Injury, Int. J. Care Injured 34 (2003) 728–734

Trauma care systems in the United Kingdom

John Albert∗, Hugh PhillipsDepartment of Trauma and Orthopaedics, Norfolk and Norwich University Hospital, 77 Newmarket Road, Norwich NR2 2HW, UK

Accepted 10 April 2003

1. Introduction

It has long been established that death after major injuryand long term morbidity depends not only on the severityof the injury sustained but also on the standards of treat-ment[1]. Throughout both the developed and the developingworlds, death and disability after severe injury, increasinglythe consequence of road accidents[17], place an increasingand unacceptable burden on society, particularly as most ofthe victims are under 40 years of age[8].

More than 30 years ago studies in the United States, andsubsequently in Europe, showed unequivocally that earlyand effective resuscitation and rapid transport from the sceneof an accident to an appropriate hospital which can pro-vide effective, definitive care, reduces mortality and morbid-ity [4,5,18]. In the late 1970s, West and Trunkey publishedthe classic study from Orange County in California, whichdemonstrated that patients taken to a centre with special ex-pertise in the management of major injuries had a muchlower risk of preventable death than those taken to the near-est local hospital[19,20]. Within a few years regional traumasystems were developed and centres were categorised ac-cording to the facilities and resources available. At the sametime the organisation of Emergency Services was centralisedso that victims of injury could be triaged at the site of anaccident and taken to the most appropriate facility.

In 1988, a report from the Royal College of Surgeonsof England (RCSEng), on the management of patients withmajor injuries, demonstrated many of the deficiencies inthe system of trauma care in the United Kingdom[7]. Thereport was based on a retrospective study of 1000 traumadeaths and it showed that of those patients who reachedhospital alive and who later succumbed, 1/3 of their deathswere preventable. The report concluded that patients withmajor injuries should be managed in large acute hospitalswith a wide range of facilities and access to experiencedsenior staff; that there should be improved training for all

∗ Corresponding author. Tel.:+44-1603-286717;fax: +44-1603-766693.E-mail address: jalbones@aol.com (J. Albert).

staff dealing with major trauma and that much investmentinto trauma research was necessary. It also recommendedthat pre-hospital care should be improved, with enhancedtraining for ambulance staff and better methods of transportto major centres[2].

At about the same time, a prospective study was carriedout by the Royal College of Surgeons of England on 150patients with major injuries admitted to four hospitals. Only11% of the patients were seen initially by a senior registrar,or a consultant. Seventy-one of the 150 patients requiredsurgery; a consultant was present at only four of these inter-ventions. The overall mortality in this group of patients was21% and in a third of those who died the recovery probabilityhad been greater than 50% using TRISS methodology[21].

In 1989, the British Orthopaedic Association produced areport: ‘The Management of Trauma in Great Britain’[15].It was recognised that too many patients with severe injurieswere being admitted to relatively small units with neitheradequate facilities nor significant consultant input and thatthere were too few consultants with a special interest intrauma care. The recommendations of the RCSEng report(1988) were endorsed and it was also recognised that betterdefinitive care should be provided for patients with severebut, non-life-threatening skeletal injuries.

Further reports on the management of skeletal trauma andseverely injured patients were published by the British Or-thopaedic Association in 1992 and 1997[16,12]. Both thesereports reiterated the same themes: there was no unified sys-tem for trauma care in the United Kingdom; many patientswere still being taken to hospitals with inadequate staffing,experience and resources; many hospitals were unable tomaintain an adequate standard of care, partly due to lack offacilities and partly due to lack of experience and frequentexposure to major trauma.

The advantages of the American and European systems ofRegional Trauma Centres, which were ranked by the facili-ties and expertise they could offer, were discussed. By defi-nition a ‘Level I Trauma Centre’ in the United States wouldhave all surgical specialities represented on site with seniormedical staff available in all those specialities 24 hours aday, to provide optimal care for the most severely injured.

0020-1383/$ – see front matter © 2003 Elsevier Ltd. All rights reserved.doi:10.1016/S0020-1383(03)00151-7

J. Albert, H. Phillips / Injury, Int. J. Care Injured 34 (2003) 728–734 729

Table 1

Major A&E departments 262A&E + neurosurgery 25A&E + neurosurgery+ thoracic 10A&E + neurosurgery+ thoracic+ maxillo-facial 10A&E + neurosurgery+ thoracic+ maxillo-facial

+ plastic surgery6

The cost implications of the development of RegionalTrauma Centres, with the re-organisation of specialities andspecialist hospitals that have grown up across the UnitedKingdom in an adhoc manner, were recognised. In theUnited Kingdom in the mid 1990s there were only sixhospitals where all specialities were represented on onesite (seeTable 1). For geographical, historical, but largelyshort-sighted financial reasons, the American model wasnot recommended. It was agreed that the bulk of majortrauma should still be treated in District General Hospitals(DGHs). The concept of hub and spoke trauma systemswas introduced, in which DGHs, the spokes of the wheel,would work together and in collaboration with a large acutehospital at the hub.

In this model, some 30 large acute hospitals around theUK would provide regional specialist expertise in most as-pects of trauma and would provide an integrated system ofcare, together with smaller hospitals in their region. A na-tional strategic plan was advocated to provide the quality ofcare seen in other developed nations[12].

Unfortunately, despite the profusion of reports all advo-cating the development of systems of trauma care and collab-oration between hospitals, there has been little support fromthe Department of Health, or other Government agencies,for an integrated national trauma care framework, largelybecause of the financial investment now necessary for sucha programme[13]. The political consequences of the re-configuration of emergency services required may have alsoproved a disincentive for action, politicians fearing the alien-ation of their potential voters by closing down cosy, but inef-fective, local Accident and Emergency departments in smallneighbourhood hospitals.

The most recent review of trauma care in the United King-dom is a joint report from the Royal College of Surgeonsof England and the British Orthopaedic Association (2000),entitled ‘Better Care for the Severely Injured’[3]. This com-prehensive review identifies the persistent lack of adequatetrauma care systems in Britain and strongly advocates thedevelopment of a national trauma service, which would raisethe standards of provision of care within an acceptable costframework. Unlike previous reports it also establishes ac-ceptable standards of care for patients with major injuries.All body systems are covered and, in addition, recommen-dations are made for initial assessment and resuscitation,anaesthesia, intensive care and rehabilitation. These stan-dards are designed to provide hospital Trusts with attainablegoals against which to audit current activity.

2. Trauma systems in the UK—the current situation

2.1. The incidence of severe injury

One of the reasons that there has been little enthusiasmfor the development of American style Regional TraumaCentres is that the pattern and incidence of severe injury isquite different in the United Kingdom from both the UnitedStates and the rest of Europe. Whilst it is accepted that themajority of traumatic injuries are musculo-skeletal and theincidence of new fractures in UK hospitals is over 900,000per year, significant musculo-skeletal injury occurs in onlyin one in sixty-four patients. The incidence of polytrauma,which can be defined as multisystem injury with an injuryseverity score (ISS) greater than 15, is at present 10,500 pa-tients per annum. This is equivalent to 1 per 1000 patientsseen in Accident Departments. The incidence of polytraumacontinues to decrease annually. If British hospitals see onlyfour severely injured patients per million population perweek, this means that the average DGH, with a catchmentarea of 250,000 people, may only see one such patient eachweek[12]. In spite of spectacular headlines identifying dra-matic increases in firearms-related crime, the incidence ofpenetrating injuries due to personal violence is still 30 timeshigher in the United States than in the United Kingdom.

The majority of severe injuries are the result of roadcrashes, and in the United Kingdom there has been a steadydecrease in the deaths from road traffic accidents (RTAs)since 1980, whilst the number of injuries has remained fairlyconstant (seeTable 2).

Deaths from RTAs in the UK are lower per 100,000 popu-lation than any other country in Western Europe, apart fromSweden. In 1997 there were 3500 deaths on the roads in theUnited Kingdom and 11,000 in France, which has a similarnumber of road users.

It is recognised that the most effective way of reducingdeath on the roads is by prevention; government legislationon speed limits, seat belts and legislation against drivingunder the influence of alcohol have had a dramatic effect.Improvements in car design and the development of airbagshave also made road accidents more survivable.

2.2. The cost of injury

The overall costs of major injury are difficult to estimatesince they also include the costs of lack of employment and

Table 2Road traffic and pedestrian fatalities, UK

Year Population (million) Deaths Injuries (thousands)

1980 54.4 6010 3291985 55.1 5165 3181990 55.8 5402 3411995 56.6 3650 3152000 56.9 3409 320

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rarely take into account the issue of patients, and indeedtheir families, as net tax contributors. Nevertheless, in a re-cent Government initiative on accident prevention (October2002) it was quoted that injury costs the NHS £2.2 billionper annum. Figures from the Department of Environmentand Transport, relating to death and injury following roadaccidents, estimated the costs in terms of medical expen-diture, loss of economic activity and the cost of pain andsuffering. In 1997 the cost of a fatal injury was estimated at£902,500, a major injury at £102,880 and a minor injury at£7970. Obviously the direct medical costs were only a smallpart of this total and were twice as high for a major injuryas for a fatality[12].

What these figures fail to show is that for every pa-tient dying as a result of a road accident, three survivewith long term disability. This often leads to the inabilityto work and maintain a pre-injury quality of life, and life-long reliance on State income. The failure to provide timelyand appropriate medical care after serious injury has enor-mous economic impact. It has been said that the value ofgood trauma care is that it returns the victim to tax-payingstatus.

2.3. Pre-hospital care

Following the 1988 report of the RCSEng, which iden-tified the need for enhanced training for ambulance staff,and improvement in communications between ambulanceand hospital, significant steps have been taken in the provi-sion of enhanced pre-hospital care for injured patients. Mostemergency ambulances are now staffed by paramedics withenhanced training, even up to university degree level, par-ticularly in emergency assessment and resuscitation. Pro-tection of the airway, intubation and ventilation and theadministration of intravenous fluids have all become moreprevalent in the pre-hospital management of the severelyinjured. The dilemma as to whether the emergency ser-vices should ‘scoop and run’ or ‘stay and play’ remains,but with better communications and the reduction in transittime to secondary care, there have been significant increasesin the number of severely injured patients reaching hospitalalive.

An important continuing problem is the multiplicity ofAmbulance Authorities, each with a separate organisation,requiring radical rationalisation.

During the past 5 years there has been a large expan-sion in the provision of air ambulances and helicopterservices, which have been particularly useful in the rapiddelivery of patients to secondary care in rural areas, andalso in urban environments where severe traffic is a prob-lem. The cost effectiveness of airborne transport servicesstill remains controversial, as the cost of running a he-licopter service is very high, but the continuing experi-ence in the United States, Western Europe and now theUnited Kingdom has ensured that helicopter services willcontinue.

2.4. Medical staff

In the late 1980s, the majority of patients admitted tohospital after major injury were seen first by the most in-experienced doctors with the least specialised training. Thehierarchical system of patients being reviewed first by aHouse Officer or SHO, then by a Registrar or Senior Reg-istrar and only occasionally by a consultant, has changedin the past 10 years. The development of Trauma Teamsand improved communication between pre-hospital andhospital services have led to more timely intervention byexperienced staff with regard to initial resuscitation, inves-tigation and definitive care. The almost universal adoptionof Advanced Trauma Life Support (ATLS©) principles inthe emergency management of injured patients has had animportant impact on the speed of access of the severely in-jured to definitive care[1,8]. However, for the less severelycompromised, who nevertheless have, for example, com-plex fractures, important delays still occur in investigationand definitive treatment, often due to inadequate staffing,or poor access to appropriate facilities.

The changes in training arrangements and the reductionin hours of work for higher professional trainees, have leadto substantial increases in supervision of emergency workby, and more direct involvement of, consultants in the frontline specialities. Most hospitals now have regular daytimetrauma lists where consultant involvement is the rule, at leastin theory, and although only one hospital, The John RadcliffeHospital in Oxford, requires that trauma consultants be resi-dent on-call, there is much more participation in out-of-hoursemergency work by consultants than there was 10 years ago.

However, the persistent lack of adequate medical man-power remains of great concern in the organisation and run-ning of an adequate trauma service. Britain still has halfthe number of consultants per head of population than mostother developed countries and the management of skeletaltrauma continues to have low priority both in the plans ofcentral government and at a local level in the hospital trustswhich provide secondary care. This is aggravated by politi-cal targets to reduce elective waiting lists; these distort med-ical priorities and compete forcibly with emergency traumacare for limited and inadequate resources. In most hospi-tals, more than 50% of the operative workload is trauma,but less than one third of the allocated operating time is foremergency work. This explains at least in part, why traumacases are consistently delayed. Hospital Trusts pay publiclip service to prioritising emergency care, whilst insistingthat waiting list initiatives take precedence in the operatingtheatre schedules.

Although consultants have been encouraged to take an in-creasingly large part in the direct management of skeletaltrauma, recruitment remains a significant problem. In a re-cent survey of orthopaedic surgeons in the United Kingdom,72.9% expressed a special interest, but only 7.3% of the to-tal identified this interest as trauma. Nevertheless, between85% and 90% of orthopaedic consultants in Great Britain are

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on-call for trauma. Both trainees and consultants are reluc-tant to specialise in skeletal trauma and post-trauma recon-struction for very obvious reasons, including the prospectof having to be resident when on-call, with the implied im-pact on daytime working and continuity of care, and thepoor recognition by trusts of the trauma workload and theresources required to service it. Finally, and perhaps mostimportantly, there is concern at the lack of financial recogni-tion for the continuing increase in workload and the unsocialhours required to maintain a high standard of trauma care,as demonstrated by the recent rejection by the profession ofa proposed new consultant contract[9].

The Department of Health have responded to the defi-ciencies in recruitment of consultants by proposing that by2004 there will be an increase in consultant numbers of 25%,which equates to 1100 new posts. In addition, by the sameyear the number of specialist registrars in surgical speciali-ties is supposed to increase by 334, of which 40 will be inTrauma and Orthopaedics. It is further proposed that by theyear 2010 there will be an increase in the total number ofconsultants of 43%, both by an increased number of doctorstrained in Great Britain and by overseas recruitment. It is asad reflection on the state of the British NHS that it is par-asitic on less developed countries for medical and nursingrecruitment.

Of the 1000 new consultant posts desired within the next2 years, so far only 45 have been appointed.

2.5. Training in trauma

Increased consultant participation in trauma care has pro-vided better opportunities for the training of Higher SurgicalTrainees, both in the resuscitation and the operative man-agement of severely injured patients. At the same time, thedecrease in junior doctors working hours, required by theNew Deal,1 has reduced opportunities for skill acquisition.Proposals for changes in training, including seamless train-ing for surgeons and the possible earlier acquisition of theCertificate of Completion of Specialist Training (CCST) inorder to provide more doctors on the Specialist Register willfurther compromise the future consultants’ competencies re-quired to manage complex skeletal trauma[10].

2.6. European working time directive

The European Working Time Directive (EWTD) willprobably have a greater impact on the way that emergencyservices are run in British hospitals than in any other leg-islation since the inception of the National Health Service.The directive lays down minimum periods of rest for work-ers and a maximum working week of 48 h. It will be fullyin place for junior doctors no later than 2009, possiblyextended to 2012. The EWTD rest requirements are:

1 Junior Doctors—The New Deal (Calman Report), London, HMSO,1991.

1. a minimum daily continuous rest period of 11 h;2. a minimum rest break of 20 min when the working day

exceeds 6 h;3. a minimum rest period of 28 h in each 7 day period (as-

sessed as an average over 14 days).

The overall limit on working hours is absolute, but itwas intended that individual member countries could makechanges to the rest provisions, either by disapplying the restrequirements in legislation or by national collective agree-ment which will modify the rest requirement. This has notoccurred in the UK. The EWTD is already supposed to ap-ply to all consultants, whose derogations are likely to be ap-plied much more stringently within the near future, but theimplications of the legislation for the provision of traumaservices and also for training of junior doctors, is particu-larly relevant as it applies to trainees[6].

At present 97% of Specialist Registrars work an on-callrota. The SiMAP judgement of the European Court of Jus-tice in October 2002 stipulates that if a doctor is availablefor work in the hospital, whether awake or asleep, that timecounted as work done. This will reduce drastically the day-time working time available for all staff with resident, on-callstatus, by an average of 79%. In effect, it will require alljunior doctors to be on a shift working system to avoid thisrestriction; a working practice which has been almost uni-versally condemned by surgical trainees at all levels.

Under the current training system, a trainee will work 56 ha week for 42 weeks a year during 3 years Basic SurgicalTraining and 6 years Higher Surgical Training. This amountsto a total of 21,000 h of training and experience. Under thenew system, compliant with the EWTD, if the present train-ing structure is retained a junior doctor at the end of theirtraining will have lost 3000 h of training and experience.

Even more alarming is the drop in exposure to daytimeservice in the 48 h week. In the best case scenario, withnon-resident SpRs, a trainee working a 1:9 rota would expe-rience only 21 h of daytime service and training each week.This translates to a total training time of about 8000 h, adrop of 13,000 h[14]. It has been suggested that the reducedperiod of training, particularly in surgical subjects, will stillproduce doctors whose experience is ‘fit for purpose’: pro-viding specialists who are trained to deliver emergency careand “a selection of routine elective skills”. It has, perhaps,not been appreciated that skills in the management of emer-gency surgery, and especially the complexities of assess-ment and treatment of trauma patients, will in fact requirelonger periods of training and greater exposure to clinicalwork rather than less.

The consequences of such a draconian reduction in train-ing time and availability of intermediate cover in hospitalswill inevitably result in a major reconfiguration of emer-gency services. Centres providing 24 h trauma care willrequire a minimum of nine doctors providing intermediatelevels of cover. For District General Hospitals, serving apopulation of 250,000–300,000, such levels of cover will

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be impossible, even if full shift systems are developed infront line specialities. The likely result is that most smallerhospitals will close their doors to emergency admissionsoutside the normal working day. Twenty-four hour emer-gency services would only be provided by larger institutionsand in a financially constrained National Health Service,these hospitals will be able to devote correspondingly lessof their scarce resources to elective surgery.

Paradoxically, it will therefore probably be the EWTD,and its implications, which will drive the development ofthe networking of trauma care, advocated by the Royal Col-leges in the United Kingdom[11]. It is likely that the largeacute hospital, which will be able to receive acutely injuredpatients for the full 24 period will provide the majority ofacute emergency services, leaving the peripheral institutionsto cater for elective surgical activity, and those injuries, thetreatment of which can be completed during daylight hours.

3. The future of trauma systems in theUnited Kingdom

The major prerequisite for the development of an effec-tive system for the management of trauma is a NationalTrauma Service, developed from defined trauma systems, us-ing a network arrangement between adjacent hospitals withdifferent levels of provision for the more severely injured.These systems would be based on geographical distributionand would integrate pre-hospital care, initial transfer andsubsequent inter-hospital transfer where necessary, sophis-ticated assessment and resuscitation facilities, and definitivehospital care and rehabilitation. These geographical systemsmay well lie across the present administrative boundaries ofthe National Health Service and significant cross-boundaryco-operation will be necessary under the remit of the Strate-gic Health Authorities[11].

Each system will need to contain a Major Acute Hospital,probably equivalent to an American Level I Trauma Centre,having all of the appropriate specialist departments on onesite. Acute General Hospitals (Level II and III equivalents)will be District General Hospital based and supported by themajor acute hospital. The development and audit of identi-fiable national standards with ensure uniform provision oftrauma care. Cost implications may mean that some special-ties will not be immediately represented in all Major AcuteHospitals, but mechanisms would be in place to provide ap-propriate specialist services (especially Neurosurgery).

Reconfiguration of emergency services, which will bedriven largely by the provisions of the EWTD, will resultin a reduction of the number of hospitals that receive majortrauma. Each geographical system would serve populationsof up to 3 million.

Each system would also have to provide sufficient inten-sive care and high dependency beds for its own local popu-lation. This would include intensive care facilities for pae-diatric emergencies.

In addition to definitive treatment of the severely injured,each geographical system would provide a comprehensiverehabilitation service for its local population[3].

3.1. Objectives of a national trauma service

Both the Royal College of Surgeons of England and theBritish Orthopaedic Association are firm supporters of thedevelopment of a National Trauma Service which wouldguarantee universal standards of provision of care[3]. Themain objectives of a National Trauma Service can be sum-marised as follows:

1. Organise the assessment and care of patients with majorinjuries and those with more severe complex injuries fromthe time of injury through to rehabilitation.

2. Ensure the maintenance of adequate clinical experiencefor all staff treating major trauma.

3. Strike a balance between cost effectiveness and clinicalexcellence.

4. Allow the implementation of national standards of care.5. Provide appropriate Information Technology.6. Facilitate outcome research through effective data collec-

tion.7. Test standards by audit with subsequent improvement in

provision and patient care.

Required facilities at major acute hospitals (level I)

• A fully staffed A&E Department working 24 h a daysupported by on-call A&E consultants and sufficientintermediate staff to provide immediate decision mak-ing capability at all times.

• A resuscitation trauma team available 24 h a day, leadby an appropriate trained consultant (ATLS© or equiv-alent).

• Adequate numbers of beds for the admission of traumapatients including HDU and ITU beds on the samephysical site.

• Twenty-four hours facilities for imaging and investi-gation, including CT and MRI scanning.

• Four to eight WTE consultants with a major interestin Orthopaedic Trauma.

• Dedicated trauma theatre available and staffed 24 h aday with daily consultant trauma lists.

• A helicopter landing pad on site which would allownight flying.

It would be expected that in the course of time all special-ities dealing with trauma would be available on site. Theseinclude

1. Orthopaedics and Trauma.2. Neurosurgery.3. General and Vascular Surgery.4. Plastic Surgery.

J. Albert, H. Phillips / Injury, Int. J. Care Injured 34 (2003) 728–734 733

5. Cardiothoracic Surgery.6. Head, Neck and Maxillo-facial Surgery.7. Urology.8. Anaesthesia and Intensive Care.9. Interventional Radiology.

10. Paediatric Surgery.11. Children’s Anaesthesia and Intensive Care.

Required resources for the acute general hospital (levelII)

Acute General Hospitals will generally be rather smallerin size and will not have all the major surgical disciplineson site. They may be at some distance from the majoracute hospital, but would act in partnership with thiscentre. They must be able to resuscitate the severelyinjured.

• A fully staffed A&E Department supported by A&Econsultants and intermediate staff available 24 h a day.

• ITU and trauma beds on the same site.• A trauma team available 24 h a day, lead by a con-

sultant with appropriate training (ATLS© or equiva-lent).

• Twenty-four hours X-ray facilities including CTscanning. The CT should be linked to the localneuro-surgery centre by computer networking to al-low immediate transfer of clinically important in-formation.

• A minimum of six consultants in Orthopaedics withan interest in Trauma taking part in an emergency rota.

• A dedicated trauma theatre with daily consultanttrauma lists.

Required resources for an acute general hospital(level III)

This would be a smaller District General Hospital withOrthopaedic Surgery, General Surgery and GeneralMedicine on site. Requirements would be for a dailyconsultant Orthopaedic trauma list, a 24 h a day staffedA&E Department and 24 h X-ray facilities. Thereshould be arranged protocols for the transfer of severelyinjured patients between these hospitals and the MajorAcute Hospital.

Minor injuries units

These small hospitals have a role in catering for theso called ‘walking wounded’. They have no role inthe management of the severely injured and shouldnot receive emergency trauma admissions. Appropriateby-pass policies must be in place.

These proposals represent a major alteration in the con-cepts of the organisation of trauma in the United Kingdom.Although some capital investment would be required to pro-vide such an integrated service, the most important changesneeded would be the mindset of the staff working in thesystem, and in our political leaders, who would have torecognise the advantages of such a National Trauma Service,as their colleagues in most developed nations have alreadydone. As yet there is no commitment whatsoever even totest the feasibility of such a plan.

3.2. Trauma audit

The basic philosophy of improved trauma care is to deliverthe most appropriate treatment with the minimum of delay.This requires early decision making and effective pathwaysof care, from the time of initial contact with a patient untilfinal discharge from follow up.

Satisfactory outcomes of trauma care and the mainte-nance of standards are the major criteria by which a traumasystem should be judged, rather than the size of the hospi-tal or its local catchment population. Most hospitals haveprocedures in place to measure the effectiveness of theirlocal trauma service. Improvement in communications andreduction in decision-making delays are important factorsin improving the process of trauma care, but may havelittle influence on the outcomes of treatment. Most traumascoring systems in current use measure the effectiveness ofcare in terms of mortality. They rarely assess the effect oftreatment on the quality of life, or functional outcome insurvivors. The British Trauma Audit Research Network ob-tains its data from about 50% of acute hospitals in Englandand Wales and has demonstrated improvements in survivalafter major trauma in British hospitals in the past 14 years.The data are however still very deficient with only 50%of hospitals participating. Little progress has been madeso far in measuring disability, rather than mortality, afterinjury.

3.3. National trauma audit research network (NTARN)

The Royal College of Surgeons of England and the BritishOrthopaedic Association in their recent publication ‘BetterCare for the Severely Injured’ have proposed a NationalTrauma Audit Research Network (NTARN)[3]. The statedaim would be to develop, monitor and improve standards ofcare for injured patients in hospitals in the United Kingdom.Returns from individual hospitals would allow the accumu-lation of national data which could promote changes in ser-vice configuration and clinical practice based on appropriateoutcome measures.

The working party further proposed the setting up of aNational Trauma Audit Committee, overseen by the RoyalCollege of Surgeons of England. The role of this com-mittee would be to receive recommended standards fromsub-speciality groups involved in the management of trauma

734 J. Albert, H. Phillips / Injury, Int. J. Care Injured 34 (2003) 728–734

and to agree priorities for standard setting. The overall effectof the collection of data and evidence of good practice wouldbe to improve uniformity in developing high standards ofcare in the management of the severely injured. A collectionof coherent data from large numbers of hospitals would al-low standards to be based much more on objective criteriathan on anecdotal and subjective opinion as at present.

3.4. Summary

In spite of a mass of evidence collected and repeatedlyreported over many years, which suggests that co-ordinatedsystems of trauma care reduce mortality and morbidity aftersevere injury, there has been no co-ordinated developmentof such systems in the United Kingdom. Successive Gov-ernments have failed singularly to provide the resources andfacilities necessary to achieve a uniformly high standard ofcare for the injured throughout the country. Repeated pleasby the profession have met with inertia and indifferenceon the part of Government and the Department of Health,largely for financial reasons. The changes in doctors’ work-ing hours and particularly the implementation of the EWTDmay paradoxically have more beneficial effect on the im-provements in standards of care for the victims of traumathan previous logical initiatives proposed during the last 30years.

Improvements in the prevention of severe injury after roadaccidents in the United Kingdom may have militated againstdirect developments within the secondary care system, butit should be recognised that there have been striking im-provements in the management of the injured in the pastdecade. This is in part due to the technological improve-ments in facilities for resuscitation, investigation and defini-tive treatment. Improvements have also been derived froma better understanding of the pathophysiology of major in-jury. Finally there has been a recognition by clinicians thatthe management of major injury requires the highest levelsof clinical judgement and technical skills, and educationalinitiatives, driven by clinicians, have brought great patientbenefit in this sphere.

The development of effective systems of trauma care inthe United Kingdom can only improve the outcomes of pa-tients unfortunate enough to be the victims of severe injury.The profession can do no more. It is high time for the Gov-ernment to support the development of a coordinated traumaframework to care for severely injured patients.

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