Reconfiguring emergency and acute services: time to pause and reflect

• Published in: BMJ quality & safety Vol. 32; no. 4; pp. 185 - 188
• Main Authors: Vaughan, Louella, Browne, John
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd 01.04.2023; BMJ Publishing Group LTD
• Subjects: Abdomen; Abdominal surgery; Coal mines; Data Collection; Editorial; emergency department; Emergency medical care; Emergency Medical Services; Emergency Service, Hospital; Health care management; health policy; Heart attacks; hospital medicine; Humans; International studies; Length of stay; Mortality; Pandemics; patient safety; Patients; Quality of care; State Medicine; Trends; Workforce; hospital medicine; patient safety; health policy; emergency department
• ISSN: 2044-5415; 2044-5423
• DOI: 10.1136/bmjqs-2022-015141

[...]the trend has been for improvements in mortality coupled with a decrease in hospital length of stay.2 Crucially, mortality improvement trends were faster before the onset of centralisation in both the Flojstrup and colleagues study and a similar study conducted in Ireland.1 3 This suggests major ongoing improvements in the delivery of care over the past two to three decades that are independent of reconfiguration. EDs are the ‘canary in the coal mine’ for a host of structural problems, such as poor access to general practice, lack of capacity elsewhere in the health system, economic challenges and payment reforms.5 More recently, the COVID-19 pandemic has exacerbated ongoing problems with recruitment and retention of qualified hospital staff, most markedly in acute settings. In England, for example, analysis across a basket of quality and performance indicators for smaller versus larger hospitals did not find any relationship between quality of care and size.7 Findings were similar for national studies of individual conditions, such as emergency abdominal surgery, general surgery and intensive care.8 9 International studies of surgery also show that lower-risk procedures can be safely conducted in lower-volume settings.10 Moreover, the characteristics of individual clinicians and teams are probably more important than the type of hospital in which they work. [...]the literature supports the notion that safe and high-quality care for at least 95% of patients with acute and emergency conditions can be provided in smaller organisations, close to their own homes.