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.

Chair: Thank you very much for those comments, Sir David.