Nigel Hawkes, The Times's Health Editor, analyses the proposals in reports by two leading clinicians published today that call for reform of emergency services and the creation of super A&E departments to treat heart attack and stroke patients.

Can you explain the debate between specialist units vs general A&E departments?

Consultants have long argued that many conditions are best treated in specialist units, but any move to set up such units undermines the provision of services in district general hospitals.

So they have been torn: clinical logic points to specialist units but they do not want to lose their own departments. The more patients they lose to specialist units, the less pass through their own wards. This has implications for training - the Royal Colleges will not approve training of junior doctors in hospitals that see too few cases - and for staffing. The fear is that the whole fabric of the hospital will be damaged.

Consultant equivocation on the issue has been reinforced by public anxiety that they are "losing" their local hospital - even if it means getting better services a bit further away. Politicians have consistently failed to grasp the nettle.

What has changed now is that the financial problems of the NHS mean that reconfiguration - reorganising services in more economical ways - can no longer be postponed. This has provided an opportunity for Sir George Alberti and Professor Roger Boyle to make the case for specialist A&E Units, making a virtue of changes forced by financial pressures.

Is there evidence to support the closure of some emergency centres?

There is evidence that for some clearly-defined emergencies, traditional A&E units provide a poor service. These include heart attacks, strokes, and aortic aneurysms (when the main blood vessel springs a leak). These are better treated in "super A&Es" where rapid revascularisation and brain scans are available 24 hours a day, seven days a week. The provision of such centres implies the reduction of others, and the closure of some. But minor injury units would remain, and they can deal with a lot of routine emergencies.

Who opposes the plans?

Local campaigners are always vocal, usually backed by consultants who see their own units undermined. Politicians are terrified of the Kidderminster effect, when a local argument over hospital changes led to a Labour MP losing the seat to a hospital consultant.

When will these changes happen?

There are proposals all over the country for changes to A&E departments. Plans made by Strategic Health Authorities are out to consultation, on a range of different timescales. The risk is that these changes will be made without the provision of the "super A&Es" envisaged in the two reports, giving patients the worst of all worlds.

How does this fit into the wider debate about reforming the NHS?

Most patients are likely to be sceptical about what appears to be a sudden discovery by experts that closing A&Es is good for them. Ministers will have a hard time selling the plan, because it has come at a time when most of their political credit is spent. But when they still had that credit in the bank, they did not use it for reforms such as these, so they have only themselves to blame.

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