NHS at 70: Patients used to die of broken legs, now doctors are trained by the military to face terror and knife crime, says UK’s top trauma doc
Prof Chris Moran is the national clinical director for trauma for NHS England, and a Prof of orthopaedic surgery at Nottingham University Hospital
I will always remember one of the first patients I treated as a young surgeon.
He was on a motorbike and about the same age as me and came to casualty with a severe head injury after a road accident.
He needed immediate brain surgery to save his life but the hospital I was working in didn’t have neurosurgeons on site and we were unable to save him.
A tragic loss of a young life and now in 2018, as the NHS celebrates it’s 70th anniversary, things would be very different.
We now have paramedics and air ambulances that would bring him to one of our 27 Major Trauma Centres, where he would have a brain scan within ten minutes and be in theatre with a neurosurgeon 20 minutes later.
'We've seen a revolution in trauma care'
I now have so much extra science and technology at my disposal and we have also changed the system to get trauma patients safely and quickly to the right hospital at the right time.
Even in my lifetime, what we now know as A&E departments has changed beyond recognition.
Then called "casualty" departments, they started off really very small. There were hundreds of them around the country and they were manned by just one or two doctors.
It wasn't really the front door to the hospital, most people would have been admitted via their GP.
Now, the A&E department has become the epicentre of the hospital and of modern medicine. It is the main gateway into hospital for most patients.
When the NHS first began, the old Nottingham General Hospital , would have had just one or two resuscitation beds.
Now, at my hospital in Nottingham we have 12.
Emergency departments are maybe four or five times bigger and they are providing front line services.
The doctors in these tiny departments would have been very experienced in dealing with trauma as many of them would have served in the war.
They would have been experts at sewing up wounds and treating burns, but what they could do was very different to how we treat patients today.
'Years ago, broken bones were potential killers'
One of the biggest differences in patient care is how we treat broken bones.
New developments have completely revolutionised trauma care.
Today, about a million people every year suffer a fracture. On average, most of us suffer two or three broken bones in a lifetime.
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In 1948, only one in 50 would be treated with surgery. It was just too risky because of the high risk of infection.
Most would have been put in a plaster cast or a splint or admitted to hospital on traction.
If a young lad came off his motorbike and broke his thigh bone, he would have had a one in five chance of dying.
If he survived, he would have been in hospital six months.
Now the same 18-year-old falls off his bike and he has a very small risk of dying, and he would probably only spend three to six days in hospital.
He'd have an operation and the bone would be fixed very quickly with a big nail that would hold the bone together.
In less than a week, he’d be up on his feet and away.
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In 1948, there were wards and wards full of young and old people resting for months in bed while their fracture healed.
Now, one in four people who suffer a broken bone have surgery. It's often done through keyhole surgery, we have X-rays and the risk of infection is far lower.
They recover much quicker, they get home much quicker and they can go back to work, school and home to their families.
This is one of the biggest changes in trauma care since the NHS began.
'Drink driving was rife, fire safety didn't exist and mining accidents were deadly'
We have so many major advances coming together so a patients’ care in 2018 is very different to how it would have been in 1948.
Shortly after the war there were a lot less cars on the road, but there was no road safety either.
There used to be many more serious accidents. People didn't wear sealtbelts.
There used to be many more serious accidents. People didn’t wear sealtbelts. In the mines alone, there were one million injuries per year
Motorcycle helmets have been made compulsory and the difference that has made is unbelievable.
Drink driving was rife and more recently, smart motorways have reduced traffic accidents and airbags protect car occupants.
This means the number of patients we are seeing after major car accidents has reduced, and the ones that do come in are usually less severe.
Britain was also a big industrial nation in 1948. There were, quite literally, thousands of industrial accidents.
If you go back through some of the old medical journals of around that time, the numbers were startling.
In the mines alone, there were one million injuries per year. And we are not talking about people cutting themselves on a piece of rock, they were very serious injuries dealt with by surgeons who had worked on battlefields.
'Now we face terror attacks, knife crime and an ageing population'
The patients you see in A&E today have changed. Now, we have many more frail, elderly people.
They suffer simple falls but because they are in their 80s and their bones are weak from osteoporosis, they will often get fractures and it takes them longer to heal and recover.
And while we still live in a very safe country, violent crime has increased.
Gunshot wounds are thankfully still very rare, but we are seeing a lot more knife wounds as stabbings increase, particularly in some parts of London.
In 1948 there was a period of peace, but it was in the 1970s when doctors started having to deal with terrorist attacks following the IRA bombings.
Now, making sure they are ready to deal with a terrorist attack has become a very real problem for each of the UK's 27 trauma centres.
I was national clinical director at the time of the Manchester bombings and had to coordinate the national response to make sure that the surgeons in Manchester, who did a fantastic job, had the right supplies and experts available.
Civilian doctors do not routinely have to deal with bomb injuries so we have had to learn very rapidly.
We had to work closely with our military colleagues and everything we learned was passed on immediately, so that if Britain is to suffer another atrocity, the doctors on duty will know what to do.
Within days of the Westminster attack in London, I was briefing teams around the country on how they could best treat patients for what was a new type of attack in this country.
'We're not better doctors now than those who manned casualty departments in 1948'
If there is one thing I have learned, it is to never underestimate our forefathers.
They were incredibly bright and hard working people. We have made many medical advances over the past 70 years and now we have become far more specialised. Most surgeons in 1948 were generalists.
If you were an orthopaedic surgeon then you would fix everything - broken bones, spinal injuries, knee surgery, hip surgery.
But because of the way science has advanced it has now become almost impossible to be a jack of all trades.
Trauma is my speciality and I suspect I know more than they did about that area. But they had such a huge breadth of knowledge.
We've also changed how we treat patients. In 1948, patients would just be taken to the nearest casualty department.
That hospital would have had to deal with it even if they didn't have the proper facilities or expertise.
Gunshot wounds are thankfully still very rare, but we are seeing a lot more knife wounds as stabbings increase
If the patient had a head injury and they didn’t have any neurosurgery, they'd still have to try and deal with it.
Now, we have specialist trauma centres and people with bad injuries will be taken very rapidly, often by helicopter, straight to the major trauma centre where there are the best people and facilities to give them the best chance of life.
This single change has made a huge difference to how we now respond in a terrorist event.
It used to be that everyone who was injured in Manchester would have just gone to the nearest hospital.
But when the Arena was bombed, the most severely injured patients were taken direct to the major trauma centres. The less severe went to other hospitals in the area.
'A&E attendances have gone up but fewer patients have serious injuries'
Attendances at A&E have gone up hugely but the vast increase in numbers is mainly related to older patients, becoming more frail and having medical issues such chest problems, waterworks infections or heart problems.
The number of patients admitted with serious injuries has actually decreased.
Our roads are the second safest in the world, we've seen less accidents and deaths from road accidents have reduced.
Industrial accidents have gone down. Fire patients, as fire safety has greatly improved, have gone down.
'Antibiotic resistance presents the next big threat'
We’ve been hugely successful with prevention programmes both at work, on the road and in the home and while I enjoy my job as a surgeon, I'd obviously far rather people didn't get hurt in the first place.
In 1948, hospital infections were a huge problem. Antibiotics hadn't really been introduced into modern practice. The use of penicillin was not widespread.
One of the reasons people did much less surgery was because the risk of infection was enormous. Now, our rates of infection are incredibly low.
The risk of infection from surgery on a broken bone are 1 in 100 or less and that is because of antibiotics, better cleanliness and all the things we’ve learnt about infection.
Going forwards though one of the biggest challenges we face is the multi-resistant bugs which have become resistant to antibiotics.
When they started using penicillin in the NHS, nothing was resistant so it effectively treated everything. Sadly that is not the case any more.
If a patient gets something like MRSA, which is resistant to penicillin, it is far more difficult to treat.
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Prevention is key - cleanliness of the hospital, cleanliness of the operating theatres and washing hands.
Staff will often use the alcohol hand rub to make sure they don't transfer any bugs.
Doctors don’t wear ties any more and they don't wear long sleeves.
I firmly believe that Britain's accident and emergency departments are among the best in the world, despite the huge pressures they face. Of course, we can always improve.
It may be that we find a magic bullet that will make fractures heel quicker. That would be brilliant for everybody.
Patients would be in and out of hospital so much quicker and it would free up medical staff for other areas in which they are so desperately needed, but unfortunately I think we are long way away from that yet.
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