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Service Design & Delivery

Service Design & Delivery

Welcome to the Royal College of Emergency Medicine's Professional Affairs information pages. Here you will find resources and documents on Emergency Department Design and Delivery, Informatics, ECDS, Research, Workforce and AAC.

Service Design & Delivery

The Royal College of Emergency Medicine is dedicated to achieving the highest standards of practice and patient care. Designing and delivering services is at the heart of delivering these standards and the Service Delivery Cluster works to support this. Navigate the below tab menu to explore the resources that have been collated about emergency medicine service design, configuration and delivery. Find information on current services, delivery issues, what delivering quality looks like in emergency medicine, ED crowding, ED design and system integration and service configuration. There is a separate page for workforce and informatics can be seen below. Payment mechanisms are within informatics.

Key guidance

The College has developed this important strategy to improve the working lives of clinicians working in Emergency Departments in the UK. The guidance documents are specifically aimed to help guide Clinical Directors of Emergency Medicine, clinicians, employers and commissioners of emergency healthcare.

Key elements

  • Work patterns: For Emergency Medicine doctors these need to be well structured, sustainable and satisfying. The College has produced suggested solutions for working practices especially for out of hours and night time working by senior medical decision makers through annualised job planning. Recommendations on the ways in which annualised job plans can enhance working patterns are described.
  • Models of ED function: These have changed over the years and the approaches that clinicians must consider both working in the ED in different roles, how to describe the specialty and profile it to others is vitally important.
  • Flexible careers: Working practices for females and males in Emergency Medicine are changing and the specialty lends itself to allowing better work-life balance and integration as well as enhancing portfolio careers for those choosing to work less than full time.
  • Decades of clinical life: The ways in which careers can be developed pro-actively through each decade of a clinical career to maintain satisfaction and longevity are described.
  • Team working and leadership: A range of tips on how to optimise your team and leadership skills as well as better develop these skills in members of your team are described.
  • Maintaining well being: Creating tailored strategies to maintain well being and embedding them into daily practice are critical to career sustainability. Equally important is the need to recognise early features of chronic stress to prevent possible burnout in colleagues. This is an area that the College will continue to expand on in the future.
  • Valuing trainees: Much formal work is ongoing via Health Education England, the GMC and other agencies in this area. In our guidance, a range of top tips from trainees and trainers provides an overview of things that cost little and yet can have a dramatic impact on the future career paths of the young trainee.

What next?

We urge all working in Emergency Departments or responsible for emergency care systems to take the time to read the strategy. Then ensure that:

  • You act upon those components that you can directly influence.
  • Give the strategy to your Clinical Director (if you are not one) and your team. Decide upon the areas of the strategy that most apply to you and devise a local implementation plan.
  • Decide how you can best influence the Executive team and non-Executive team at your Trust/ Hospital Board as well as commissioners to firstly read and then act upon the strategy.
  • Devise a timetable to monitor progress.

Service Delivery and Workforce Toolkit 2013: Tools to help address service and workforce pressures

Emergency Departments across the UK are facing considerable service pressures relating to workforce and activity. The College has published a toolkit with the aim of providing assistance to Emergency Medicine clinicians and Departments by listing in one place existing resources together with a description of new developments that we hope will help to address these pressures. It also provides an update on College work to support Emergency Departments and focus attention on finding solutions to the workforce challenges.

This is not a complete resource – where there are blanks the College is working hard to identify or develop resources/guidance, and we are grateful for all the suggestions and good practice examples provided by Fellows and Members to date. If you are aware of existing resources or new initiatives that could appear in this document please contact Download the Service Delivery and Workforce Toolkit.

Delivering Quality and Models of Care

Models of Care

What does good look like? Safer, faster, better
The document Transforming Urgent and Emergency Care Services in England contains much useful advice.

Initial Assessment of ED Patients

Below is how the College believes an ED should be set up to initially assess patients when they present. See Initial assessment of Emergency Department patients toolkit (Feb 2017) for further details.

Emergency Department Follow Up Clinics

The Guidance on Emergency Department follow up clinics can be found in the RCEM Clinic Guidance (Dec 2015).

Quality Indicators

The new clinical quality indicators for Emergency Departments in England were announced in December 2010 and implemented in April 2011. The quality indicators (QIs) were developed by the Department of Health team in conjunction with clinicians from RCEM and RCN, with input from the RCEM Lay Advisory Group.

The five quality indicators are:

  • Left department before being seen for treatment rate
  • Re-attendance rate
  • Time to initial assessment rate
  • Time to treatment
  • Total time in A&E

System Integration and Service Configuration

This section contains information and resources regarding the configuration of emergency care services:

Revised operating framework – Regional Trauma Networks (20th Dec 2010)

Sir David Nicholson has launched the Operating Framework for the NHS in England 2011/12 setting out the key priorities for the NHS over the next year. Find the details here. Page 43 (para 4.52) details commitments to the NHS on the establishment of Regional Trauma Networks. Please note that there is a typo at the end of the first sentence, which should read 2011/12 (rather than 2010/11). All regions should be moving trauma service provision into regional trauma network configurations in 2011/12. Previous updates:

ED Design

Hub model

As part of the STEP campaign, the A&E Hub Concept proposes that additional services such as pharmacies and crisis mental health teams should be located alongside emergency departments to help tackle the increasing rate of type 1 A&E attendances – which has increased by nearly 2 million in a decade.

Design the Smartest ED (7-9- July 2014)

This document reports on a conference held at Downing College, Cambridge in July 2014. It facilitated a purposeful interdisciplinary dialogue between clinicians, and service and space designers. It created a supportive conference environment that is hoped to permeate through into the planning and design of projects (new or refurbishments) across the world. Its aim was to achieve a common understanding of ED in terms of process, space and people.

Accident & emergency departments – Planning and design guidance (30 April 2013)

The Department of Health has published planning and design guidance for accident and emergency departments. Building a new department or refurbishing an existing one happens rarely but when it does, it provides the opportunity to design a modern department that inspires and intuitively supports effective, efficient and safe patient care, with the flexibility to meet future developments in healthcare, technology and patient volumes. This guidance provides information on how to approach a new build or redesign, specifically aimed at senior emergency clinicians and designers so key to making a new build successful. It aims to facilitate purposeful dialogue between those responsible for service delivery and those responsible for design response, and is therefore essential reading for all those involved in planning and designing their department.

Reducing violence and aggression through ED design (29 Nov 2011)

Service Reviews

The College is established to advance education and research in Emergency Medicine and is the leading authority in the UK and Ireland in this field. The College is also responsible for setting standards of training and administering examinations in Emergency Medicine for the award of Fellowship and Membership of the College as well as recommending trainees for CCT in Emergency Medicine. The College works to ensure high quality care by setting and monitoring standards of care, and providing expert guidance and advice on policy to relevant bodies on matters relating to Emergency Medicine.

As part of this work the College undertakes reviews of emergency care services at the invitation of NHS organisations. A service review can help a failing ED to become good, and a good ED to become excellent.

Service reviews are conducted by at least two senior Faculty members of the College who are expert in this area. Depending upon the agreed Terms of Reference for a review we will provide a detailed assessment and key recommendations to support organisation needs. The visit will be supported by asking for a structured pre-visit series of materials to allow reviewers to manage the time efficiently and have maximum effect. Based upon the review visit we will provide a structured report covering the key domains of an Emergency Medicine service.

Find out more

If you wish to contact the College about arranging a service review, please contact the quality department for more information, and see the documents below.


Health Informatics is the internationally recognised and Department of Health term covering the use of resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. The number of Emergency Department attendances has been increasing rapidly over the last few years, which has focused attention on why this has occurred. The Royal College of Emergency Medicine Informatics page features Informatics information and resources including: clinical records, emergency care data set, informatics (and introduction), summary care record and syndromic surveillance. Use the navigation tab below to browse the resources available.

+ Informatics


Health Informatics is the internationally recognised and Department of Health term covering the use of resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine.

The number of Emergency Department attendances has been increasing rapidly over the last few years, which has focused attention on why this has occurred.

There are several aspects to the RCEM Informatics group work:

  • What information should be collected in Emergency Departments? [See Emergency Care Data Set (ECDS)]
  • How should diagnostic information be collected [See Emergency Care Data Set (ECDS)]
  • How should information be collected in Emergency Departments?
  • How should information from Emergency Departments be shared?
  • How should information be used to remunerate Emergency Departments? How can remuneration of Emergency Departments improve patient care, and what information is required for this?
    (See “Casemix: how your ED is paid” – in the tab below.)
+ Casemix: How your ED is paid

National Tariffs

See details of the National Tariff Payment System.

+ Clinical Records

Document naming standard

The Professional Record Standards Body (PRSB) has published a Document Naming Standard endorsed by RCEM in May 2019.

Standards for the clinical structure and content of patient records

The standards for the clinical structure and content of patient records were published in July 2013 by the Academy of Medical Royal Colleges. They were developed through extensive consultation to ensure that they address the requirements of clinicians, patients, carers and health information technology professionals.

They are needed:

  • to ensure that information can be recorded and integrated in electronic patient care records across professions, disciplines and specialities, while properly reflecting best practice
  • to generate data that can be used for service delivery and performance management, commissioning, audit and research from data recorded for patient care at the point of care.

These standards were developed for use by:

  • clinicians and healthcare professionals from across all clinical disciplines
  • those who develop and implement electronic or paper care records.

Download the standards for the clinical structure and content of patient records.

Helping to reduce prescribing errors by developing standards for the design of hospital in-patient prescription charts

The Academy of Medical Royal Colleges together with the Royal Pharmaceutical Society (RPS) and Royal College of Nursing (RCN) has produced a report on standards for the design of hospital in-patient prescription charts. The Academy wishes to promote these standards throughout the NHS. The standards were developed by an inter-professional group of doctors, pharmacists and nurses drawn from the medical Royal Colleges, the RPS and the RCN, who reviewed hospital prescription charts from a variety of sources, examined the scientific publications in the area and consulted widely with colleagues in their own organisations and in the NHS using an extensive iterative approach before finalising the recommendations outlined in the report.

See full report and appendices.

+ ED Commissioning & Funding

The Health and Social Care Act 2012 is the most extensive reorganisation of NHS in England to date. This may act as a powerful stimulus for optimising efficiency and cost effectiveness of care if managed effectively through Clinical Commissioning Groups (CCG). Whilst much of the infrastructure for commissioning is being built, the first 1-2 years will require close co-operation between stakeholders to create and bed down new systems. As witnessed with past events, failure to develop and support an integrated emergency care pathway can potentially result in parts of the pathway becoming overloaded and failing. The commissioning landscape at present can seem confusing to many. Regardless of the new arrangements, Emergency Departments are facing a continuous rise in attendance that shows no indications of declining in an era of reduced financial support, increasing costs of providing 24/7 care and a shortfall in the workforce required to deliver emergency medicine. This page acts as a resource base to support our Fellows and Members with commissioning.

Guidance on commissioning Emergency Medicine Services

Commissioning the delivery of high quality care in the Integrated Emergency Department – Guidance for Commissioners, clinicians & managers (18 November 2013).

This position paper by the Royal College of Emergency Medicine provides guidance for commissioners, clinicians and managers on how to deliver high quality care in the integrated Emergency Department. This guide recommends ten key recommendations that the College believes should always be considered when the configuration of local EDs are made.

Reconfiguration of Emergency Care system services – 10 Key Principles (31 May 2012)

This position statement by the College describes the principles that relevant stakeholders must consider when decisions regarding reconfiguration are being made. These will be especially relevant where stakeholders decide that part of reconfiguration will involve down grading or even closure of an Emergency Department.

Urgent and emergency care: a prescription for the future (18 July 2013) – The Royal College of Physicians, NHS Confederation, the Society of Acute Medicine and the Royal College of Emergency Medicine have set out ten priorities for action to address the challenges faced by urgent and emergency care services. These challenges include:

  • Rising demand and the changing needs of an ageing population
  • Lack of comprehensive, effective alternatives to hospital admission across seven-days
  • Complex discharge issues
  • Handover and flow
  • Recruitment into emergency and acute medicine.

Download full report: Urgent and emergency care: a prescription for the future

Download the press statement: Press statement from CEM

Specialised guidance on commissioning

Mental Health in Emergency Departments – A toolkit for improving care.

External commissioning guidance

Breaking the mould without breaking the system: new ideas and resources for clinical commissioners on the journey towards integrated 24/7 urgent care (1 Dec 2011).

This report has been published by the Primary Care Foundation in partnership with the NHS Alliance. This resource is designed to offer ideas and inspiration to everyone responsible for commissioning urgent and emergency care in the UK, in particular, the new clinical commissioning groups in England.

+ Emergency Care Data Set (ECDS)

To provide a more accurate, detailed and complete picture of all emergency attendances, the new Emergency Care Data Set (ECDS) has now launched. The ECDS replaces the Accident and Emergency Commissioning Data Set (CDS type 010).

The good news is Type 1 and 2 Emergency Departments in England are already implementing the mandated changes and submitting new data.

To help staff understand the importance of the ECDS and how they can help support the roll out of this data set, we have developed a simple animation. Please watch our short video and share this with your ED colleagues (including medical, nursing, clerical, reception, operations and management staff).

For more information about the ECDS, please view:

+ Summary Care Record

What is the Summary Care Record?

A Summary Care Record stores a defined set of key clinical data for every patient in England who has elected to have one. The majority of the population of England have had an SCR created by their GP practice and uploaded onto the National Spine. As of February 2015 almost 90% of the population, more than 50 million people have a Summary Care Record. SCRs can be accessed electronically by healthcare staff providing care to a patient in an urgent or emergency care setting, anywhere in England, any time of day or night. SCRs provide access to information held on GP clinical systems about, as a minimum, a patient’s medicines, allergies and any past drug reactions. The Summary Care Record is helping to improve safety, and the quality and continuity of care to patients.

Staff viewing a patient’s SCR must be able to demonstrate a legitimate relationship with the patient and must use a smartcard to access the SCR via the secure NHS N3 Network. All accesses will be auditable. The patient’s permission to view must be obtained before the SCR is viewed. If the patient is not able to give properly informed permission to view then a clinical decision can be made to access the record in the patient’s best interest, without first obtaining consent. Such accesses in the patient’s best interest will be recorded and can be investigated should any queries arise about the appropriateness of the access.

SCR information for NHS staff

How do organisations initiate SCRs?

SCR viewing can be achieved relatively easily and without incurring significant expense to the provider organisation. A web-based SCR application is available which can provide access to authorised healthcare professionals with a smartcard, via the secure N3 Network, to the Patient Demographic Service (PDS) and to SCRs on the National Spine. Alternatively, embedded information systems which are deployed by some urgent and emergency care providers may provide integrated SCR viewing capability. The same access controls apply. The Summary Care Record Implementation team at the Health and Social Care Information Centre will help organisations that are interested in introducing SCR viewing.

Contact the team at:

Further information

NHS Digital provides comprehensive implementation advice and up to date information about the benefits of SCR to patients and healthcare staff.

+ Syndromatic Surveillance

Emergency Department Syndromic Surveillance System (EDSSS)

Public Health disease surveillance is the ‘systematic ongoing collection, collation, and analysis of data, and the timely dissemination of information to those who need to know it in order for action to be taken.

In recent years, syndromic surveillance has become an increasingly important tool for disease surveillance. Syndromic surveillance is the collection, analysis, interpretation and dissemination of health-related data, typically on a real-time (or near real-time) basis, to enable the early identification of the impact (or absence of impact) of potential human or veterinary public health threats which require effective public health action.

The EDSSS is a joint project between RCEM and the Health Protection Agency. The data that Emergency Departments routinely collect are anonymised and sent securely to a data warehouse where they are analysed to produce reports. No extra burden is placed on clinicians. Hospitals engaged in this project also have the opportunity to view their own data in real time.

Requests to joint the scheme or for access to data from the project should be sent to the RCEM representatives on the project:

  • Tom Hughes –
  • Tom Locker –

See the HPA website for more information about syndromic surveillance .

+ Usability

RCEM Usability Survey

The RCEM Informatics committee is performing an audit of the usability of IT systems in Emergency Departments.


The usability (‘user experience’) of IT systems in emergency departments matters to clinicians as these clinical areas have high patient and clinician turnover. This means that training needs and the cost of learning how to operate the IT system is high.

The RCEM informatics committee often hears clinicians complain about their ED IT systems. This is a chance to collect the data that will indicate if usability is a significant issue.

How will it work?

The survey is conducted using a secure app on an Android tablet or phone provided by you. The software will automatically open up and configure itself on the Android device, will be hosted on the same fully secure servers that also holds the RCEM audit data and will be anonymised.

How much does it cost me?


Do I have to participate?

No – the audit is voluntary.

What will I get from the usability audit ?

Your system will be rated on a scale of 1-100, most IT systems will rate between 50 and 70. The responses will be collated and then feedback to trusts via the College Informatics Committee.

The System Usability Scale

The System Usability Scale (SUS) is a valid and reliable tool for measuring IT usability. It consists of a 10-item questionnaire with five response options for respondents; from ‘strongly agree’ to ‘strongly disagree’.

Originally created in 1986, it allows one to evaluate a wide variety of products and services, including hardware, software, mobile devices, websites and applications.

Benefits of using SUS

SUS is the industry standard, with references in over 1300 articles and publications. The benefits of using SUS include that it:

  • Is a very easy scale to administer to participants
  • Can be used on small sample sizes with reliable results
  • Is valid – it can effectively differentiate between usable and unusable systems

The System Usability Scale

Participants are asked to score 10 items with a response from ‘strongly agree’ to ‘strongly disagree’:

  1. I think that I would like to use this system frequently.
  2. I found the system unnecessarily complex.
  3. I thought the system was easy to use.
  4. I think that I would need the support of a technical person to be able to use this system.
  5. I found the various functions in this system were well integrated.
  6. I thought there was too much inconsistency in this system.
  7. I would imagine that most people would learn to use this system very quickly.
  8. I found the system very cumbersome to use.
  9. I felt very confident using the system.
  10. I needed to learn a lot of things before I could get going with this system.

Interpreting Scores

Though the scores are 0-100, these are not percentages and should be considered only in terms of their percentile ranking.

For a computer system with a Graphical User Interface, as with the vast majority of ED IT systems, the mean score is 75, and the standard deviation is 21.

Sample sizes as small as 5 per group have been shown to be surprisingly reliable.

For further information please contact

More reading on usability

Aaron Bangor, Philip T. Kortum & James T. Miller (2008) – An Empirical Evaluation of the System Usability Scale, International Journal of Human–Computer Interaction, 24:6, 574-594, DOI:  10.1080/10447310802205776

+ Advice for clinicians involved in ED IT procurement

Advice for clinicians involved in ED IT procurement

IT system procurement is usually undertaken at a Trust level and can be bewildering for clinicians involved in the process. We suggest that these issues should be considered during the process. This is clearly not an exhaustive list, and members of the Informatics Committee are happy to help with specific questions.

  • Single sign-in: the entire system should be accessible from a single login, without a need to re-enter usernames or passwords.
  • Persistent sessions – when moving between screens, switching users, the state of each user’s last interaction with the record system should be maintained to prevent replication of work. User sessions should expire after a sensible period or when the patient is discharged.
  • The system should have integrated access to core clinical functions:
    • Pathology ordering and results
    • Radiology requesting, reports and images
    • Inpatient and clinic letters from the rest of the hospital
    • Electronic prescribing and medicines administration – for e-prescribing to be safer than routine care patient name bands should be incorporated.
    • Electronic referrals to specialty teams
  • Consider whether integration with clinical hardware (e.g., automatic electronic observation capture, recording of POCUS images) is required.
  • There should be a link within the system to shared care records (e.g., primary care, mental health, social care, 3rd sector) – this should not require a separate login.
  • The system should integrate with the NHS spine for demographics and safeguarding alerts.
  • The system should send FH-IR Transfer of Care messages to allow electronic distribution of ED discharge letters.
  • Consider compatibility with other relevant EDs e.g., in a trauma network.
  • Ease of use: the interface should not impact on clinical flow i.e. number of clicks per task should be minimised. For further information on this and System Usability see
  • Internal consistency: processes for e.g., pathology and radiology should be the same; allergies/diagnoses should be presented consistently through the system.
  • Tasks (e.g., ECG, plaster application) and coding should be captured and timestamped automatically within the clinical workflow.
  • Command and control functionality for shift leaders: how does the system display a “whiteboard”? Can this be subdivided by different clinical areas/acuity? Can it display real-time summary statistics e.g., numbers waiting for triage, bed requests.
  • The system should have resilience to service interruption e.g., is there an ability to “print all” in a business continuity incident?
  • Training burden: what is the time commitment to train existing and new staff on the system?
  • Will a new system require a change to the department’s processes?
  • Ease of updates: if the department changes its patterns of workflow how easily can the system be modified to affect this?
  • All systems must be implemented with accompanying data strategies (storage, access, analytics, national opt-out etc.) to support quality improvement and research.

Some trusts will procure a single electronic record across all clinical areas; others will have a stand-alone ED information system. Where a standalone ED system is procured consideration should be given to how deeply integrated this is with the rest of the trust to minimise switching between systems.

Download a printable version of this information.

+ Further Information

Emergency care performance data and statistics

Royal College of Physicians, Health Informatics Unit

The Health Informatics Unit of the Royal College of Physicians has been pivotal in the development of standards for medical records. It co-ordinated a project that has produced Generic Medical Record Keeping Standards, and Standards for Content and Structure of inpatient notes that have been jointly published by the Academy of Medical Royal Colleges and the NHS Digital and Health Information Policy Directorate.

Additional Resources

Sources of legislation, to include:

  • the Computer Misuse Act 1990
  • the Data Protection Act 1998
  • the European Directive on Data Protection
  • the Access to Health Records Act 1990
  • And any subsequent revisions to this legislation.

Patient Safety

Information Commissioner’s Office

Data Security and Protection Toolkit

Hospital Episode Statistics

Hospital admission data are currently available through the Hospital Episode Statistics (HES) database which is a centralised data collection facility covering all NHS and private hospitals in England. Data from this system are available for use for surveillance activities, however the current availability of these data are not timely and are released with an approximate 6 month delay. Therefore, for use in a real-time system HES data are not suitable and more likely to be used for retrospective analyses or validation exercises. There are also costs involved with accessing these data. See more information on hospital episode statistics .

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