The reconfiguration of clinical services report provides new insights into the drivers of reconfiguration and the underpinning evidence. It builds on a major analysis, commissioned by the National Institute for Health Research (NIHR), of reviews of service reconfigurations conducted by the National Clinical Advisory Team (NCAT).
This page summarises the report's findings on the reconfiguration of A&E and urgent care services.
Proposals reviewed by NCAT
- Downgrading emergency departments to urgent care centres or minor injury units
- Developing new urgent care centres or minor injury units
- Closing or relocating walk-in centres
Key drivers of A&E and urgent care service reconfiguration
Cost, workforce and safety were the primary drivers of this type of reconfiguration.
Context and relevant policy
- Increase in attendances at A&E and urgent care centres.
- Sir Bruce Keogh’s urgent and emergency care proposals:
- a two-tier approach to emergency departments, divided between ‘emergency centres’ and ‘specialist emergency centres’
- development of broader emergency care networks
- greater access to information and support for self-care
- enhanced NHS 111 telephone service
- urgent care services outside hospital, including better access to GP, primary and community services
- greater use of health care professionals, including community pharmacists and paramedics.
The current evidence base
There is strong evidence to support a senior doctor presence in A&E seven days a week. Professional guidance suggests consultants should be available at least 16 hours a day. Nurse practitioners are a safe alternative to junior doctors.
The evidence also shows that A&E services require:
- 24/7 support from diagnostics, including pathology and radiology
- rapid access to critical care
- rapid access to specialist medical opinion, including geriatricians and paediatricians (on-site) and specialist surgical opinion (senior staff may be remote but part of a network)
- liaison mental health services.
All A&E departments should be part of a formal trauma network. There have been very few studies to assess the impact of centralising A&E services. The limited evidence available suggests that if services are centralised, there are risks to the quality of care where the centralised service does not have the necessary A&E capacity and acute medical support for the additional workload. A proportion of A&E attenders can safely be seen in community settings but there is little evidence that developing these services in addition to A&E will reduce demand.
Changes to A&E services may not result in savings, and significantly increased distances to A&E may increase mortality for the very few patients with the severest illnesses. This needs to be taken into account when assessing the net benefit of any proposal to centralise A&E services. There are opportunities to support local access through networked arrangements and to provide remote support to A&E through telemedicine links to smaller units.
Relevant college guidance
The College of Emergency Medicine argues for ‘senior decision-makers’ at the front door of the hospital. Every emergency department should be staffed by at least 10 working-time equivalent (WTE) consultants to provide a consultant presence 16 hours a day, seven days a week.
Where an emergency department does not have on-site back-up from particular specialties, there should be robust networks of care and emergency referral pathways.
College of Emergency Medicine et al 2014, p 3
There is a balance between centralising or rationalising some services with the consequent risk of patient deterioration en route and the economic cost and reduced expertise of maintaining numerous smaller units. This remains an area of continuing research.
College of Emergency Medicine 2013, p 16