The Healthcare for London programme is carrying out a clinically driven service reconfiguration that will ensure world class care at all stages of the patient journey. The Healthcare for London major trauma team explains how they have tackled the challenge of centralising trauma care in the capital.

The centralisation of trauma services in the UK is gathering momentum. There is widespread agreement that major trauma care needs to be improved: for example, an NCEPOD study of 183 UK hospitals found that almost 60 per cent of patients had received a standard of care that was less than good practice [1].

Clinicians have been convinced for some time that the centralisation of services has an important role to play in improving the provision of major trauma care, based on an ever increasing body of clinical evidence [2],[3].

The next stage review[4] encouraged the political recognition of the necessity to improve the standard of trauma care, without which attempts to effect change had previously failed. The NHS now plans to set up a number of regional trauma services as part of a national scheme. Strongly signalling this intention, the Department of Health has recently appointed a national clinical director for trauma care.

For London specifically, Lord Darzi advocated centralisation of major trauma care around a small number of specialised hospitals, with lower level injuries cared for at trauma units networked with these centres.[5]

Severely injured patients do better if they are taken straight to definitive care in a specialised hospital with a dedicated multi-speciality trauma service. This observation remains true even if the journey to the trauma centre takes somewhat longer than it would if the patient went to the nearest hospital.

In addition to improving clinical outcomes for the most seriously injured patients, centralised care has the potential to increase the quality of care across the networks from pre-hospital care to rehabilitation, through consistent standards, systematic audit, coordinated research and training.

Our challenges in centralising major trauma services

The Healthcare for London programme was set up by NHS London to deliver the vision outlined in A Framework for Action and is funded by the London primary care trusts. As part of this programme, the major trauma project was tasked with centralising major trauma services, as advocated in Lord Darzi’s recommendations. In doing so, our challenge was to design the optimal system for treating major trauma patients and select the providers to operate it.

Getting the service design and specification right is key

In designing the London trauma system, we followed existing international examples of centralised trauma care. The London system will consist of several trauma networks, each of which will be responsible for the care of trauma patients in its geographical area. 

At the centre of each network, a major trauma centre will receive patients identified during pre-hospital triage as those potentially most severely injured (typically less than 0.01 per cent of all patients). Patients with less severe injuries will be triaged to the nearest trauma unit, situated at an A&E department, where they will receive high quality care. 

The major trauma centres will work in conjunction with trauma units in their network to disseminate best practice and lead on research and education. Pan-London governance of the trauma system will monitor quality and support continuous improvement of the networks, to ensure that that all trauma patients in London receive the right care in the right place at the right time.

At the service level we needed to translate available clinical guidelines on trauma care into a practical service specification that would deliver the system design of networks, major trauma centres and trauma units. This specification would allow us to differentiate between potential providers and would act as a blueprint for subsequent implementation of the system.

Our exhaustive service specification, the first one developed for a major trauma system in the UK, was written with and endorsed by clinicians. It defines clinical and organisational requirements for potential providers, based on established service models from the American College of Surgeons Committee on Trauma[6] and the Royal College of Surgeons[7]. There is an emphasis on consultant-led service and multidisciplinary teams, including not only specialist surgeons and nurses but also administrative staff, together with occupational therapists and physiotherapists.

The specification covers organisational and network requirements to ensure coordinated service delivery, together with provisions for systematic data collection and audit across the system.

The service specification consists of 88 “designation criteria” organised in four sections: major trauma centre, trauma units, rehabilitation, and network capability (i.e. the ability of major trauma centres to work with trauma units to share best practice, increase capability and ensure efficient patient transfers). An example of the designation criteria is shown in figure 1.

The criteria are innovative in the level of detail they provide: different levels of service (1, 2, or 3) specify the seniority of clinical coverage required and the timescales in which a particular service/ specialty needs to be available.

Designating the service providers

The selection of the right providers was in some ways a more complex challenge.  The only hospital currently operating a multi-disciplinary trauma service close to the specification in London is the Royal London Hospital in Whitechapel. There are a number of other hospitals that could potentially become major trauma centres but we believed that we needed just two or three more.

The requirement for a small number of such specialised centres in London was introduced in A Framework for Action. It is based on evidence that, to attain and sustain the expertise required to deliver good clinical outcomes, a major trauma centre needs to see a “critical mass” of the most severely injured patients each year. Not all the providers currently treating major trauma patients would therefore be able to become major trauma centres, though they could host trauma units providing care to less seriously injured patients.

Our task was to make the right choice of major trauma centres - and to be seen to do so, ensuring that the public had confidence that the future trauma system would provide high-quality care across London.

Our detailed designation criteria formed the basis of the procurement process, helping to ensure a thorough, relevant and consistent assessment of potential providers. The Office of Government Commerce rated our efforts as “gold standard” for such exercises. The selection of providers was made in three stages.

We first tested that there were sufficient providers in the market willing to provide centralised major trauma services and take the responsibility of leading a trauma network. This was achieved through a pre-qualification questionnaire in which providers were asked to self-certify the presence or ability to provide key specialties on site.

In the bid evaluation stage, providers had to submit proposals demonstrating how they planned to meet the designation criteria, taking into account in their current services and the project timescales. Providers needed to bid as trauma networks, which required them to start establishing links, organise themselves and work collaboratively, thereby stressing the importance of networks in the design of the future trauma system.

We supported providers during this stage of the process through bidders’ briefings, coaching them on the process and sharing any additional information or data as it became available.

The bids were evaluated by an independent panel of senior clinical and management experts, who tested the feasibility of the proposals to ensure the clinical quality standards set in the designation criteria would be met. Site visits proved to be a fundamental part of this evaluation process, allowing the panel to discuss the proposals with the bidders and assess institutional commitment across all providers in the bidding network.

The third stage of the provider selection was to assess the different configurations of trauma networks that were successful in the individual bid evaluation. This stage was required if there were more candidates than needed for major trauma centres in the future trauma system to treat a critical mass of patients. We developed a set of criteria to assess the possible configurations, which were rated by clinical experts, commissioners, patients and members of the public. The main focus was to provide the highest possible quality with optimal coverage across the region.

When we conducted this selection process, three providers demonstrated in the bid evaluation that they could provide high quality trauma services across their network in the required timescale. However, the assessment of the resulting configuration identified that one part of London could be disadvantaged in terms of coverage and that a three major trauma centre system might not be resilient enough to deal with the expected volume of patients. Therefore a second selection process needed to be run that allowed a slightly extended timescale to establish an additional trauma network.

The rigour of our process and service specification stood us in good stead as we did so: the same designation criteria and configuration criteria were applied, ensuring that all providers in the future London trauma system meet the same level of quality.

Clinical involvement has been one of the key elements of success

Clinical engagement is now a fundamental component of any successful change in health provision. There are elements in our approach to transforming London major trauma services that delivered this over and above what is generally done.

The project benefited from the clinical leadership of an un-biased, non-trauma clinician and the wide range of specialties and clinical groups represented in our expert panel, which reflected the complexity of the patient pathway from ambulance to rehabilitation.

We also sought input from internationally renowned experts to design key building blocks of our approach, such as the service specification, bid evaluation and future performance management framework. The experts forming our independent evaluation panel contributed to the quality of the designation effort, through their in-depth knowledge of civil and military trauma care and experience in running and shaping health services.

Clinical leadership has been vital throughout this exercise, and will remain so as the London trauma system is implemented. Pan-London governance will shape the development of the trauma networks, drive the continuous improvement of clinical quality and have a key clinical advisory role supporting commissioners with performance management of the London trauma system.

Improving major trauma care in London

Following a public consultation, the proposal to designate major trauma centres was approved by a joint committee of London primary care trusts. Our approach to specifying and procuring centralised major trauma services has received wide support from the public and from health service stakeholders and experts across London.

The Healthcare for London major trauma project has been a partnership between the Healthcare for London programme, NHS clinicians, managers and commissioner and PA Consulting Group.

[1] “Trauma: Who cares? A report of the National Confidential Enquiry into Patient Outcome and Death” (2007) available from www.ncepod.org.uk

2 Brohi, K., “Trauma Specialist Centres”, Ann R Coll Surg Engl (Suppl) 2007; 89:252–253

3 Cameron, P.A. et al, “A statewide system of trauma care in Victoria: effect on patient survival”, MJA, Volume 189 Number 10,17 November 2008

4 Darzi, A. “High quality care for all: NHS Next Stage Review final report” available from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825

5 Darzi, A. “Healthcare for London: A framework for Action” available from http://www.healthcareforlondon.nhs.uk/assets/Publications/A-Framework-for-Action/aFrameworkForAction.pdf

6 American College of Surgeons “Resources for the Optimal Care of the Injured Patient”, 2006.

7 Royal College of Surgeons, “Better Care for the Severely Injured, A Joint Report from The Royal College of Surgeons of England and the British Orthopaedic Association”, July 2000