS Trust. The actual activity for major trauma in any financial year cannot be accurately predicted due to the nature of the conditions arising and the variability of case mix. However, based on historic activity numbers and case mix agreed with the BCUHB Critical Care Network, an assessment of the current annual average provider costs and a comparison to the likely annual costs at UHNS has been undertaken. The annual major trauma patients numbers agreed with the BCUHB Critical Care Network for the cost assessment is 63 (ISS > 15 only). English NHS Trust contracts are primarily charged at Payment by Results (PbR) tariff prices which are nationally set and are the same for all English NHS Trust providers. However, each NHS Trust has a Market Forces Factor (MFF) uplift, set by the Department of Health to compensate for local market conditions. For NHS Trusts in Liverpool the MFF for the 5 main Liverpool Trusts are in the range 3.87% (Royal Liverpool) to 4.31% (Whiston). The MFF for The Walton Centre is 4.03%. From 2012/13, English NHS major trauma providers will be also be entitled to a best practice top up for compliance with nationally set information and quality requirements. It is assumed that any English NHS major trauma provider will qualify for this top up of approximately 2.9k per patient spell, including MFF. The MFF for UNHS is 2.42%, i.e. 1.61% less than The Walton Centre. Based on the agreed case mix, as such the cost difference between UNHS and Liverpool major trauma providers for admitted patient care (excluding critical care and charges not applicable to Welsh commissioners*) is likely to be 260 per patient spell. A key exception to the PbR national Tariffs is critical care. Critical Care is a locally set by NHS Providers, with local prices agreed by the host commissioners. The Walton Centre currently charge 4

6 a flat bed day rate for all ITU. UNHS are proposing to charge a sliding scale bed day rate based on the number of organs supported. Assuming an average case mix for major trauma that equates to critical care supporting 4 organs then the UNHS will be approximately 3.5k cheaper than the Walton Centre per patient spell. The overall financial assessment of current costs payable under mandatory PbR tariffs and local critical care prices at The Walton Centre and other Liverpool NHS providers is 0.24m higher than the likely costs for the same activity and case mix at UHNS. The above analysis excludes the cost of Rehabilitation. Rehabilitation is currently provided at The Walton Centre only for patients admitted to Walton. Rehabilitation bed prices are outside of PbR national tariffs and so are set locally by each NHS Trust. Rehabilitation for current major trauma admissions at UNHS is provided by Staffordshire and Stoke-on-Trent NHS Partnership Trust at a bed day price 24% cheaper than the Walton Centre. Therefore for every 100 bed days of post major trauma rehabilitation, the costs in Stoke would be approximately 10k cheaper than the Walton Centre. *charges not payable by Welsh Commissioners at English Trust include A&E attendance, CQUIN and RTA Income. These charges are either payable by the host PCT Commissioner or the patient s insurers (RTA Income). Recommendations The following recommendations are made for consideration by Board: 1. To formally support implementation of option 2 and recommendation for University Hospital North Staffordshire (Stoke) as the provider of major trauma (ISS >15) services for the North Wales population. 2. To note the Operational Protocol for Referral of Patients with Serious Injuries (ISS>15) (Appendix 2), process for image transfer and be assured that due diligence has been given to all areas of work, clinically and financially. In addition, to note the outcome of the CHC area planning Committee and judgement around substantial change protocol 3. To support formal engagement with providers based on the recommendations and agree timescale for implementation. 4. To support two key priorities for BCUHB s strategic work plan: i. The assessment of Trauma Unit status for the Emergency Departments within BCUHB ii. The review of rehabilitation pathways as part of neurosciences network programme and services to enable timely repatriation from the MTC and improved patient outcomes. 5

7 Rank Criteria Descriptors 1 Safety of Care 2 Standards of Care 3 4 Appendix 1 Accessibility of Service Sustainability of Service 5 Acceptability North Wales Evaluation for Major Trauma Services Single point of contact/referral Commitment to accept neuro patients (GCS<9) regardless of bed availability Senior decision makers on site within 30mins and plans for residency 2013, or before. 24hr imaging & embolisation Guaranteed access to NCEPOD theatre 24hrs Support damage control surgery philosophy Senior neurosurgical trainee / middle grade on site at all times Continuity of [speciality] care Escalation planning. Defined Rehabilitation pathway Adherence to Major Trauma System Performance Framework; QIs e.g. Response times (e.g. surgical specialists, neurosurgical response, imaging) Audit sharing; commitment to TARN/ICNARC/UKROC etc. Clinical protocols including updates Regular M&M evaluations/bcu attendance at M&Ms Defined interface between Providers and wider trauma network system Defined process for review of Critical incident monitoring + feedback to TUs (North Wales/BCU) Building infrastructures (e.g. 24/7 helipads, services adjacencies etc.) Actual air-frame assets; capacity. Day/Night capability, bad weather capability (navigation aids), fuel re supply Travel times/problems for secondary transfers; impact on WAST, Air Ambulance, RAF Defined repatriation process (who, when) Sustainability of senior staff, dependence of a reducing junior workforce. Succession planning Delivery of strategic development plans. Impact on local community; EqIAs Facilities for attending relatives PPI from TUs [BCUHB] Clinical support WAST, Air Ambulance, RAF (and other) support Weighting Consensus Weighted Scores North UHNS West Totals

8 Appendix 2

9 Appendix 3 BCU Trauma Group: Neil Bradshaw Executive Director of Planning Pat Billingham - Chief Officer, CHC Aruni Sen Consultant in Emergency Medicine Aeneas O Kelly Clinical Lead Musculoskeletal Trauma Julie Wilkins Head of Physiotherapy Gordon Roberts Regional Director Welsh Ambulance Service Pat Mowll Assistant Director of Business Improvement David Southern Lead Clinician for Intensive Care Ed Farley-Hills Clinical Director, Critical Care (Chair) Paul Birch Assistant Medical Director John Falcus Associate Chief of Staff (Operations), Medical CPG Andrew Cheesman - Interim Finance Lead - Commissioning Sue O Keeffe Critical Care Network Manager Interview Panel: Ed Farley-Hills Clinical Director, Critical Care (Chair) Paul Birch Assistant Medical Director Aeneas O Kelly Clinical Lead Musculoskeletal Trauma Jason Williams WAST/Air Ambulance, Clinical & Operations Manager Richard Taylor Master Aircrew, Rearcrew Leader, Paramedic Winchman RAF SAR. Lloyd Jenkinson Clinical Director, Surgery David Southern Lead Clinician for Intensive Care, representing Anaesthetics John Darlington Assistant Director of Planning Kamala Williams Specialist Planner (WHSSC) Nigel McCann - Assistant Director of Finance Sue O Keeffe Critical Care Network Manager (Note taker)