evolution of trauma care in the uk: current developments and future expectations

3
Short communication Evolution of trauma care in the UK: Current developments and future expectations Graham Sleat a, *, Keith Willett b a Department of Health, Medical Directorate, Area 423, Wellington House, 133-155 Waterloo Road, London SE1 8UG, UK b University of Oxford, UK Introduction Major trauma is a major public health problem. It is the leading cause of death in people from the age of 1–40, accounting for one in ten deaths overall, and leads to significant morbidity. 1 Over the last 40 years many countries in the developed world have developed regionalised trauma systems to improve the survival rates of their patients who sustain traumatic injury. In this article we will present how the implementation of regional networks for major trauma care in England is progressing. The need for change The benefits of a systematic approach to the management of trauma care were first realised in the military setting during the first world war, but civilian major trauma systems did not start until much later, initially in the United States of America. The 1966 report 2 of their National Research Council highlighted inadequa- cies in the care of the seriously injured patient and made recommendations for change. In response to this, following legislation and changes to funding, trauma systems were pioneered. Early experiences in Orange County, CA showed a significant improvement in the numbers of deaths following trauma, 3 and many regions of the USA followed suit, their results showing improved survival rates of 15–20% for seriously injured patients in a review in 1999. 4 In the United Kingdom there have been repeated calls for the reorganisation of trauma services for more than two decades. In 1988 the Royal College of Surgeons of England (RCS) published The Management of Patients with Major Injuries which found one third of the deaths from injury in England and Wales were preventable. They highlighted serious deficiencies in the management of seriously injured patients and recommended that major trauma patients should be managed in trauma centres. Subsequently reports in 1992, 1997 and 2000 from the British Orthopaedic Association (BOA) and the RCS have reiterated a lack of adequate staff, resources and experience to maintain acceptable standards for major trauma patients. In the intervening years Regional Trauma systems have been successfully implemented in other countries across the world including Canada, Australia, and many European countries, with multiple studies showing that the UK performs worse than other developed countries in treating major trauma. A recent study 5 comparing serious head injury in major trauma patients found England & Wales to have a significantly higher mortality than those in Australia. A comparison with South Moravia showed a lack of senior medical input into major trauma patient care in England and significant delays in transferring to the operating theatre. 6 A further study showed that severely injured patients had a 20% higher in hospital mortality in England and Wales compared to the USA. 7 It was only following the National Confidential Enquiry into Patient Outcomes and Deaths report Trauma: Who Cares? in 2007 which identified deficiencies in both organisation and clinical care leading to almost 60% of patients receiving a standard of care below that of good practice, that, the then Minister of State for Health, Ben Bradshaw, committed the Government of the day to introducing Regional Trauma Networks and setting up the Regional Trauma Programme. The Regional Trauma Programme The first National Clinical Director for Trauma Care was appointed in April 2009 to lead the development of policy and facilitate the implementation of regional networks for major trauma care through all regions of England. The plan is for networks to be created by the regional strategic health authorities, tailored to fit their locality’s specific needs and circumstances. The programme is working through three stages of implemen- tation: Injury, Int. J. Care Injured 42 (2011) 838–840 A R T I C L E I N F O Article history: Accepted 12 May 2011 Keywords: Major Trauma Networks Systems * Corresponding author. Tel.: +44 0207 972 3207. E-mail address: [email protected] (G. Sleat). Contents lists available at ScienceDirect Injury jo ur n al ho m epag e: ww w.els evier .c om /lo cat e/inju r y 0020–1383/$ see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.05.014

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Injury, Int. J. Care Injured 42 (2011) 838–840

Short communication

Evolution of trauma care in the UK: Current developments and futureexpectations

Graham Sleat a,*, Keith Willett b

a Department of Health, Medical Directorate, Area 423, Wellington House, 133-155 Waterloo Road, London SE1 8UG, UKb University of Oxford, UK

Contents lists available at ScienceDirect

Injury

jo ur n al ho m epag e: ww w.els evier . c om / lo cat e/ in ju r y

A R T I C L E I N F O

Article history:

Accepted 12 May 2011

Keywords:

Major

Trauma

Networks

Introduction

Major trauma is a major public health problem. It is the leadingcause of death in people from the age of 1–40, accounting for one inten deaths overall, and leads to significant morbidity.1 Over the last40 years many countries in the developed world have developedregionalised trauma systems to improve the survival rates of theirpatients who sustain traumatic injury.

In this article we will present how the implementation ofregional networks for major trauma care in England is progressing.

The need for change

The benefits of a systematic approach to the management oftrauma care were first realised in the military setting during thefirst world war, but civilian major trauma systems did not startuntil much later, initially in the United States of America. The 1966report2 of their National Research Council highlighted inadequa-cies in the care of the seriously injured patient and maderecommendations for change. In response to this, followinglegislation and changes to funding, trauma systems werepioneered. Early experiences in Orange County, CA showed asignificant improvement in the numbers of deaths followingtrauma,3 and many regions of the USA followed suit, their resultsshowing improved survival rates of 15–20% for seriously injuredpatients in a review in 1999.4

Systems

* Corresponding author. Tel.: +44 0207 972 3207.

E-mail address: [email protected] (G. Sleat).

0020–1383/$ – see front matter � 2011 Elsevier Ltd. All rights reserved.

doi:10.1016/j.injury.2011.05.014

In the United Kingdom there have been repeated calls for thereorganisation of trauma services for more than two decades. In1988 the Royal College of Surgeons of England (RCS) published The

Management of Patients with Major Injuries which found one third ofthe deaths from injury in England and Wales were preventable.They highlighted serious deficiencies in the management ofseriously injured patients and recommended that major traumapatients should be managed in trauma centres. Subsequentlyreports in 1992, 1997 and 2000 from the British OrthopaedicAssociation (BOA) and the RCS have reiterated a lack of adequatestaff, resources and experience to maintain acceptable standardsfor major trauma patients.

In the intervening years Regional Trauma systems have beensuccessfully implemented in other countries across the worldincluding Canada, Australia, and many European countries, withmultiple studies showing that the UK performs worse than otherdeveloped countries in treating major trauma. A recent study5

comparing serious head injury in major trauma patients foundEngland & Wales to have a significantly higher mortality than thosein Australia. A comparison with South Moravia showed a lack ofsenior medical input into major trauma patient care in England andsignificant delays in transferring to the operating theatre.6 A furtherstudy showed that severely injured patients had a 20% higher inhospital mortality in England and Wales compared to the USA.7

It was only following the National Confidential Enquiry intoPatient Outcomes and Deaths report Trauma: Who Cares? in 2007which identified deficiencies in both organisation and clinical careleading to almost 60% of patients receiving a standard of carebelow that of good practice, that, the then Minister of State forHealth, Ben Bradshaw, committed the Government of the day tointroducing Regional Trauma Networks and setting up theRegional Trauma Programme.

The Regional Trauma Programme

The first National Clinical Director for Trauma Care wasappointed in April 2009 to lead the development of policy andfacilitate the implementation of regional networks for majortrauma care through all regions of England. The plan is fornetworks to be created by the regional strategic health authorities,tailored to fit their locality’s specific needs and circumstances.

The programme is working through three stages of implemen-tation:

G. Sleat, K. Willett / Injury, Int. J. Care Injured 42 (2011) 838–840 839

Phase 1 – Gathering evidencePhase 2 – Facilitating planningPhase 3 – National implementation

The first phase has now been completed, and phase two is underway.Phase 3 is planned to run from April 2011 to April 2012.

Phase 1 – Gathering evidence: learning from others, facilitatingchange

As major trauma networks are being set up on a bespokeregional basis, it was necessary to develop a process by whichevidence and guidance could be provided to help the regionalmajor trauma programme boards and prevent duplication of work.This responsibility fell to five Clinical Advisory Groups (CAGs) thatwere established to produce advice to regional commissioners ofmajor trauma and to lay out the case for change.

They brought together clinicians experienced in trauma from allrelevant specialties and professions, alongside lay members todiscuss the evidence collated via systematic review, stakeholderengagement, and data analysis. Five separate subgroups evaluatedthe evidence: pre-hospital care, acute care, ongoing care andreconstruction, rehabilitation, and network organisation. With therecent conflicts in Iraq and Afghanistan it was felt essential that thesubstantial experience of the Defence Medical Services (DMS) inhow to deal effectively with major trauma in areas of clinicalpractice and systems design was harnessed. As such DMS wasrepresented on all Clinical Advisory subgroups.

Evidence gathering

The Department of Health commissioned research into theevidence base behind networks for major trauma to assist the workof the CAGs. A systematic review8 of guidelines and papers wasproduced jointly by TARN and the Cochrane Injury Group andmade available to the CAGs to guide them in their production ofguidance. The report covered all five subgroups of the CAG, andhighlighted areas of best practice both in network design and inclinical practice.

Work to model trauma workload, critical care capacity andtransfer needs was commissioned from TARN and the IntensiveCare National Audit & Research Centre. The output from this wasfed into the advisory groups to help them understand the incidenceof major trauma and patient flows within the existing system andenable the effect of the planned changes to be appreciated.

The evidence obtained through this process has been broughttogether and published on the national evidence portal: NHSEvidence9 where other relevant papers are referenced.

Stakeholder engagement

With any change of this magnitude it is vital to engage with allgroups who have an interest in major trauma services. Somegroups are hard to reach and this is especially the case whendealing with patients who have suffered major trauma as there isno unifying patient organisation and patients are often reluctant toengage with consultations as it can make them relive theirprevious experiences.

A stakeholder engagement exercise was conducted thattargeted a full range of stakeholder groups including professionals,patients and carers. It aimed to generate a detailed understandingof the strengths and weaknesses of the current major traumapatient pathway, increase understanding of the evidence forchange and obtain responses to the preliminary recommendationsfrom the CAGs. Engagement was multi-stranded and involvedtelephone and face to face interviews, the setting up of a purpose-

built website and a major trauma summit. Social media includingFacebook and Twitter were used to amplify and extend the reach ofthe engagement programme to encourage stakeholder input.

The findings demonstrated widespread support for improvingthe trauma care system; stakeholders felt that the current systems’care was fragmented and uncoordinated especially in regards torehabilitation. However they also stressed that we should learnfrom the best international and military examples.

Advice to strategic health authorities – facilitating change

The evidence collated from these various sources was discussedby the five subgroups and a collective NHS Clinical AdvisoryReport10 was published in September 2010 as advice to the NHS.This is now being taken forward by the regions as they design andimplement their networks. These strategies that are customised totheir locality involve working with their local hospitals, ambulanceservices and commissioners to develop models that will work forthe patient from pre-hospital care through to discharge fromrehabilitation including local solutions for finances. Most networksare phasing in their implementation over a number of years to easein what will be a significant change in practice albeit for a verysmall proportion of emergency patients.

National audit office report and public accounts committee

Change is beginning to happen, and further impetus was givento this when the National Audit Office published their Report onTrauma Care in England2 in February 2010, which referred tounacceptable variations in care dependent on when and wherepatients are treated leading to poorer patient outcomes. Theystated that NHS Trauma Care in England was not providing valuefor money and recommended the setting up of Regional TraumaNetworks to address these issues. Sir David Nicholson, the NHSChief Executive, committed the NHS to implementing RegionalTrauma Networks at the Public Accounts Committee Hearing in theHouse of Commons on 22nd March and this is due to be completewithin the financial year 2011–2012.

Tariff changes

Finance is a difficult area for the reform of major traumasystems as the initial setup costs of creating inclusive RegionalTrauma Networks and the enhanced specifications costs toupgrade hospitals to major trauma centre status can be significant.With no new money, reforms to the funding system have beendesigned to more fairly distribute the existing resources by basingpayment on both the severity of all the patient’s diagnoses and thecomplexity of all the procedures they have to undergo and will beimplemented from April 2011.

At present hospitals are paid for treating major trauma patientsvia the Payments by Results system. This is a complex process,payments depend on certain factors which include the diagnosis,interventions and complications which define into which Health-care Resource Group (HRG) the treatment episode is placed;accurately identifying those cases that are truly major traumaacross the breadth of injury diagnoses is difficult and there areinherent errors. Most income change for Major Trauma Centre willfollow the increase in case volume as a result of greater direct andsecondary transfers.

Approximately 40–50% of major trauma cases (as defined by anInjury Severity Score > 15) are grouped by the HRG systemalgorithm into the current VA Chapter called Multiple Injuriesalong with all cases where there is more than one injury diagnoses(including many cases with lesser or minor injuries). Currently thetariffs allocated to these HRGs do not reflect the true cost of

G. Sleat, K. Willett / Injury, Int. J. Care Injured 42 (2011) 838–840840

providing care for these severely injured patients as the payment isbased on the single most significant procedure a patient undergoesduring that admission. A comprehensive restructuring of thisallocation and tariff spectrum will match income to complexityand multiplicity of procedures to partly address the any fundinggap in the resulting from Major trauma Centre designation. Thefinancial challenge is amplified by the flat cash environment thatthe healthcare economy is negotiating during the currentrecession.

The good news for the NHS is that RTNs appear to be costeffective. Recent evidence11 from work commissioned by theDepartment of Health suggests that RTNs will be cost effective ifthe investment required is less than £60 million, even without anyimprovements to the acute care pathway. In addition it isanticipated that there will be a saving of approximately £72million from reductions in Intensive Care bed usage and in lengthof stay equating to approximately 4 days according to TARN, andVictorian State Trauma Registry data. These savings should berealisable by networks over the initial 1–3 years of networkoperation and along with changes to tariff should cover theestimated additional costs of £700 000–£1.4 million per millionpopulation for running a major trauma centre. Further work isongoing to ensure that SHAs and potential MTCs are able to releasesufficient funds to fund the initial set up costs before cost savingsare realised.

The future

Published outcomes of the major trauma patient are almostuniversally based on mortality, however there needs to be a focusnot just on reducing the mortality, but also the burden ofmorbidity. The sequelae of serious, but non-fatal injuries hasrarely been taken into account in trauma research and policy, andyet these patients are the ones who survive with physical, socialand psychological problems. There are large cost implications tosociety with estimates of the annual lost economic output inEngland from major trauma at £3.3–3.7 billion.12

The Department of Health is working with clinicians and theTrauma Audit and Research Network, the largest trauma registry inEurope, to develop outcome measures other than mortality thatwill facilitate the national and international comparison of traumanetwork performance. The inclusion of trauma & injuries as animprovement area of Domain 3 of the NHS Outcomes Frameworkin England has accelerated this development.

Rehabilitation is the greatest challenge facing the implementa-tion of effective Trauma Systems; that is not unique to England.Most patients treated in major trauma networks will have physicaland neuropsychological rehabilitation needs, some complex andmany specialised. Historically, rehabilitation services have beenpoorly supported. Addressing this deficiency is fundamental to thesuccess of networks for major trauma.

We advocate that each patient should have their rehabilitationcoordinated and defined by the major trauma centre’s specialists.Each patient must be discharged with a personal prescription forrehabilitation managed by a named key worker from the majortrauma centre and to a care facility or home where suchrehabilitation and reablement can be delivered. The trauma care

community would do well to reflect that the true outcomes oftreatment, beyond survival, are best measured in return toeducation or employment and social independence. Work isongoing to develop tools to improve the patient journey such as arehabilitation directory to maximise access to the availableresources and develop ways to incentivise the development ofbetter systems for rehabilitation and learn from the excellentrehabilitation for services developed for military personnel duringthe Iraq and Afghanistan conflicts.

Conclusions

Major trauma is rare, but the potential social and economiccosts are great. International evidence of best practice exists andthere is now a common clinical and political will to implementchange to improve patient outcomes in England. Many of thecomponents of good care exist in the NHS but lack the rightstructure, priority and a culture for major trauma care.

London has led the way in England, and since April 2010 traumanetworks have been up and running centred on Major TraumaCentres at the Royal London, King’s College and St. George’sHospitals. (a fourth network joined the London System inDecember 2010 centred on St Mary’s Hospital) England is learningfrom the early experiences of the London Trauma System andalthough there is much still to do before Regionally ‘‘Inclusive’’Trauma Networks will be in place throughout England, we are oncourse to have trauma systems in place to deal with the mostseriously injured by the middle of 2012.

Conflicts of InterestThe authors do not have any conflicts of interest to declare.

References

1. World Health Organisation. The Global Burden of Disease: 2004 Update. 2008.2. National Research Council. Accidental Death and Disability: The Neglected Disease of

Modern Society. Washington: National Academy of Sciences; 1966.3. West JG, Cales RH, Gazzaniga AB. Impact of regionalization. The Orange county

experience. Arch Surg 1983;118:740–4.4. Mullins RJ, Mann NC. Population-based research assessing the effectiveness of

trauma systems. J Trauma 1999;47:S59–66.5. Gabbe BJ, Lecky FE, Bouamra O, Woodford M, Jenks T, Coats TJ, Cameron PA. The

effect of an organised trauma system on mortality in major trauma involvingserious head injury. Ann Surg 2011;253:138–43.

6. Yates DW, Svoboda P, Kantorova I. The influence of medical care on the deathfrom Trauma in England and South Moravia. Eur J Trauma 2002;28(5):304–9.

7. Davenport RA, Tai N, West A, Bouamra O, Aylwin C, Woodford M, McGinley A,Lecky F, Walsh MS, Brohi K. A major trauma centre is a specialty hospital not ahospital of specialties. Br J Surg 2010;97(January (1)):109–17.

8. Trauma Audit and Research Network, Cochrane Injury Group. SystematicReview of Major Trauma. NHS Evidence. Available at http://www.library.nh-s.uk//emergency/ViewResource.aspx?resID=345713. (accessed 29.11.10.).

9. NHS Evidence Organisation of trauma services. Available at http://www.librar-y.nhs.uk/emergency/viewResource.aspx?resID=345713. (accessed 29.11.10.).

10. NHS Clinical Advisory Groups. Regional Networks for Major Trauma: NHSClinical Advisory Groups Report. Available at http://www.excellence.eastmi-dlands.nhs.uk/welcome/improving-care/emergency-urgent-care/major-trau-ma/nhs-clinical-advisory-group/. (accessed 29.11.10.).

11. Nicholl J, Young T, Pickering A, Turner J, Goodacre S. The cost-effectiveness ofregional trauma networks in England. ScHARR Report to Department of Health.Available at http://www.excellence.eastmidlands.nhs.uk/welcome/improving-care/emergency-urgent-care/major-trauma/major-trauma-related-docu-ments/. (accessed 22.05.11).

12. National Audit Office. Major Trauma Care in England. London: The StationeryOffice. 5th February 2010.