Meeting date: Tuesday, January 26, 2021
Health and Sport Committee 26 January 2021
Agenda: Scottish Trauma Network, Provisional Common Framework on Food and Feed Safety and Hygiene, Subordinate Legislation, Petitions
- Scottish Trauma Network
- Provisional Common Framework on Food and Feed Safety and Hygiene
- Subordinate Legislation
Scottish Trauma Network
Good morning and welcome to the third meeting in 2021 of the Health and Sport Committee. We have received apologies from Alex Cole-Hamilton. I ask all witnesses and members to ensure that, during the meeting, mobile phones are in silent mode and notifications are turned off.
The first item on the agenda is a one-off evidence session on the Scottish Trauma Network. I welcome to the committee Dr Martin McKechnie, who is national clinical lead of the Scottish Trauma Network; James Anderson, who is lead clinician at the north of Scotland trauma network; Michael Donald, who is lead clinician at the east of Scotland trauma network; Edward Dunstan, who is lead clinician at the south-east of Scotland trauma network; Dr Iain Wallace, who is interim lead clinician at the west of Scotland trauma network; and Peter Lindle, who is a consultant paramedic in major trauma at the Scottish Ambulance Service. I thank our witnesses for joining us and for the comprehensive report and information that they provided to the committee in advance of the meeting.
We move straight to questions. I will start with a question for Martin McKechnie, and I will then invite members, in turn, to ask additional questions. If witnesses wish to respond or to contribute to the discussion and I have not called them to speak, I ask them to indicate that they wish to be called.
I want to look back to the origins of the trauma network. I refer to the geospatial optimisation of systems of trauma care—GEOS—study, which was published in 2015. The study suggested that major trauma centres should be set up in Glasgow and Edinburgh only, but Aberdeen and Dundee have led the way and are where trauma centres are now up and running. Does that mean that the GEOS report got it wrong in all important respects?
Dr Martin McKechnie (Scottish Trauma Network)
No, it does not mean that the report got it wrong. A lot of decisions were made based on the GEOS study, which were then reviewed. Committee members will know about the processes that took place before the political decision to set up the four major trauma centres was announced. I note that many of the people on my team who are attending today’s meeting, including me, were appointed subsequently.
Decisions were made before the trauma network was set up to carry out work on the conclusions of the clinical academic GEOS study and to implement the political decisions about where trauma centres and units would be located. There were many considerations regarding place, such as the movement of patients around the country at the time and, perhaps, the infrastructure that was available in Scotland at the time. We in the trauma network have tried to make progress by creating the network and enabling far more cross-boundary working.
Some of the major factors involved in translating the GEOS study into clinical practice are geography, weather and distance. Scotland is very interesting—almost unique in the world—in terms of its population distribution and concentrations, as well as its remote, rural and island communities.
We have set high standards to get optimal trauma care to patients at the roadside and all the way through their care pathway into rehabilitation, which is a new approach to trauma care. It has not been done before anywhere in the world to the same extent that we are doing it. That might sound bullish and ambitious, but it is important.
Trauma centres are located where they are to try to create a system of multiple specialties. That has translated into a multispecialty system, by which I mean that trauma centres were not previously joined up in the way that we are trying to achieve now. We are doing that by collaborating across territorial, geographical and specialty boundaries, which did not happen before. The GEOS study has presented us with information about what happens, where it happens and how it happens, and the trauma network has taken that on to provide the best care, whether in an urban centre or a remote and rural area.
It is an on-going moving battlefield. I would not be surprised if there were changes in the future in relation to where services are located and how they are delivered. Certainly, in the past three years of our involvement in delivering trauma care in Scotland, things have changed markedly. The GEOS study was an important leading study. We are presented with four major trauma centres; it is our ambition to deliver the final pieces of that jigsaw in the next few months.
That was an interesting answer. In a sense, you are saying that, rather than there being a fault in what was originally proposed, you have gone well beyond that and are working across boundaries in a way that was perhaps not envisaged five or six years ago.
Given that major trauma centres are at the pinnacle of the structure as originally envisaged and indeed as delivered, will the coming on stream of two further major trauma centres in Glasgow and Edinburgh affect the throughput of patients in the existing centres in Aberdeen and Dundee? Will that have any impact on the expertise available in the major trauma centres in Aberdeen and Dundee?
The answer is yes and no. I will explain. We have a relatively small number of major trauma patients every year in Scotland. If we talk about trauma in its entirety, we are talking about several thousand—say, 6,000—patients. Severe injury may account for up to 1,500 of those patients. Those are incredibly complex cases—they are what we call multisystem cases, which can involve a head injury as well as a neck or chest injury and so on. Such specialist care requires lots of areas of surgical and clinical expertise, if we are to deliver the optimal patient care and rehabilitation that we want to deliver for those patients.
That is an on-going and long-term benefit to Scottish society, and it is therefore right that we invest heavily up front in trying to deal with those patients as quickly as possible and as closely as possible to the location of their accident or injury. That is why the trauma centres are spread out across the country. Again, I go back to geography. In the past couple of years, we have had extremes of meteorology and climate difficulties. That is part of the thinking behind placing hospitals, as well as trauma centres and services, where they are. If you wish, we can go on to that in greater detail in due course.
In answer to your question, I say that a small number of patients will necessarily be taken from trauma units, which are a step down from major trauma centres but are still well equipped to deal with most trauma injury. The most serious stuff goes to the major trauma centres. On occasion, there may be a requirement for certain multitrauma or polytrauma patients to be moved from one trauma centre to another. That would be the case for significant injuries that need neurosurgery, paediatric care, burns care or what we call orthoplastic care, which is a combination of orthopaedics and plastic and reconstructive surgery. By necessity, such services might be based in only one hospital in Scotland.
If I am in Aberdeen, for example, and I have a surgical issue that requires transfer from the initial reception at the Aberdeen royal infirmary, I might need to go to another centre for on-going burns care. We almost saw that in August last year, when the train crash happened on the line from Aberdeen to Glasgow. Luckily, there were only a few people on the train. Sadly, there were deaths, but it could have been a whole lot worse. Part of the planning for that was about making sure that we were able to transfer and transport certain types of patients across regional and health board boundaries to the place where they would get the best, quickest and most optimal treatment, based on their injuries. I hope that that answers your question.
It does, absolutely.
The other aspect I wonder about is whether there is an optimal number of patients and throughput that is appropriate for maintaining skills and expertise in major trauma centres. If so, how does that compare with the numbers that you described?
There is an optimal number, and the centres that we have available will deal with those optimal numbers.
A lot of the answer to the other part of that question will be based on data that comes out in the coming years. It will not be easy to tell that story right away.
In years gone by, we have perhaps not had the completeness of information to allow us to benchmark that in as detailed a way as we would always have liked. However, that is because of the complexity of individual patients’ distribution of injury and the patterns of care that are required to be delivered in areas outwith their regional home territory and the area of reception of the patients’ local trauma centres and units.
Therefore, the answer to your question will come in some years, when we get a full reflection of the data and the network is fully up and running. I hope you appreciate that although, behind the scenes, we are ready to be activated as a national trauma network, one or two pieces of that jigsaw are still to be completed.
Doing that has been slightly scuppered during the past year, because of additional pressures that we all know about. Those are caused by difficulties in staff redeployment, recruitment and demands made upon health services.
I think that that story will come out, but we are already on the right path. We have some unpublished data. I cannot share that with you at the moment, but it will come quickly once the trauma network is fully established and running.
Thank you. We will move on to the next question, which is on the same theme, from Sandra White.
Good morning, gentlemen. Following on from the convener’s questions, I have two of my own to ask. They relate to the Glasgow and Edinburgh trauma centres, which are not yet operational.
As constituency MSP for Glasgow Kelvin, I am particularly interested in the situation in Glasgow. Initial recommendations were that Aberdeen and Dundee open trauma centres—I note the fact that there is a lot of cross-boundary working, as the witness mentioned—and that Glasgow and Edinburgh’s centres were to be operational in 2021.
Last night, the committee received a letter from the Cabinet Secretary for Health and Sport. If you could bear with me, I will read a couple of paragraphs from that letter to you all. In her letter, the cabinet secretary mentions that
“The committee will be aware, both Major Trauma Centres ... in the West and South East have yet to be officially opened”
“While both the West and South East continue to treat and care for trauma patients through existing pathways, the expectation was that”
they would go live and be
“supported by the Trauma Triage Tool by the end of 2020/21”.
However, as has been mentioned by Dr McKechnie, there have been
in relation to Covid. There is also the issue of training.
I note that the submission from the Scottish Trauma Network says that in Dundee, at Ninewells hospital, one of the trauma wards had to be turned into a Covid high-dependency unit. Therefore, I see that Covid is having an effect in Dundee, also.
The cabinet secretary’s letter also said:
“While both areas can be reverted back to their original purpose, it would be retracting critical COVID-19 capacity and as a result applying further pressures to other parts of the service.”
Do you agree with the cabinet secretary’s explanation as to why the trauma centres are not open yet in Glasgow and Edinburgh? If you want to raise any other issues in regard to that, I would be pleased to hear them.
Also, has the delay in opening centres in Edinburgh and Glasgow had any effect on the trauma cases in Aberdeen and Dundee and has it had any effect on trauma care in the west and south-east of the country?
We will go first to Iain Wallace, who is interim lead clinician in the west of Scotland.10:15
Dr Iain Wallace (Scottish Trauma Network)
First, it is disappointing that we have not been able to open as planned, in March. However, I think that everyone understands the reasons for that, and the cabinet secretary has laid that out in the letter.
We hope to keep on top of all of this, and we are ready to go. As soon as things appear to be under control, we will begin the process of opening the centres. It has been quite a challenging time, because of Covid. Staff have been moved to deal with Covid cases.
I think that establishing the major trauma centre ward at the Queen Elizabeth university hospital is difficult, given the situation, because, at the moment, as has been mentioned, it is a high-dependency area for medical patients. However, we are, in many respects, ready to go. Some capital build changes have been a bit delayed, as have some appointments—that is, being able to put people in place—again, because of Covid. However, most of it is there.
I also assure you that in the west, we are working as a network anyway, as are colleagues across Scotland. People are meeting and discussing cases. We have a monthly clinical governance meeting at which we discuss cases. Our aim is to improve the quality of care, even without the opening of a major trauma centre. Things have moved along at quite a pace and are better than they were a few years ago, even though we have not yet got the MTC opened.
We go to Edward Dunstan, from the south-east of Scotland.
Edward Dunstan (Scottish Trauma Network)
We in the south-east are also very disappointed that we are unable to open, but I assure every member of the committee that we have made very significant progress over the past four years when it comes to dealing with major trauma patients. Iain Wallace has talked about the robust clinical governance processes that are in place. We have morbidity and mortality meetings; we have standardised paperwork; and we still adhere to the key performance indicators, which you may well hear more about later. There is also a lot of shared learning. Each region produces its own newsletters. We feed off each other. We have regular clinical and non-clinical meetings.
We have appointed a very large number of staff to support the process. For instance, at the Royal infirmary of Edinburgh, we have appointed six emergency care consultants, which means that there is now 24/7 senior doctor front-door coverage . We never had that before.
To open as a major trauma centre, we need to attain some minimum requirements. As Iain Wallace has already talked about, one of those is having a major trauma ward. That is where all critically injured patients go, are cohorted together and cared for and looked after by appropriately trained, skilled and supported members of the healthcare team, such as physiotherapists, pain specialists, psychologists, nurses, and doctors across a whole ream of specialties. Before the major trauma network was even considered, such patients were scattered around the hospital. They might be on a general surgery ward, an orthopaedic ward or a medical ward, but now we need to put them into one area where we have appropriate skills and expertise.
Unfortunately, the proposed major trauma ward at the Royal infirmary of Edinburgh is a Covid assessment area, which would be an inappropriate place for such critically injured patients. As Iain Wallace has already mentioned, we have managed to proceed despite the Covid pandemic. The team has worked so hard. We have still managed to appoint to all the necessary positions so, from a staffing point of view, we were ready to go in March.
We have had to completely change the way we have done education and training. It has all gone online—all our morbidity and mortality meetings are online now—but it still works. We did not have that in 2017. Major trauma cases are still being dealt with in a much better way than they were in 2017.
However, you are absolutely right. Any delay to opening will be to the detriment of major trauma care. There is no getting away from that. However, I can assure you that, in our region, we are still doing everything possible to make sure that individual patients are treated effectively. People might think that, because of the Covid pandemic, people are not driving cars and there is not so much major trauma around, but that is not the case. We have hardly seen a fall-off. People are injuring themselves in different ways, such as, more recently, by tobogganing.
It is disappointing, but there is no question in my mind that we will open this year. The team is ready to go.
I thank the witnesses and all the staff for the good work that they are doing.
Peter Lindle might want to talk about the trauma triage tool, which was to have come in for the Ambulance Service but is not yet operational in the west or the east—is that correct?
Peter Lindle (Scottish Trauma Network)
That is correct. Our front-line staff will use the triage tool to make decisions about where best to take patients for care, whether it be a local emergency hospital, a trauma unit or a trauma centre. We cannot start using it until all the trauma centres are open and are an option to us, which is why it has not gone live in the west or the south-east yet.
I am interested in how Covid has affected trauma. The submission from the Scottish Trauma Network says:
“Trauma has continued throughout the pandemic, with some changes in presentations and changes in numbers during periods of lockdown, clinicians across the country continue to respond to trauma calls alongside management of Covid patients,”
I would assume that certain types of trauma, such as that resulting from road traffic accidents, reduce during lockdown. I am therefore interested in whether the witnesses think that the number of major trauma cases remains largely unchanged while other types of trauma were affected by the restrictions.
I remind everybody of my prior experience as an operating room trauma nurse in Los Angeles. I am interested in how Covid has affected trauma and the types of trauma in Scotland.
I will ask James Anderson from the north of Scotland network to respond to that.
James Anderson (Scottish Trauma Network)
I agree with the earlier comments and with Martin McKechnie’s comments. In the north, the number of major trauma admissions has continued largely unchanged in absolute terms, but it is the type of case that has changed. Because people were spending more time at home during the first lockdown, we saw more injuries in domestic settings, such as falls from height, or falls during domestic tasks. Unfortunately, the clinical impression is also of an increase in injuries related to alcohol and, to a degree, self-harm, which I suspect is an indication of levels of distress that some people are experiencing.
Road traffic accidents are still occurring. Again, this is my clinical impression rather than the numbers—it is difficult to be sure statistically—but my impression from the network is that accidents involving multiple people have dropped a bit because people are travelling individually rather than with multiple occupancy in a car.
During the current lockdown, general trauma has still seen some road traffic accidents and, of course, in the north of Scotland, with ice and necessary travel because of geography, we are still seeing on-going admissions.
I assume that there have been some challenges during the pandemic with engaging and managing the network. NHS Dumfries and Galloway had issues with slips and trips and fractures because of the weather and, obviously, that had an impact on its ability to manage Covid numbers. What have some of the challenge been during the pandemic?
With Covid in general, there have been ward and staff pressures from having to reorganise within the hospital. As is stated in our report, there has been a degree of cross-support to the intensive care unit and the high-dependency unit as needed, as well as the slips, trips and falls aspect, which has added a little bit of pressure on the accident and emergency side, too.
It has been shown in recent submissions of data to the Scottish trauma network that very major trauma has increased, interestingly. There has been the status quo or a slight reduction in what we would call less severe trauma, and the reasons for that are behaviourally interesting. Clearly, we have been in various degrees of lockdown over recent months, but there is evidence showing that severe trauma from road traffic accidents and leisure-related activities has increased.
Other areas where there has been an increase include, sadly, domestic violence and mental health-related self-inflicted violence and violence against others. Within that melange, or pudding, of trauma patients, we are seeing patterns developing, and major trauma has increased during the pandemic. Shielding or elderly patients are perhaps not out and about quite as much as they were before, and levels among those groups have remained static or slightly less. There has been a changing demographic there.
I suggest that Peter Lindle may wish to come in on that, given the pre-hospital aspects of transferring and treatment at the roadside.
We are still seeing a lot of slips, trips and falls, especially given the weather over the past few weeks, and the investment from the trauma network has really been helping us to deal with those cases better, despite the fact that we do not have the full network running yet.
For example, we can now give antibiotics to people with open fractures. That is a new thing for the Ambulance Service, and it has been evidenced to improve outcomes for patients. We have better splinting. We have advanced practitioners who can now go out and look after complicated fractures better so that, when patients go into the emergency department, they are already adequately analgesed, reduced and packaged, which makes the job of the ED a bit easier. Those things are happening now, thanks to the investment that we have put in, despite the fact that we are not fully operational yet.
I will make a further small point about Covid and the investment that has already been made in major trauma centres. Regional anaesthesia allows for the avoidance of general anaesthesia for people with limb injuries. Certainly in the west, we have been able to invest a bit in that, so there is now 24/7 availability of it. That reduces the need for general anaesthesia, which is a risk factor in terms of Covid and staff. That is a further benefit.
I was going to ask Peter Lindle to talk about new ways of working—he has described some of them already. It is important to hear about pre-hospital treatment, or treatment in advance, so that we can help to achieve better outcomes for patients. I would be interested to hear any expansion on new ways of working.
I have a final question on what was described by Edward Dunstan. He mentioned that people feed off one another in the trauma network and learn from one another. Are we learning from other places that have rural challenges such as Canada, Alaska or Australia, which has a rural health commissioner, and working with them to see how they manage things?10:30
That question might be ideally suited for James Anderson to kick off with. I also want to hear from Michael Donald in the east network.
Yes, we have some links with other countries. We have been considering the preliminary results of some projects with one of the Australian groups that did a lot of remote—[Inaudible.]—and one of our consultants in Raigmore worked remotely in Australia as well. We also had a visit from a group from Norway. We try to learn from other people’s experiences, but I also feel quietly proud that we lead the way a little bit, as Martin McKechnie said previously, by creating the network in the geography of the north of Scotland.
Despite Covid, the need for flexibility and, as Edward Dunstan mentioned, the degree to which things have been done virtually, we have really tried with the investment of the network to push for continued contact with the people for whom we care, irrespective of geography, for both pre-hospital treatment—again, I would always defer to Peter Lindle on that—and discharge at the other end.
I rewind to address one of the points that Emma Harper has raised, which is relevant to her prior experience of work in the operating theatre environment. The challenge that Covid has presented to us in running a major trauma service—this is equally relevant to Peter Lindle’s Ambulance Service colleagues—is the requirement for adequate protective personal equipment for the major trauma team that now assembles to manage the patients at the front door of the hospital. The additional complexities of having to don aerosol-generating procedure PPE to receive patients who will require critical care intervention have produced a significant strain on the system that we had developed.
Prior to the inception of the major trauma service, many of those critical patients were managed by just an A and E team, who would then contact specialist colleagues in the hospital to deal with them, depending on their injury load. In the east of Scotland, we have now assembled a multidisciplinary team that will be available at the front door of the hospital to manage those patients. As trauma team leaders, we have had to be creative in our management of the numbers of staff who receive the patients at the front door, in order to protect the team and provide its members with adequate PPE. That has been one of the significant effects of Covid, particularly in the first wave, in which we elected to reduce the number of individuals in aerosol-generating procedure PPE to receive the patients initially.
We have learned a lot from that initial lockdown, which has allowed us to get back to a point at which we can wrap all the necessary specialists around that major trauma patient safely and continue to deliver seamless care, from the roadside to rehabilitation, while protecting our staff. That point is relevant to Emma’s experience in the theatre environment and to how important it is that the team feels safe in the environment that it works in.
On the second point about remote and rural medicine, I did trauma management work on a rescue helicopter about 15 years ago in New South Wales in Australia. Australasians were 20 years ahead of the UK at that time in relation to major trauma management. I am pleased to say that the developments in Scotland now surpass what has for many years been available to the public in Australasia. There is a high-level care system there, but it is very much devolved to regions. There is not a huge amount of cross-pollination at the borders of New South Wales and Queensland, whereas the network in Scotland has been developed across all geopolitical boundaries.
Wherever in Scotland someone ends up experiencing major trauma, the network assumes responsibility for that patient and works hard to wrap care around them. That cannot be said for the entirety of Australia and New Zealand. In Scotland, we can be proud that we are moving close to that, and it will be the outcome by—I hope—the end of the year.
In response to Emma Harper’s questions, I was going to suggest that Michael Donald should say what he has just said. I am glad that he has spoken about that and I will not go back to it. His international experience and his reflections on what has happened here are telling and important.
To extend what Michael Donald said and address Emma Harper’s point about international learning—I am getting a lot of echo, so I ask the committee to forgive me if I sound stilted—I note that we have had visits from teams from Norway, given presentations at meetings in New Zealand and Denmark and had visits and queries about how we are setting things up from governmental and healthcare organisations in Qatar and Philadelphia. I suggest that—surprisingly—the balance of information flow is in the opposite direction, which goes along with what Michael Donald said. People are asking us how we are doing this, which is important for the network’s kudos and prestige and for how it has been set up.
I will be brief, as a lot of what I was going to say has been mentioned. I give the absolute reassurance that there is a huge amount of shared learning. All the trauma units and major trauma centres have their own morbidity and mortality meetings at which difficult cases are discussed. We have regional meetings at which we discuss such cases in more depth and national meetings at which we do so again. We produce quality improvement newsletters that contain shared learning points about what could have been done better and what went particularly well.
As with other regions, those from the south-east have visited trauma centres in Nottingham and St George’s hospital. Working in major trauma centres outwith Scotland is still part of the job contract of some colleagues in the south-east. There is a flow to and from places.
Before Covid, Martin McKechnie and the team set up excellent national days every year when we heard from guest speakers from all parts of the world. They gave us top tips, quick wins and low-hanging fruit to pick so that we could change patient care.
I give the absolute reassurance that there is a huge amount of shared learning. Our regional and national clinical governance structures, which did not exist before, have made a huge difference.
I will answer a bit of one of Emma Harper’s questions. The changes that are taking place in pre-hospital care are detailed in our submission. We have three levels of response to major trauma patients.
To answer another question, the key thing that we learned from Australasian models was that clinical co-ordination of the assets is needed. To get past the geographical boundaries and the challenges of working round mountains and lochs, we need someone who is at the centre of everything to ensure that the limited resources are directed to the patients who need them most.
The key point that we learned from other parts of the world was that we need someone in our control centres to point the assets at the right people. That is why we have invested heavily in the trauma desk model of clinical co-ordination.
As a paramedic, the big change for me is that, through the network and the relationships that we have built with the people who are on this call today, for the first time, we are receiving feedback on our performance in looking after our trauma patients. That has been a massive change, and those relationships, which we did not have before, are what will bring about big improvements in pre-hospital trauma care.
Good morning to all the witnesses. Many of my questions about pre-hospital care and the main changes have already been answered. How is the standard of pre-hospital care assessed? How do you grade it, as it were?
As Martin McKechnie said at the start, ultimately, we will grade the quality of the pre-hospital care that we have delivered on the basis of the feedback from the major trauma centres and through the relationships that we have with them. When we bring patients in, there are expectations about how they will have been looked after—[Inaudible.]—and which medications they will have been given. If that care has not met the required standard, we will hear of that through our various governance meetings and feedback from our colleagues in the major trauma centres. We have our own suites of internal measures, which are in their infancy. However, in trauma care, identifying the things that can potentially kill our patients and treating those as quickly and effectively as we can are the most important factors for us.
From evidence, we know that we tend to lose people in pre-hospital scenarios because of things such as bleeding, chest injuries and major head injuries. A great deal of the investment that we have made in trauma care, particularly at the green level—the paramedic level—has been in equipment and medications that can address those issues. Those include better splints and tourniquets to stop bleeding and pre-hospital medical teams that can give patients blood at the side of the road, which is a completely new thing. We also have advanced practitioners, who can give adequate analgesics to trauma patients, over and above what we could give before. Chest injuries can now be addressed at the side of the road by performing surgical procedures that previously could have been provided only in an emergency department.
As I said, to answer your question, we measure the effectiveness of pre-hospital care on the basis of feedback from our colleagues in major trauma centres. That is why the idea of the network is so important—because that is how we will gauge the effectiveness of our work.
I hope that that answers the question.
Yes. I will bring in Edward Dunstan now.
The Scottish Ambulance Service is an absolutely key part of our family—our team. There is a representative of it at every regional clinical governance meeting. It has warning about the patients who are chosen to be discussed, and we are able to go through a patient’s journey, all the way from the first 999 call. Sometimes we even listen to the recordings of those phone calls in the meetings, and we are able to support and offer peer review of the decisions that were made. For example, we look at whether the patient was transferred to the major trauma centre—[Inaudible.]—by land or by air and whether they bypassed the local trauma unit. Everything is broken down into time slots. We are able to offer peer support and critique to see whether anything could have been done better. If there are things that could have been changed, we share the learning points through our quality improvement newsletters, which we share across the region and discuss nationally. The role of the Scottish Ambulance Service is critical. We support each other, and there is critique when it is required.
On the point about pre-hospital care and the changes and improvements with the Scottish Ambulance Service through the network, the feedback from the remote and rural hospitals and the local emergency hospitals is that the creation of a single-point-of-contact critical care desk with the ability to reach expertise and support for what are still relatively infrequent events in some rural places has been revolutionary. A number of senior clinicians on the islands and in places such as Caithness have spoken highly of the changes. They used to make many phone calls to arrange care and seek advice, but there is now a network, so they have one point to contact. That has been a huge benefit to pre-hospital care and the initial staging into hospitals.10:45
I will take Donald Cameron’s question a bit further. In addition to the governance aspect that you have heard about from Peter Lindle and Edward Dunstan, it is important to understand that the Scottish trauma audit group absolutely scrutinises us—in fact, it sometimes feels as though we are being persecuted by it—in relation to improving and assuring our quality. STAG feeds into the network externally and looks at patients who stay in hospital for three nights or more as a result of trauma.
We are trying to extend that remit into general information governance. We have appointed an information manager to consider trauma information from other areas, such as the Department for Work and Pensions, the Crown Office and Procurator Fiscal Service, the police and fire services, and the Crown Office if the matter crosses borders into England and beyond. To answer your specific question, we are trying to get all the data in order to get the whole picture.
To take the point a bit further, you will have seen links in our submission to both STAG and the trauma app. We are developing the app to get a much higher standard of recording, safety governance, quality improvement and quality assurance. All those things coming together will create a far more robust structure of governance and safety for patients, and provide for the quality-assured performance of the staff of all constituent parts of the network.
Evidence suggests that, if we do well all the things that Peter Lindle and Edward Dunstan described, we are probably looking at a 30 to 40 per cent reduction in deaths in hospital. By that, I mean that, if we improve the pre-hospital care, by the time they get to their definitive care in the trauma unit, the major trauma centre, or even the local emergency hospital, a third or more of the patients who previously would have died will not die. Accompanying that is an expected reduction in the length of hospital stays. The bang for buck here—which is important to me and, I am sure, to you—is based on improving the clinical care that is provided from the minutes after the accident or injury.
STAG has been great. The clinicians are really involved in the data and looking for improvement.
The culture of the network is very supportive. There is constructive challenge, which is good. It is about working together—without the network, that would not exist—and there is a focus on quality improvement.
Thank you for those comprehensive answers.
I want to ask about transfer times. We know that trauma systems work to an optimum transfer time threshold of about 45 minutes. This may seem to be an obvious question, but how important is it to get patients to a trauma unit within 45 minutes, and what proportion of patients have been transferred in that time?
The evidence around the timing of 45 minutes is not particularly strong. You will have seen that some of the English networks have recently expanded that to 60 minutes. I guess that that is our starting point. We will be looking to use the network to assess whether that time limit is correct, and maybe to extend it, as has been done down south.
On your question about how many people have been transferred within the time, I would need to look at that and come back to you on it, if that is all right. I am happy to submit some data on that to the committee’s clerk.
My final question is also about transfer times. We know that 14 per cent of the Scottish population are outwith the 45-minute threshold for transfer to an MTC and that 7 per cent of the population are unable to reach an MTC or a trauma unit within 45 minutes by road. Many of us on the committee represent rural communities that may be particularly affected by that. What is being done to mitigate the effect of longer transfer times on people who are unable to reach a unit or an MTC within 45 minutes?
We acknowledge the challenge of having such a large part of the population living on islands and in remote communities. To address those challenges, we have put together our Scottish specialist transport and retrieval service—ScotSTAR—teams. You will be aware of those teams—we have just put in a new one as part of the work of the trauma network in the north of Scotland. The idea is that, when someone cannot make it to a major trauma centre or trauma unit within the ideal timeframe, we can use one of our ScotSTAR consultant-led retrieval teams to bring the emergency department to them. We can provide a lot of the interventions that people would expect to get in the first few minutes of arriving at a major trauma centre by sending one of those teams out to the patient by helicopter or fixed-wing aircraft. Whether the patient is in a district general hospital on an island or even at a remote general practice, we can send out those consultant-led teams, and effectively take the care to the patient. That makes use of the air assets that we are very lucky to have in Scotland. We can use our two funded air ambulances, which our charity ambulance colleagues support us with, and our fixed-wing aircraft to cut down the timeframe.
I mentioned clinical co-ordination. We identify people who need that type of help as quickly as possible by having clinicians listening to 999 calls as they arrive and ensuring that the assets that we have at our disposal are tasked as quickly as possible, which minimises the delay in getting patients to where they need to be.
Peter Lindle has said pretty much what I was going to say, but I will add a little to that.
We took a conscious decision in the core group, which was ratified by our network steering group, not to go to 60 minutes. We challenged ourselves to deliver the 45-minute standard. That is currently being measured. The data is unpublished, but we will report on that in due course, once the network is fully established.
Mr Cameron’s point is well made. We bring the expertise to the patient. A development in that sense has been ScotSTAR north, which has involved collaboration with Scotland’s Charity Air Ambulance. We now have fixed-wing and rotary assets based in the north at Aberdeen airport, which we did not have before. We also have the augmented pre-hospital immediate care team—PICT—at Raigmore hospital in Inverness, which has a range and a capability for a lot of roadside accidents up in Mr Cameron’s neck of the woods. With support from the trauma desk and the ScotSTAR teams, we aim to deliver care in that critical time window when we know that the most severe injuries cause the most damage unless they are managed immediately.
We have collaborated in our pre-hospital group with the British Association for Immediate Care Scotland—BASICS—service of advanced trained general practitioners in remote and rural communities and the Sandpiper Trust. They are part of our on-going education system to deliver augmented roadside care until we either transfer the patient to the appropriate facility or the red team comes to the patient.
For certainty, you said that a decision was reached to stick with the 45-minute target rather than changing it to 60 minutes. I take it that that was made on clinical grounds.
It was taken on clinical grounds, but it was based on perhaps more urban environments. We see that as a lever to improve pre-hospital care across the whole of Scotland. The job that we have been tasked with is to deliver equity of care, whether a person is in Orkney, Dumfries, Stornoway, the Borders or the urban central belt.
Martin McKechnie got it on the nose. It is about equity of care. No matter where a person lives in Scotland, they should have access to exactly the same resources that someone else has access to. In the south-east, we are an urban trauma network, which means that the vast majority of our patients are within a 45-minute reach. However, I reassure the committee that not only major trauma centres have minimum requirements; the trauma units do, as well. The trauma units can still supply a significantly high level of care for critically injured patients if that is required. That has required investment in staffing and training in the trauma units.
For instance, a minimum requirement in a trauma unit is that there must be the ability to open the chest of a critically injured patient. Essentially, that is extremist life-saving surgery. Those skills have been disseminated. There is a minimum requirement for the nursing and the doctors, the seniority of doctors, and the time that key specialists need in order to get to the emergency department. It is about networks and not just the major trauma centre, and it is about upskilling the trauma units in case they have to deal with those patients.
We have also worked very hard nationally on hot transfers. It has to be remembered that up to 20 per cent of people who are critically injured will self-present to a hospital or a trauma unit and will not be picked up by the Scottish Ambulance Service. We have worked hard nationally on protocols on how to get those patients, who might be unstable in an ED, to go from ED to ED. The committee heard earlier on from James Anderson, I think, that, previously, a person would have to pick up the phone and call a lot of different people in different specialties to get the patient accepted. That is not the case when the network goes live. There is a single point of contact. If a trauma unit calls a major trauma centre, there will be no denying of that patient being transferred. The patient will be put in an ambulance with the appropriate staff, and they will get to the major trauma centre in a timely manner. I reassure members that our trauma units are also very capable of dealing with major trauma patients.
Much has already been said. Through our governance process, a couple of incidents have been identified of late in which it was crucial that either the red team or PICT was able to triage on scene and make those—[Inaudible.] In those cases, that had a direct impact on survival.
My questions are on triage, although some of them have been answered.
A key role of the Scottish Ambulance Service is to triage patients to the most appropriate hospital for their needs. The service is guided in those decisions by the major trauma triage tool. Are the triage decisions and the MTTT subject to any kind of audit or evaluation? I know that STAG has been mentioned, but I would like to hear more on that issue from the panel members.
We have the major trauma triage tool, which is based on and similar to other tools that are used around the globe. When the tool goes live, our paramedics document the decisions that they have made using it on our electronic patient report forms in the backs of ambulances. Once paramedics have made a decision, they key in how they made it by choosing exactly which trigger caused them to make that choice of destination. All the data is collected electronically and shared with STAG. The tool has already gone live in some regions and, as soon as it goes live in the other regions, we will be collecting that data.
Of course, we will look at whether the tool is sensitive enough—whether it over-triages or under-triages patients too often—and, as has been said, the trauma network will meet to tweak it accordingly. That is absolutely our intent.11:00
Have the changes to triage improved patient outcomes? I know that that was mentioned earlier, but will somebody expand on it?
That would be for the STAG data to tell us. The triage tool has been live for a while in the north and east of Scotland networks. In those networks, because the geographical distances between hospitals are so large, a 45-minute triage does not make a huge amount of difference in where the patient will end up. Of all the regions, the west of Scotland network is where we will see the biggest difference in the places to which patients are triaged. We need to wait to see the impact of that through the STAG data and to see whether triage is making a big difference in patient outcomes.
Other panel members might want to come in on that.
The answer to David Torrance’s question is not yet—we cannot yet prove results, because the network is not fully live, but there is strong evidence from our overlapping clinical governance set-ups. By that I mean the Scottish trauma network clinical governance structure, the Scottish trauma audit group structure, and the trauma desk at the Scottish Ambulance Service and its clinical governance structures. We all overlap, feed into one another and learn.
There is some evidence that the processes and the times to treatment, times to computed tomography scan for head injury, and times to assessment and administration of, for example, anti-bleeding or anti-infection drugs are having an effect on patient care. However, the long-term results from traumatic injury are, by their nature, long term. We will see increased survival, but we are looking for the quality of that survival. At the risk of sounding brutal, I point out that a lot of trauma patients are young, and it is in the best interests of society that we rehabilitate and resuscitate them to the maximum so that they become functioning members of society again.
The bang for the buck in the long term remains to be proven, but I think that it will be. However, there is clear evidence that it takes about five years for that information to really begin to feed through so, if we are allowed to reconvene in five years, we could probably tell you the full story. I hope that, over the next few years, we will begin to see upward trends.
That sounds like the term of the next session of Parliament.
I want to push a little further on outcomes, because the trauma centres were created in the hope of saving additional lives. The STAG report shows mortality for trauma patients and estimates that, in four of the last seven years, the number of survivors has been lower than the predicted number of survivors. How reliable is the analysis of mortality, and should we be concerned by those findings?
It is reliable in the context of what STAG reports, which relates to patients who spend three days or more in hospital as a result of traumatic injury. Earlier, I alluded to the fact that there is an area of governance that has never really been explored, or has not been joined up, I should say. I am referring to people who die at scenes and people who die very quickly after traumatic injury. There is information on that from the Procurator Fiscal Service, the police and other public bodies. We have formed initial links and relationships with those bodies and, in years to come, we hope to be able to report about how those gaps were filled and perhaps give a more robust structure for the answer that Mr Whittle seeks.
The evidence from our governance structures so far is that early interventions are improving patient care and that the training and education that we are putting in place are augmenting that.
If I could summarise the point, I was saying that you might be able to analyse the data to examine the factors that might be impeding survival and perhaps to explain away the initial STAG report findings. Do you have access to that kind of data?
As I said, we have access to some of that information. Additional information will come as our information probing extends. Part of that is because the information manager who we have appointed will have access to data across public health, STAG data and Government data. The picture will become clearer.
The other aspect is that the governance structures that we set up are increasingly mature and refined, and I hope that that will translate into easily publishable data. However, it takes some time—until we come to the end of each patient’s journey—to prove that it was, in fact, effective.
To return to a previous question, the trauma triage tool is absolutely evidence based, and we took a long time picking useful bits from other major trauma systems. With the English model, it was probably five to eight years before robust improvement could be demonstrated in care in England.
As Martin McKechnie has discussed, it is not just about survivability—that is not what we are dealing with; it is a whole different picture. We are dealing with reducing disability and reducing the economic and social burden to the individual, the individual’s family and society. A lot of that is about reducing psychosocial impairments. I have talked about reducing family disruption and addiction, and about an early return to work. You must remember that only 36 per cent of critically injured people with major trauma return to their normal place of work within six months. That is why rehabilitation—which is a massive part of the project—is key.
You need to think about the reduction in tax revenue that is caused by major trauma, and the change in benefit uptake from reducing major trauma. By putting all these systems in place, we should absolutely be able to show not just the physical and psychological benefits but the financial benefits of dealing with those patients in a scientific and evidence-based manner.
One thing that we never did previously in the south-east was gather patient-recorded outcome measures, or PROMs, which concern the physical and non-physical wellbeing of an individual. As part of our key performance indicators, PROMs now have to be gathered and presented, and they will come in through the STAG audit.
We now have a major trauma co-ordinator in all of our regions. They are a first point of contact for all our patients who are injured. Those individuals follow up patients not just in a hospital setting but after they have been discharged, ensuring that they have access to appropriate pain clinics, physiotherapy, rehabilitation and all those sorts of things.
The things that have been done have been a game changer—it is like night and day. The changes that we have seen since 2017 have been extraordinary and I assure you that they are to the benefit of the population of Scotland.
I am conscious of the time, so let us move on.
I wish to move on to consider key performance indicators. How do you evaluate the results of each KPI, and how do you remedy poor performance?
[Inaudible.]—by scrutiny across the various bodies that are involved in the trauma network. We do it through the governance structures that I have described, with STAG as a crucial part of that.
If poor performance is identified via those sources, it is my job to address that. However, I am happy to say that the integrity of all the people who work in the network means that I have not yet had to wield any of that soft power, because any deviation from an accepted standard or benchmark that comes out of the scrutiny or poor performance via the governance structures is automatically and swiftly dealt with at regional level. That is the answer to your question. The system is internally governed, but with scrutiny from external structures that overlap with every aspect of the trauma network’s function.
Thank you for that answer. I got most of it, although you were muted just at the start, unfortunately. I got the drift of your answer, however.
If my reading of the results are correct, performance improved across the board between 2018 and 2019, with one exception regarding computed tomography scans and, specifically, the time to undergo a head CT scan. Why was that?
Basically, we had parameters that were not practical. The structures around CT scanning required a lot of external input from the radiology services and from reporting systems, as well as the availability of scanners. Under our embedded KPIs, we want to get people into a CT scanner within a very short time of their arriving at an emergency department. Not every department was set up in a way that allowed that to happen but, through various measures and collaborations with the radiology managed clinical networks as well as through STAG, we have been able to refine those parameters and to review some of the criteria, based on clinical evidence, that mandate CT scanning of the head at various points in the patient’s journey.
Part of that involves a collaboration between us and our colleagues in radiology—by which I mean X-ray and CT reporting. A lot of new investment has taken effect in the world of radiology, and that is now bearing fruit in the management of trauma patients. It is easy to get quick CT in major trauma centres and in lots of trauma units, but it is not so easy sometimes in the more remote hospitals. However, a lot of reporting and investment in radiography staff has since taken place, and the information is coming to us much more quickly, which will ultimately be to the benefit of the patient, based on a neurosurgical decision for the treatment of their head injury, for example.
That was very clear. I can fully understand that. For the 2020 KPI, which you compare with 2019, are you changing the goalposts in what you analyse, or are you keeping the same measure? If so, do you hope to improve the 2020 KPI compared with the 2019 one?
I would use the term “refining” rather than “changing the goalposts”. I know that you will appreciate that terminology.
The analysis is based on clinical evidence. I have alluded to the pressure that my senior team and I perhaps put on the network not to drop our standards but to strive to achieve the highest and best standards. I am not surprised that there have been some dips in performance—I expected that. I also expected the rebound improvement in performance that is now coming through.11:15
I am conscious of the constraints on our time, convener, so I will go to my last question, which is on an issue that might have been touched on earlier. Has there been any significant increase in trauma from self-harm since the start of the pandemic?
That has been mentioned by one or two of the witnesses. Does anyone in particular want to respond?
The answer is yes, there has been. A lot of that is lockdown or pandemic related. People have struggled and, unfortunately, we have seen a lot of serious violent self-harm and harm to others. I would not say that that was unpredicted, but it is a new feature of some of the cases that we have been seeing during the past year.
Treating those patients’ physical injuries has been part of the trauma network’s remit. However, as James Anderson, who is a clinical psychologist, would state, the on-going aftercare and rehabilitation of the patient is much improved.
That is very good to know.
I am conscious of the time. I have not been able to call some witnesses to respond, so I will be directing one or two questions to witnesses after the event.
George Adam will ask our final questions of this session.
I was interested in Edward Dunstan’s point about the trauma co-ordinator’s role being a “game changer”. I agree, having read about that. As has been said, rehabilitation is a long process. A patient being seen by a trauma co-ordinator within three days of their stay at hospital and creating a rehabilitation plan for them while they are in hospital and for when they are at home is obviously the way forward.
I have two brief questions. How well received have the co-ordinators been by patients, who, at the end of the day, are the most important people? Could such a role be used for other services?
Perhaps James Anderson would like to comment on those questions.
I will again do so quickly, convener. The short answer is that the trauma co-ordinator roles have been very well received.
The experience of major trauma for the patient and their family is extraordinarily complex. There are an enormous number of systems and specialties, and having one or two people who you can contact, who your family know and who will speak to you when you are discharged is hugely useful in finding a way back into the systems. That single point of contact for the patient, which in a way reflects Peter Lindle’s point about the ambulance service, has been useful and well received.
I think that the role has utility for other conditions in which multiple specialties are involved, and we have had interest in it as a model.
Excellent. I thank all our witnesses for that comprehensive introduction to and report on the work of the trauma network and centres across Scotland. There are a number of matters on which the witnesses offered further information following the session, and there will be other questions that we will want to explore further in writing. We will seek your co-operation in that.
Thank you very much for attending. We look forward to a future report to Parliament on further development of the network, as Martin McKechnie described.