The delivery of emergency care has changed significantly over the last decade, driven by several factors which include better disease understanding, improved access to diagnostics, emergency care access targets and the working time directives. The delivery of emergency and urgent health care has proved challenging for many organisations within the UK and internationally,1 and is compounded by the fact that patient outcomes vary between services and these differences are not adequately explained by demographic factors or illness severity.2 3 If emergency systems are not to become overrun and higher quality services are to be provided, then further change is necessary. The solutions must respond to the increased public scrutiny and the desire to deliver care more locally while also resolving potential workforce constraints that relate to working time directives and the new competency-based training structures (table 1). This direction of travel is further emphasised in the recent Darzi review which also supports a policy shift to focus on measuring quality of care, improving patient choice and preventing illness.4 This poses further challenges for delivering emergency care. Measuring quality and outcome has never been easy, and is perhaps a particular problem for acute and emergency care where standards of care are not routinely measured for all patients and patient contacts with secondary care services are increasingly short-lived, especially in emergency departments.

To redesign emergency care requires an understanding of the presenting patterns and clinical needs of patients with acute conditions. Future solutions will necessarily vary in different health economies; however, generic principles will apply, some of which we will outline here. A robust …