NHS England set out plans for major reform in its milestone urgent and emergency care review in 2013. But now over three years since its publication, the flurry of A&E reclassifications has simply not materialised.

The urgent and emergency care review set out plans to reclassify emergency departments in a major shake up of services designed to concentrate specialist services in larger units. NHS England said in November 2013 it “envisaged” between 40 and 70 of the existing circa 185 A&E departments becoming “major emergency centres” and the rest becoming “emergency centres”.

“Emergency centres would be capable of assessing and initiating treatment for all patients [while]…major emergency centres [would] be much larger units, capable of not just assessing and initiating treatment…but providing a range of highly specialist services,” the document said.

The controversial proposal was opposed by many senior emergency medics at the time, including the then College of Emergency Medicine president Cliff Mann, now NHS England clinical lead for the accident and emergency improvement plan.

The target for 40 to 70 major emergency centres was however said to have been shelved in the run up to the 2015 general election because it was politically unpalatable – though NHS England rejected this at the time, insisting it was “a central part of the NHS Five Year Forward View and the pace is about to accelerate”.

HSJ’s analysis suggests, however, that the number of likely downgrades on the cards in the next few years is nowhere near large enough to deliver the radical reform originally envisaged. Twenty four downgrades would, however, be easily sufficient to ensure noisy protest – leaving the system potentially with the worst of both worlds: no meaningful reform and a big row with politicians and the public.

The King’s Fund’s director of policy Richard Murray said the NHS appeared to be “caught betwixt and between”. The number of potential downgrades, he said, “is not high enough to conclude we are seeing a radical redrawing of urgent and emergency care, but it is high enough to suggest a lot of political noise and require a lot of potentially noisy public consultations.”

RCEM vice president Chris Moulton told HSJ the scale of likely downgrades was “nothing like the drastic reconfiguration suggested by the Keogh Review in 2013…NHS England has clearly decided the performance figures from the last two years do not support a reduction in ED capacity of this size”. He said: “It seems that statistics and common sense have at last prevailed over dogma and rhetoric. Nevertheless, no ED downgrade should take place without due consideration for patient safety and convenience and the effect on neighbouring hospitals.”

However, even the relatively conservative level of change discovered in our analysis may well prove over ambitious, according to Nuffield Trust chief executive Nigel Edwards. He said: “The first challenge is that some of these will require capital funding [of which there is very little available]…Secondly, many of [these reorganisations] have been going on for a significant number of years…in some cases since the 1990s. 

“If you were an optimist you might say that they may be well on the way by now….But a pessimist might say it’s not immediately clear whether they are going to get a breakthrough with their local health systems, politicians, and the public.”

Mr Murray added it was interesting that some hospitals where many believed there were very strong cases for change, such as Weston Hospital, were those where closure plans were not explicit in their current sustainability and transformation plans.

“It raises questions about the status of the STPs and how many areas have really fully addressed delivering a sustainable urgent and emergency care system,” he said.

HSJ asked NHS England if its target for 40 to 70 major emergency centres stood, but it declined to comment.

Revealed: 24 A&Es could be closed or downgraded