Healthcare provision for acutely unwell or injured children in the UK is changing fast. Paediatric emergency medicine (PEM) is now a recognised subspeciality for certification of completion of training for consultants in either paediatrics or emergency medicine. Facilities for children in emergency departments (EDs) have improved since 2000 (following central government funding). At the same time the case mix of children attending EDs is changing, with less serious illness or injury and more children with minor, self-limiting conditions being brought by parents and carers who find the lottery of primary care arrangements confusing, inaccessible or inadequate (particularly out of hours).

Add to this the political changes which include the 4 h emergency target, Modernising Medical Careers, the European Working Time Directive effects on doctors’ rotas, continuing reconfiguration of services towards centralisation of specialist services (which affects EDs and paediatric units), and Payment by Results tariffs which can result in some perverse incentives around acute admissions to hospital, and we see a changing landscape.

As a subspeciality with an ED-based infrastructure, PEM does not exist in Europe. The USA is 10 or so years ahead of the UK in developing PEM medical and nursing training, while Canada and Australia are roughly on a par with the UK. There are interesting differences in medical training, but also a large degree of overlap in both training and practice in these four countries.1

In 1999 a set of standards was published by an intercollegiate working party under the auspices of the Royal College of Paediatrics and Child Health (RCPCH). The document Accident and emergency services for children,2 often known as “the red book”, contained recommendations which were practical and feasible. However, a survey in 2005 showed that many EDs were still falling far short of the recommended standards.3 In 2007 …