On Thursday 27 September 2018, The Shrewsbury and Telford Hospital NHS Trust Board agreed to temporarily suspend overni...
The following blog provides the views of the three clinicians leading NHS Future Fit in Shropshire and Telford & Wrekin. It is a discussion on the balance between travel time access and clinical outcomes in advance of the planned future consultation on the reconfiguration of hospital services within the county. It is from Dr Stephen James, Clinical Director of Information and Enhanced Technologies, Shropshire Clinical Commissioning Group; Dr Michael Innes, from Telford and Wrekin Clinical Commissioning Group; and Dr Edwin Borman, Medical Director at The Shrewsbury and Telford Hospital NHS Trust:
The NHS Future Fit Programme is being undertaken to redesign the provision of hospital based services. It has done this by describing first how those services can be provided best from a clinical point-of-view. This entailed developing a description, or model, of services. The clinical model that was developed took into account all available evidence about models of service and it included wide public and clinical engagement. As one of the recommendations, it stated that there should be one emergency centre supported by two urban urgent care centres in the two principal towns (Shrewsbury and Telford). From a clinical point of view it was agreed that this provided the greatest opportunity for improved outcomes for patients.
It was also recognised that for some patients this would mean an increase in travel times. The reason we are recommending this model is that this would provide the best outcomes for the population as a whole, given the current and likely future availability of specialist medical and nursing staff. Most importantly, it will deliver care that is better than if no changes were made.
While all of us would love to have the comprehensive and ideal medical facilities right on our doorstep, part of the reality that we have to work with is that this is not possible, even in a highly developed part of the world like the UK.
Some detail behind the reasoning
Whenever we consider quality of care, there is a tension between the unification of services, which brings improvements in care and outcomes, and the resultant changes in travel times, which might benefit some and disadvantage others. It is the balancing of these two factors that makes for most of the debate.
In the vast majority of circumstances, any adverse change in travel time will be outweighed by an improvement in the quality of care that a patient receives on arrival.
The evidence for this comes from the national database for major trauma units, which has shown a consistent reduction in mortality across the UK for patients who have suffered major trauma.
Even though Shropshire would be unlikely to have a major trauma unit, the same principle is recognised for smaller trauma units such as the one currently provided at the Royal Shrewsbury Hospital where all required resources – emergency department, advanced specialists, surgical anaesthetics and Intensive Therapy Unit services – are concentrated1.
Further evidence from within the county comes from the temporary unification of the Trust’s stroke units2 and the management of patients who have suffered a heart attack.
In addition, evidence from ambulance services that provide paramedic delivery of advanced monitoring and commencement of treatment has proven the principle that patients can be stabilised and treated before they even arrive in hospital.
When we discussed provision of planned care, such as big investigations (scans), and planned operations, people were clear that they placed distance travelled to get the care (and so travel time, by association) lower in their priority list than the opportunity to get consistent high-quality care. This might be summarised by the statement: “I would rather go further to get better care than stay closer and receive potentially less high quality care”.
Increasingly, travel to receive care requires emergency transport with professional support (e.g. an ambulance with a paramedic). This is especially so with the more major emergencies. For a small, but important, set of circumstances that require emergency care (e.g. heart attacks, stroke, major accidents etc.) time to treatment is more critical for the best outcome. In an even smaller set of circumstances, time to treatment can be critical for life. In these circumstances, it is also the case that the level of experience and skill in the treating team is very important for the outcome.
Given the challenges, both nationally and within the county, of staffing emergency departments, it makes sense for there to be one emergency department where all members of staff are concentrated3. This provides the greatest opportunity for senior decision makers – consultants – to be present, another intervention that has been shown to provide the best outcomes for seriously ill patients4.
With the professional support of a paramedic comes the opportunity to start treatment at the scene, bringing care closer to people and reducing time to treatment. Increasing amounts of evidence, especially from rural Scotland, have demonstrated that this can actually improve care further. For example, people living further away from a hospital can have clot-busting treatment administered at home faster than those conveyed to hospital.
This is particularly relevant for the county of Shropshire and beyond, where travel times and distance can be significant. Work with West Midlands Ambulance Service is helping to prepare for a model where patients are monitored and treated to a far greater extent prior to arriving in hospital5. We look forward to working with our colleagues in Wales to achieve the same and have a good track record of working well with them6 .
NHS Future Fit has provided very detailed evidence, for each of the options considered, regarding the travel distance and duration for the population of the county as a whole. While clearly each option will have implications for some areas, meaning they may have either longer or shorter travel distances and times, it is the view of the clinicians involved in NHS Future Fit that national and local evidence supports centralisation of acute services and that this evidence outweighs the potential impact of increased travel times.
This is our view based on the balance of the evidence but any proposals would undergo full public consultation in the future. We will keep the evidence under review and would welcome hearing your thoughts about this.
1. The College of Emergency Medicine (2008) lists seven key specialties required to provide support to A&E departments: critical care, radiology and diagnostic imaging, laboratory services, acute medicine, orthopaedics, general surgery and paediatrics. Where paediatrics, general surgery and orthopaedics are not available, it is stated that on-site ‘robust and safe’ policies must be in place to ensure rapid access to senior opinion and that transfer must be available.
2 The temporary unification of stroke services has benefited all patients who access Hyperacute stroke services via the Princess Royal Hospital in Telford. We have greatly reduced the time from onset of stroke symptoms to accessing specialist assessments and treatment to minimise the impact of stroke and maximise the potential recovery of all patients wherever they may live. The proportion of patients now accessing thrombolysis, a clot busting treatment which can only be given within the first 3 hours from onset of symptoms, has increased from 7% to 13%, since the move. The national target for thrombolysis is 10% with a national average of 10.9%. We are seeing more strokes patients, but with earlier intervention and preventative measures are seeing a drop in the severity of strokes. Patients are still repatriated at the earliest opportunity, for on-going stroke rehab to their nearest Stroke Rehabilitation Unit, either at the Princess Royal Hospital, the Royal Shrewsbury Hospital or Newtown. As part of our ongoing audit we haven’t identified any missed opportunities to treat related to increased travel time to the unified service.
3 The Urgent and Emergency Care Review undertaken by NHS England (2013) found that appropriate staffing is fundamental to providing a sound NHS service: "Proper staffing is the ‘single most important factor’ in providing a high quality, timely and clinically effective service to patients”. Furthermore, “there is a need to ensure a balanced workforce within an A&E department in order to provide a safe service.
4 The Urgent and Emergency Care Review undertaken by NHS England (2013) highlighted that many NHS A&E departments failed to achieve such standards: “a recent study of A&E departments in the United Kingdom, of which nearly 60 per cent of respondents were in England, carried out by the College of Emergency Medicine highlighted the variation in consultant ‘shop-floor’ cover to help maintain quality and safety in A&E departments, with the situation worsening over the weekend. Seventy-seven per cent of responding UK A&E departments reported that they had at least one emergency medicine consultant present in the A&E department over 12 hours on weekdays, but only 17 per cent reported such presence for 16 hours.
5 The Urgent and Emergency Care Review undertaken by NHS England (2013) states:
“Rural and remote patients present a specific challenge due to the density of the population and the distances involved. The low-density population of rural areas means that healthcare facilities are spread far apart, and there may not be the critical mass necessary to provide a fully functional major acute hospital within the region”. Evidence collected from the most seriously ill patients 12 to 15 years ago is frequently cited that suggested an increase in the distance travelled was associated with an increase in mortality (cited Nicholl et al., 2007). The Urgent and Emergency Care Review undertaken by NHS England (2013) points out that both the ambulance service and hospital treatments have changed substantially since then, but these findings indicate that it is important to monitor the effects of distance and any changes in service configuration. Spurgeon et al (2010) report that the discussion on the clinical case for emergency care reconfiguration is based around the conflicting arguments of the advantages of specialist care versus the risks of delay in reaching a specialist centre. The authors highlight that it is the timing of the start of appropriate treatment, rather than the timing of arrival at hospital that affects the outcome, so interventions by paramedics and/or rapid access to the specialist team once at the hospital can offset or overcome the risk created by the additional travel time (Spurgeon et al 2010).
6 SATH did a lot of work with the Welsh Ambulance Service NHS Trust in the lead-up to the opening of the Shropshire Women and Children’s Centre at the Princess Royal Hospital (PRH) in Telford in September 2014. Ambulance service representatives were members of the clinical pathway groups that designed the service changes and helped SATH to understand the activity and flow of patients from wales into Women and Children’s Services. In partnership with both the Welsh Ambulance Service and West Midlands Ambulance Service, SATH also developed protocols and guidance for crews taking patients to and from the centre. Both ambulance services were also involved in “dry runs” of transferring a newborn baby between the Royal Shrewsbury Hospital and PRH in an emergency.