Socialist Health Association (SHA) Cymru Wales
Response to NHS consultation on Major Trauma Services in South Wales
1.1. Local Health Boards in South Wales are seeking views on a decision about where a new Major Trauma Centre should be located to serve people badly injured in South Wales needing this level of hospital care. A (largely clinical) expert advisory group has recommend a) that a Major Trauma Centre should be located at University Hospital Wales (UHW) Cardiff and b) that Morriston Hospital in Swansea should co-ordinate a Major Trauma network within South Wales as well as providing a trauma service. Other hospitals in South Wales might also offer such a higher level of service. Health Boards in South Wales have agreed that a public consultation about these recommendations should be undertaken.
1.2. It may presently be unclear to the general public what level of accident service hospitals across South Wales presently offer in respect of serious injuries. Both Morriston Hospital and UHW are perceived to provide currently a level of care over and above an “accident and emergency” service. For the public, the exact gradations between a) minor injuries service b) accident and emergency services, c) major accident services, d) trauma services and e) major trauma services are felt to be ill defined or not fully understood.
1.3. The Major Trauma Centre is the hospital base where various surgical specialties, diagnostic services (X ray and other scanning techniques, pathology), anaesthetic, nursing, theatre, ITU, rehabilitation and other clinical services can be marshalled at short notice 24hours a day. The Network is a term for the wider range of NHS, social care and other services that play a part at the scene of any incident (road and air ambulance and other specialist services), and then assist the patient and family in the recovery and rehabilitation phase. The network includes both the proposed Major Trauma Unit and the proposed Trauma units of which Morriston Hopital will be the first. It is felt that the exact scope and number of Trauma Centres, such as that proposed for Morriston Hospital, is not clearly described in the consultation documents.
1.4. The consultation poses three questions. Is the concept of a network supported? Are the recommendations of the Expert Panel (as summarised in paragraph 1.1 above) supported? Do respondents have other comments? In summary, SHA Cymru Wales response to the first is a qualified “Yes” but the nature and organisational locus of the of the network is insufficiently detailed. Our response to the second is “no”. In regard to other comments these emerge from addressing the first two questions in the response below.
1.5. Finally, in addition to the three questions relating to the immediate issues about whether Wales needs its own Major Trauma Centre, and if so where that should be and within what wider range of complementary services that the term “network” implies, SHA Cymru Wales has some reservations about how this consultation process has been conceived and processed. In particular, there are concerns that well understood standards that set out how public consultations should proceed (known as the “Gunning principles”) may not have not been followed. The implications of this are explained in section 4.
2.1. Major Trauma is a term used to describe serious life threatening and multiple injuries usually arising from major accidents, criminal/terrorist acts, and similar events. Hospitals receiving major trauma are expected to have a wide range of surgical, anaesthetic, diagnostic, rehabilitative, and intensive care resources – medical, nursing, rehabilitative, and technical – available on a 24 hour, seven day a week basis. North Wales looks to Liverpool for its major trauma service, Mid Wales looks to Birmingham and North Staffs. South Wales is not part of a trauma network but could look to Bristol.
2.2. Where major trauma is suspected, high quality patient care and good outcomes depend upon a speedy and skilled response to the scene, high quality triage, early and accurate diagnosis of immediate threats, appropriate life sustaining interventions and patient stabilisation at the scene, and fast but safe transfer to a hospital equipped to continue the clinical care.
2.3. Wales Air Ambulance provides a fast and skilled response to many such suspected incidents, although it is constrained by the number of aircraft it can deploy, weather conditions, night flying capability, and – where multiple casualties occur – the limited patient load any one aircraft can carry. Incidents that create multiple casualties – such as multi vehicle crashes, train accidents or terrorist activities – pose particular challenges in respect of triage and getting the right patients to the appropriate level of hospital care.
- SHA concerns about the process leading to the recommendations being put forward concerning the siting of the Major Trauma Centre.
3.1. It is understood that Welsh Government tasked NHS Wales with looking at how patients who suffer major trauma in South Wales might be better cared for, but it appears that no political guidance was given regarding the wider strategic direction within which such a decision should sit. For example, should there have been broader economic and social considerations taken into account relating to the way that economic activity in South Wales might be impacted by the choice of location – given the public sector spending in the Welsh economy has a knock on effect within the private sector? Should Welsh Government have chosen to see any Major Trauma Unit sited in South Wales as needing to complement the existing chain of Major Trauma Centres operated by NHS England – and upon which Welsh residents currently rely? SHA Cymru Wales is clear that, were the clinical arguments to be finely balanced (as we feel is the case here) the answer to both of these questions is a clear “Yes”. The narrower approach taken to weighing selected clinical factors involved in this major investment decision highlights a possible lack of a clear strategic vision about the Welsh NHS.
3.2. We understand that the terms of reference given to the expert advisory group were left for Chairs and Chief Executives of Health Boards and Trusts in Wales to devise. SHA Cymru Wales believes that the terms of reference were too limited – effectively requiring the Expert Group to assess the current clinical capabilities of two major hospitals (Morriston Hospital Swansea and UHW Cardiff) and recommend which of the two was better equipped clinically to house the Major Centre were one to be created in South Wales. The existence of head injuries services at UHW was seen as a strong factor in UHW’s favour but if this was indeed seen (in a clinical sense) as the deciding factor, moving the head injuries unit back to Morriston Hospital to sit alongside the burns unit would not be a major problem if other factors, on reflection, were judged to be more strategically important. Indeed, the past decision to locate the Burns service in Morriston Hospital was taken in recognition of the likely sources of burns injuries and its more accessible location. The move from Chepstow to Swansea was accomplished on time and within budget.
3.3. Whilst the existing clinical capabilities of both hospitals are important, SHA Cymru Wales believes that other factors also carry weight – especially if clinical arguments are finely balanced. Thus the terms of reference given to the expert group should have been to advise on whether South Wales (unlike the rest of Wales) needs to have a Major Trauma Centre based within it, and if so, to assess where this would be best located in order to complement the existing range of Major Trauma Centres in England and so strengthen the major trauma coverage for populations within the UK as a whole.
3.4. We believe the failure to provide such terms of reference was a fundamental error which undermines the recommendations of the Expert group. A Major Trauma Centre located in Wales ought to complement and enhance those based in the West Midlands, Bristol, Merseyside, (and Devon and Cornwall). On this basis, given the existing major trauma centres in Bristol, Birmingham and Plymouth and the increased reliance on air cover for serious trauma, a Swansea site would seem to offer more enhanced resilience as far as any new Centre based in South Wales is concerned when compared with the Cardiff option which is but a few minutes by air from the Major Trauma Centre in Bristol.
3.5. The ability of the wider hospital infrastructure around both localities to absorb the inevitable knock on effect that adding a major trauma load to existing theatre, ITU and after care provision brings must be considered. It is not clear from the work done so far that adding a major Trauma Centre to UHW Cardiff can be done without impacting upon existing services on an already congested site, whereas Morriston Hospital has acquired further land upon which additional clinical capacity can be placed and already has its helicopter landing site within its grounds.
3.6. As implied in paragraph 1.3., the proposed two roles of Morriston Hospital – retaining a high level (undefined) of trauma work and of leading the trauma network – are not fully described in terms lay people would understand. The consultation process should make these roles clear and explore what would happen were Morriston Hospital to be the site of the Major Trauma Unit and the leadership of the network was located elsewhere. The expert group states that evidence supports placing the leadership of a major trauma network in the hands of a body other than the major trauma centre, but it does not make a convincing case as to why the work of both initial response agencies and then longer term management and rehabilitation services (often, presumably, where the patient was living at the time of the trauma) should be added to either UHW or Morriston Hospital. Indeed, there could be strong arguments for either a West Wales, Mid Wales or Valleys body to ensure the resilience and resourcing of such a network – but this appears not to have been explored. (Morriston Hospital’s leadership of the network might be seen as a consolation prize for not becoming the Major Trauma Centre).
3.7. Another justification for choosing Cardiff seems to be based on the population density of South East Wales including the capital city coupled with a desire to avoid sending the Welsh patients receiving traumatic injuries in South East Wales to Bristol Hospitals. There are two problems with this justification. First, what data there is about the incidence and volume of major trauma (obtained from Public Health Wales) shows that the loads placed on Morriston and UHW (that are retrospectively classified as major trauma) are broadly equal at about 500 patients a year each. Second, the financial and opportunity costs of creating a South Wales unit in Cardiff – for what is in overall NHS terms a tiny number of people who may receive a higher level of care than they presently get from Bristol because of their distance from Bristol – needs to be weighed against all other current unmet demands upon scarce NHS resources. Some of these unmet demands, for example meeting the needs of mentally ill young people, also cause distress and premature death. It is assumed that, politically and in the current austere times, such a judgement on priorities has been made in favour of improving major trauma services.
3.8. The travel time data, from the sites of past incidents giving rise to major trauma to the competing sites, needs to be in the public domain in much more detail. It is concerning to note the Expert Group’s comment that travel time data and “accessibility” to both sites is not fully agreed. Travel times by road and air are very different and travel times by road are subject to weather and traffic conditions. Given the impact that travel times – initially of emergency services to the incident and then from the incident to the Major Trauma Centre – have on patient outcomes for those needing specialist trauma care, this crucial data needs to be available to the public. Also, air cover for parts of North and Mid Devon could come into play if the District Hospital currently in Barnstaple is downgraded as has been proposed, given Swansea and South Wales being as close by air to parts of North Devon as is the Plymouth Major Trauma Centre currently used.
3.9. If the Cardiff option is chosen, there are fears among some key professional staff that accident services to the West of Bridgend will increasingly struggle to recruit senior consultant and nursing staff leaving West Wales hospitals struggling to maintain an adequate accident service
- Concerns about the consultation process
4.1. Well established “rules” that have been honed over time govern the way that public consultations on matters such as whether and where to provide and locate major public facilities ought to be conducted. These are often referred to as the Gunning principles. In short, these set down a number of principles that pubic consultations should follow if the process is to be seen as valid and the essentials are that :
- The issues should be clearly described, in terms the general public would understand, the options being considered and the pros and cons of adopting different courses of action
- The consultation process itself should be easy to use, and should allow enough time for individuals and groups to consider the issues and respond to them
- The consultation must be genuinely open, that is the public body undertaking the consultation must proceed with an open mind.
4.2. Contrasting the process used to explore the public’s views on whether a Major Trauma Centre ought to be created in South Wales and if so where with the requirements of the Gunning principles, SHA Cymru Wales has some concerns.
4.3. First, with regard to A above, as noted earlier the differences between what appear to be three different levels of hospital response – accident and emergency, trauma, and major trauma – are not well described. SHA Cymru Wales feels itself to be reasonably familiar with NHS jargon, but we are not totally clear about what the proposals imply for the accident and emergency services currently offered at Morriston or other major Hospitals. How would its proposed designation as a trauma unit change the services it offers patients from its current or a changed catchment area? How would patient flows for people injured in West Wales be changed – for those judged to be seriously injured how many would still go to their local hospital, or to Morriston Hospital for either ongoing care or to be stabilised before going on to UHW? If it is difficult for a knowledgeable body to form a view of the (one) option out for consultation, it must be even more difficult for a lay audience.
4.4. Second, the uncertainty about air and road travel times to the three possible sites makes comparison of the options difficult.
4.5. With regard to B, the final details for the consultation only became clear in October and we have been advised that many feel that these were not widely publicised and that great reliance was placed on social media. Given the Christmas period in the middle of the three months, we feel that bodies that needed to formulate responses using existing meeting cycles would face tight timescales to understand the issues, consult their members or communities, and hone their response.
4.6. Finally, with regard to C, SHA Cymru Wales is concerned that the terms of the consultation – first by seeking approval to the notion of a “network” which is difficult to contest, and second by asking for approval to the Expert Group recommendation of using UHW – might be seen as implying a level of approval by NHS Wales of the recommendations of the expert group. This perception is also aided by the apparently unintended public release of the conclusions of the Expert group which clearly came as a surprise to many who might have been expected to be aware that such deliberations were in train. SHA Cymru Wales feels it would have been more appropriate if the public had been invited to comment upon how the expert group had assessed the pros and cons of three options, Bristol, UHW and Morriston Hospital.
5.1. This major national investment decision should be carefully considered so that the right decision is made for Wales and the UK as a whole. A correct decision is preferred to a quick one. This is an issue that, with help, lay people can understand. SHA Cymru feels that:
- The need for a Major Trauma network with several trauma units within it is clearly stated and is self evident. However the case for placing the leadership of this with an acute hospital has not been made and placing this role with other health Boards should be examined. (We would also wish to see Bristol Hospitals having a formal relationship with the network in case this capacity is needed from time to time, for example if multiple casualties arise).
- The recommendation to locate a Major Trauma Unit to serve South Wales at UHW is based upon a narrow assessment of existing hospital facilities at both Morriston Hospital and UHW. The preference for UHW seems to rely upon the availability of head injuries services . Consideration of the locational advantages of Morriston hospital as a complementary facility to existing English capacity was apparently not attempted. SHA Cymru Wales believes this was unwise and undermines the recommendation of the expert group.
- SHA Cymru Wales requests that the advice of the Group be further tested by i) assessing the resilience of an England and Wales chain of Major Trauma Units comprising Morriston Hospital rather than UHW
- ii) looking further at the accessibility indicators for both road and air
conveyed patients from S. Wales if Morrison Hospital was relied upon
iii) providing further clarity about the number and siting of Trauma
units that are envisaged as part the network.