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 acute medical services.
Proposals reviewed by NCAT
- Concentrating acute medical services onto fewer sites
- Maintaining acute medical services while concentrating emergency surgical services
Key drivers of acute medical service reconfiguration
Cost, workforce and safety were the primary drivers of this type of reconfiguration.
Context and relevant policy
- Increase in emergency admissions each year, most of which are for medical problems.
- Sir Bruce Keogh’s proposal to designate A&E departments as either ‘emergency centres’ or ‘specialist emergency centres’ will have implications for the supporting acute medical and surgical services.
- Recommendations from the NHS Services, Seven Days a Week Forum, including:
- all emergency admissions should be reviewed by a consultant within 14 hours of admission
- hospital inpatients must have access to diagnostic services such as X-ray, ultrasound, CT scanning, magnetic resonance imaging (MRI), echocardiography, endoscopy, bronchoscopy and pathology
- hospital inpatients must have timely 24-hour access, seven days a week, to consultant-directed interventions that meet the relevant specialty guidelines.
The current evidence base
Consultants should be actively involved in all stages of the care pathway. Acute medical units should have a continuous admitting consultant presence, enabling early consultant review and assessment (within 12 hours). Acute medical services should have rapid access to critical care, a surgical opinion (on-site for unselected emergencies, can be off-site if selected), 24/7 access to diagnostics (including MRI and CT), and seven-day support from therapies and pharmacy as well as liaison psychiatry.
There is some evidence that units and/or consultants undertaking higher volumes of care deliver better outcomes, but the link between volume and outcomes is not well understood – and volume may not be the primary driver of improved outcomes.
Relevant college guidance
Emergency medicine with clinical decision unit (CDU) facilities or combined medical / surgical assessment units would be able to provide the initial assessment, investigation, triage and management of many patients with abdominal pain. They would need good surgical support with access to CT 24 hours a day. This will allow sustainable out of hours surgical rotas in most hospitals.
Academy of Medical Royal Colleges 2007, p 19
10 consultants can deliver early assessment by a consultant 7 days a week.
Royal College of Physicians 2012a
We recommend that within regions there must be a wider range and more innovative options for acute medical care, scaled to meet patients’ specific needs, fit for purpose and conveniently located… We recommend the development of major acute hospitals serving local regions, providing the most intensive level of emergency and complex acute medical care.
Royal College of Physicians 2007, p xiii