Dear Drs Wallace and Kahn

I am hugely relieved to finally see an editorial published ("Severe sepsis in the UK and the case volume-outcome association" D J Wallace, J M Kahn BMJ 2012;344:e3494) that places the good outcomes achieved by small units above the important but not over-riding case volume-outcome association. As a consultant in a smaller (6 bed) ICU I have seen services taken away from this hospital (notably elective AAA repair) despite good evidence that our outcomes have been better than average (and better than some large centres). The ICU medical and nursing team here have worked hard to produce our consistent low SMR on the ICNARC case mix programme outcome data (SMR 0.7-0.85 over the last 10 years, data available to the public on the ICNARC website). I'm sure we are not alone in our concern that our good results will be ignored by health planners when they try and re-organise to bigger units justified entirely by the case volume argument. We all accept that patients must get the best treatment. When that best treatment is being delivered in a small unit there should be as much recognition as for a large unit.

Yours sincerely

Dr A D Walder
Consultant in ICU and Anaesthesia
North Devon District Hospital

Competing interests: None declared