The Dutch are driving forward ambitious, if underfunded, plans for a national, integrated network of trauma care - complete with helicopters. Tony Sheldon reports

The NHS has been moving towards fewer but bigger accident and emergency departments for years. But so far, ambitious plans to reinvent the system from scratch through a network of trauma centres have come to nothing.

Not so across the North Sea, where Dutch health minister Els Borst, herself the former medical director of Utrecht University Hospital, has launched ambitious plans for a national, integrated network of trauma care.

The Netherlands lends itself to such a network. It has an excellent road system and is one of the most densely populated countries on earth. Some 15.6 million people are packed 380 per square kilometre - more than one and a half times the population density of the UK.

But for the network to succeed there will have to be losers as well as winners. Dr Borst is asking for hospitals to bid by 1 December for the 10 national trauma centres she deems necessary. Others argue that 10 is too few for safety.

These centres will become the elite of A&E care, 'gathering and spreading knowledge and wisdom', working closely together on treatment protocols and scientific developments.

University hospitals with their research and education base are preferred, and only those hospitals which have a trauma centre and a licence to perform neurosurgery need apply.

An experienced traumatology team must be available round the clock, with at least one surgeon, an anaesthetist and two specialist nurses. Within 15 minutes, consultants must be available in 10 different specialties. Intensive care and operating theatre facilities must be constantly available.

Each hospital will have to offer a regional service to a catchment area of at least 1.2 million people. Centres must also provide 'mobile medical teams' comprising a doctor and nurse experienced in giving urgent preclinical care, who will assess patients' injuries at the scene of an accident.

Four of the trauma centres will have helicopters to help the mobile medical teams. They will be geographically spaced to cover the whole country. Those chosen will have responsibility for providing trauma care in their catchment areas. They will not be able to refuse admissions.

The financial rewards, however, are meagre. Approximately£3.25m has been set aside for the plan for 1999, with the same amount again for the four helicopters.

Talks have already taken place between, among others, the Dutch Association of Surgery and the Dutch Hospitals Association (NVZ). Meanwhile, telephone lines between the ministry and hospitals haven't stopped ringing.

Amsterdam typifies the problems. It does not have the population to support two trauma centres. Here, the Free University Hospital stands just a few miles from the prestigious Academic Medical Centre.

Both sites have a neurosurgical clinic and handle trauma patients, but the Free University has the 'primary function'. Dr Borst has ruled out joint sites or 'bi-location', so even the Academic Medical Centre was unsure whether to apply. The answer came in requests from hospitals in the towns of the Flevoland polder, east of Amsterdam, to supply trauma care. The Academic Medical Centre thus annexed a hinterland.

But at least one or two hospitals will see their bids rejected. The burden of providing staff for 24-hour mobile medical teams and intensive care beds or trying to cobble together a large enough catchment area may prove too much for provincial hospitals in the north and east.

Although the NVZ agrees wholeheartedly with the network idea, it argues that 10 centres are too few. Hanny Schulten, of the NVZ senior policy staff, says 11 or more centres are required.

'Our proposal is that once the network has been operating for a year, we evaluate it. We need to ask how many patients come, what sort of care they receive, what the effect is on the availability of intensive care beds or operating theatre space'.

The NVZ fears the plans are underfunded and that the£3.25m will go not to patient care but to build up the network. Ms Schulten argues that becoming a trauma centre will lead to 'an intensification of patient care'. It will attract more patients and the range of staff and facilities will need to be available 24-hours-a-day. 'Without more financial support, will trauma centres be forced to take decisions to cut care elsewhere?' she asks.

But the Dutch are fully behind the theory. It makes clear where the responsibility for trauma care lies in every region.

Dirk Jan Bakker, executive manager of medical services at the Academic Medical Centre, explains: 'Discussions such as 'we are full; we can't take any more patients; can you take over?' cannot take place.

'The hospital director and the medical director have to make sure every trauma patient can be accommodated from its catchment area.'

No longer will patients be first stabilised and then sent on to a specialist unit. If in doubt, patients will be taken first to the trauma centre. 'I think in future more lives will be saved,' says Dr Bakker.