Henry Guly, A history of accident and emergency medicine, 1948–2004, Basingstoke, Palgrave Macmillan, 2005, pp. xviii, 183, £45.00 (hardback 1-4039-4715-5).

Abstract

A history of accident and emergency medicine, 1948–2004 traces the development in the UK of that specialty. “A&E is a curious specialty” in that whilst most specialties originated out of increasing sub-specialization, A&E was born out of the need to provide immediate and broad coverage of acute disease and injury in all body systems (p. xii). The author, Dr Henry Guly, has been, over the last three decades, a central figure in this developing area of health care, having held a consultancy in A&E since 1983. Drawing on the archives of the Royal Colleges, the British Association for Emergency Medicine, and other involved bodies—and on his own participation in and considerable personal knowledge of events—he meticulously documents the struggles within the NHS, with other specialties, and within the specialty itself, which gave rise to A&E as a medical specialty and the A&E as a health care institution. Guly begins by reviewing the state of casualty services between the 1948 founding of the NHS and the Platt report of 1962. The Report of the Standing Medical Advisory Committee on Accident and Emergency Services by Sir Harry Platt is cited as the crucial point at which “casualty” services began to be reconfigured around a more specific concept of “accident and emergency”. In the 1950s, postings in casualty departments were unpopular, and staffing was through rotas of attending GPs, house surgeons, and casualty officers with joint appointments in other specialties. Throughout the 1960s, orthopaedic surgery, general surgery and anaesthesia vied, often quite robustly, for leadership in this area of health care. However, in 1966, Senior Casualty Officers formed the Casualty Surgeons Association (now the British Association for Emergency Medicine). Familiar with the reality of the A&E, where care involved not only trauma but medical, paediatric, psychiatric and social problems, Senior Casualty Officers recognized that such work required specialist expertise not encompassed by any one of the traditional specialties. They lobbied for the creation of A&E positions within hospitals at the consultant level. Between 1971 and 2001, A&E became the fastest growing specialty in the UK, with consultant positions increasing from an initial 32 to just under 500. However, the battle for control of the specialty by its own members was a long one. Though Edinburgh established an FRCS in A&E in 1981 and, in England, a Faculty of Accident and Emergency Medicine was established in 1993, it was not until 2003 that the specialty gained full control over its own training programmes, exams, and entry requirements. Most of the book is concerned with detailed descriptions of individual battles lost and won in this long process. In the latter chapters of the book, Guly goes on to describe the implications for the specialty of changes in pathology, work patterns, and medical practice over the last thirty years. In particular, he singles out the expanding role of the A&E in primary care, increased acuity of medical problems, a relative decrease in trauma, limited availability of GPs out of hours, and an aging population. As Guly himself points out, his book has a narrow focus. It does not set out to examine the progress of the specialty in other countries, nor is it intended to address the larger questions of relations between health care demand, demographics, economics, technologies, etc. It is not intended as a social history of A&E, nor as a theorization of disciplinary formation. Rather, it is an internalist history dealing specifically with “the battle to get the specialty recognized” (p. xiii). As such, it is a careful documentation of precisely that. It should be of interest to practitioners within the specialty of A&E, and of value to those involved in research on emergency medicine, the NHS, and the development of disciplines in general.