Tackling the severe trauma lottery

According to the report Major Trauma Care in England, published by the National Audit office (NAO), there is an unacceptable variation in major trauma care in England depending on where and when people are treated. Moreover, with a marked spike in admissions of patients during night time hours over the weekend when the trauma specialists are least likely to be on hand, it is perhaps surprising that only one hospital, the Radcliffe in Oxford, has 24-hour consultant care, seven days a week. Major trauma describes serious and often multiple injuries where there is a strong possibility of death or disability. The most common cause, accounting for around 98% of severe traumas, is blunt force caused by road accidents or falls; the remaining 2% are caused by knife and gunshot wounds. There are approximately 20,000 major trauma incidents a year, 75% of which involve young males, resulting in 5,400 deaths. It is the leading cause of death in men under 40 years old. There are around 28,000 other cases which, although not meeting the precise definition of major trauma, would be cared for in the same way. This state of affairs is not a recent development either; the NAO states that care for patients who have suffered major trauma has not significantly improved in the last 20 years despite numerous reports identifying poor practice and services not being delivered effectively or efficiently. Given these circumstances it is perhaps no surprise that research has indentified a 20% higher in-hospital mortality rate for trauma patients in England compared to the US. The situation is highlighted by Edward Leigh MP, chairman of the Committee of Public Accounts in his response to the NAO report: “For more than twenty years almost nothing has been done to remedy the lamentable provision of care for people suffering serious injuries, most commonly as the result of a road accident or fall,” he asserted. “The Department of Health and NHS Trusts were warned by the Royal College of Surgeons in 1988 and similar warnings have been repeatedly published since then, but progress has been slight. The shocking truth is that an estimated 450 to 600 lives are being unnecessarily lost each year because of poor care,” he continued. “If you have an accident at night or over the weekend you are unlikely to be seen immediately by a consultant, given that only one hospital in the entire country has the required specialist consultant care 24 hours a day, for seven days a week.”

The high cost of trauma

It would appear that the probability of survival depends on when the accident happens and to which hospital the ambulance goes. While there are hospitals that have surgeons trained to tackle major trauma, many do not. Furthermore, many do not have formal bypass arrangements for ambulances. There are currently 193 hospitals in England that provide major trauma services within their emergency departments. However, major trauma accounts for a small part of the overall A&E service – representing only 0.2% of the total activity. The NAO estimates that major trauma costs the NHS between £0.3 bn and £0.4 bn a year in immediate treatment, while the cost of any subsequent treatments, rehabilitation, home care support and carer costs are unknown. Perhaps more startling is the estimate that the annual loss to national economic output from major trauma is between £3.3 bn and £3.7 bn. In fact, the extent of the problem may actually be underestimated. With only 59% of hospitals with Accident & Emergency departments in England submitting statistics to the Trauma Audit and Reporting Network (TARN) on how they deal with trauma patients, there is a gaping 41% hole in the overall picture. “Major trauma services are currently provided in a disorganised and uncoordinated fashion,” concluded Edward Leigh. “It cannot be beyond the capabilities of the Department and NHS Trusts to establish a system, at little extra cost, enabling seriously injured patients to be delivered quickly to those parts of the health service best equipped to treat them.”