Professor Keith Willett has been set the task of redesigning and improving NHS trauma care. Richard Staines and Steve Ford report on his plans and how they will affect nursing
Nurses are set to play key roles in making a planned shake-up of NHS trauma care a success, according to the Department of Health’s trauma tsar.
Keith Willett, professor of orthopaedic trauma surgery at Oxford University, took up post as England’s first national clinical director for trauma care on 1 April this year.
Since then he has generally kept a low profile while formulating how he is to achieve the main priority of his remit – to improve the quality of care for trauma patients, in line with the broader aims of the NHS next stage review.
While his task involves improving services for two very different patient groups – older patients with fragility fractures and those with serious traumatic injuries – the solution for both groups is seemingly the same.
In an interview with Nursing Times, Professor Willett said the key would be to make all trauma services more joined up than at present with more multi-disciplinary working and a series of clinical networks.
For both groups of patients, he said, there is a need to take a more co-ordinated view and break down any barriers between professional teams.
He said: “[My main task] is to create integrated fragility fracture care, and to construct regional trauma networks.”
These are intended to ensure that patients are treated by the best professional team for each stage of their care – from initial treatment, to rehabilitation and on to eventual discharge – moving from one team to the next as their condition allows.
While serious trauma affects a smaller percentage of NHS patients than fragility fractures, the range and complexity of injuries encountered means that highly specialised care is needed.
Professor Willett said that, at present, the NHS was not adequately organised to provide these patients with most appropriate care at the right time.
“There are high numbers of patients, high activity – the volumes far exceed the capacity of the hospitals in each area. There is no infrastructure to get those patients the specialist care they need,” he said.
His aim is to develop a series of regional trauma networks, which hospitals “will link into”, so that a patient is sent quickly to the most appropriate place with the right specialist care available for their injuries.
These networks would then plug into an nationwide network covering the whole of England. The idea is based on the model already being set up to cover different parts of London but would be designed around local needs.
“What I am setting up is a workstream to bring [about] an integrated trauma network,” he said. “It will be a similar thing to London – but I would expect things to be very different in each area. The one in the South West Peninsula will be different from the West Midlands.”
Professor Willett suggested that specialist nurses may play a key part in triaging patients in such networks. “Nurses could have a trauma co-ordinating role,” he said.
However the profession looks set to be more involved in the second half of Professor Willett’s remit, which deals with the improvement of fragility fracture care. This is a hugely important area for the NHS that may get worse as the number of older people in the population continues to increase.
“There are 200,000 fragility fractures a year and it is one of the most expensive injuries that hospitals have to deal with,” said Professor Willett.
He has highlighted hip fractures as an area that needs particular focus. Treating hip fractures alone costs the NHS and social care in the region of £2bn a year.
“There are 70,000 hip fractures, accounting for 87 per cent of NHS spend on fragility fractures,” said Professor Willett. “The average length of stay for patients with hip fracture is 28 days on the NHS – that is a massive cost driver.”
He suggested it was a clinical area that had not previously received much political attention, despite the cost attached.
“It is a group of patients who have rarely been given primacy. The average of age of patients with hip fracture is 84 and three quarters of them are women. Often they don’t have the same influence politically, they don’t have the same advocacy in terms of family – they are not people who have others fighting their corner for them.”
“A third have dementia. The majority will have co-morbidities,” he added.
Like care for major trauma injuries, he wants the NHS to move to a more joined-up and integrated pathway approach. “What I need to do is to integrate the services,” he said.
“Integrated care is everything from falls prevention, osteoporosis [treatment] and rehabilitation of patients with fragility fractures,” he said.
Achieving this will require closer working from clinical specialties that have previously worked in a less cohesive way.
“There is a challenge because it will require joint working between two different disciplines – fractures and falls,” said Professor Willett. “We need to force that merger. Historically this requires two different medical specialities to be pulled together.”
In both specialities and at each level of the patient pathway, he sees nurses playing an important role in fragility fracture care. However, evidence suggests there are potential pitfalls to overcome before the nursing profession can fulfil its potential.
Research presented at the National Osteoporosis Society’s 2009 conference last month suggested that many acute nurses lacked training on identifying osteoporotic fractures.
Interviews with A&E, fracture clinic and orthopaedic nurses from West Wales General Hospital found misconceptions and knowledge gaps about osteoporosis prevalence, risk factors, detection and treatment.
To potentially counter problems such as this Professor Willett said he wanted to develop a baseline triage assessment for falls and bone health, which could be done by a nurse in different settings, from general practice to A&E.
“That will be an integral part of the initial assessment of the patient. Once they have done that, if the patient requires referral that may be through a fracture clinic or falls service,” he said.
Additionally Professor Willett highlighted the importance of specialist nurses both immediately before and then after orthopaedic surgery, and the need to make doctors aware of this. “You have to educate medics to really put them to the fore,” he said.
“The medical complexity requires a specialist team who have specialist nurses preparing patients for theatre,” he said.
He added that post-surgery it was critical to “get those patients to outpatients and into rehab” – again noting the key role that specialist nurses might play.
“[The team must] determine a patient’s rehab potential after surgery. Some people will be able to go straight home, other patients will need a lot more rehabilitation and to go home with some support.
“Some will have a significant reduction in their mobility and they need a different home environment – 15-20 per cent of patients need to go back to a different place. That is an assessment that can really be done by nurses,” he said.
One of professor Willett’s ideas for improving rehabilitation is the introduction of “prescriptions”, which would cover a range of services provided by both health and social care.
He said: “Rehabilitation for the severely injured patient in the UK is poor. Historically we have under invested in rehabilitation. There is a lot of important work to be done.
“One thing I am working on is a prescription for rehabilitation,” he told Nursing Times.
“That prescription tells the hospital and the rehabilitation nurses the treatment the patient is going to receive,” he said. “Nurses will have responsibility for ensuring patients get the treatment in that prescription.”
While there is little doubt that NHS trauma care is in need of reform, its high cost is almost certainly a factor in the government’s appointment of a tsar. However, Professor Willett maintains that increased efficiency and quality – with the nursing profession playing a central part – will be the way to achieve this.
“Cost effectiveness and quality are two components in the same sandwich. NHS expenditure will be reduced by quality treatment,” he said. “There is a need for specialist nurses.”
The trauma tsar: Professor Keith Willett
Appointed national clinical director for trauma care on 1 April 2009-08-26
Professor of orthopaedic trauma surgery at Oxford University and continues to work as honorary consultant orthopaedic trauma surgeon at John Radcliffe Hospital
Co-founded the unique consultant-delivered Oxford Trauma Service in 1993
Co-founded the Kadoorie Centre for Critical Care Research and Education, and the Oxford Trauma Research Group in 2003