Changes in safety on England's roads: analysis of hospital statistics
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38883.593831.4F (Published 06 July 2006) Cite this as: BMJ 2006;333:73
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We were very interested to read the article highlighting the
considerable morbidity and mortality on England’s roads. These articles as
well as recent experiences of stopping at several roadside incidents have
made us consider if an accident victim could benefit from our years of
training and experience whilst the emergency services arrive?
For example: it is a quiet Sunday afternoon and you are unfortunate
enough to encounter an accident on a deserted country lane. A motorcyclist
has collided with a car and two victims are presented before you. With no
basic equipment you might offer little more first aid than a member of the
public. However with equipment in the car considered essential by
paramedics for personal protection and basic life support, one could
perhaps be of more help to these patients.
This posed us another question. What items would you have in your
car? You certainly will not need a spinal board and thoracotomy set,
however we suggest the following items are cheap, easy to use, treat life
threatening conditions, offer personal protection and have no expiry date.
Therefore, once assembled, your kit can be forgotten about until the
need to use it arises.
• Gloves – a few pairs can be given to others to help.
• Reflective tabard
• Hard collar - adjustable
• Oropharyngeal airway
• Resuscitation mask
• Gauze / Crepe bandage
• Strong tape
• Strong scissors
This is not a comprehensive doctors field medical bag, nor will it
cover every eventuality. However, this may provoke others in the primary
care community to think how they will use their skills next time they stop
at a roadside incident.
Competing interests:
None declared
Competing interests: No competing interests
Gill et al show that the police report fewer RTA casualties than is
evident from hospital admissions, invoking concern that an unduly rosy
message is being conveyed about road safety. There are other reasons for
believing that RTA statistics over many years should be interpreted with
caution.
British RTA deaths are down 50% per year from a peak of 7500 in the
late 1960s to 3400 at present. The improvement in RTA injuries has been
proportionately much less: down 20% from 373,000 in the late 1960s to
290,000 at present (1) - and without correction for anomalies of the sort
Gill et al report. One reason for the reduced mortality relative to injury
may concern traffic density: while traffic jams fifty years ago were
confined to urban routes at the start and end of the working day, they are
now common. Slowed traffic inevitably elicits less severe RTAs. Comparing
low-density rural areas with high-density urban areas for a given year
supports this assertion: rural mortality relative to injury is 3-4 times
greater than urban mortality relative to injury(2). Multiplying the
current RTA deaths by this value would suggest that the roads are less
safe than fifty years ago.
The issues are exacerbated by those RTAs that do not cause either
injury or death. Unfortunately, the rates of these damage-only RTAs have
not been recorded, a serious omission for the interpretation of RTA rates
as a whole. Insurance data provide some insight, but are intermittent and
do not list RTA claims separately. Nonetheless, Davis in 1992 estimated
that damage-only RTAs accounted for 80-95% of all RTAs. He also reported a
61% increase in the number of insurance claims during 1981-9 (3). Recent
government statistics indicate a continuing upward trend: for 1997-2003,
the monetary value of insurance claims increased by 44% (1).
Increase in damage-only RTAs relative to casualty RTAs is consistent
with changes in safety-related engineering: seat-belts, ABS brakes,
"crumple zones" and so on. A severity of RTA that previously killed or
injured motorists now merely damages property. And, of course, there is
plenty of evidence that the safety advantage is undermined because driving
becomes less cautious (4). One can conclude that RTA rates as a whole have
increased substantially.
The issues go beyond those of the motorist's safety: less cautious
driving and more RTAs make walking and cycling less attractive. Public
transport is also undermined, since walking and cycling are the likely
means of accessing public transport. The issues therefore extend to the
encouragement of healthier lifestyles.
References
(1) Transport Statistics Great Britain. London: HMSO, 2005.
(2) Adams J G U. Risk. London:UCL,1995.
(3) Davis R. Death on the Streets. Hawes:Leading Edge, 1992.
(4) Reinhardt-Rutland A H. Seat-belts and behavioural adaptation.
Safety Sci 2001;39: 145-155.
Competing interests:
None declared
Competing interests: No competing interests
Schools in my home county of Surrey seem to compete to have the most
conservative school uniforms (despite a complete absence of evidence that
school uniforms bring any benefits). Most require students to wear dark-
coloured outer clothing, and explicitly ban brighter coloured outer
clothing. This prevents students from following the universal guidance to
wear light- brightly-coloured clothes to increase conspicuity and reduce
their odds of adding to the pedestrian accident statistics. School
governing bodies have absolute say over this, and many refuse to discuss
the issue, simply dismissing as "inappropriate" advice from road safety
officers and organisations, and suggestions from parents, that they might
permit more appropriate outer clothing.
We should be encouraging children to walk or cycle to school; and
schools should help us by not creating unnecessary additional
disincentives.
Competing interests:
I have children at school in Surrey
Competing interests: No competing interests
It is an anomaly that road traffic injuries are taken from police
rather than health service figures and this article does an important job
of highlighting difference in their trends. However, it is a mistake to
identify improvements in safety with reduction in injury rates. Motorways
are extremely dangerous for pedestrians, hence it is illegal to walk on
them and few would try. One impact of more and faster traffic is less
walking and cycling, reducing the opportunities for injuries among these
groups and for physical activity. However, this is not an improvement in
road safety but a response to increased danger.
In response to Paul Smith, he is widely known as a campaigner against
speed cameras. If he
would like to consider reasons why injury rates are not falling he
could try looking at increased use of mobile phones and SUVs, both
established risk factors for crashes.
If one wants to read from campaigners who support serious reasearch
and put health and environment before love of speed, readers would be
advised to check out the Slower Speeds Initiative, http://www.slower-speeds.org.uk
Competing interests:
None declared
Competing interests: No competing interests
I observed anomalies in the official serious injury statistics in
2003. In particular a drift in ‘lethality ratios’ caught my eye. [1]
Further investigations revealed that the official serious injury
statistics were extremely vulnerable to a range of external influences,
and that they were not behaving consistently with other road safety
indicators. [2]
Consideration was given to the idea that lethality ratios were
varying due to safety interventions (for example air bags) so a further
check was carried out to determine if the effect was apparent across
different road types and different road user groups. [3]
I drew the conclusion that the serious injury series was not reliable
due to alterations in reporting or other consideration, and that the
series was unsuitable for year on year road safety comparisons.
Wider views of road safety policy based on speed limits, speed
enforcement and reducing vehicle speeds indicated that this policy was
very unlikely to be effective – mainly because road safety actually exists
in the psychological domain. Issues like average driver quality are far
more significant than marginal changes in the speed chosen by the majority
of responsible motorists.
While engineering improvements have been ongoing in vehicles and
roads, and while post crash medical care has continued to improve,
something else has apparently offset these substantial benefits to provide
static death rates and, we are just learning, static serious injury rates.
The obvious confounder is growth in traffic, but even the most cursory
examination reveals that traffic growth has been nowhere near sufficient
to account for the unexpectedly poor trends.
I believe that policy - particularly high levels of enforcement by
speed camera - has had substantial negative effects on driver quality.
I am most grateful to Mike Gill et al for bringing this issue to the
fore and providing solid evidence that Department for Transport claims and
policies are optimistic at best.
[1] http://www.safespeed.org.uk/lethality.html
[2] http://www.safespeed.org.uk/serious.html
[3] http://www.safespeed.org.uk/serious2.html
Competing interests:
Founder of the Safe Speed road safety campaign
Competing interests: No competing interests
Road casualties and collisions - more work required
I read with interest the analysis of road casualty data and
observations of driver behaviour within the 8th July BMJ, and as someone
who is involved in road safety I would like the opportunity to provide
some comment.
The reason for the analysis of risk taking behaviour within drivers
of ‘four wheel drive’ vehicles out was unclear. There was no comparison of
behaviour between other readily identifiable groups, such as drivers of
high value luxury saloons, two seater 'sports cars', family saloons, light
or large commercial vehicles etc.
Within the ‘four wheel drive’ market there is a differentiation
between larger 4 wheel drives and so called ‘softroaders’. The two sub
types of vehicle are sold in to different market segments, with different
appeal, with no doubt different behavioural attributes, to further
compound the complexity, a survey of rural versus urban behaviour may have
been useful.
To state the obvious, it is the driver, not vehicle which exhibits
behaviour, although the vehicle may or may not give an insight into the
individual driving it, I would suggest that it is not safe to make
assumptions driver behaviour purely on the basis of vehicle type.
It is not known if other observable data (for example approximate age
or sex of the person driving, time of day etc.), was gathered to enable
identify detailed driver risk taking behaviour, but clearly this would
have been useful and readily gathered.
The research into under reporting of casualty collisions is
intriguing; I have seen some of the data for both police and the NHS
locally.
The local trends suggest that the reporting of killed or serious
injury collisions by the police has fallen over the period from 1996 to
2004. The reporting of casualty collisions reported via hospital sources
has shown less consistent trends (over a shorter time period). However the
number of ‘Damage Only Collisions’ (where no serious injury is reported)
has also increased in the same time period. So the implication that minor
collisions are simply not being reported seems to be contradictory here.
One hypothesis is that increased reporting of ‘Damage Only’
collisions and higher levels of reporting in hospital data may be related
to behaviour driven by insurance claims, however no research has been
conducted into this as far as I am aware.
Figures quoted from the Police data are sometimes for killed or
serious injury (KSI) collisions rather than casualties. I would imagine
that HES data could only report the number of individuals affected rather
than the number of incidents causing them, I am not sure if this was the
case in this study.
The number of admissions is potentially significantly affected by
changes in hospital practice and facilities. An area where admissions were
seen to increase may also correspond with an area where the opening of an
additional observation ward was known to have occurred.
Hospital data as well as police data has been shown to have flaws. In
some cases road casualty incidents recorded in hospital data had no
obvious correlation with traffic related injuries. These error sources are
unquantified in both data sets as far as I am aware, as are any changes in
the methods of data gathering activities within the NHS.
At the more tragic end of the scale - a casualty who is 'dead on
arrival' at hospital, rightly, is not likely to get the same level of
follow through in the NHS, as a patient who can be treated. Conversely for
the Police, a death on the road will receive a high level of resource and
follow through.
Identifying risk groups by looking into admission rates for males to
females, or age ranges for example, may be more useful in establishing
useful interventions. Looking to the casualty rates within different
professions and employing organisations in order to identify further risk
groups. Those who drive as part of their employment are also exposed to
greater risk by virtue of being on the road more frequently..
The observation concerning motorcyclists and children is also thought
provoking. The increasing number of motorcycling fatalities has by and
large mirrored the increased levels of motorcycle ownership in the UK.
Locally the number of motorcycling casualties represents between 20 –
30% of police reported fatalities (with significant variations from year
to year). It is generally thought that motorcyclists represent 1-2% of all
road users. Clearly this is of concern to all those involved in road
safety. Dry weather and bank holidays seem to be factors linked to
increased numbers of casualties, and interventions again need to be
tailored to suit these need.
I do not have the corresponding figures for the child population
changes, but I suspect that it has not dropped at the same rate as the
casualty levels, so what have we been doing right with child road
collision casualties?
I am not aware of how issues such as the outbreak of foot and mouth
may have affected collisions on the road, but some data suggests there was
an improvement in road casualty rates in that year.
Over the last few years I have had the opportunity to see some of the
research conducted concerning road safety and collision injuries. Multi
factorial events such as road traffic collisions, defy simplistic
uncompensated analysis, so I fear there is a lot more work to be done.
Competing interests:
None declared
Competing interests: No competing interests