A massive shift of patients to relatively specialized types of care has occurred. Until recently these patients had been treated in local centers with good results and at much less expense. The issue of the loss of moral authority at the local level is not insignificant. One cause for optimism has been the good relationship with neurosurgeons at several local trauma centers. This has allowed for most head injury patients to be treated locally, though this is not reflected in these data, as these patients were not transferred.