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More rationalisation of services threatened with PBR? Acute plans call for A&E split Emergency surgery and trauma services would not need to be provided on the same site as accident and emergency departments under controversial proposals submitted to the Department of Health. The National Leadership Network, which was asked by the government to draw up plans for the shape of acute hospitals under choice and payment by results, has specified what it sees as the 'core' services to be protected at all hospitals with A&E departments. The proposal to protect some services responds to concerns that the new market could lead to the closure of services which were financially unviable but needed to support A&E. The document identifies the services – such as 24-hour access to acute medicine and diagnostic radiology – which the authors say should be protected. But they say some other services, such as emergency surgery, which are required by A&E teams need not be provided at the same hospital, but elsewhere locally. These services should be protected by the beefing-up of multi-hospital networks, perhaps through the establishment of joint ventures between trusts, the report says. Primary care trusts and practice-based commissioners will also be expected to ensure all patients have access to the necessary A&E services. Project director Martin Hensher said: 'Present multi-hospital networks are soft partnerships between trusts and in some places there are reports of a bit of trouble where foundation trusts are part of networks. 'We have suggested ways of making networks more robust organisational structures, with firm contracts between trusts.' The document says A&E departments should be supported on site by 24-hour access to acute medicine, level-two critical care, a non-interventional coronary care unit, an essential services laboratory and diagnostic radiology. However, the following services need not be provided on site and should be supported by 24-hour local multi-hospital network access: emergency surgery; trauma and orthopaedics; paediatrics; obstetrics and gynaecology; mental health; specialised surgery and interventional radiology. Dr Dermot O'Riordan, chair of the Royal College of Surgeons reconfiguration working party, said if there was not emergency surgery on site, an A&E department would not be able to admit someone with, for example, intestinal bleeding.