Burns are more common in Wales than anywhere else in the UK - just one reason why the nation needs to keep its burns centre. The next month will be critical for the future of this highly acclaimed service as a review decides whether the Wales Burns Centre in Swansea becomes a centre of excellence or is downgraded. Hamish Laing, a consultant in plastic surgery at the Welsh Centre for Burns and Plastic Surgery, argues that Wales must keep the service....
MAJOR changes are being planned for the delivery of burns care across the NHS which will have far-reaching effects for the victims of burn injury in the UK, and for Wales in particular.
The specialty of burns care developed in the UK between the wars and achieved public awareness with the treatment in southern England of fighter pilots from the Battle of Britain - the so-called guinea pigs, most of whom had severe burns to their hands and faces.
Sir Archibald Mcindoe and his colleagues brought the skills of reconstructive plastic surgery to these patients and, along with a better understanding of the effects of major burns on the body, considerable advances were made in the likelihood and quality of survival.
It was not long before burns units were established around the country, responsible for caring for the people of each region in the NHS.
These regional burns units were nearly always co-located with plastic surgery units and were often placed outside the major cities, possibly to provide a better environment to recover and rehabilitate after major injuries such as these.
In Wales the unit in Chepstow opened in 1950 where it remained until 10 years ago when it moved to its current home in Swansea.
That move, which has been mirrored around the UK, reflects a growing appreciation that burns and plastic surgery patients sometimes need the expertise of other specialists and the back-up found in major hospitals.
Indeed, Swansea is one of only a tiny handful of hospitals in the UK to have all the specialties involved in treating trauma on one site, and the only such hospital in Wales.
Since the early part of the last century there has been a change in the pattern of burn injury in the UK as a result of social, employment and legislative changes.
In Wales the loss of mining has made the terrible pit fires a thing of the past but the remaining steel, oil and chemical industries still have real risk of major burns, as the devastating blast furnace explosion at Port Talbot in 2001 revealed.
Some new industries to Wales have created new dangers, such as the use of hydrofluoric acid in microprocessor production, which can produce very severe burns.
Most burns, however, happen in the home and here too there have been changes. Children remain at greatest risk and nearly half of all admissions to hospital with burns are under the age of 12 years.
Legislation for electric bar fires, kettle flexes and clothing materials have reduced many of these devastating injuries but a proliferation in market stalls selling imported clothes, which do not meet the strict flame-proof rules, has meant that clothing can still catch fire with terrible consequences.
The move away from open fires towards central heating has also helped and smoke detectors, if mains-wired or with regular battery replacement give more time to escape if there is a fire in the home.
But modern life has brought with it new dangers - barbecues, the ready availability of fireworks all year round and the threat of terrorism and modern warfare.
Meanwhile the traditional dangers of boiling saucepans, baths with the hot water run first and mugs of tea within reach of toddlers are ever present.
Wales still has its share of deprivation and poor quality housing and sadly it is here that scalds and burns are most likely to occur.
The treatment of burns has changed too. All members of the burn team have seen changes in their areas of expertise: new artificial skin substitutes are expensive but can be life-saving for some severe burns, new techniques and drugs in intensive care for burns, new dressings and wound care methods, better rehabilitation and psychological support.
The falling number of the most severe burns in adults and children and the recognition that the best burns care requires a large team of professionals working together led, in 2001, to the UK National Burn Care Review, a wide-ranging report with over 200 recommendations to improve the quality of burn care throughout the UK and to provide care for all degrees of burn severity that matched the best in the world.
The most significant changes proposed are that the existing 30 burns providers be divided into three types - six or seven Burns Centres of Excellence, providing care for the most severely injured patients in a large population area (such as the whole of south west England and Wales); Burns Units providing care for the majority of patients from the local region (for example South Wales); and Burns Providers, local plastic surgery units dealing with minor burns.
The implications for this reorganisation are great. If the current Welsh Burns Centre in Swansea is designated as a Centre of Excellence, then patients with major burn injuries from southern England and even further afield would be transferred to South Wales for their care.
In fact this already happens from time to time because we have the largest burns centre in the UK with its own 10-bed burns intensive care ward. The Welsh burns centre has never had to turn away a patient - something unheard of in English units.
However if the decision goes against us and we are not awarded centre of excellence status then patients from South Wales may have to be transferred out of Wales to the nearest centre with an available bed.
This might be Bristol but is more likely to be one of the other major English cities.
In North Wales, major burns are uncommon - just a handful each year - and these have traditionally been sent to Liverpool. However it is likely that this too will change following reorganisation.
This report is now being implemented through a rigorous process of inspection of all burn care providers in England and Wales against standards for every aspects of the service for patients.
Swansea NHS Trust is seeking to be recognised as a centre of excellence for both adults and children - the latter in partnership with colleagues in the Welsh paediatric intensive care service.
We have always been able to care for severely burnt patients of all ages and with the back up of the other specialties on site in Swansea believe that we are well placed to become one of the national centres.
The UK National Burn Care Group, which has representation from Health Commission Wales, will make its decision in late December or early January.
The recommendations could provide a vital boost for NHS Wales with colleagues across the border recognising the quality of the service available here in Swansea by contracting with us to care for their most seriously injured patients as part of a wider network with England.
There has been much written recently about the increasing trend for patients from Wales having to be sent to England for specialised care. This review could provide an important counter-balance to that flow of patients.
The team and facilities in Swansea are widely recognised to be of the highest standard and were considered to be "standard setters" by the inspection team.
Designation as a Centre of Excellence would not only be good for the reputation of Wales but also for healthcare in Swansea, giving an important boost to recruitment and retention of staff and bringing in much needed investment to the trust from England, which would benefit all our patients wherever they live.
Indeed, in England over £6m is being pumped into their burns services, ahead of the decision, to strengthen possible contenders for centre of excellence status.
We are working closely with Health Commission Wales and the Welsh Assembly Government to ensure that the Welsh Burns Centre is as well placed as possible in this process and gets the recognition that it deserves.
We have already introduced an innovative outreach team to save some patients from having to travel to hospital and have recruited an additional burns specialist to join the team.
We are jointly bidding for a Professorial Chair in Burn Injury Studies with colleagues in Cardiff and the university.
Burns are more common in Wales than elsewhere in the UK and we work with other agencies to deliver prevention programmes.
We celebrated the 10th anniversary of our move from Chepstow to Swansea, in September - the next few months may determine the whole future of the burns service for Wales.
We are determined to play a full part in the Network of Burns Care for the UK and hope to become a centre of excellence for all patients of all ages with burns.
A copy of the UK Burns Care Review 2001 can be downloaded from: www.baps.co.uk