Discussion

There are a number of limitations to this survey. The distribution of volunteer-based pre-hospital services is dynamic and thus our results may not precisely reflect the current situation. There are also artificial borders between the NHS ambulance service regions on figure 1 and we recognise that there is more flexibility in cross-cover arrangements than may be implied by our aggregation of survey responses. We also identified that BASICS organisations, air ambulance charities and EDs are, in many cases, interlinked. This may result in an over-count of the number of services and doctors able to provide critical care. There have, however, been no major organisational, policy or funding changes within the regions that would dramatically alter the overall picture of extensive geographical and diurnal variability and inequity in the provision of physician-based pre-hospital critical care in the UK. The results reflect the view expressed by the Royal College of Surgeons to parliament in 20086:‘there is great inequality in access to, and provision of, pre-hospital critical care. As a consequence, there are preventable pre-hospital and early-hospital deaths that could have been averted had there been access to appropriate services’

Although a survival advantage has been demonstrated for severely injured patients treated by physician-based pre-hospital critical care teams operating within an organised system of care,11 12 15–22 considerable debate remains about their role and cost effectiveness.5

Only in a few cases and places can critically injured patients who might benefit from such care receive it from NHS-commissioned pre-hospital critical care physician-based teams. The inequity is striking (figure 1). Only one NHS-commissioned physician-based service exists and operates (London). Five of the regional air ambulance charities provide non-NHS regional physician-based pre-hospital critical care services during the day. The populations served by these services have access to a completely different level of care than the rest of the country. The remaining population can only access similar care when a volunteer doctor able to provide critical care is available to support their NHS ambulance trust, BASICS scheme and local air ambulance. This provision largely depends on volunteer doctors and cover is therefore incomplete, unpredictable and inconsistent. The situation is much worse at night (figure 1B). It is unsurprising that the National Confidential Enquiry into Patient Outcome and Death2 concluded that: ‘The current structure of prehospital management is insufficient to meet the needs of the severely injured patient’.

Figure 1 also highlights the existence of large areas of the country in which there is no guarantee of receiving physician-based pre-hospital critical care at any time. We emphasise the word ‘guarantee’. We recognise that there are individuals and organisations within these areas who are capable of providing pre-hospital critical care support and frequently do so when available. Indeed, the differences in social and physical geography across the UK necessitate differences in the structure of pre-hospital care provision. However, the medical requirements of the critically injured are independent of their injury location or time. The NHS constitution's principle of ‘access to services being based on clinical need’23 is clearly not being applied to the critically injured before they reach hospital.

A nationwide development of regional trauma networks is currently underway. In order for trauma systems to function, patients must be transported safely to major trauma centres. This requires clinicians with the ability to triage and safely transport the critically injured. In hospitals and between hospitals, critical care physician-led teams exclusively carry out this role. This survey shows that outside hospital, the NHS does not provide physician-based critical care to facilitate this.

The use of volunteer doctors to fill this gap in service provision is considerable, with 6155 recorded scene attendances in 2008 and true activity levels that are likely to be much greater. The call for these doctors indicates that NHS ambulance services recognise a cohort of patients whose needs exceed their capabilities.5 If all 13 ambulance services had reported similar levels of physician utilisation, this would equate to nationwide crude minimum estimates of the order of 13 000 requests and 9500 scene attendances a year. The lack of data from ambulance trusts about whether these doctors were all able to provide critical care inevitably means that this may be an overestimate. These are also small numbers in relation to overall urgent and unscheduled care demand. They do, however, represent a significant potential pre-hospital critical care workload which needs further delineation. We support the recent National Audit office recommendation that: “ambulance trusts should collect data on the resources dispatched and treatment provided, and link it with data collected by NHS acute trusts in order to monitor the quality and safety of care provided in the pre-hospital environment”.8 We would emphasise that such data should include air ambulance activity data as well as the capability of any deployed physicians. Helicopter emergency ambulance service activity in the UK was reviewed in a postal survey in 2001 but services have evolved considerably since then and no unified capability or operational activity data source exists.24

There is also considerable variation in the availability of doctors with emergency anaesthetic skills and disordered patterns of use of this capability. Pre-hospital care doctors come from a range of backgrounds, including general practice, emergency medicine, surgery, anaesthesia and intensive care medicine. There are many aspects of pre-hospital care beyond organ support for the critically injured and ill. We particularly focused on pre-hospital critical care in this survey, as it is within this domain that the balance of evidence of benefit is strongest22 and the inequity of access most striking.

No major ED regularly deploys a team able to provide critical care and only 15 described a pre-planned system to deploy any form of 24 h team. If neither a major ED nor an ambulance service can easily access this capability for incidents involving one or two critically injured patients then they will struggle to access deployable critical care support for larger multi-casualty incidents. This brings the recent NHS Emergency Planning Guidance on the widespread provision of major emergency response incident teams (MERIT) into sharp focus.25 The guidance states that:‘The scope of incidents that would warrant a MERIT response would include any incident where ambulance personnel at scene attending an incident identify a potential benefit, following assessment and triage, of having specialist or advanced clinical care at scene and decision making and critical interventions for adults and children.’

The Clinical Advisory Group on Trauma recently highlighted the obvious skills overlap between MERIT requirements and provision of accessible pre-hospital critical care.13 One solution may be to combine funding streams for MERIT and pre-hospital ‘enhanced care’ provision to ensure a regional 24/7 pre-hospital critical care support capability. This would meet day to day ambulance demand while also acting as the first medical component of a response to a disaster. Innovative integration of our national need for pre-hospital critical care and major incident provision could provide the economic efficiency required for development of the pre-hospital ‘enhanced care’ component of our newly developing trauma systems.