Memorandum from The College of Emergency
Medicine (RS 81)
Response to request for written information
from the Parliamentary Transport Committee on the future Road
Safety strategy—June 2008
The College is grateful for the opportunity
to assist the Parliamentary Committee on issues relating to Road
Safety. We provide written evidence in response to the questions
detailed below.
Question 1
What is the Reliability of road casualty data,
including the variances in police and hospital records, reliability
of serious/slight casualty > distinctions in reporting, divergence
of trends in deaths and serious > injuries (in Police data).
Response 1
Police data does not capture a significant proportion
(perhaps up to 25%) of road casualties admitted to hospital and
tends to underestimate severity in those it does record—there
is value in data linkage with hospital and trauma registry records
but this would need investment.
Central to the development of epidemiological
understanding of road related injury is the creation, maintenance
and analysis of injury registers or trauma registers. Such registers
have been shown to be effective for improving understanding and
focusing resources for a wide range of disease states. In the
case of traumatic injury, population based injury research registers
have also been successful in identification of higher risk populations
and modifiable risk factors within populations.
Despite the fact that a great deal of information
is actually available regarding road traffic related injury, the
existing information sources are fragmented across a range of
NHS and non-NHS agencies each focusing on different details and
using differing definitions of the same phenomena. There is great
potential for developing epidemiological research in this field.
There is also good evidence that inter-agency data sharing improves
our understanding of the epidemiology of road traffic related
injury and allows us to target and evaluate primary prevention
strategies and emergency/immediate care resources (secondary prevention).
Although such inter-agency data sharing was first recommended
in the Health of the Nation white paper in 1993 little progress
has been made. A charity funded pilot project is underway in Cambridge.
There is therefore an opportunity to develop
policy within both the Department of Transport and Department
of Health to enhance existing injury prevention and control work
by actively supporting the development of injury research registers
which utilise ethically and legally robust information sharing
arrangements to access all existing sources of injury data (NHS
and non-NHS) within a known population area and combine these
into population based injury research registers which allow sub-regional,
regional and national bodies to:
— More clearly understand the pattern
and distribution of injury events and identifying factors associated
with more severe injury or poorer outcomes.
— Identify and evaluate existing injury
prevention and control strategies.
— Explore and evaluate the impact of
novel injury prevention and control strategies (such strategies
to improve targeting of injury prevention measures)
— Evaluate clinical services and interventions
with regard to the impact of secondary prevention on reducing
deaths and disabilities—eg integrated pre-hospital critical
care and retrieval teams
Evidence supporting response 1
A review of the literature found two important
studies in this regard. One published in the BMJ (Goldacre) 2006
reviewed hospital episode statistics which did not show the 25%
decline in number of road casualties suggested by the police data
between 2000 and 2004. The hospital data suggested a plateau in
numbers of road casualties admitted to hospital and implied that
the police data completion was declining.
A further study from Salford (Yates et al 1996)
showed that police had no record of 25% of road incidents causing
children to be admitted to hospital with injuries and that 27%
of the injuries recorded as "slight" were in fact "serious".
The comparative hospital data was obtained from the national trauma
registry (Trauma Audit and Research Network www.tarn.ac.uk).
Question 2
Is it possible to estimate the number of road
deaths saved by advances in emergency procedures and medical care
over the past decade? Is this an area that deserves priority alongside
in future road safety budgets?
Response 2
It is only possible to estimate whether advances
have occurred in hospitals that submit data to the national trauma
registry TARN. TARN contains reliable information on the severity
of injuries sustained by each road casualties using a validated
international injury dictionary. Routine hospital discharge data
is unsuitable for this purpose as it codes categories (brain,
liver, limb) rather than severity of each patient's injury. Unfortunately
TARN submissions are not compulsory so data on this question is
only available from the 50% of trauma receiving English and Welsh
hospitals that are TARN members.
TARN data suggests that 10.5-13.5% (equivalent
to 3,500 people every year) of road casualties admitted to hospital
between 1996-2003 die from their injuries, however this figure
has been declining; 8.9% in 2004, 7.4% 2005 without any change
in the severity of injury in the patients admitted. This suggests
that advances in medical care have saved hundreds of lives since
2003 in addition to the thousands being saved prior to this. These
advances include hospital systems that now give better access
to early brain scans and specialist neuro (brain) surgical care
for head injured patients, and interventional radiology which
can stop bleeding without need for invasive surgery. Access to
effective rehabilitation facilities is variable across the country
and unacceptably poor in some areas.
TARN hospital analyses show the quality of trauma
care varies across the country. Work with the Healthcare Commission
is on going to address these issues in TARN member hospitals;
non participation of up to 50% of hospitals in TARN is a major
concern. Road trauma is the number one killer of UK citizens under
the age of 44 and probably the country's most expensive disease.
Effective road safety strategies should include improved investment
and research in trauma care and compulsory membership of TARN
for all trauma receiving hospitals alongside prevention initiatives.
This has also been recommended by the recent report "Trauma—who
cares" from the national confidential enquiry into patient
outcomes and deaths (NCEPOD) and in NHS regional responses to
the recent Darzi review.
In general terms, most existing road injury
prevention policies focus on primary (pre-event) prevention and
on how education, engineering and enforcement strategies can be
developed to reduce injury events. The development of additional
policies focused on improvements in secondary prevention (the
impact of focused clinical care within trauma systems) and improvements
in understanding the epidemiology of road traffic related injury
might significantly improve our ability to reduce road traffic
related deaths and injuries. The CTARP project (Cambridgeshire
Trauma Audit and Research Project) is an example of how this approach
might be implemented.
Evidence supporting response 2
TARN analysis of hospitals submitting consistent
data returns since 1996-2005 (cases still being submitted from
2006).
Routine Hospital Episode Statistics giving numbers
of road trauma deaths in UK hospitals in 1994.
"Trauma who cares?" NCEPOD 2007.
"Healthier Horizons" NHS North West response
to Darzi review www.northwest.nhs.uk/healthierhorizons.
"Head injury care for Adults in Greater Manchester:
Greater Manchester Traumatic Brain Injury Audit Group http://www.burypct.nhs.uk/538.html.
CTARP 2007.
Question 3
For drivers who may have a medical condition
or be taking medication that affects their capacity to drive safely,
how big a problem is this and does the current self-reporting
system work or should doctors be placed under a stricter duty
to report patients to the authorities (DVLA etc)?
Response 3
There is no evidence that road traffic collisions
are being caused by drivers who are unfit to drive as a result
of a medical conditions and / or medication. A change to the current
legislation, placing the reporting onus on doctors is in our view
not indicated.
Evidence supporting response 3
Literature review of reports on road collisions
and medical conditions revealed no reports indicating a failure
of the current reporting system in the UK.
Question 4
The Association of British Drivers claims that
the effects of alcohol are less when the BAL level is falling
(the morning after). Is there any evidence of this?
Response 4
There is no evidence to support this claim.
The influence of any level of blood alcohol at any given time
will be the same regardless of whether the level is rising or
falling. The effects of alcohol on any driver are however influenced
by level of driving experience. Drivers causing collisions through
intoxication are usually young and / or inexperienced. There is
a case for lowering the permitted blood alcohol level to less
than 20 milligrams per 100ml in drivers who have had a full license
for less than 5 years. This could reduce alcohol related road
collisions and save lives.
Evidence supporting response 4
Literature review of studies relating changing
direction of blood alcohol levels and ability to drive. No specific
studies in the controlled (laboratory) environment have reliably
addressed this issue in terms of simulation or response times.
The is evidence from the road safety literature that novice drivers
ability to drive may be significantly impaired by a BAL below
the current UK legal limit of 80 milligrams per 100 ml. Significant
road casualty reductions have been achieved by states within Canada
and Australia where the legal limit has been lowered for novice
drivers.
Australia, Austria, Canada, Croatia, Italy,
Macedonia, New Zealand, Slovenia, Spain, and the United States
are amongst countries with either fixed age definitions or probationary
periods following the initial granting of a license (at any age)
at which a lower BAL level applies (Stewart, 2000). While this
lower limit tends toward zero tolerance for such drivers, in practice
it is often set at 0.2 mg/ml (Deshapriya & Iwase, 1996) in
order to reduce the possibility that other variables could confound
the BAL reading.
June 2008
| 
