FOR DEBATE So many unanswered questions : the emergency care system of the future

All the pressures on the health service are converging on that part of the service that cannot say no. The buck stops with the emergency health care system. It is the first place that the media and the public sees the pressure and points the finger. The accident and emergency (A&E) department sits on the fault line where the "tectonic plates of primary and secondary care meet,"' where the worlds of need, demand, and supply meet abruptly. It is one of the few places where all the dominant issues in the health service coexist: acute services configuration, patients' charters, emergency admissions, general practitioner (GP) out of hours service, and medical staffing. The features of a good health service: effectiveness, efficiency, access, responsiveness, equity, are all traded around emergency health care. An accident and emergency system should support a wide range of facilities and specialties including A&E departments, orthopaedics, coronary care units, intensive care units, ambulance services, primary health care teams, and minor injury units. Figure 1 emphasises the A&E department as the hub around which not only activity but also information and advice is coordinated, both within and outside the hospital.2