The case for the development of ambulatory day care centres for orthopaedic trauma within the United Kingdom

In January 2022, a total of 6,104,056 patients were on the waiting list for consultant-led non-urgent treatment. ¹ The accumulation of this backlog has led to the allocation of funds and the establishment of 87 national elective surgical hubs across 64 of the 179 acute NHS trusts in England. Among these, 43% are stand-alone hubs, 34% are integrated, and 23% are ringfenced. These elective hubs have been designed to enhance productivity, reduce last-minute cancellations, improve both staff and patient experiences, ensure financial viability, and elevate the quality of care. ¹ Half of these hubs were operational before 2019, with three-quarters catering to either day-case or inpatient surgeries.

Furthermore, 80% specialize in elective orthopaedic surgery and 40% offer enhanced care. ² While network collaboration is increasingly being used to streamline elective healthcare services, trauma care has yet to be included in these initiatives. ³

The government has supported these initiatives, emphasizing their role in facilitating a swift return to normal function, employment, and family life for patients. This, in turn, contributes to economic benefits and patient well-being. Such considerations were pivotal in justifying the investment required to enhance care delivery. ⁴ Currently, the primary focus of these elective care centres is hip and knee arthroplasty, which predominantly benefits the elderly—many of whom are retired. However, trauma cases exhibit a bimodal distribution, with a significant proportion affecting individuals under 20 who have extensive working lives ahead of them. Preventing unnecessary disabilities and ensuring a timely return to work are critical, particularly for younger patients who often bear family responsibilities.

The Getting It Right First Time (GIRFT) initiative has only recently started addressing trauma care, initially targeting non-ambulatory cases through a Non-Ambulatory Fracture Fixation pathway in May 2024. However, ambulatory trauma patients tend to be younger and could potentially be managed through day-case pathways, depending on the severity and location of their injuries. Despite the substantial burden of trauma-related diseases, funding for trauma care remains inadequate, a trend observed in both the UK and the USA. ⁵ Approximately one-third of trauma cases could be managed through ambulatory pathways rather than hospital admission. However, due to bed shortages caused by seasonal pressures and elective surgery demands, timely care is often delayed.^6–9 Developing dedicated ambulatory care centres for trauma patients could provide cost-effective and timely care across different UK regions. The recent GIRFT for trauma report ¹⁰ released in November 2024 advises that "trusts and Independent service commissionner should work to ensure that day case surgery is carried out as default for all orthopaedic trauma cases where criteria for suitability is met”, within a clearly defined day case pathway and that 60% of wrist and 25% of ankle fractures should have a zero stay. Although the metric does not yet specify in a day care unit it is an important step forward giving surgeons support in developing this service.

Development of elective centres

In April 2002, the government announced investments aimed at reducing NHS elective surgery waiting times. As part of this initiative, Treatment Centres were introduced. ¹¹ By October 2002, the Department of Health undertook an extensive planning exercise, requiring all Strategic Health Authorities to assess, in collaboration with Primary Care Trusts, and any projected shortfalls in capacity needed to meet the 2005 waiting time targets. The findings highlighted significant gaps, particularly in orthopaedic surgery, necessitating expansion beyond existing NHS providers. To encourage participation, service providers were offered a 40% premium above reference costs to develop the required infrastructure. ¹¹

By December 2002, a procurement exercise was initiated to invite both independent sector and NHS centres to establish Treatment Centres, with the first patients undergoing surgery in early 2004. Some of these centres relied on overseas-recruited surgical teams. A notable success was the South West London Elective Orthopaedic Centre (SWLEOC), which began operating in 2004. By February 2006, a total of 21 centres, varying in design and functionality, had been established nationwide.

However, concerns emerged regarding the quality of care provided at these centres, particularly due to a lack of experience among surgeon operating outside their specialties. Poor surgical techniques resulted in severe complications, necessitating management in NHS units. Revision surgeries were required in approximately 20% of cases. ¹² Additionally, there were issues related to continuity of care and inadequate follow-ups. ¹¹ Outsourcing surgery altered care pathways, potentially increasing complication rates and yielding poorer outcomes. ¹³

To address these concerns, recommendations for outsourced surgeries included radiographic reviews before patient discharge, streamlined rehabilitation programs, pre-assessment, surgery, follow-up by a single clinician, and proper handovers to local teams if further care was needed. Long-term surveillance via the National Joint Registry was also advised. ¹¹ Initial scepticism regarding these centres largely revolved around the quality of surgeons. Over time, this issue was mitigated through consultant recruitment, NHS choice initiatives, and increased private practice involvement.

Elective hubs have since proliferated across NHS regions, with the highest concentration in London, where efforts have been focused on mitigating the COVID-19 pandemic's impact on elective surgery. ² Less densely populated regions, such as the East of England and South West, have fewer hubs due to longer travel distances between trusts. The NHS's emphasis on expanding elective care capacity has sometimes diverted resources and staff away from trauma care.^6,14,15 In May 2021, the GiRFT programme launched the high-volume, low-complexity (HVLC) initiative to help surgical hubs adopt best clinical and operational practices. ⁴ A £1.5 billion investment facilitated the creation of 47 new hubs and the expansion of 26 existing sites between 2023 and 2025. By September 2024, 108 surgical hubs were in operation, with 26 more expected to open by late 2025. As of June 2024, 7.6 million patients were on the consultant-led waiting list, with 1.2 million awaiting hospital admission for elective surgery, such as hip replacements or cataract procedures. These patients often endure prolonged waits, leading to unnecessary pain and discomfort. With the government's commitment to eliminating the backlog within five years, prioritizing this patient group is essential. ¹⁶

Impact of trauma in the UK

Every year, trauma affects approximately 45,000 people severely in England, while another 500,000 experience less severe trauma, a proportion of whom require hospitalization due to pre-existing conditions, disability, frailty, or environmental factors. ¹⁷ Trauma spans all age groups, with a bimodal distribution: younger individuals (often due to sports, travel, or employment injuries) and older individuals (mainly due to osteoporosis and frailty). ¹⁷ Trauma remains the leading cause of death among individuals under 45, and many survivors sustain permanent disabilities.

Major Trauma Centres (MTCs) predominantly treat younger patients (average age: 56.6 years, 60% male), whereas non-specialist hospitals primarily care for older patients (average age: 72.1 years, 53.2% female). ¹⁸ Paediatric trauma accounts for less than 5% of all cases, with around 300 children experiencing major trauma annually. ¹⁸

Elderly trauma patients are usually treated at non-specialist hospitals, with a median age of 83.4 years and 86.9% of injuries resulting from low-level falls.^17,18 Over a third of these cases could be managed through ambulatory pathways. ⁸ Although GiRFT has begun addressing non-ambulatory trauma, ambulatory trauma still lacks standardized pathways.

Cost and future directions for trauma care

The estimated immediate treatment costs of major trauma range between £0.3 and £0.4 billion annually. However, long-term rehabilitation, home care, and informal caregiver costs remain unquantified. The National Audit Office estimates an annual economic output loss of £3.3–£3.7 billion due to trauma, affecting approximately 45,000 individuals. Given that major trauma cases have risen over the past decade, these financial estimates are likely conservative.^17–19

There is an urgent need for dedicated ambulatory day-case trauma centres to reduce treatment delays and improve patient outcomes. Such centres could follow models established for elective care, utilizing specific funding mechanisms like those in elective surgical hubs. Developing these facilities would facilitate quicker recovery, enable a faster return to work and ultimately benefit both patients and the broader economy.^1,4