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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To
be published as HC 502-i
House of COMMONS
MINUTES OF EVIDENCE
TAKEN BEFORE
THE COMMITTEE OF PUBLIC ACCOUNTS
MONDAY 22 MARCH 2010
MAJOR TRAUMA CARE IN England
DEPARTMENT
OF HEALTH
SIR DAVID NICHOLSON, KCB, CBE, SIR BRUCE KEOGH
and PROFESSOR KEITH WILLETT
NHS TRUST
MS FIONNA MOORE
Evidence heard in Public Questions 1 - 86
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Oral evidence
Taken before the Committee of Public
Accounts
on Monday 22 March 2010
Members present:
Mr Edward Leigh, in the Chair
Mr Ian Davidson
Nigel Griffiths
Mr Austin Mitchell
Dr John Pugh
________________
Mr Amyas Morse, Comptroller
and Auditor General, National Audit Office, gave evidence.
Mr Marius Gallaher, Alternate Treasury Officer of Accounts, HM Treasury, gave evidence.
REPORT BY THE COMPTROLLER AND AUDITOR GENERAL
MAJOR TRAUMA CARE IN ENGLAND (HC 213)
Examination of Witnesses
Witnesses: Sir David Nicholson, KCB, CBE, Chief Executive of the NHS in England, Sir
Bruce Keogh, NHS Medical Director, and Professor Keith Willett,
National Clinical Director for Trauma Care, Department of Health, and Ms Fionna
Moore, Medical Director, London Ambulance Service, NHS Trust, gave
evidence.
Q1 Chair:
Good
afternoon. Welcome to Committee of
Public Accounts. Today we are
considering the Comptroller and Auditor General's Report on Major Trauma Care in England and we
welcome back to our Committee for the last time this Parliament Sir David
Nicholson, who is the Chief Executive of the National Health Service. We do know your colleagues but perhaps you
would like to introduce them anyway, Sir David, for the sake of the record.
Sir David Nicholson: Fionna Moore is the Medical
Director of the London Ambulance Service; Sir Bruce Keogh is Medical Director
at the NHS and Professor Keith Willett is the National Clinical Director for
Trauma.
Q2 Chair:
Thank
you, Sir David. Perhaps we can look at
progress on reforming major trauma care around the country. If we look at figure 18 of this Report which
we can find on page 32, my question is: when are we going to implement major
trauma centres beyond London? Obviously you are doing well in London. There seems to be good progress in the East Midlands, but I wonder how the roll out is going in
the rest of the country.
Sir David Nicholson: You are absolutely
right. Trauma networks now are being
rolled out across the country as a whole.
London
comes on-stream on 6 April and the East Midlands
some time during this year. Our
expectation is that every trauma network will have gone through the design and
planning stage to the end of March 2011, so we will have a position where they
are all planned and designed. We have
not yet worked with each of the SHAs to work out their implementation timetable
because some of them will be relatively simple to implement and some of them
will be significantly more complex, but we will certainly have a programme by
the end of 2010/11.
Q3 Chair:
Obviously good information is very good. If we look at paragraph 3.21, we can see that
59% of the 193 hospitals which treat major trauma voluntarily submit data for
analysis. That obviously means that 40%
do not. Data is very important. How are you progressing this to ensure that
all hospitals submit the data that we need to have to do our job?
Sir David Nicholson: You are absolutely right, data
is absolutely vital. One of the issues
that has bedevilled us really in the work we have had is the lack of data and
the relatively patchy nature of it. The
key bit of data collection is TARN, the trauma
audit. We have been working with
organisations - certainly Keith has over the last period - and we have moved
from I think just over 40% of organisations putting the data in to now just
over 70%. That is clearly not good
enough because not only is it about the data collected; it is also the quality
of it. London has kind of led the way here because
what they have said is it is mandatory.
If you want to be part of the trauma network, which all organisations
need to be, you need to submit the data.
As the trauma networks get designed over the next year or so, we would expect
all organisations by the end of 2010/11 to be producing this data as being part
of a major trauma network. The other
issue, of course, is that one of the disincentives in the past has been that it
costs money. You have to pay a
subscription fee in order to join. It is
a relatively small one but nevertheless for some organisations it has been the
sticking point. In Keith's work that he
has done redesigning the tariff, from next year within the tariff will be the
amount of money for all hospitals to have their subscription paid for the data
collection process. We expect that all
to be between 2010 and 2011.
Q4 Chair:
Thank
you very much. If we turn over the page
in this Report and look at figure 16, observed survival rates, we see there is
a big variation. Why does the quality of
treatment depend so much on where you are unlucky enough to have your accident?
Sir David Nicholson: This is a really important
issue for us and we are tackling this as part of the major trauma. I will ask Keith to say a little bit about
that in a while. We are tackling this as
far as rolling out the major trauma networks are concerned. There is undoubtedly an issue around where
people start from and in big cities the challenges are different, for example,
than they are in rural areas. Over the
last few years we have not been idle in this area. We have been opening new intensive care
beds. We have been recruiting new
A&E consultants. That has not gone
uniformly across the country. Keith will
talk about the variation and the implications of that.
Professor Willett: As with any biologic system,
we would expect a degree of variation.
The points you see there represent the average that would be expected
and obviously with any average there are units that will be above and below the
average, that is part of the normal distribution. What is of interest in those figures is those
units that are consistently below that figure.
That figure does not mean that those deaths are avoidable or
preventable. What it means is they are
unexpected deaths statistically. The
other thing about major trauma is there is a relatively small number of
patients. 90% of hospitals will receive
less than one of these patients a week; 75% will receive less than one a
fortnight. For the smaller hospitals,
these represent very small numbers of patients and therefore the statistical
variation is going to be much wider.
What is important is to look at those hospitals which consistently have
more unexpected deaths that are reviewed.
I would invite you to go to the Trauma and Audit Research Network
website. The first page for each
hospital, the public data, looks at those patients across the survival
categories. You will see that those
patients who have the most severe injuries are where most of the unexpected
deaths occur. What we are looking at is
for hospitals to review very carefully those patients who have the highest risk
of injury and see how they should have perhaps been treated and also to look at
the breadth of variation. We are looking
for consistent performance but I would caution you that these figures, because
they are small numbers and it is a biologic system, are case adjusted in that
we take age and certain other factors into account but what you see in that
variation is the normal variation you would see around a patient
population. For instance, we know that
the socio-economic status for men with head injuries is a significant factor,
which is not case adjusted.
Q5 Chair:
On
these statistics really, if we look at paragraph 1.4, Professor, we can see
that 2,400 people died before they got to hospital. Because of the lack of completeness of the
data that you have, you cannot be entirely certain that some of these people
could not have been saved, could you?
You just do not know.
Professor Willett: Are you talking about between
the accident and arriving at the hospital?
Q6 Chair:
Yes,
exactly.
Professor Willett: Within the new trauma
networks that we will be establishing, the TARN
data does collect a lot of pre-hospital data already. For the patients who are submitted to TARN, we do have good information. Within the new setups that we are proposing
for the regional networks, it becomes critical that we can track those
patients. TARN
will include the patient identification number from the Ambulance Service so we
can track the patient through. Then we
will be able to look at that in the future but at the moment very often in
these patients I think we need fairly early on in this discussion to quite
understand what we mean by "major trauma".
We are talking about patients who either have one system injury which is
very severe and life threatening or they have multiple injuries to different
body parts which accumulate to a life threatening event. These patients at the scene are frequently
unidentified. They are not
conscious. You do not know who they
are. You do not know their age. Identifying those patients through the system
is a technical difficulty, particularly if they are moved through various
stages in the organisation. That will be
put right by the new system that comes in and the linking of the Ambulance
Service patient report form to the NHS data sets that exist.
Q7 Chair:
Sir
David has promised me that progress has been made. If TARN
participation is not complete, are you going to be sure you are going to have
the information to do all this by 2011?
Professor Willett: TARN
will have to be complete. The SHAs, as
they are putting their project boards together, without exception so far, all
of them, are requiring that the hospitals that will be functioning within the
network will return TARN data.
Q8 Chair:
Again, Professor, a lot of these accidents
occur at weekends and in the evening but if we look at paragraph 3.6 we can see
only one hospital has 24 hour consultant presence. What are you doing to encourage your
consultants to be there?
Professor Willett: As the National Audit Office
have also indicated in recommendation 19, it is not feasible or efficient to
expect all hospitals to provide that because quite simply, when you are only
receiving one major trauma patient every few weeks, it is illogical that you
have a consultant there for the 24 hour period.
Plus, from a workforce point of view, it would be an enormous number of
people to train. Most hospitals will
have between two and six emergency medicine consultants. If you allocate them 30 hours of clinical
practice a week, that does not come to 168 hours in the biggest units. What is important is that also for those
patients arriving, if it takes eight doctors to work most 24 hour rotas, that
means that they will come across a seriously injured patient of this magnitude
in a hospital perhaps once every two months on a statistic. The patient that they receive this week may
have a serious brain injury; the one in two months' time may have a burst lung
or a ruptured bowel and the one in three months' time may have a crushed pelvis
and mangled limbs.
Q9 Chair:
Do
not go into too much detail, thank you.
Professor Willett: I think it is important we
understand. That means that even if you
have a consultant present you are still compromising the others. What we have to do is to make sure that the
patient either goes directly to a hospital that does have the consultant
presence and all the facilities to support what they need or the patient, if
they arrive in a hospital for geographical transfer time reasons that cannot
support that, is moved expeditiously to one that can.
Q10 Chair:
As a
matter of interest, is it your hospital, Oxford Radcliffe, which is the only
hospital in the entire country to have a trauma consultant?
Professor Willett: That is what the NAO have
indicated, yes.
Q11 Chair:
Why
is that? Obviously you would not expect
a small hospital to have this kind of cover but some of the big teaching
hospitals in London
for instance you might? I do not
understand, why Oxford Radcliffe?
Professor Willett: The reason it is Oxford
Radcliffe is because a colleague and myself, in response to the 1988 Report and
the National Audit Office Report of 1992, managed to collect together enough
clinicians who had the interest and the expertise, and we have created quite a
unique focus. We did that in 1994. That is something that is very difficult to
do. It has been difficult to maintain
but it does prove from the outcome figures that it is a model that is
sustainable and that is where we need to get to for those big hospitals.
Q12 Chair:
You
are obviously a hero of the Committee of Public Accounts for your work. Well done.
My last question, Professor, is what do you want? You are national director for trauma. What do you want out of the pot?
Professor Willett: I want what we are
getting.
Q13 Chair:
What
more do you want?
Professor Willett: What Sir David has said will
do me nicely. That will deliver if we
have planning through 2010 and we have implementation in 2011, led by Strategic
Health Authorities. The effect of a
network will not appear overnight. It
will be an evolution. Some things will
appear and be advantageous very quickly.
Other things will take longer because there is quite a cultural change
that goes on across a network and hospitals about having the confidence to move
patients with severe injuries longer distance, rather than moving to your
nearest hospital. It is about some of
those things that take a while to bed in.
We have seen internationally that you get some effects within the first
year but there is an evolution over five years to achieve the full effect,
particularly in the complex mortality areas.
Q14 Mr
Mitchell: I was involved in a traumatic accident on the
A1, just after I was elected. I was
lucky in the sense that it was fairly near Bedford Hospital
where I got excellent care. The Sun
by the way announced on that day that I was not expected to live. The Labour Government was hanging by a
thread, so it was quite an exciting event, but it demonstrated to me the
importance of the proximity of facilities.
Why is it in that situation that the US has a lower mortality rate for
blunt trauma than the UK? We are a densely populated country. They are
a scattered population. Why do people
survive better in the US?
Sir David Nicholson: They have understood the
importance of trauma networks for a long time.
We have had one or two attempts at this in the past. We tried to develop a major trauma centre as
a pilot in North Staffordshire Hospital
in the late 1980s/early 1990s. It did
not show any appreciable benefit to outcomes.
What does show an appreciable benefit is if you have the whole network
working together. All hospitals cannot
do everything. You need to concentrate
expertise and knowledge and kit in particular.
Q15 Mr
Mitchell: It does look, from the table on page 14,
figure 5, as if you have been dragging your feet in a horrendous fashion. Here in 1988 you have the Royal College of
Surgeons publishing its recommendation.
We have a study of 1,000 deaths in England and Wales which finds that
of 514 patients admitted to hospitals 170 deaths were preventable. Why has it taken since then right up to 2008
before you are actually doing anything about it?
Sir David Nicholson: We have been doing lots of
things about it.
Q16 Mr
Mitchell: Not much on this table.
Sir David Nicholson: We have doubled the number of
accident and emergency doctors. We have
increased the number of intensive care unit beds by over 50%. We have implemented a whole set of
arrangements around training particularly for ambulance staff, all necessary
things that were needed in order to built the trauma networks. What you are saying is absolutely right. This has not been identified by the NHS or
the Department as a major priority over the last few years in particular. Our focus was on improving emergency
services. It was also in national terms
focused on cancer, coronary heart disease, stroke and COPD. All of those things were necessary pre-conditions.
Q17 Mr
Mitchell: You have not even collected basic information.
The National Audit Office gives us usually reports of what services are in our
area. Diana, Princess of Wales Hospital,
more data; more data. They are not even
members of TARN. You do not even have the basic information on
who is doing what and where.
Sir David Nicholson: All of that is absolutely
true.
Q18 Mr
Mitchell: Why, after all this time?
Sir David Nicholson: What I am saying to you is
that you can only have nationally a certain number of priorities. Not everything has been a priority
nationally. In some parts of the country
people have moved on it, but now, as part of the work that we did around the
next stage review, the development of the Darzi pathways and the work that has
come out of the National Audit Office and the appointment of Keith, it has now
put us in a place where we can articulate what major trauma networks look like
and start to implement them across the country.
A significant part of that is the data and that is what we are moving on
to. We moved from 40% to over 70%.
Q19 Mr
Mitchell: You have not even set a timetable for the
development of regional trauma plans.
Sir David Nicholson: We have already identified, I
think today, that our planning and design is in 2010 and 2011. Outside of London and the East
Midlands, who are moving on at a faster rate, we expect after 2011
to begin that.
Q20 Mr
Mitchell: I am a bit confused by the maps of what is
happening in the regions. I thought the
colouration might tell us - this is figure 18, page 32 - who is doing well and
who is doing badly. It does not, it just
delineates the areas. Can you tell us
now who is doing well and who is doing badly?
Sir David Nicholson: Keith will give you a more
objective view than I will.
Professor Willett: I was appointed in April last
year, so over the last 12 months I have met with all the Strategic Health
Authority medical directors, all the Ambulance Service medical directors, and
initiated the piece of work. Some of
them have picked it up and are running with it already like East
Midlands and London,
as you have alluded to, and others all have different local priorities. What I have been doing is to raise the
profile of this as an initiative to take forward. As of now we are at the situation where all
of the SHAs are addressing it. Those who
need to make substantial changes, which are the majority, have put in place
strategic or project boards to do that. They
are now going through the process of encouraging TARN data collection but using
the other data sources to do their planning and modelling, because that is very
difficult and it is very complex, as Sir David said. What you do in London and how you design it in London will be and should
be very different from the South West peninsula.
Q21 Mr
Mitchell: It is not easy to deal with sprawling areas
with a scattered population. I am
particularly interested in Yorkshire and
Humberside. Can you tell us who is good
and who is bad or are they all bad?
Professor Willett: I can tell you that
nationally, on the data that we have, we do very well up to a certain level of
trauma. Your minor injuries, your
moderate injuries, up to an injury severity which gives you a risk of death of
about 20%, we do very well on nationally and on international comparators. It is that third tier that we have to move
to. At the moment, we are sub-optimal
but safe in the system as it is. The
system needs to move one step further.
If we go back to where you started, if I may, you talked about why the USA had a better
fit rate and you talked about the other countries. The reason for that is that, by their
geography, the large size of their countries, they were forced to regionalise
all care, not just trauma. If you were
having a baby or you had appendicitis or whatever, you had to be moved a long
distance. As a result of that, by using
the methods of long distance movement, they identified the improvements that
could be achieved in major trauma. In
this country where we have a hospital every 10 to 40 miles, that has not been a
necessity and indeed in fact there has been a resistance to restructuring
hospitals in a more regional way. That
is why it has taken longer. Also, I
think there were significant advances during the 1990s. We then had a difficult period, all of you
remember the emergency departments being overloaded. Then we sorted that out and we looked at the
major priorities, the big killers, as Sir David has said. We have got through that phase now and I
think the NHS has done very well. That
is not my area.
Q22 Mr
Mitchell: We do need to know. I accept all that. All to the good. From the Report, paragraph 2.8, there do not
seem to be protocols for determining where people should be taken for
treatment; nor is there a formal system for transferring patients between
hospitals. That is paragraph 3.12. Only 36% of patients requiring a transfer
from one hospital to another with a more specialist facility actually get
transferred. If the ambulance crews do
not know where they are taking them, how are people to find out?
Professor Willett: I fully accept that. That is the key change that comes with
regional trauma networks. In London starting on 6
April, they have those protocols in place as to where the patients move
to. That is the complex planning that
needs to go on, because if you are close enough to one of those major centres
ideally you go directly, unless you have a need for a time critical
intervention, in which case you will have to use the local hospital as a stop
off. For some smaller hospitals in
geographically remote areas or with long transfer times, we will have to
improve the calibre of their response because they will become an important
player in the network as an integral step.
Q23 Mr
Mitchell: Why do we see in paragraph 3.15 that major
trauma patients are not always placed in critical care beds when they should
be? Is it shortage of beds? Is it lack of planning? Why is it?
Professor Willett: That is information, as I
understand it, that has been gleaned from the TARN
data. That is looking at the severity of
patients and whether or not they would benefit from critical care. If a patient has a need for intensive care,
they will be there. Critical care covers
more than one level of bed. This is
about the high dependency beds. That is
about patients being in the right place.
With networks, we will be making sure that the critical care bed
planning is done so that critical care beds appear in the right place. At the moment, we are if you like wasting
critical care beds because patients are being held in them in hospitals that
cannot deliver their definitive care.
That is something that will improve.
Q24 Mr
Mitchell: You have given the example, commendably, of
Oxford Radcliffe. I hope I have my major
trauma, if I have one, in Oxford. There is a problem, is there not? You have instanced the problem of getting
consultants there with the right skills and a continuous presence. There is a real problem, is there not, in the
sense that in my experience consultants like to play golf at weekends and a lot
of accidents occur at weekends. I
remember I had an accident. I was carted
off to Grimsby Hospital and I was told the consultant
could not deal with it because he was playing golf. How can you account for that in a system
which is planned, which provides consultant care at the right points at the
right time?
Professor Willett: I am sure you would not like
me to comment on your injury in Grimsby
but in general that will be a requirement.
The designation criteria that the Strategic Health Authorities come up
with when they plan their networks will include that. The London Trauma Network has been
established and part of those designation criteria are that consultants who
lead the trauma team are present 24 hours a day. It goes beyond that to indicate that in those
centres where we concentrate this large number of patients there will be
consultant availability within 30 minutes, or whatever is deemed appropriate,
to support all the interventions and the surgery that may be necessary. We will be dealing with that.
Q25 Mr
Mitchell: You are going to stagger time off for golf.
Professor Willett: I do not play golf.
Q26 Nigel
Griffiths: You rightly stress that Strategic Health
Authorities have different priorities and I think it is important, when we are
asking you questions especially about the 170 possible avoidable deaths, with
their priorities, whether they are saving lives or getting better outcomes on
different types of patient injury or are they below par on those as well
generally? I am just exploring the
general principle. We could say that the
reason one authority was not doing this was because they were playing golf, I
do not accept that. If we are saying
that they have other priorities - "different priorities" I think was the phrase
used - are they achieving really good outcomes because they are able to focus
in a different area? Unfortunately trauma
is not one of those.
Sir David Nicholson: If you look across the
country and you look at the number of lives saved through the work on cancer,
you are talking about 9,000 across the country as a whole in a year; if you are
talking about coronary heart disease, you are talking about over 30,000 lives
being saved, which covers stroke as well, respiratory disease, a large number
of lives saved. All SHAs are doing some
of that and you will find that some of them are better at it than others. Some of them have better outcomes than
others.
Q27 Nigel
Griffiths: Is Professor Willett better at them as well or
does your hospital fall down the league table or whatever?
Professor Willett: No. I think what we are looking at here is a
change in the cultural shift. There will
be different priorities within the hospitals and perhaps led by Strategic
Health Authorities appropriately. That
has been one of the advantages of taking commissioning down to the local level,
that you do focus on the local needs of the population, but there are some
things like major trauma, like cancer, that we do need to draw back from a
strategic level.
Q28 Nigel
Griffiths: I remain to be convinced that the needs of the
local population differ nationally. I am
sure obviously mesothelioma is endemic in certain parts of the country but
generally I usually find that where people have the worst eating habits they
have the highest heart disease and they have the poorest rates of
treatment. Let us not go there. You basically spent quite a number of years
perfecting a model which you achieved in 1994.
Are you a bit frustrated that 16 years on that model is not nationally
adopted?
Professor Willett: Not now I am national
clinical director and making it happen, no.
Q29 Nigel
Griffiths: Are you frustrated that you were not perhaps
made national clinical director earlier?
Do not answer that.
Sir David Nicholson: The answer would be yes.
Q30 Nigel
Griffiths: What we want to be assured of is that
different priorities are not being used as an excuse by SHAs for poor
performance all round.
Professor Willett: I think the answer to that is
no. I am not taking anything away from
the other clinical areas about complexity but in terms of things like ischaemic
heart disease, stroke and cancer they are very much single entities. They involve perhaps two or three specialties
or components of a hospital. When you
come to major trauma, you are dealing with everything from the pre-hospital
through emergency medicine. You will
have neurosurgery, cardiac surgery, general surgery, interventional radiology,
and it is a small part of each of their practices and all the patients are
different. That makes it a much more
difficult nut to crack and it is understandable that some of those other
priorities have led. We are now in a
position where it is the right time. The
time has come for trauma to be sorted.
Q31 Nigel
Griffiths: If there are possibly 170 avoidable deaths, is
that a fair way of putting it? Is that
the figure?
Professor Willett: The National Audit Office has
indicated 450 to 600 preventable deaths a year.
Q32 Nigel
Griffiths: Is avoiding those deaths then a priority?
Sir David Nicholson: Yes. That is the whole purpose of developing major
trauma networks.
Q33 Nigel
Griffiths: If that is a priority, how is compliance with
data submission then voluntary?
Sir David Nicholson: What we are saying is, if you
want to be in the major trauma network, you have to submit the data. That is what happens in London, which essentially means then it is
mandatory in all organisations in order to claim this.
Q34 Nigel
Griffiths: It is not voluntary you are saying?
Sir David Nicholson: We have not written out to
everyone saying, "You must send this data in."
What we have said is that everyone should have a major trauma network
and that to be a part of a major trauma network you have to submit data, which
is the same thing but doing it a different way.
Q35 Nigel
Griffiths: Are you saying you are not allowed to opt out
of being part of a major trauma network?
Sir David Nicholson: No. No-one would want to, or very few. I cannot think of any organisation who would
want to.
Q36 Nigel
Griffiths: So it is optional? They could opt out?
Sir David Nicholson: Theoretically, I suppose it
is possible. We have never come across
it yet.
Q37 Nigel
Griffiths: How many are in and how many are out at the
moment?
Sir David Nicholson: We have the major trauma
networks in London
as set up from 6 April followed by the East Midlands
next year. Our expectation is that by
the end of the financial year 2010/11 all hospitals will be submitting TARN data.
Q38 Nigel
Griffiths: In what stages do you expect impact on the 400
plus possibly avoidable deaths?
Sir David Nicholson: Of course we already will be,
in London and
parts of the East Midlands, but I think Keith
can talk about how the roll out of the improvements and the benefits will take
place.
Professor Willett: As I said a little earlier,
going into more detail, we would expect that the early impact of regional
trauma networks will be in the expedited transfer of patients from one hospital
rapidly to a hospital that can deliver the definitive care. We know from the data that is already
published, if you go to the TARN website and you look at Oxford or you look at
the Royal London or Queen's Medical Centre in Nottingham, which are some of the
units that are running with informal networks already and are providing that
full definitive care, their preventable death rate is much lower. In fact, in the very complex cases, they have
much lower death rates than across the country.
That is what we have moved to.
Initially, we will see an improvement in mortality. That will grow over the first five years but,
at the end of the first year, if I do not see a massive change I will not be
surprised because that is the international experience. What we will see though is significant
improvement in disability. Currently, if
you have a very severe, complex fracture or pelvic injury and you need to move
within the network, that is one of the things that we know is tardy. We will see a significant change in that and
you will see a reduction in patients' lengths of stay in hospital and their
quality of ability, their functional capacity at discharge will improve and
their disability long term will be better.
We will see an early gain in disability and then a gradual gain in
mortality.
Q39 Nigel
Griffiths: I fully understand that. We have had a letter from West Sky which I think
also represents some of the HEMS Helicopter Air Ambulance Services. You have actually stressed - and I think it
is increasingly obvious in a high-tech medical setup - that there are going to
be fewer centres but those centres are going to be really specialist and that,
in the next five years one of the keys is going to be transferring people to
centres of excellence, like your own, as they build up. What role do you see air ambulances playing
in this?
Professor Willett: I think we have to be quite careful
at the start of this point that we separate the air ambulance as a helicopter
and a transport platform from HEMS, which is the Helicopter Emergency Medical
Services. The Emergency Medical Service
is the delivery of a more skilled team to the scene to intervene with time
critical interventions. The helicopter
is a form of transport. I think it is
important that we separate the two. In
terms of the helicopters, which was your specific question, helicopters have a
variety of roles in major trauma internationally that is recognised. They are obviously ideal at reaching remote
locations.
Q40 Nigel
Griffiths: I am interested to know if anybody else is
using them more effectively than we are.
Professor Willett: The difficulty we have in the
UK
is that our transfer distances are very short.
They are highly effective in large, geographic countries.
Q41 Nigel
Griffiths: They are not going to be very short if there
is only one Oxford Radcliffe.
Professor Willett: They will still be
comparatively short compared with Nordic countries, Germany, America and Australia. They are very short. Helicopters are good weather, good
visibility, daylight flying; most accidents occur in bad weather, out of
hours. A helicopter has a capacity and
has a role, but it has to be looked at very carefully within the planning of a
network to say what role a helicopter may have, but more importantly, what role
an enhanced medical team at the scene would have and perhaps a helicopter gets
them there.
Q42 Dr
Pugh: The theory is, is it not, that if you have a
major trauma you normally want to go to the quickest A&E but if it was a
complex condition which needed specialists that were not at the ordinary
A&E you would want to go somewhere else?
That is the fundamental theory we are dealing with, is it not?
Sir David Nicholson: You need to go to the place
where the skills and expertise are to do what you need to do.
Q43 Dr
Pugh: Assuming it is something straightforward like
a knife wound, which you would expect every A&E department to be able to deal
with ---?
Professor Willett: No. If you are stabbed in the heart, you need a
heart surgeon. Heart surgeons are in
less than one ---
Q44 Dr
Pugh: Let me qualify that. Suppose it is a flesh wound. You would expect an ordinary A&E
department to be able to deal with that, would you not? I am losing confidence in A&E here.
Professor Willett: Many stabbings can be superficial. Fionna Moore is an emergency medicine consultant. Penetrating wound makes up a tiny proportion,
less than 2% of our major trauma. Yes,
you can clearly have surface wounds. You
do not know that until you have explored the wound to see what it has involved.
Q45 Dr
Pugh: That is the point. You would accept that ordinary A&E
departments are fairly talented and have people there who can deal with a range
of traumas otherwise they would not be A&E departments. There are major trauma centres that have a
wider skill set and can deal with complicated problems like being stabbed in
the heart and so on. Clearly the crucial
factor is at what point is a person referred to one or other. I suppose the logic takes us in the direction
of looking at the paramedics and the Ambulance Service as the first line of
defence, is that right?
Sir David Nicholson: Yes.
Q46 Dr
Pugh: I was interested in that because, like Mr
Mitchell, I have been in a car accident.
I do not want to give the impression that the Committee of Public
Accounts is particularly accident prone but I was chatting to the ambulance
man, having exited from the wreck of a car in the fast lane of the M1, and he
opined to me that sometimes at the scene of an accident you cannot actually
tell how seriously injured a person is.
Sometimes people can walk from the scene of an accident but have very,
very serious complications, sometimes not.
Clearly, what kicks in then is some sort of triage protocol, is it not?
Ms Moore: Certainly in London we have developed a triage system to
assist our crews, both emergency medical technicians and paramedics, to decide
where they should take patients because clearly we want patients who can be
properly treated in their local emergency department to go there, and that is
the vast majority of patients. We want
to be able to triage those patients with serious trauma to the major trauma
centres as rapidly as possible and ideally to go straight there, rather than
going to the local emergency department.
Q47 Dr
Pugh: There are better and worse protocols. The London
protocol is a particularly good exemplar?
Ms Moore: We are about to introduce it,
so we will be auditing that process. We
have used as a basis the protocol used in America by the American College of
Surgeons Committee on Trauma and we have adapted it so that we think it will,
if you like, suit the British market.
That is based on the patient's vital signs for first steps. For some patients it will be quite clear they
are seriously injured and at that stage the decision is made to go to a trauma
centre.
Q48 Dr
Pugh: When you say you are going to assess it, there
would be some benchmarks that a good protocol would have to meet. Would one of those benchmarks be fewer than
average transfers from one A&E department to another more specialised one?
Ms Moore: Yes. We will look at the rate under triage, so the
number of patients who are taken to a trauma unit rather than to a major trauma
centre and then require secondary transfer.
Q49 Dr
Pugh: You cannot tell from the London protocol whether it has actually had
that effect yet?
Ms Moore: The London protocol comes into effect on 6 April.
Q50 Dr
Pugh: Moving to trauma networks, obviously the idea
is to populate the country with trauma networks in every region. Is it supposed that the major trauma centres
in every region will be of comparable quality?
Is that the objective?
Sir David Nicholson: Certainly the objective is
that we would expect similar outcomes from all of them, although they will look
and feel different.
Q51 Dr
Pugh: Whatever region you are in, it would be a 45
minute journey as in London
to a major trauma centre?
Professor Willett: How the network plans will be
unique. As I said before, the network
planning will look at the facilities you have and where you have them. In some places that is going to be relatively
straightforward because you may already be in one hospital and the geography
may suit direct transfer. In other
places it will be different, so you may elect to use an interval hospital which
runs at a higher calibre and then expeditiously move the patient following
resuscitation and rapid CT scanning into the major trauma centre as a secondary
event. What we will be looking for is
that patients across the country are getting the same outcomes. The delivery methods may well vary and should
vary.
Q52 Dr
Pugh: In some of the bigger regions there might be
two major trauma centres?
Professor Willett: Yes.
Q53 Dr
Pugh: And a half way house, as it were?
Professor Willett: Yes.
Q54 Dr
Pugh: Okay. I
understand that. What about perimeter
issues though? I am looking at your map
again in figure 18. I am, say, round
about Macclesfield and the trauma centre is in Liverpool or Manchester but it
might suit me to go to wherever is the major trauma centre in the Midlands
region.
Professor Willett: The NHS boundaries are of no
consequence here. Each of the networks
will be looking at transfer times between hospitals. What they are doing is to map the number of
incidents and where they occur, the times of the day they occur and the
isochromes, the time it takes from that scene to a hospital. All of that mapping is quite complex. That is currently going on. They will
identify a protocol that will deliver you to the major trauma centre in the
right way.
Q55 Dr
Pugh: What if you find you need an additional major
trauma centre, say, in one rather large region and because hospitals are all
very independent now, self-managing with their own budgets and so on, no
hospital volunteers to be that because it simply does not pay the bills in that
hospital.
Professor Willett: If we are going to the money
and is it financially viable, as Sir David said, we have done a lot of work in
changing the tariff. That has been fast
tracked through so that there will be no financial disincentive for hospitals
to take patients that are seriously injured.
Q56 Dr
Pugh: You use the tariff as the tool to ensure that
you have the right health configuration.
Is that what you are saying?
Sir David Nicholson: We have the opposite issue at
the moment whereby, if you nominate someone a major trauma centre so they get
more major trauma, the tariff works against them. They do not get enough money to cover the
costs of a concentration of conditions in that way, so we need to change the
tariff in order to support the clinical configuration that we want.
Q57 Dr
Pugh: At page 25 the Report says, "The current
Payment by Results regime, under which hospitals receive much of their funding,
represents a potential barrier to the efficient transfer of patients."
Sir David Nicholson: If I can give you an example,
I was at the Queen's Medical Centre last week and they have put a business case
together to become the major trauma centre.
If they got all the complex trauma from the region that they work in
coming into their hospital, they calculated they would lose £4 million. It would cost them £4 million more to run the
service than they would get in income from the tariff. Clearly, the tariff is not supporting the
clinical configuration so we need to change the tariff in order to support
that.
Q58 Dr
Pugh: If no hospital can make for itself its own
business case for becoming a major trauma centre in a region, then you will not
get major trauma centres in lots of regions, or you will not get enough major
trauma centres.
Sir David Nicholson: It is not just for a
hospital. The whole group of hospitals
has to come together to make the business case.
I do not know what your experience is but there is no shortage of people
who want to be it. It is a prestigious
thing for a hospital.
Professor Willett: This is something that is
professionally accepted, I think that is the first thing to say. You are not going to meet professional
resistance because it is your constituent; it is my patient who currently is
not getting the optimal care if they are in a certain category of severity of
injury. This is not something that is
professionally obstructed. What we have
to make sure is that that process, which is getting good engagement from the professionals
clinically and at the SHA level, has no financial barriers to prevent that
happening.
Q59 Dr
Pugh: I do not think you can altogether rule out the
effect of financial barriers of one kind or another because they do get in the
way, do they not? Without going into the
reasons, another personal anecdote is that I hit myself on the head with a
large, iron bar some time ago and the first thing people wanted from me was not
to triage me or find out whether I had complex needs or whatever, but to find
out who my doctor was so they could bill appropriately. If that can happen on a micro scale, I assume
that can happen on a macro scale and you can get, in an area, a dearth of
hospitals wishing to volunteer to be major trauma centres.
Sir David Nicholson: You are not suggesting that
in any way your treatment was compromised because of wanting to know who your
GP was?
Q60 Dr
Pugh: They inquired that first rather than what was
the state of my head at the time.
Sir David Nicholson: They might have ---
Q61 Dr
Pugh: I am not going into it.
Sir David Nicholson: What was the question again?
Q62 Dr
Pugh: I am just saying that you have not
demonstrated to me that the financial levers are sufficient to enable you to
get an adequate network, such as the London
network, where everybody is 45 minutes from a major trauma centre.
Sir David Nicholson: You are absolutely
right. If you just rely on the tariff
and use incentives and penalties in order to take it forward, it will not
happen. For example in London, what has
happened is that all the PCTs pooled the money together into a pooled resource
that they could then spend on each of the major trauma centres identified to
support them building up the expertise.
My guess is that most SHAs will have to do something similar to
that. Just leaving it to the tariff on
its own will not deliver that change.
Chair: Professor, when Dr Pugh was
asking you about knife wounds, it recalled a comment I once made that the only
reason why I voted for Michael Heseltine in the leadership election was that at
least he stabbed her in the front, while the rest of the Cabinet stabbed her in
the back.
Ian Davidson: That is something to ponder.
Nigel Griffiths: She did not recover from the injury.
Chair: She did not recover from the
major trauma, no.
Q63 Ian
Davidson: Thank goodness for that. Can I just ask about this question of
constant change? We constantly read and
we see staff on television telling us that they dislike change. It is a constant process of change and here
is another example of change being necessary.
I think one of you mentioned the cultural change that was necessary to
make this work. On the one hand we are
getting staff complaining about change; yet you are telling us that these
changes, particularly the cultural ones, will bring about improved
outcomes. Why are the staff not
convinced?
Sir David Nicholson: There is change that is well
managed and change that is not so well managed.
One of the big lessons we learned from the work we did as part of the
next stage review with Lord Darzi is that there are certain things in the NHS
that are more likely to get changed than not.
For example, clinical consensus is very important. Evidence is very important. Getting your clinical staff on side and
understanding it is very important.
Organisational top down change is not as effective.
Q64 Ian
Davidson: Which is this then?
Sir David Nicholson: We have learned a whole set
of lessons. One of the lessons that we
have learned as well is that local is not good and national is not bad
automatically. People get into a place
where devolution is the answer to everything and this is a really good example
of where it is not. In small populations
you will not end up where we are now.
Where there has been a difficulty is that you need to look at it
regionally. We need to pool
responsibility regionally. Part of the
issue is, as you will know better than I do, once you start tinkering with
accident and emergency departments, people get very, very anxious. That is why the issue about evidence is so
important. What the NAO have done really
well here is martial all that evidence in one place.
Q65 Ian
Davidson: If the NAO had not done it, does that mean we
are not likely to have staff marching in the streets demanding change now?
Sir David Nicholson: No. The NAO have martialled a lot of evidence
that was already in that Keith and his team and his people were working on.
Q66 Ian
Davidson: We understand the point. The point you made about centralised, top
down being unpopular is pretty much what this is, is it not? For reasons that I completely understand, it
is also the least likely to get popular support.
Professor Willett: Perhaps I can answer
that. You mentioned the staff adopting
change, I think you have to recognise that, when you are presented at three o'clock in the morning, as a
junior doctor, with a severely injured patient who is potentially dying in
front of you, that is one of the most frightening experiences in your medical
career. The sense that you cannot
respond to that appropriately, you do not have the facilities on-site, you do
not have the expertise, you do not have a system in place to move that patient
on, is frightening. Add to that making
it a child and you are in a league of discomfort for staff which is not met
anywhere else I think in medical practice.
If you talk to staff who have a patient who is in the wrong hospital who
needs to move, and they are struggling to get the patient moved because of the
current system, there is an enormous desire that the right thing is not being done. Culturally, this is not an issue. Professionally, there is a clear recognition
that this is something that should happen.
You will not see major objection to this in any areas.
Q67 Ian
Davidson: Can I come back to the point about the system
being run for the convenience of the staff, when consultants are available and
so on? The evidence seems to be that the
consultants are there daytime, not at nights, not at the weekends. Looking at figure 4, clearly weekends are the
times when most accidents or most traumas occur. It is the same question - I do not suppose it
is just a question of you not playing golf - should that be one of the criteria
about how we judge these hospitals, that they actually are able to provide an
evening and weekend service?
Professor Willett: Yes.
Q68 Ian
Davidson: Why have you not done it before now?
Professor Willett: Hence this is one of the
designation criteria, I agree.
Q69 Ian
Davidson: Why has it not been done before now?
Professor Willett: If you are looking at the
workload that goes on in an emergency department, the majority of the workload
does go on through the daytime and into the early evening. Trauma is a bit different. It has a skew that is slightly different from
the rest of it, so we are talking a lot in the evenings, through to past midnight. That is a relatively small proportion of the
over workload. For 75% of hospitals, it
is less than one a fortnight. I can
understand why a lot of the hours that are worked are based around when most of
the activity goes on. Most patients will
be phoning their GPs, being referred in late morning, through the afternoon,
into the early evening and then it goes quiet.
That is not the same for trauma.
Q70 Ian
Davidson: That is right.
Looking at these figures, the thing that strikes me about these are the
similarities between police activity figures and these sorts of figures for
weekends, evenings and all the rest of it.
It has taken a long time to get some of the police to recognise that
their shift system has to recognise that they should possibly be there when the
business is rather than being there when it is quietest and easiest to have a
cup of tea. There is a lot of evidence
from what we have seen up to now that the efforts in the past have been made to
change that. I think at one point,
answering another question, you mentioned something that was professionally
obstructive. Is it the case that there
has been professional obstruction to having a rational system of consultant
provision?
Professor Willett: No. I am not an emergency medicine consultant,
who are the people we are talking about here.
Perhaps Fionna may want to comment.
I think it has been the limited workforce numbers. There are 800 emergency medicine consultants
and 193 acute receiving units. It is
about what has to date been primarily, I suspect, matching workforce to the
large activity, which is around patients with asthma, heart disease and minor
injuries, most of which are occurring in daylight hours. I think here we just have a significant
patient group that I accept should have consultant input, but currently that
has not been matched and that will change.
Q71 Ian
Davidson: Can I just clarify this? It is not the case that a consultant is a
consultant is a consultant. They do have
different specialities and presumably there are some who have specialities in
trauma and related matters. Therefore,
why are they not there, as it were, on a Saturday night?
Professor Willett: The consultants who will be
involved in trauma, in terms of the emergency surgery, will be from
neurosurgery, general surgery and orthopaedic surgery. Those are the surgical groups. They are on call and they are available in a
short period of time. That is true in all
of the current tertiary referral centres that exist. What we are talking about here is someone
actually being resident in the hospital who will be there 24/7, actually in the
hospital, not someone who is available on call at 30 minutes.
Q72 Ian
Davidson: Can I turn to the question of transfers? In one of the elements of the Report we have
an indication that only 36% of those who would require a transfer or would
benefit from a transfer get it. I
understand the point about the financial pressures and so on, the advantages
and so on. Can I just clarify, to what
extent can we consider movement of a patient to be risk free or minimal? When do you have a situation when moving
somebody is actually better for them, even though there is a risk, because it
puts them into a unit which is likely to give them a higher survival rate? Is this popularly known, because it relates
back to the point about anything we have is better than anything that you
people might produce and therefore we have to resist any change whatsoever? Can you just clarify all that for me?
Ms Moore: I think that no transfer can
be said to be risk free. There are well
known risks associated even with apparently stable patients, but inevitably
some patients will arrive in emergency departments where the facilities in
those units do not meet the requirements of that patient and therefore transfer
is necessary. Ideally the patient would
be stabilised and then moved but for some patients there will have to be a
rapid removal to a unit that has the facilities that are required to provide
the definitive care for that injured patient.
Q73 Ian
Davidson: I think the figure I had in here was that only
36% of those who would benefit from a transfer get it. That is more than just a few who would be too
dangerous to move.
Professor Willett: If I may clarify, we apply
injury scores to the magnitude of the injury in each body system. That is a statistical calculation made from
the TARN data set by the TARN
organisation looking at those patients who, if you like, have crossed the threshold
of severity of injury, who probably would be better off if they were in a
specialist unit. It is not an actual
patient number that has been measured, saying, "This one should have moved and
did not." It is around thresholds. Part of the regional trauma network will
facilitate that threshold moving. Let me
give you an example. A patient who has a
brain injury we know ideally, optimally, will be in a neurosciences unit for
their care on a neurosciences intensive care.
Some of those patients will currently be held on intensive care with
good care, but that will be in a district hospital with advice from the
neurosciences centre. That is okay but
we know that actually there would be a gain, we believe, on international evidence,
if those patients were all in neuroscience.
If you need a blood clot removed neurosurgically from your brain, you do
get moved; there is no doubt. That may
take longer than I would like, but we do move.
It is patients in this threshold categorically that currently there is a
suggestion we should be moving more. We
know we should be moving more than we are and the network will facilitate that.
Q74 Mr
Davidson: A final point I want to pick up is, if I heard
you correctly, at one point you said something about the socioeconomic status
of the patient affects the survival rates.
Is that any more than we would normally expect because poorer people are
less healthy and, therefore, less likely to withstand the trauma?
Professor Willett: We do not know, being very
honest. When I was talking about the
variation we see between hospitals, there are certain things we adjust for and
things that we do not adjust for. We do
not adjust for socioeconomic status of the patient and that has been shown in
some research to be one of the factors that may influence why you see that
variation. We cannot be more specific on
the research base. There is a strong
need for more research in this area.
Q75 Mr
Mitchell: I am just looking at paragraph 2.7 which says,
according to the Trauma Manual, unless the patient is bleeding severely the
most likely cause of death is an insecure airway, but it says that there is no
consensus on whether ambulance crews should take the patient immediately to an
emergency department or remain at the scene and presumably shove a tube down to
help them breathe. Why is this? Do they have the equipment if they decide to
go for intubation, or whatever it is called, to do it?
Ms Moore: I will start off on that
one. For ambulance crews paramedics are
trained to manage airways, as are technicians.
They start off with basic manoeuvres and go to more complicated
manoeuvres. However, trauma patients who
require intubation generally require drug-assisted intubation.
Q76 Mr
Mitchell: Intubation is putting a tube into somebody?
Ms Moore: It is.
Q77 Mr
Mitchell: And the ambulances have the equipment to do
that?
Ms Moore: They have the equipment but
they do not currently use drugs to do that, so the patients who would be
intubated at the scene of an accident would be very, very severely injured and
most of them would not survive. At the
present time our crews are trained to undertake basic manoeuvres to stabilise
the airway and then to move the patient to the major trauma centre if that is
the nearest hospital. If they are not
confident that they can drive to a major trauma centre they would go to a
trauma unit for the hospital to stabilise the airway. In London we have the additional opportunity
of using a doctor and paramedic team who may be able to go to the scene of an
incident either by aircraft during the day or, more commonly, because a lot of
the trauma occurs during the evening or night time hours, at night by car.
Q78 Mr
Mitchell: So they can do it?
Ms Moore: Yes.
Q79 Mr
Mitchell: They know what to do.
Ms Moore: The crews know what to do.
Q80 Mr
Mitchell: Is it therefore correct that there is no
medical consensus on what to do?
Professor Willett: The medical consensus issue
is essentially these patients are some of the most complex airways to
control. The patients may be partially
conscious and actually be combative and difficult. To put a tube down to secure the airway, if
the patient is profoundly unconscious that is easy, that is not the difficulty;
the difficulty is where the patient is combative. Essentially what you are doing is giving a
full anaesthetic, so as if you are going to have an operation, and that is done
in a hospital in an anaesthetic room with lots of equipment, plenty of staff,
an experienced anaesthetist and various escape manoeuvres that you learn as
part of that. If we add to that probably
a very complex airway because we have got a patient who has not starved, they
may have severe facial injuries, this is one of the most challenging airways,
and to deal with that at the scene takes an awful lot. The work that has been done suggests the
evidence for paramedics attempting to go to that complexity of airway when
inevitably they are doing very few does not support it. The evidence is the patient should be moved
immediately to a centre that can do that.
That may be a local hospital before they move on. Is there an option, therefore, to get a
medical team to the scene with that expertise?
The difficulty is with the number of emergency calls you get and because
it is very difficult to identify those patients until a paramedic gets there,
there is an argument that says "Do I now wait at the scene and wait for a
medical team to get to me?", which geographically is the same as that team
running to the nearest hospital. There
are also issues about having got a tube in place and artificially breathing the
patient. That technically is also very
difficult to get right in that setting and it is easy to either over-ventilate,
over-breathe the patient, or under-breathe them, both of which can compromise
the outcome. This is actually quite a
complex issue and at the moment the consensus from the Joint Royal Colleges
Liaison Committee on Ambulance Services is that paramedics do not do that, they
move the patient. If a medical team can
get there, yes, but only if that involves no delay in the transfer. That is the position we are at.
Q81 Mr
Davidson: I have one point related to figure 3, which is
about trauma patients by age and gender, and it is mainly young men. Can I just ask, how many of these, or as a percentage,
are alcohol-related in some way, either as a result of violence or motor
accidents and so on?
Professor Willett: I cannot give you an exact
figure on the alcohol contribution.
Fionna may be able to give you a figure on the alcohol rate in patients
attending the emergency department. The
presence of alcohol does not necessarily mean that has anything to do with the
incident, so it is not something that we worry about at the time we treat the
patients identically. You may get some
idea from Fionna about the number of patients who are alcohol-related.
Ms Moore: I would make two points. Firstly, the influence of alcohol on head
injuries: it is sometimes assumed that because somebody has been drinking that
is the cause of their reduced level of consciousness and that is a very unsafe
assumption.
Q82 Mr
Davidson: Can I just clarify that. In a sense, if somebody has been drinking and
somebody else has been drinking and one bashes the other over the head, is that
a contributory factor to the rate of consciousness as distinct from the alcohol
itself? I would say if it is alcohol
induced violence then alcohol is a contributory factor. That is what I am trying to clarify.
Ms Moore: I am saying that alcohol
makes the assessment of the patient's head injury more difficult.
Q83 Mr
Davidson: With respect, that was not the point I was
asking. What I was asking was has
alcohol played a contributory factor in either violence or vehicle accidents
contributing to these substantial figures?
It would be helpful if you gave us an estimate and said, "Well, alcohol
has played a part in 80% of these".
Ms Moore: I do not think I can give you
the answer to that.
Q84 Chair:
You
can do a note.
Ms Moore: What I can tell you is that
the number of patients who attend emergency departments after 11 o'clock at night, the proportion
where alcohol is involved, and that is across the board, not just trauma, is
around about 70%.
Q85 Chair:
You
can do a note because we will not be reporting until after the election on this
particular hearing for obvious reasons, so there is plenty of time for a
note. Sir Bruce, you are a very
distinguished gentleman and, once again, you have not said anything. Do you want to say anything? We hear that the time for major trauma has
arrived and a lot of promises have been made.
What do you think? Is this going
to be a matter of priority?
Sir Bruce Keogh: I think the time for this to
be of priority, frankly, is absolutely right.
You have heard witnesses reporting on various national clinical
strategies in this room over the years and we have learned some additional
lessons from this one even at a relatively early stage. First of all, I think we have begun to
understand the importance of the heterogeneity of trauma patients and that
means they need to be dealt with in trauma centres which have expertise in a
number of different areas ranging from neurosurgery, cardiac surgery,
orthopaedic surgery, and so on and so forth.
We have also learned from our previous clinical strategies that we need
to get the sequencing right. For
example, in coronary heart disease we realised that we needed to ensure that we
had the capacity to deal with problems before we diagnosed them and here we
have adopted a similar strategy. We have
tried to deal with issues such as A&E over the years in terms of waiting
times and places being very busy, we have tried to beef up critical care, as
you have heard from David Nicholson, and we have done quite a bit in terms of
sharpening up the Ambulance Services with particular respect to their response
times. We have become clear also that in
the previous clinical strategies there has been considerable merit in engaging
those people who deliver services to work as a team in a dispersed
network. We have seen that with cancer,
we have seen it with coronary heart disease, we have seen it with stroke, and
those have all been highly successful.
We have evidence from outside this country, North
America in particular and Victoria
in Australia,
that the imposition of networks will be beneficial in terms of both survival
and disability for trauma patients. The
other thing that has become clear is we have had some discussion about people
being resistant to change in the NHS and if you want sustainable change the
only people who can do that change, if you like, are those who actually have to
deliver the service. Where we have had
very successful national clinical strategies, such as stroke, cancer, heart
disease, and I think the evidence is that this will be very successful as well,
they have been characterised by very strong clinical leadership. I think that
is absolutely vital because having clinicians who can marshal the arguments,
dispel the myths and bring a "can-do" attitude towards the nature of the change
that is required appeals to the professionalism of those who are delivering the
service. The strength of clinical
leadership comes from appointing the right people who are highly credible in
their area, hopefully not just at a national level but also at international
level, and ensuring that we have a good working relationship between the
Department of Health and the senior leadership team with ministerial
support. That combination becomes more
important than simply throwing money at the problem or simply throwing
performance management at it. I think
that what we are going to see over the coming years is highly effective change
in trauma services which is based really on the professional will of those who
are delivering the service to improve it through strong clinical leadership.
Q86 Chair:
As
last time, thank you, Sir Bruce, for summing things up very well. Perhaps you might write to us, Sir David,
about rehabilitation because there is evidence of varying performance around
the country. Obviously we will be
looking for you to implement the recommendations in paragraph 20. Probably my successor in this Committee will
want to hear from you in the autumn about any progress that you are making
prior to another hearing maybe in 18 months' time. Is that all right, Sir David?
Sir David Nicholson: Yes, Sir, thank you very
much. I think this is the last PAC I
will be attending in this Parliament. I
have attended quite a lot over the last three or four years and they have not
always been the most comfortable experiences that a chief executive ever
faces. Certainly, in my experience of
being a chief executive in the NHS in front of this Committee, you feel very
accountable to the public when you are here.
I would particularly identify the work the Committee and the Audit
Office have done on dementia, stroke and neonatal intensive care for making a
massive difference in terms of the direction and nature of those services. Thank you.
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