• Wounds
• treatment

In February this year the National Audit Office (NAO) published a 37 page report called Major Trauma Care in England.1 The NAO, if you are not already aware, aims to spend the nation's money wisely, promote the highest standards in financial management and reporting, in the conduct of public business and also make beneficial changes in providing public services.

Its methodology included evaluation of statistical data, a review of key policy documents, standards of care and academic literature, an estimate of the incidence of major trauma, economic analysis/modelling of its costs, telephone interviews and visits with strategic health authorities (SHAs), visits to 10 ambulance trusts and nine acute trusts, a census of non-trauma audit and research network (TARN) trusts, a survey of TARN trusts, semi-structured interviews with the Department of Health and key stakeholders and, finally, telephone discussions with patient representative groups.

Key points from the report are:

• Annually England has at least 20 000 major trauma cases, 5400 deaths, many others with permanent disabilities and 28 000 cases that are not strictly major trauma but are managed similarly. Although 193 English hospitals have major trauma services in their emergency departments (EDs) they account for less than 0.2% of all ED work.

• Although immediate treatment of these patients costs the NHS £0.3–0.4 billion annually, the cost of subsequent rehabilitation, home support and informal care is unknown; annual lost economic output due to major trauma is between £3.3–3.7 billion.

• Despite the fact that since 1988 several studies have identified deficient care for these patients in England, little progress has been made to deal with and resolve the problem.

• TARN collects data from 114 hospitals (only 59% of all trauma receiving hospitals; the performance of the remaining 41% is unknown).

• There are no agreed measures to assess disability or morbidity; the physical, social and psychological impact of major trauma on survivors is unknown.

• There is a 20% higher in-hospital mortality rate for trauma patients in England compared to the USA. Trauma systems reduce in-hospital mortality by 15–20%; the NAO suggests that 450–600 extra lives can be saved each year.

• Major trauma care in England is poor value for money because the service is not delivered efficiently or effectively.

• Major trauma most commonly occurs at night and weekends when consultants are not present in ED; only one hospital has 24-hour consultants seven days a week.

• Only 36% of patients needing a transfer from one hospital to a specialist unit get transferred; for those who are, the process is often ad hoc. The 64% of patients who do not receive specialist care may have a worse outcome.

• Ambulance trusts have no systematic way of monitoring the care they provide.

• Clinical governance arrangements (quality and safety) linking pre-hospital and hospital care are weak, and data are not shared; this also applies to voluntary and NHS providers such as air ambulance services.

• There appears to be a lack of capacity for specialist rehabilitation of major trauma patients; with little hard evidence about services currently available and how they are arranged it is difficult to reach a conclusion.

• Current funding arrangements do not reflect true costs, especially for the trusts that treat higher volumes of patients. Correct funding arrangements will facilitate patient transfer to specialist care and rehabilitation.

• The Department of Health (DH) is supporting a regional trauma networks programme and in April 2009, Professor Keith Willett started work as the first national clinical director for trauma care, following his appointment in January.

• By September 2011 primary care and ambulance trusts (coordinated by SHAs) must implement triage protocols to define where seriously injured patients should go.

• All acute and foundations trusts that have EDs that receive trauma must submit data to TARN. Their performance must be benchmarked against defined standards and against each other. Ambulance trusts must collect data on the resources they dispatch and the treatments they provide and link them with acute trusts to monitor pre-hospital care. TARN and ambulance trust data must be routinely analysed to performance manage the trauma networks.

• The DH must work with the National Institute for Health and Clinical Excellence (NICE) to develop standards for major trauma—for example, 24-hour consultant presence in those EDs that receive major trauma patients. SHAs must work with all relevant trusts to develop protocols based on standards set by NICE.

• Trusts must develop audit processes to ensure that clinical standards are followed. These must also be agreed with voluntary and NHS providers such as air ambulance services.

• SHAs and hospital trusts must develop protocols to improve critical care capacity for all patients to reduce patient transfer for non-clinical reasons and also review rehabilitation services when developing their trauma networks.

This all sounds very reasonable. There have been some positive developments in trauma care since 1988, but clearly they are not enough; let's hope that trauma care can move to a new level that is sustainable, efficient and much better.