History of Accident Services in the UK

  • First comprehensive service for injured set up by Robert Jones, a surgeon to the Manchester Ship Canals
  • Casualties taken by rail to nearest of 3 hospitals each with 20 beds and resident surgeon
  • Hospital distributed along the 35 miles off the canal 
  • Robert Jones subsequently became Inspector of Military Orthopaedics during the first world war – organising comprehensive care to wounded including rehabilitation.  The aim was to return the injured to gainful employment 
  • In 1981 Miles Irving, Professor of Surgery, Salford wrote in the BMJ that although the NHS wished for an integrated Accident Service there was no indiscernible plan.  He went on to say that the Birmingham Accident Hospital was a centre for considerable excellence with a worldwide reputation that had yet to gain acceptance
  • In 1962 it had been established in the Platt Report (1962) and subsequently the Lewin Report (1978) that accidents should be concentrated on major accident departments in general hospitals, fully equipped to deal with emergencies
  • An important driver for change was the paper from the USA published by West et al, USA which was a seminal paper.  Only 1% deaths were preventable in MTCs compared to 28-73% smaller units.  West recommendations were that small casualty departments should be run by GPs, all accidents should initially go to a major A&E.  In the USA, the creation of major trauma centres and trauma networks followed Wests work in Maryland where there was approximately a third reduction in mortality. This, formed the basis for the Platt Report in 1962
  • Lewin further reinforced these changes with a three-tier system seeing 20,000-25,000 cases per annum in a fully equipped unit. A three tier system was proposed with specialist accident hospitals, central accident units represented now by our DGHs and smaller hospitals represented now by our minor injury units. Because of the lack of funding none of these recommendations were actioned.
  • Gissane advocated:
    • High quality first aid at scene
    • Transport to accident centres
    • Provision of immediate adequate treatment
  • 1,000 preventable deaths report 1988, published by the Royal College of Surgeons, England
    • 1/3 of trauma deaths preventable
    • Patients should be managed in appropriate facilities for their needs
    • Systems for transfer should be in place
    • Enhanced training for ambulance staff required 
    • Improved pre-hospital/ hospital communication
    • Improved transport platform
    • Need for outcome data collection and research
  • National Confidential Enquiry into the Prevention of Deaths Report 2007 – 60% of patients received “less than good practice”. Survival rates varied between hospitals and only 5% hospitals submitted trauma data. 
  • Lord Darzi parliamentary statement
    • Official Report, House of Lords 7th January 2008
    • Vol 697, c, 630, Lord Darzi
    • “We have taken on board the recommendations of the NCEPOD Report, not necessarily just regarding pre-hospital admission. We also need to have and define for the first time dedicated trauma centres. It is one area in which there is clear evidence that centralisation of services, with adequate competencies at the receiving hospitals, will impact significantly on the quality of care”
  • National Audit Office February 2010 reported unquestionable evidence that trauma systems reduce mortality by 15-20%. 450-600 lives could be saved in England.
  • Work of Prof Keith Willett and Prof Chris Moran
    • Set up to establish a network that could deliver the patient rapidly and safely to a hospital that can manage the definitive care of their injuries, irrespective of where they suffered the injuries.
    • They set out to evolve care models and pathways based on patient’s needs, local expertise, geography, facilities, and transport options.
    • Bespoke inclusive networks were established.
  • Improved outcomes – 2019: 850 additional lives saved (Prof Chris Moran)
    • PHEM initiatives 
    • MOSTT Course
    • DCOTS
    • Iraq/Afghanistan

Worth remembering……National Accident Service. This was Gissane’s model for the future and shared in the early 1950s.  

  • Gissane advocated a national system based on about 20 accident hospitals 
  • Few at the time shared his opinion
  • The Accident Services Review Committee (1961) recommended a system of three tiers:
    • Smaller hospitals supported
    • Central accident units 
    • Specialist accident hospitals

      Although embracing Gissane’s ideas plans were thwarted by lack of funding. Turn the clock forward to 2011 and we have established Major trauma Centres, trauma units and local emergency hospitals. Gissane’s dream fulfilled 60 years on!