Major Trauma Services for London

1. Major Trauma Services for London Commissioning and Finance Arrangements Sean Overett Divisional Director London Specialised Commissioning Group

2. Background • The London Commissioning Group (LCG) has asked the London Specialised Commissioning Group (London SCG) to develop proposals for the commissioning of Major Trauma for 2010-11 • New pan-London service • SACUs only just coming on-line • London SCG is experienced in establishing and running pan-London commissioning arrangements • The London SCG has identified a lead commissioner to develop proposals • sean.overett@londonscg.nhs.uk / 020 8433 6856 • Currently consulting with stakeholders and developing final proposals

3. Fixed / Confirmed by PCTs • Number of MTCs: 4 • Service Start Date: 01.04.10 • (For 3 MTCs, I to follow) • Patient Identification: ≥ISS 16 • Patient Activity: c1600 pa +/- • New PCT Funding: £13.9m • Funding Start Date: 01.04.10 • (For 3 MTCs, I to follow)

4. Establishing the incremental costSummary of costs included in pcb(Slide from HfL MT programme- Establishing the current and future economics – briefing for LSCG) 3 MTCs 4 MTCs £m £m Enhanced Specification 7.8 10.4 Concentrating a loss 2.4 2.4 making service Central Network 0.3 0.3 infrastructure Volume reduction to PCTs (1.1) (1.1) System costs arising from 1.0 0.9 changes to MFF Ambulance costs 1.0 1.0 Overall 11.4 13.9 This is estimated at £2.6m per MTC (work still underway) and would scale according to the number of MTCs. Variable cost is greater than income, ie a loss is created for every additional unit of activity transferred into the new MTCs,   The corollary of this is a small (<£0.1m) positive effect in peripheral hospitals from not undertaking major trauma This does not correct baseline shortfalls and relates only to the activity shifts under the new system.

5. Proposed Commissioning Approach • PCT contributions • Contribution to £13.9M will be pro-rata to annual PCT allocations • Identifying major trauma patients • Major trauma centres and trauma units will submit a compulsory data set, (as agreed between the London Trauma Office, London SCG and TARN), to the TARN Database within agreed timeframe. Patients who TARN rates as ISS ≥16 will be considered major trauma patients for the purposes of these commissioning arrangements. • TARN will provide details of each major trauma patient to the London SCG. NHS Number will be collected and provided. SACU/PCTs will be provided with details.

6. Commissioning HRGs for MT patients • Cannot separate major from significant trauma by HRG code, so • HRG activity for all trauma will continue to be commissioned by the PCTs – through the respective SACU. Cross referencing the NHS number between TARN identified ISS ≥16 patients and the PCTs should allow for detailed analysis by ICD10 and HRG to better inform future arrangements • Funding additional needs of MT patients • Need to take account of the additional resources used in the treatment and care of the major trauma patient, so • For each major trauma patient, (as confirmed by TARN), above the existing baseline activity, (and where critical care costs are around London average), it’s proposed that the major trauma centre will be paid a top up to the HRG of £2K per patient

7. Funding the MT service specification at MT centres • A ‘quality premium’, i.e. the annual payment to major trauma centres to fund the additional costs of establishing and funding the resources to meet the major trauma service specification, of c£2.6M per MTC will be funded as follows: • 70%, (c£1.82M) will be paid in April 2010 up front following the successful assessment by the review team in January 2010 that the major trauma centre will meet the essential requirements of the service specification to the required timescale. • A further 10%, (£260K) will be paid at each of three in-year review visits by the London Trauma Office, London SCG and relevant SACU following successful demonstration of achieving performance indicators / implementing best practice etc.

8. Contracting Arrangements • The London SCG will develop an appropriate contract schedule for major trauma to be included in the London SCG Specialised Services Contract with each of the major trauma centre providers. The schedule will include the financial values and payment timetable; the service specification, performance and monitoring requirements • SACUs will be provided with copies of the trauma specification that relates to trauma networks and trauma units for inclusion in their contract documentation with major trauma centres, trauma networks and trauma units. SACUs will be involved in the performance management of the relevant areas of the service specification at both trauma units and major trauma centres in conjunction with the London SCG and London Trauma Office

9. HEMS commissioning currency may need to be adjusted to reflect new arrangements and prevent two-tier approach to funding MT • The funding arrangements for patients transferred from a major trauma centre to a trauma unit needs to be clarified and agreed so that: • PCTs are not charged twice for the same episode of care • Trauma units are funded for the transferred patients they take • There is a need to transfer patients in an effective and timely manner through the system in order to not restrict capacity at the MTC, e.g. • Major trauma centre to trauma unit • Major trauma centre or trauma unit to rehabilitation • Implementation of the pan-London trauma model may result in increased demand for neuro and spinal rehabilitation services

10. Sustained over or underperformance at any MTC will require a review to be undertaken of its impact on the operation, delivery and quality of care • Out of London PCTs / SHAs • There is a need to understand the major trauma pathways being established by neighbouring out of London PCTs/SHAs • Out of London PCTs will be advised that where their (TARN identified) major trauma patients are treated at a London MTC • from 2010-11 they will be liable to pay the HRG top up • From 2011-12 they will be liable to pay a pro-rata share of the quality premium. (Likely to be based on validated activity in 2010-11)

11. Governance Arrangements • Detailed work on the governance arrangements for the London trauma office, the major trauma centres and trauma networks continues • Accountability for the London SCG commissioned element of the major trauma service will be through the London SCG Chief Operating Officer to the London SCG Executive and then through to the London Commissioning Group • Accountability for other trauma will be through the appropriate contract to the SACUs and the PCTs and the London Commissioning Group, with relevant elements of performance management through the Trauma Networks and London trauma office as appropriate • The Joint Committee of the PCTs, (JCPCTs) will require assurance that the agreed model and pathways have been established, and are operating as planned

12. Summary • £13.9 M of investment by the PCTs to implement a pan-London major trauma system • The quality premium and the HRG top-up will be contracted and performance managed by the London SCG in conjunction with the London Trauma Office. The major trauma centres, trauma networks and SACUs will be involved in the relevant elements of the contracting and performance management process as appropriate. • Out of London PCTs will be required to pay the HRG top-up in 2010-11 and a pro-rata share of the quality premium from 2011-12. • These are the initial commissioning arrangements. These may change in the light of experience, increased information, developments in PbR. • The London PCTs will want to see evidence that their investment and that of the providers, clinicians and operational staff have resulted in in the expected improvement in the care and outcomes of people with trauma