4 JAccid Emerg Med 1999; 16:48-54

PERSONAL VIEW

Accident and emergency medicine the next25 years

James Binchy

The founders of the Casualty Surgeons Associ-ation could scarcely have envisaged, back in1967, that their successors 30 years later wouldbe giving streptokinase to patients who pre-sented to their departments with acute myo-cardial infarction. Therefore I shall not try topredict what will be going on in accident andemergency (A&E) departments in 25 yearstime. What I would like to do is look at some ofthe issues that face us, suggest how these mightdevelop in the future, and how we mightaddress them.

Accident andEmergencyDepartment, DerrifordHospital, Plymouth,Devon PLI 8DH

Correspondence to:Mr Binchy, Consultant inAccident and EmergencyMedicine.

Accepted 7 August 1998

Increasing work loadThe number of new attendances to A&Edepartments has risen by an average of 2% peryear since 1981.' The rapid increase in theworkload experienced by many A&E depart-ments in recent years has exceeded this and islargely due to a rapid rise in the number ofadmissions. Most of these are due to theincreased numbers of medical admissions. Inmy department between 1994 and 1997 thenumber ofnew attendances increased by 1.4%.(This has been distorted by the opening of a

minor injuries unit two years ago.) Howeverover the same period the number of medicaladmissions via A&E has increased by 30%from 3100 to 4100. Some of this can beexplained by an increase in the elderly popula-tion with greater health needs. However muchmay be due to changes in medical practice.Other factors that are greatly increasing our

workload and will continue to do so are:

(1) Changes in medical treatment: for exam-ple streptokinase in myocardial infarction, use

of N-acetylcysteine in paracetamol overdoses,continuous positive airway pressure and theuse of intravenous nitrates in acute leftventricular failure.

(2) Greater expectation of investigation andintervention by the general population. Onestudy in Nottingham showed a twofold in-crease in chest pain assessments for myocardialinfarction in the A&E department over 10years.2

(3) Increasing numbers of patients with frac-tured neck of femur. Where I work the numberof fractured femurs coming through thedepartment has increased from 2.8/1000 newattendances in 1990 to 4.2/1000 in 1997.These patients, while not using a lot of medicalresources, consume a lot of nursing hours. The

numbers will continue to increase until 2020by which time the number of people over 75will have stabilised. There will be a similar risein the number of patients with Colles' frac-tures. As these are manipulated in manydepartments this will consume more resources.

(4) Increasing incidence of deliberate selfharm. In Plymouth the number of patientspresenting with deliberate self harm or over-dose increased by 21% between 1994 and1997 (from 2406 to 2912).

(5) Increased fear of litigation leads to anincreased referral rate, increased investigations,and decreased discharge rate.

(6) Changes in the provision of out of hoursprimary careThese pressures are likely to increase in the

future as new treatments become available forthe acute management of such diseases asstroke. Any new treatment for strokes will beextremely time dependent and will most likelyinvolve immediate computed tomography insuch patients. This will result in increasingnumbers of strokes attending A&E depart-ments for assessment and initial management.We should be embracing these changes and

ensuring that patients get the most appropriatetreatment at the earliest opportunity in ourdepartments.

General medicine in the UK appears to befollowing the same trend as in the UnitedStates, with increasing subspecialisation andconcentration on outpatient care, with thedemise of the acute general physician. Thisputs greater pressure on A&E departments tomake a definitive diagnosis, institute earlytreatment, and refer to the appropriate subspe-cialty. It may be that A&E medicine replacesacute general medicine and will fully work uppatients resulting in discharge or admissionand referral to the appropriate subspecialty. Inorder to fulfil this role A&E medicine will haveto have ready access to laboratory andradiological investigations on a 24 hour basisseven days a week. Many departments abroadoperate such a system with regard to patientswith chest pain and non-diagnostic electrocar-diography. These patients are admitted undertheir care for observation until myocardial inf-arction can be confirmed or refuted with thehelp of biochemical markers. In such a systemthe A&E department would have to have more

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high dependency beds with the appropriatestaffing levels to match.The last 25 years has seen the transforma-

tion of the casualty surgeon to the A&E physi-cian. Will the demise of the general physiciancomplete the transformation of the casualtysurgeon to the emergency physician?

Consultant work patternsIt is neither realistic nor economically viable tohave a consultant based service in which mostpatients are seen and treated by consultants.The number of consultants required would beexcessive. Most doctors in their 50s and 60s donot want to work night shifts. There is littleevidence that the presence of a consultant on

site 24 hours a day improves outcome. Unlesssuch work patterns were the norm for consult-ants in all specialties there would be difficultiesin recruiting high quality candidates to trainingposts.A&E services should continue to be pro-

vided as a consultant led service but with con-

sultants leading the charge. Consultantsshould spend a significant proportion of theirworking week on the shop floor, actively super-

vising senior house officers (SHOs) and seeingpatients as necessary. It goes without sayingthat they should be actively involved with or

supervising the resuscitation of all seriously illor traumatised patients within the department.The continuing rise in medical patients

requiring active intervention within A&Edepartments means that junior doctors requiremore teaching and supervision. The reductionin junior doctor hours, protected teachingtime, and the more structured approach totraining have already and will continue to makegreat demands on consultant workload. Weneed to embrace these changes and use themas a tool to increase the numbers of consultantand middle grade doctors. I think that thearguments in favour of having a minimum ofthree consultants in any department providinga comprehensive 24 hour service are over-

whelming.In departments with more than two consult-

ants (which I think should become the norm)there will be pressure to provide extended con-

sultant presence within departments perhapsuntil 10 pm or midnight. I think that this hasbeen accepted by the majority in the specialty.However it is important that this is undertakenwithin some national terms and conditions forsuch antisocial hours. Time off in lieu is oftennot practical as most meetings occur duringoffice hours and therefore doctors end up

coming in during their time off. It may be thatthe specialty should refuse to provide such a

service until the increased workload is recog-nised and financed appropriately. One answer

to this may be the option of early retirement onfull pension at 55, as was the case for medicalofficers of health.The present clinical role for consultants

seems to be limited to leading resuscitations,running review clinics, and queue busting.Queue shifting is a pragmatic solution to theproblem of prolonged waiting times. Howeverit is not necessarily good medicine, can be soul

destroying, and may lead to consultant burn-out. Most doctors didn't go into A&E medi-cine to spent most of their clinical time seeingsprained ankles and other minor conditions. Itis important that we try to define exactly whata consultant's clinical role should be, ensuringthat they are involved with a more balancedcase mix. It may be that we should define acomprehensive list of patient categories thatshould have consultant involvement. Perhapsevery patient referred to an inpatient team by aSHO should be discussed with a consultantbefore referral. Ensuring that departments areadequately staffed with experienced doctorswill go a long way to enabling consultants tohave a more diverse clinical involvement.The move to multiconsultant departments

will no doubt lead to subspecialisation withinthe specialty. Obvious areas include paediat-rics, sports injuries, pre-hospital care, acutegeneral medicine, and possibly toxicology. Thiscan only be of benefit to patients anddepartments.

Middle grade coverThere is no doubt that, if we are to improveand maintain standards of care to patients,increasing numbers of patients must be seen bytrained and experienced doctors. It is not feasi-ble for all of this to be taken on by consultantsand so there needs to be an expansion in thenumbers of middle grade doctors.

If most departments have three or more con-sultants the total needed will be 700 to 800.3Estimating the average consultant life span as30 years' service, we would then need about 30new consultant appointments each year. As-suming a five year training programme thatgives a total of 150 trainees nationally. Thesetrainees will spend one year on secondmentsoutside the department leaving 120 trainees toprovide a middle grade service nationally. Evenif we expand to 1000 consultants we areunlikely to need more than 200 trainees toreplenish them. These will almost certainly beconcentrated in teaching hospitals and thelarger centres with some rotation out to smalldistrict general hospitals. Obviously it isimpossible to provide an adequate 24 hour oreven 16 hour middle grade cover with thesenumbers and therefore most departments willcome to rely on other grades, such as staffgrade doctors, to fill this role.

Staff grade doctorsIn 1990 there were 40 staff grade doctors inA&E. There are now between 250 and 300. Ifthe specialty is to recruit and retain suitablytrained candidates for these posts it will have toredefine and increase the profile of the staffgrade doctor. It is important that they are notsolely used as work horses to fill gaps in theservice but are given appropriate teaching,management, and audit roles as well. Theymust also have protected study time and beencouraged to continue to develop profession-ally. With the present system and the inabilityto advance both professionally and financiallythere is a risk that we could end up with adisillusioned workforce. The new staff grade

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contract with its optional points system may gosome way to addressing this.These positions are often perceived as being

second rate and filled by doctors who didn'tquite make the grade in hospital medicine. Weneed to be proactive in dispelling this miscon-ception as many are highly trained doctors whohave for personal reasons chosen not to pursuea consultant career path. It may be that weneed to reinvent the post with a more positiveimage and a new title such as staff physician.

Part time working and job sharing havebecome accepted career options and theirpopularity will probably increase. A&E work isespecially suitable for sessional work and weshould be actively encouraging appropriatelytrained and motivated doctors who wish to fol-low this career option to take up such posts.

Senior house officersA&E departments will continue to requireSHOs to see a large proportion of the patients.However as the staffing levels in A&E expandwith more middle grade doctors I expect SHOnumbers to remain static and so become asmaller proportion of total staffing require-ments. These will remain as training posts forgeneral professional training.

Centralising trauma services and theamalgamation of smaller departmentIn its report By Accident or Design? the AuditCommission suggested closing some A&Edepartments that were seeing fewer than50 000 patients a year and were less than 10miles from an alternative centre.' However thecase for centralising trauma services has beenweakened by the recent findings from theNorth Staffordshire experience.' Major traumaonly accounts for about 0. 1% of all A&Eattendances and the mortality from road trafficaccidents and industrial accidents has contin-ued to fall over the last 20 years. I think thatwhile the management of multiple trauma willremain a priority and continue to consume alarge amount of resources it will be a small partof our workload and will probably decrease.However life threatening medical emergen-

cies, which are 10 times more common thanmajor trauma and now account for 1% ofattendances, are likely to increase with anincreasingly elderly population at risk. Inter-vention in medical emergencies is more likelyto be time critical and therefore the argumentfor centralising key services to larger units, withthe closure of more peripheral smaller units, isnot necessarily valid. There is no acceptableevidence as to what good access is: 10 miles ina rural area may be fine but in a built-up met-ropolitan area it is another matter!

Minor injury unitsThe Audit Commission suggested that somesmaller departments be replaced with minorinjury units. There is also a move to openminor injury units in large urban areas to meetthe local needs while major injuries and medi-cal emergencies are admitted to a larger centralunit, thus relieving the pressure on the centralA&E department. However this is unlikely to

result in cost savings as it may lead to anincrease in supply led demand. The marginalcost of treating minor injuries in larger A&Edepartments is low. Ifmost of these patients arediverted to minor injury units the marginalcosts of treating other patients will rise.However minor injury units can provide a

local service which is responsive to the needs ofpatients. Reports suggest that patients usethese appropriately and that their satisfactionwith them is high.5 These units should notreceive ambulance calls and it must be wellpublicised that they do not treat medical emer-gencies.

It is important that the specialty continues tomaintain standards in A&E care and thereforeit should ensure that these units continue to beunder the control of consultants in A&E medi-cine based at the central A&E department.This will provide the opportunity for trainingand supervision of both medical and nursingstaff and allow members of staff to rotatebetween the departments. It will also facilitatethe transfer of care of patients between the twodepartments. There needs to be good commu-nication, probably with video links, betweenmore remote units.

Nurse practitionersThere is an increasing trend to employ nursepractitioners to see and treat patients withminor injuries and illnesses and so decrease thenumber of patients who have to be seen by ajunior doctor, thus freeing up their time. I amnot sure that the rush to develop the role ofnurse practitioners in A&E departments is agood idea in the long term. Much of thisappears to be based on the push to reduce jun-ior doctor hours by off loading some of theirmore mundane tasks onto the nursing staff. Iknow ofno A&E department that has a surplusof nursing staff to its requirements and simplygiving nursing staff further duties, in the glori-fied guise of nurse practitioning, is adding totheir already overstretched position.

If nurses can be trained on day releasecourses to assess wounds and prescribe, whydo doctors need five years in medical schoollearning about anatomy and pharmacology?While there have been some studies looking

at nurse practitioners ordering and interpret-ing x rays I am not aware of any studiescomparing the clinical effectiveness or the costeffectiveness of nurse practitioners as com-pared with junior doctors in A&Edepartments.6 In large A&E departments thereare disadvantages to training nurses to practiceas nurse practitioners in that it decreases thenumber of nurses available to undertake nurs-ing roles for the iller patients. In the short termand especially around the changeover periodsof February and August it may be very advan-tageous to have members of the nursing staffwho can see, treat, and discharge patients.Moreover I think that recruiting nurse prac-

titioners in place ofSHOs may be short sightedin that it decreases the flexibility availablewithin departments. SHOs are an extremelyversatile group generally and can be trainedvery quickly and adapt to rapidly changing

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circumstances. If you replace large numbers ofSHOs with nurse practitioners who can seeand treat possibly up to 20% of the A&Eattendances you may find that you do not havethe medical staff available when large numbersof medical or more seriously injured patientsattend. The advantage of having SHOs seeingthe minor conditions is that when all hellbreaks loose the SHOs can be redeployed toworking on the major side. If SHOs are notexposed to these conditions they may have noother opportunity to gain experience in them.Having to employ extra nurses at F grade orabove decreases the financial argument forsuch a move.The major role for nurse practitioners is in

minor injury units where they can see and treata wide variety of minor illnesses and injuriesaccording to strict protocols.

If we want to free up doctors' time we needto train people as physician assistants who willhave no medical or nursing role but who willundertake manual tasks such as cannulation,phlebotomy, arterial gas sampling, electrocar-diographic recording, plastering, etc, and cleri-cal duties such as contacting inpatient teams,etc. Such a system already operates in theUnited States and in the military here. Theseposts must be new posts extra to present staff-ing levels.

Government white paperHaving read the white paper I am verydisappointed by the absence of any concreteproposals as to how they plan to manage theever increasing demand for A&E services.7There is usual talk of "hard choices and thirdways" but the only real references to emer-gency services were:

(1) Individual patients, who too often havebeen passed from pillar to post betweencompeting agencies, will have access to anintegrated system of care that is quick and reli-able.

(2) Front line patient services will be backedby more resources and better technology.

(3) If you are ill or injured there will be aNHS there to help: and access to it will bebased on need and need alone.There is of course the commitment to estab-

lish a 24 hour nurse based help line. The gov-ernment appears to be under the delusion thatincreased access to health information willdecrease demand. While increased access toinformation may help the public choose themost appropriate service there is no evidencethat it will decrease demand and anecdotal evi-dence suggests that it will increase.

Telephone advice linesA&E departments have historically providedmedical advice via the telephone to the localpopulation. In its recent white paper thegovernment states that it intends to set up tele-phone advice lines nationally. It has apparentlyallocated pl/person in England and Wales toset up such a service. This amounts toC250 000 for the average district generalhospital population. This is an opportunity forA&E medicine to gain recognition and funding

for a service which is already provided on aninformal basis in many areas. A&E depart-ments are in a unique position to provide thisservice. They are staffed 24 hours a day byexperienced nurses who have been trained intriage. There is always a doctor on site and inmany cases there is a senior doctor available.The specialty has already drawn up guidelineson how these should be run. There are reportsdocumenting their usefulness and there issome evidence that it may reduce the workloadat A&E departments.8

If we are to take this forward we must actquickly as more work needs to be done tostandardise the service and to ensure that theadvice given is safe and consistent. This shouldbe undertaken in conjunction with local GPgroups, ambulance services, and health infor-mation services.

Hospital admissions unitThere should be a single unit through which allemergency admissions to the hospital come tobe assessed by a senior doctor in the appropri-ate specialty.Many hospitals have already established

medical admissions units as a method of deal-ing with increasing numbers of general prac-titioner (GP) referrals and admissions. Thereare many reports of these working well. Thereis no doubt that they greatly improve the proc-ess of patient care and will no doubt becomemore widespread. However it is important thatthey are adequately resourced and are staffedby senior doctors, who have no other fixedcommitments for that session, and not viewedmerely as a means of avoiding admissions.These units could be expanded to includeacute surgical and gynaecological patients. It iscommon sense to have these units located closeto A&E departments and radiology facilities.These units will provide an invaluable

opportunity for training in acute general medi-cine and a period working in such units shouldbe an essential requirement for training in A&Emedicine. Some of these units may well comeunder the control of A&E physicians. One ofthe ways that we could greatly improve therelationship between medical assessment unitsand A&E departments is by the appointmentof consultants with shared responsibilitiesacross the two units. It may be the appointmentof a consultant physician with a special interestin trauma or a consultant in A&E medicinewith a special interest in general medicine.Such posts already exist between intensive careand A&E and apparently work well.

Information technologyMost of the recent advances in computer tech-nology other than advances in radiology havefailed to deliver any real benefits to the practiceof A&E medicine. Most departments are com-puterised, some better so than others, but mostof these are mainly concerned with collectinginformation for management purposes andmeeting patient's charter standards.On the whole computer systems will not

improve the quality of care in terms ofoutcome

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to the patient but they may greatly improve theprocess of care. Examples that come to mindare:* Real time tracking of patients through the

department, entering of discharge diagnosisand management, with creation of thedischarge letter before discharge. This couldeither be typed and picked up by the patientor e-mailed to the GP.

* Online ordering of radiography and labora-tory investigations.

* Rapid access to previous records and results.* Online prescribing where the pharmacy

receives the order before the patient has evenleft the A&E department.

* The move to digital radiology will allowrapid access to x rays and joint viewing witha radiologist at another site.

In the long term there is the possibility of directaccess to GP records and the possibility ofpatients carrying SMART cards with theirmedical histories into which we could putupdates.

Audit and quality assuranceAt the present time the only way of comparinga department's performance with others na-tionally is via the patient's charter standardssuch as triage times and times to see a doctor.While these do have some reflection on theprocess of care, they take no account of the dif-ferent case mixes.The specialty needs to be proactive in defin-

ing standards or goals which will be useful inassessing the performance of departments.Many departments are already involved withone of these, namely the Major TraumaOutcome Study. Other parameters that couldbe measured that reflect both on the quality ofcare and the clinical outcome are:(1) Outcome from cardiac arrests that occur

within an A&E department.(2) Door to needle time for patients present-

ing with acute myocardial infarction.(3) Percentage of patients with fractured necks

of femur who spend more than two hoursin the department.

(4) Number of unplanned return visits.(5) Number of patients who did not wait to be

seen.Individual departments should develop qualitystandards for the management of commonconditions presenting to A&E. These mayinclude national standards but would need tobe much more comprehensive. Some examplescould be:* All patients who fulfil the criteria receive

streptokinase within 15 minutes of arrival.* All deformed fractures receive analgesia

within 10 minutes of arrival.* All patients discharged with asthma receive

steroids.* All patients who are discharged with frac-

tures receive analgesia.Staff would be expected to treat patients tothese standards and regular audit wouldhighlight cases that failed to reach the acceptedstandard.

College of accident and emergencymedicineWe now have our own intercollegiate facultywith a fellowship examination. However I donot think that we will be accepted as equalswith other specialties until we have our owncollege. It is important to have the prestige ofcollege status if we are to have a majorinfluence on the future development of emer-gency services.The specialty is already being discriminated

against in that it is not represented on the Spe-cialist Training Authority or the Academy ofRoyal Colleges.

Service alone will not gain college recogni-tion. We must increase our academic profile ifwe are to get proper recognition from ourpeers. If A&E medicine is to advance theremust be high quality research within the field.This requires the establishment of full timeacademic posts within the specialty. Most A&Edoctors are not particularly interested inresearch and we will need to attract academi-cally minded doctors into the specialty. Thebest way to do this is to have some academiccentres with a track record for quality researchand attracting grants.

Defining a core serviceMany of the roles thrust upon A&E medicineover the last 25 years have been reactive and asa result of failings of other parts of the healthservice to provide comprehensive cover. A&Emedicine has established itself as a unique spe-cialty with its own training programme, exami-nations, and intercollegiate faculty. It is impor-tant that we take a more proactive role indefining what is a core A&E service and how itshould be provided. Obviously there will be theneed for some flexibility to take account of thevariations in the needs of the local population.However while A&E departments will continueto function as a safety net for the healthservices we must strive to ensure that A&Edepartments are not used to plug the deficien-cies in other aspects of the health service. Asclinicians at the interface between primary andsecondary care we should be the driving forcebehind future developments in the provision ofemergency care.The British Association for Accident and

Emergency Medicine (BAEM) has, in itsdocument The Way Ahead, already definedwhat should constitute a core service.3 Thiscan be essentially summarised under fourheadings:(1) Assessment, resuscitation, and treatment,

by appropriately trained staff, of all acuteemergencies be they medical, surgical, ortraumatic in all age groups.

(2) Management of acute injury-less than 48hours.

(3) Management of acute pain.(4) Management of patients with acute

changes in respiratory, cardiovascular, ormental status.

In defining a core service it is often importantto define what is not appropriate use of A&Edepartments. Again this has been addressed byBAEM. The problem, however, is that "Joe

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GP pracic

A&E'

P Admimons- unit

Main hospital

";MIU = minor injuries unit.

Public" hasn't read and is unlikely ever to readThe Way Ahead. A simple measure may be forthe specialty to announce nationally that itdoes not provide a family planning service andthat departments would not stock the morningafter pill. This would not involve a great changein practice and would only affect a small groupof patients. However it may help to get themessage across that the role of A&E is not toprovide a primary care service.

Perhaps we should take this a stage further asthere appears to be an ever increasing demandon A&E services. The specialty could an-nounce that it was no longer prepared to seeand treat patients with conditions more thanfive days old, unless they were accompanied bya letter from a GP. The cut off period couldthen be reduced by one day each year until wereached the 48 hour threshold. Of course wewould not refuse to see such patients but theywould be informed at triage that they wouldhave to wait until the more acute patients hadbeen seen. Again this may not greatly decreaseour workload but it may to get the messageacross as to what is the role of an A&E depart-ment. This would have to correspond withimproved access to primary care services.

Primary carelinappropriate attendersThe first question is from whose point of vieware these inappropriate. Most of the patientsthat we classify as "inappropriate attenders" donot think their attendance is inappropriate.They may have a minor medical condition butthey do not perceive it as such and until theyare reassured to the contrary their attendances

Ambulancen control

Figure 2 Out of hours telephone advice.

are probably appropriate. Studies have shownthat a significant number of these patients endup being admitted to hospital.9 Many areprepared to wait three to four hours or longerto be seen.The size of this group of patients has been

estimated at between 7-70% depending on thesource. More realistic figures are between25-30%, though there is wide geographicalvariation. However the term "inappropriateattender" is probably inappropriate and it isbest to think of these patients as havingprimary care problems-that is, they are in aninappropriate place. Many of these patientsattend because of the difficulty in gettingaccess to primary care, especially out of hours.Whether we like it or not the "inappropriate

attender" is here to stay. I do not think the wayto tackle this problem is by trying to decreasethe demand side. There have been studies inthe United States that have showed thatredirecting primary care patients back to thecommunity does not have any significantimpact on the A&E workload. The way totackle this is to identify this group of patientsand to accept that they have a need. It hasalready been demonstrated that this need maybe more efficiently met when the patients areseen by more experienced doctors.'0 In usingthis we should be pushing either for theemployment of more consultants or staff gradedoctors in the A&E department.

In departments that have an excessivenumber of these patients, such as inner citydepartments, there may be an argument foremploying GPs to see these patients. HoweverI think it would be best to take this one stepfurther and open adjacent primary care units.

Single point of access to emergencyservices: the "one stop shop"The answer to the problem of inappropriateattenders and out of hours primary care covermay be to embrace the "one stop shop" model(see fig 1). A&E departments, primary careclinics, and admission/assessment units locatedtogether on one site. These would be separatedepartments, probably with a common en-trance and triage area but with close linksallowing for the easy transfer of patients andstaff between them. There would need to be 24hour access to high tech investigations such ascomputed tomography, venography, biochem-istry, etc. Patients would be worked up and adefinitive diagnosis made before admission ordischarge. Under such a system patientspresenting with chest pain would be admittedwhen a myocardial infarction was confirmed byelectrocardiography or by biochemical mark-ers. Patients with non-diagnostic electrocardio-grams or biochemistry would have an exercisestress test before discharge or within 24 hours.Similarly patients with an acute wrist(?scaphoid) injury would have bone scan orcomputed tomography.

If such units were to function properly theymust have their own support services such associal workers, physiotherapists, and occupa-tional therapists working on an extended hoursbasis.

MIU

Figure 1 The "one stop shop'

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Similarly the nurse telephone advice serviceand primary care out ofhours service would bebased at the same centre (see fig 2). Patientswould ring to seek medical advice. If it wasthought that the patient needed to see a doctorat that time they would be instructed to attendeither the primary care centre or the A&Edepartment. If it was felt that a doctor shouldmake a home visit this would also be arrangedfrom the primary care centre. Where it was feltthat the caller warranted emergency care anambulance or a paramedic response vehiclewould be dispatched.

ConclusionI have given a personal view of some of theissues and challenges that face the specialty.This is by no means comprehensive and thereare many other challenges facing us. I do notclaim to have any of the answers. However Ithink it is important that we address theseissues and be proactive in determining the

future provision of emergency care. I hope tohave raised some points for further discussion.

1 Audit Commission. By accident or design? Improving A&Eservices in England and Wales. London: HMSO, 1996.

2 Williams B, Nicholl J, Brazier J. Health care needs assessment:accident and emergency departments. Sheffield: Departmentof Public Health Medicine and Sheffield Centre for Healthand Related Research, University of Sheffield, 1996.

3 British Association for Accident and Emergency Medicine.The way ahead. London: BAEM, 1997.

4 Nicholl J, Turner J. Effectiveness of a regional traumasystem in reducing mortality from major trauma: beforeand after study. BMJ 1997;315:1349-54.

5 Dale J, Dolan B. Do patients use minor injury units appro-priately? J Public Health Med 1996;18: 152-6.

6 Salt P, Clancy M. Implementation of the Ottawa ankle rulesby nurses working in an accident and emergencydepartment._ Accid Emerg Med 1997;14:363-5.

7 Secretary of State for Health. The new NHS. London:Stationery Office, 1997.

8 Srinivas S, Poole F, Redpath J, et al. Review of a computerbased telephone helpline in the A&E department. Jf AccidEmerg Med 1996;13:330-3.

9 Dale J, Green J, Reid F, et al. Primary care in the accidentand emergency department: 1. Prospective identification ofpatients. BMJ 1995;311:423-6.

10 Murphy AW, Bury G, Gibney D, et al. Randomised control-led trial of GP versus usual medical care in an urban acci-dent and emergency department: process, outcome, andcomparative cost. BMJ 1996;312:1 135-42.

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