Ensuring responsive and timely access within an emergency department is likely one of the most common "hot button" issues facing all of us involved in socialized medicine. There are many variables at play here, and discussed in this featured article. As reported, there has been relatively little research and evaluation to assess the most effective way to drive system-performance improvement. Experience in both the NHS and in Western Canada leads me to believe that many of the themes and strategies discussed here have some universal relevance and "currency" on both sides of the "pond." We should absolutely look at these learnings; however, there are some fundamental issues and differences between our health systems that need to be recognized and addressed before some of these could be optimized in Canada.

The issues of system alignment, role demarcation and the way in which doctors and other health professionals are paid, to my mind, remain major stumbling blocks to effecting and sustaining transformational service redesign and improvement. A good example of this is the capacity of primary healthcare to deal effectively with the tidal wave of chronic disease in the community. Given the constraints of the fee-for-service reimbursement models in most Canadian jurisdictions and the lack of access to interdisciplinary group practice models/clinical support tools, all too often, patient care defaults to an episodic emergency visit, rather than being dealt with "upstream" as part of a focused prevention and shared care model. Such models do exist, of course, but sadly are not the norm. Interdisciplinary primary healthcare is well developed in the UK. This is not the case in many parts of Canada. Here, the emergency department often remains the one-stop shop, with all of the associated capacity and congestion issues that that brings. Fast track/minor injury centres are commonplace in Canada with good evidence to support their use.

I agree with the expert opinion expressed in the paper supporting the need for improved bed management. To my mind this remains the key challenge of managing outflow from the emergency department once a decision to admit or discharge is made. Here, the debilitating impact of "blocked" acute beds and the lack of rapid access to appropriate community care options, to my mind, remain the most significant challenges to be addressed. There are a number of Canadian-based examples of a successful application of patient flow/ bed management technology such as Strata Health's Pathways and Care-First products. Evaluation of the use of these systems in Calgary, Edmonton and Vancouver Island Health systems have demonstrated the significant benefits of focused bed management and patient transition across the continuum. This is one area where Canadian experience and innovation is leading the way, with adoption of this model now moving forward on three continents around the world.

In Canada, we have made some great strides to redesign and reengineer our systems, but rarely do we formally evaluate the perceived and real benefits of our efforts, let alone publish and share these learnings as an industry. I believe that there is an opportunity to learn from the findings and conclusions of this work in the NHS, but we also need to look carefully and critically within our own systems - to identify and share what works well, and what does not.

There are no magic bullets for success in healthcare, and, as an industry, we need to be more open to critically reviewing and sharing our experiences in areas where we share such common challenges.

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