Intended for healthcare professionals

Editorials

Planning trauma care services in the UK

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f738 (Published 11 February 2013) Cite this as: BMJ 2013;346:f738
  1. Jan O Jansen, consultant in general surgery and intensive care medicine 1,
  2. Nigel R M Tai, consultant trauma and vascular surgeon 2,
  3. Mark J Midwinter, honorary professor 3
  1. 1Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK
  2. 2Trauma Clinical Academic Unit, Royal London Hospital, London, UK
  3. 3School of Health and Population Sciences, College of Medicine and Dental Sciences, University of Birmingham, Birmingham, UK
  1. jan.jansen{at}nhs.net

Surgical workforce development remains a challenge

In response to a 2011 analysis by the Centre for Workforce Intelligence on regional trauma networks,1 the Royal College of Surgeons of England began compiling a report, to be published in spring 2013, that illustrates the need for, and defines the shape of, specific training paths in trauma surgery. In 2006, a BMJ editorial, published in the wake of the 2005 terror attacks in London, highlighted deficiencies in the delivery of trauma care and the training of general trauma surgeons in the United Kingdom.2 Six years on, healthcare policy has changed greatly, and trauma infrastructure is rapidly evolving. However, there is still an urgent need for the development of training routes for specialist trauma surgeons.

In 2010, the UK’s first trauma system was set up in London. It was built around four trauma networks, comprising a major trauma centre and several associated units, which were governed by a system of triage and bypass protocols. The aim was to treat “the right patient, at the right place, at the right time.” These developments are often attributed to a seminal National Confidential Enquiry into Patient Outcome and Death report, which concluded that most patients with major trauma received a standard of care that was less than good practice.3

The successes of other networked care programmes (such as those for cancer and stroke care) helped to overcome the inertia that similarly critical reports had previously failed to surmount.4 A national clinical director for trauma care was appointed, and in April 2012 a further 22 regional trauma networks and major trauma centres were designated in England. After decades of neglect, these systems—which encompass delivery of treatment, governance, and accountability—are welcome and may reduce mortality and morbidity from trauma to levels seen in countries where trauma care is better structured. However, clinical leadership, particularly regarding the coordination and delivery of ongoing clinical care, remains an unresolved challenge.

That “all patient care should be overseen and coordinated by a trauma service” forms part of the Department of Health’s key recommendations on the implementation of trauma networks.5 The institution of a specialist trauma service has been associated with significant improvements in mortality in the UK.6 However, mere designation of a hospital as a trauma centre will not produce similar benefits unless it is truly configured around trauma care.6 In the UK, orthopaedic surgery is still the only specialty that recognises trauma as a subspecialty interest, yet trauma patients do not present only with bony injuries. Such patients—especially those with complex multi-system injuries—are currently insufficiently served by trauma services in the UK.

The concept of trauma care centred on a dedicated surgically led and surgically delivered service is fundamental to the American College of Surgeons’ trauma centre designation and verification programme.7 Currently, most English major trauma centres rely on a hybrid system that involves a small number of clinicians from different specialties. Such “start-up” solutions should be seen as an interim measure only. In countries with well developed trauma services, trauma centres are staffed by specialist surgeons, usually with a general surgical background, a model that has been shown to reduce death rates.8 To provide an acceptable and uniform standard of trauma care, the UK needs a similarly defined workforce, trained to deliver expert trauma care that goes beyond the initial evaluation and treatment phase.

General surgeons currently staffing major trauma centres who are interested in taking on such additional responsibilities should be supported through structured and individualised development programmes, which might include courses such as the definitive surgical trauma skills course, secondments or fellowships, and mentoring relationships. Trainees should be offered both pre-CCT (Certificate of Completion of Training) placements, and post-CCT fellowships. All available expertise, especially that of military surgeons, should be utilised. The quality of trauma care provided by the Defence Medical Services in Afghanistan has been rated as exemplary by the Healthcare Commission.9 Media reports of lifesaving treatment administered to British soldiers, in austere conditions, have indirectly demonstrated the value of specialist trauma care to the medical profession and the public.10 Regular and reserve military consultants, returning to their NHS practice after high intensity deployments, should add their experience of swift triage, sophisticated transfusion strategies, and new surgical techniques to quality improvement programmes for civilian trauma care.11

Although the organisation of trauma care in the UK has improved vastly since 2006, a specialist workforce with the appropriate training is urgently needed to ensure that new English trauma centres succeed in improving outcomes for victims of trauma. The Royal College of Surgeons needs to make this clear in its report.

Notes

Cite this as: BMJ 2013;346:f738

Footnotes

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; MJM is a serving officer in the Royal Navy, and JOJ and NRMT are serving officers in the British Army; NRMT is a member of the Royal College of Surgeons of England trauma workforce working group.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References

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