The future shape of accident and emergency servicesBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7033.720 (Published 23 March 1996) Cite this as: BMJ 1996;312:720
Cannot be considered in isolation
Emergency services are under strain across the board in Britain, as demand for out of hours visits from general practitioners, new attendances to accident and emergency departments, and emergency admissions increase. The crucial importance of scarce specialist resources as back up to accident and emergency departments was illustrated in the recent case of Nicolas Geldard, who died in December after ambulance crews visited four hospitals before finding one that could provide computed tomography and a neurosurgical bed.1 The latest report from the Audit Commission into initial hospital emergency care2 substantiates reports of pressure on accident and emergency departments. Increasing attendances and staff shortages mean that patients still wait for long periods before they are seen by a doctor, delays that are often related to meeting Patient's Charter standards. Junior doctors are in short supply, 60% of departments have only one casualty consultant, and only three of the 11 sites visited by the commission had on site, around the clock, experienced medical cover.
Once a patient requires admission, the commission found that long trolley waits for beds and “logjams” in accident and emergency departments often depended on factors outside the control of department staff. Specialists and facilities needed to treat children, frail elderly, and psychologically disturbed patients were unevenly distributed. Coordinated teams trained in advanced trauma life support and supported by on site computed tomography scanners, anaesthetics, and intensive care facilities were not universally available.
The commission's solution is fewer, larger accident and emergency departments each treating at least 50000 patients a year to “maintain even the present quality of care.” Only a third of accident and emergency departments in England and Wales are this size. If “good access” is defined as being within 10 miles of an accident and emergency department, and if half of the smaller departments were amalgamated, 31 departments would close, perhaps to be replaced by minor injury units.
How much weight should be put on the commission's recommendation? There are four reasons why it should be regarded with caution; the nature of the evidence offered, the effectiveness of alternative services, the implications for access, and the potential impact on other forms of hospital provision.
What is the appropriate size for an accident and emergency department? In the management of major trauma, evidence of “optimum” size is unclear,3 although reviews indicate the benefit of larger departments and trauma systems.4 The commission acknowledges that some small departments provide well coordinated trauma care. However, given the rising demand and the scarcity of accident and emergency and specialist staff, the commission's report (in common with other reviews5 6) recommends larger departments on the grounds that these would provide improved quality of care. This would include 24 hour cover, better training for junior doctors, and access to specialist back up for all serious conditions, not only trauma, which accounts for less than 1% of accident and emergency workload.
The report itself indicates that patients who attend accident and emergency departments with more minor conditions can be seen in alternative minor injury units or by their general practitioner. Numbers of minor injuries units have already increased substantially—there will be 13 in London alone by 1998.7 In tandem, general practitioner cooperatives, primary care emergency centres, telephone advice lines,4 and emergency, community based response teams are being set up. But little is known about the effectiveness of these new models or their ability to substitute for care in accident and emergency departments,4 8 and coordination may be hampered by perverse financial incentives. Studies have now been commissioned as part of the NHS research and development initiative. In addition, the government's chief medical officer is currently reviewing community based emergency services.9
Closing accident and emergency departments will mean reduced access for patients. The 10 mile criterion is too crude: as the report acknowledges, evaluations of access should take account of travel time, ambulance response times, availability of community based emergency services, and local transport. The impact of access time on mortality and morbidity needs to be established.10 While local accident and emergency reviews have been scuppered by the recent public outcry, the commission's report may enable an objective debate about trade offs between access and quality at a national level. Finally, closures of accident and emergency facilities have in the past been linked to changes in associated specialist services, which would further reduce access to hospital care. But should accident and emergency departments drive the reconfiguration of acute services? At the very least, the wider implications for acute services have to be assessed.10
By Accident and Design is an important report containing useful recommendations for addressing the current crises facing accident and emergency departments in Britain. Steps have already been taken to increase the number of accident and emergency staff.9 The distribution of accident and emergency and back up facilities, availability of specialist expertise, and coordination of services now need to be addressed, and the emergency service offered by the NHS reviewed as a whole. The Audit Commission acknowledges this, in arguing for analysis at regional level, something which may not be within the capacity of the new regional offices. The commission's report must not be considered a blueprint for closure. Its recommendations must now be set in context to allow the full implications for acute health services to be assessed.
I thank Anthony Harrison from the King's Fund Institute for his helpful comments and support.