Editor,—We read, with interest, the letter from Pau and Buxton, regarding the need for neurosurgical referral of patients with an admitting diagnosis of minor head injury.¹ We agree that these patients are a low risk group. We performed an audit of patients admitted to our observation ward with the primary diagnosis of minor head injury. From October 1997 to July 1999, 668 such patients were admitted under our care. Of these patients, only two were subsequently transferred to the regional neurosurgical unit after the finding of intracranial haematoma on computed tomography. This finding, and our general experience, leads us to agree that patients with an admitting diagnosis of minor head injury do not require neurosurgical referral, in the first instance. However, we suspect, given that only 12% of responding accident and emergency (A&E) departments (71% response rate) in the UK have on-site neurosurgical facilities,² this practice is not widespread anyway.

Pau and Buxton's conclusion is in keeping with the recommendations of the Report of the Working Party on the Management of Patients with Head Injuries.² One of the logistical concerns raised by this report, and highlighted in Pau and Buxton's letter, is the fact that observation wards have a finite capacity. Our current practice is that, when our observation ward is full, these patients are admitted under the general surgeons. The Way Ahead document recommends that A&E observation wards should be within, or immediately adjacent to, the A&E department.³ We feel that it is inevitable, when the only specialty admitting patients with isolated minor head injuries is A&E, that problems will arise when the observation ward is full. It goes against the spirit of the report of the working party to then admit these patients under other specialties, just because the observation ward is full. If these patients are to be admitted to wherever there are beds within the hospital, but still under the care of A&E, we fear a major step backwards in the standards of our practice if, when a seriously ill or injured patient arrives in the A&E department at 5 am, the only A&E doctor on duty is at the far end of the hospital, assessing a head injured patient.

The recommendations of the report have provoked widespread debate and polarity of views within the specialty. It probably represents a watershed in the management of A&E departments that do not currently accept inpatients under the care of A&E consultants. We do not yet know how we will resolve this issue locally, but would welcome other views on ways of managing the patient.