In 1988, it was evident that trauma care in England and Wales was far from ideal. A retrospective, subjective, panel review of coroners reports from eleven regions in England and Wales concluded that nearly one third of all fatalities and two thirds of non-CNS-related deaths were possibly preventable . The preventable rate of non-CNS-related deaths and the key reasons for this (hypoxia, inadequate haemorrhage control, delayed surgery and missed injuries) are remarkably similar to those detected in Orange County almost 10 years previously . A major trauma report in 1988 from the Royal College of Surgeons of England (RCSE) highlighted these deficiencies in UK trauma care  and proposed improvements in the delivery of pre-hospital care, Advanced Trauma Life Support (ATLS) training for hospital doctors receiving trauma patients, improved audit programmes to monitor progress and the formation of a major trauma outcome study (MTOS). However, by the mid ‘nineties, major deficiencies were still very much evident. The first UK MTOS report in 1992 found that junior doctors were responsible for the resuscitation of 57% of severely injured patients and only 46% of those deemed to require urgent surgery were operated on within 2 h. The mortality rate was significantly higher than in a comparable North American dataset, with large inter-hospital variation in mortality . In the north of England in 1995, 35% of major trauma victims died before arrival at the ED, with only 58% of those arriving at hospital alive surviving to hospital discharge . Overall survival from major trauma was only 38% and it was encountered uncommonly in most EDs, accounting for only 0.82% of departmental workload . By 1997, there was evidence of some improvement of the situation in England, Wales and Northern Ireland. From 1989 to 1997, the mortality from trauma reduced by almost 40%. This corresponded with an increase in the involvement of more senior doctors at presentation to the ED . However, during the later half of the ‘nineties no further mortality reductions occurred. This appeared to correlate with no further increase in consultant involvement at presentation and no reduction in pre-hospital times . In 2000, the RCSE recommended the ‘concentration of trauma services and skills’, plus the formation of trauma systems, as well as the formation of trauma teams and the use of ambulance pre-alerts, to try and improve trauma care . In 2003, only 21% of hospitals in England, Wales and Northern Ireland met the recommended standards considered essential to good trauma care by the RCSE . The 2007 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Trauma: Who cares? provided further evidence of the ongoing deficiencies in trauma care, with 60% of the patients in the study considered by an expert group to have received sub-optimal care . The report predictably found that the study population consisted mainly of young men (75%), including a high proportion of road traffic collisions (55%). More than 60% had head injuries and more than half presented ‘out of hours’. Major trauma accounted for a small percentage of most hospitals’ acute workload, with 91.5% of the hospitals in the study managing fewer than one major trauma patient per week and 14% encountering no major trauma patients during the 12-week study period . These findings were similar to previous UK trauma studies . The report again identified deficiencies in pre-hospital care management and organisation, the trauma team response, initial involvement of consultants and other aspects of in-hospital care. It highlighted the lack of senior staff presence ‘out of hours’ and the resulting lack of appreciation of severity of illness, as well as incorrect and delayed clinical decision making . The report made recommendations to address these issues including the provision of major trauma centres, with centralisation of expertise and resources as part of an inclusive trauma system. The 2010 National Audit Office report Major Trauma Care in England highlighted the same deficiencies and raised others, such as the ‘uncoordinated’ delivery of trauma care, incomplete Trauma Audit and Research Network (TARN) data submission and an absence of any link between or sharing of pre-hospital and in-hospital data. It also stated that major trauma care did not represent good value for money because of the inefficient way in which it was delivered . Given that major trauma makes up such a small proportion of UK hospitals’ workload [29, 33], the principle of concentration of experience as is seen in other specialised areas of medicine [34–37] is a logical step to improve outcome [6, 38–40]. Despite the number of studies reporting poor trauma care in England, Wales and Northern Ireland since 1988 [12, 27–29, 31, 33, 41, 42] and the international evidence of a 15–40% reduction in mortality [16, 21, 22, 40] with the implementation of trauma systems, only modest progress occurred until recently. This lack of development may have been due to concerns over the deskilling of bypassed hospitals , cost , the transferability of mortality data from the US  and failure to establish trauma as a political health priority, combined with a reluctance to embark upon the reorganisation of healthcare systems required to implement effective change . Also, the first study examining trauma system care in England, following the establishment of the experimental trauma system in Staffordshire during the 1990s, found no mortality benefit . However, the trauma system described was basic, the trauma centre would not have met the minimum requirements for a major trauma centre, the population of the study’s catchment area was small and there were many methodological issues with this study. Recent development of formal trauma systems has had to take account of medical and nursing employment changes including the challenges associated with providing trauma services at multiple sites and out of hours while complying with working hour restrictions imposed by the European Working Time Regulations, limited trainee numbers and increased scrutiny of consultant working patterns .
Following the publication of Lord Darzi’s NHS Next Stage Review in 2008, which stated that there are ‘compelling arguments for saving lives by creating specialised centres for major trauma’  and the appointment of the first National Clinical Director for Trauma care to lead the development of regional trauma networks , the political drive for change materialised. Guidance for implementing trauma systems in England was published [3, 46] and 20 years after this need was identified, the London trauma system began operating in 2010, followed by the majority of regional systems in England in April 2012 . Internationally, outside the US and UK, other regionalised systems of trauma care delivery have been adopted [48–53], with reported falls in mortality [40, 42].
In Scotland, Wales and Northern Ireland, formal trauma systems have yet to be implemented. Improvements have been documented and in 2011, for the first time since 2002, the Scottish Trauma Audit Group started collecting data . The 2011 data showed an improvement in survival from major trauma (ISS > 15) from 75% in 2002 to 83% in 2011. The W-statistic also shows an improving trend: there were 1.75 unexpected survivors per hundred trauma patients during 2011 . However, only 60% of victims of major trauma were attended in the ED by a consultant, only 25% of Scottish major trauma-receiving hospitals have trauma teams and 29% of major trauma patients were not triaged to the resuscitation room by the Scottish Ambulance Service [54, 55]. The secondary transfer rate remains high (37%), which is considered detrimental in certain patient groups [56–58] and patients are often triaged to a facility incapable of fully meeting their needs [54, 59]. Change is occurring, with improved ambulance service links, the use of pre-hospital medical trauma teams and the adoption of quality indicators for trauma . The Royal College of Surgeons of Edinburgh’s 2012 report Major Trauma Care in Scotland has clearly stated the case for change, recognising the need for an inclusive trauma system in Scotland, while acknowledging that the most appropriate configuration of such a system requires further investigation . The definitive strategy for the management of trauma patients in Scotland has yet to be defined .