Plan for two-tier A&E as part of radical shake-up

Patients waiting to see a doctor Pressures have been growing on A&E units for a number of years

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A two-tier A&E system in England should be created as part of an overhaul of services, NHS chiefs say.

The review by NHS England suggested the biggest 40 to 70 units - specialising in heart attacks, strokes and trauma - be called major emergency centres.

It would leave the remaining 70 to 100 A&Es - known as emergency centres - to deal with less serious conditions.

It also suggested changes to the way ambulance crews and the new 111 phone service work to "decongest" A&Es.

Greater co-ordination between community services, such as GPs and pharmacists, would also help, it said.

The measures have been put forward in response to the growing pressures on accident and emergency departments.

Emergency conditions

Patient numbers have risen by 50% in the past decade and last winter the problems got so severe that the NHS missed its four-hour waiting time target.

What this means for A&E units

There are about 140 A&E units. The review proposes they be designated into two categories - major emergency centres and emergency centres.

The major ones would focus on specialist care, such as heart attacks, strokes and trauma.

This has already been done in London for stroke. There are now eight main centres that provide fast access to expert care. The remaining 24 focus on rehab. It is saving 400 lives a year.

Extra money has been set aside to help the NHS through this winter and the next one.

But this review aims to set out the long-term vision for the service.

Many of the proposals are already in operation somewhere and in essence the review is calling for this to be formalised across the system.

For example, there are already a number of A&E units that act as major centres in everything but name.

But by setting a target of having between 40 and 70 major emergency centres it means this will have to be extended across the health service.


This is likely to end up a controversial process because of the fear some hospitals could lose services.

NHS medical director Prof Sir Bruce Keogh, who led the review, said: "A&E is creaking at the seams. It is not broken, but it is struggling.

"We need to change the way we work. But what we are suggesting here already exists in places, we are just trying to formalise it so it is available for everyone."

Professor Sir Bruce Keogh: "It's about improving the outcomes for patients with very serious conditions"

The review said there also needed to be further changes to the system if pressure was going to be relieved.

About 40% of people who attend A&E do not need treating there.

What is more, the problems developed by a fifth of patients who are eventually admitted to hospital with emergency conditions could have been avoided with better and earlier treatment in the community.

The review said key to tackling these problems was ensuring patients got access to the services that were best suited to them first time.

To achieve this, 111, which has been beset by problems since it was launched in April to replace NHS Direct, will need to be much more responsive, giving patients direct phone access to doctors, nurses and other health professionals.

What this means for 999 and 111

The 111 non-emergency service needs to be providing better access to doctors, nurses and other health professionals so patients get the right advice first time.

But perhaps the most ambitious challenge is for the 999 system - and in particular ambulance crews.

The review says half of callouts could be dealt with at the scene. Some services, such as South East Coast Ambulance, have already started working towards this.

They have given paramedics extra training so they can treat a range of physical injuries and wounds at the scene.

Ambulance crews will need to treat more patients at the scene to reduce the number of patients transferred to hospital.

Service 'creaking'

Meanwhile, there needs to be greater co-ordination between GPs, pharmacists and the network of minor injury clinics and walk-in centres to give patients 24/7 access to care outside of hospital.

Shadow Health Secretary Andy Burnham: "It's not what the government promised"

Shadow health secretary Andy Burnham said Labour welcomed Sir Bruce's report but deplored "the government's attempt to avoid presenting it to Parliament and abdicate all responsibility for the crisis in A&E".

"Ministers said this report would have lessons for the immediate winter, as well as the longer term," he added.

"But they are failing to act and their response remains 'crisis, what crisis'? They are forcing A&Es to go into winter with too few nurses, doctors and beds."

What this means for community services

In a nutshell, greater integration. The review wants to see GPs, pharmacists and the array of walk-in centres and minor injury units working together to provide 24/7 access to care to relieve the pressure on A&E.

For example, many pharmacists now have consultation rooms and can give advice on a range of minor ailments and carry out medicine reviews.

But key to this will be GPs and the lead they take in co-ordinating the care of the frail elderly.

He said the prime minister had "made it harder to get a GP appointment, closed NHS walk-in centres and scrapped NHS Direct, leaving people with no alternative but to go to A&E".

Patients Association chief executive Katherine Murphy said the review had presented a "promising vision".

"At present there is genuine confusion amongst some patients, who then opt for A&E as a safe default option," she added.

College of Emergency Medicine president Dr Clifford Mann welcomed the proposals, although he said NHS chiefs would need to be careful the reorganisation of A&Es did not lead to "detrimental" increased journey times.

Dr Clare Gerada, Royal College of GPs: "We must not design the health service around the emergency department"

He also said: "Any plan to provide emergency care must be based upon an adequate number of appropriately skilled clinicians and on this matter the review is disappointingly silent."

The changes will now go out to consultation and the review team will spend the next six months looking at the cost and staffing implications before producing another report in the spring.

It is likely to take three to five years before the overhaul is completed.


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  • rate this

    Comment number 15.

    I think there should be a 3rd tier, one where drunks and idiots are charged for "mis-use" of A&E

  • rate this

    Comment number 14.

    I am a GP and volunteer for BASICS attending pre-hospital accidents and emergencies in Lincolnshire. In one previous change, hospitals became either Major Trauma Centres or Trauma Units (or neither). Lincolnshire now has NO MTC and our seriously ill patients travel 60 - 80 miles to Nottingham. If this split occurs, this rural county will no doubt end up with even less - postcode lottery again!

  • rate this

    Comment number 13.

    Goves Silly Temper Tantrum

    All these changes to the NHS are deliberate. Jeremy Hunt wants to destabilise our NHS, in order to soften up public opinion ahead of privatisation to his corporate crony chums.

    All ready in the pipeline. I've heard that there is a program on R4 coming up about Virgin and Serco having the first input into the NHS. Look out for badges with NHS Virgin or NHS Serco soon.

  • rate this

    Comment number 12.

    "About 40% of people who attend A&E do not need treating there."

    They do if it is an evening or weekend and there is nowhere else to get treatment.

  • rate this

    Comment number 11.

    Should they not concentrate on fixing the NHS as it currently stands?? The pressure on hospital services such as A&E will be relieved simply by getting GP surgeries to work different hours to suit everyone....not many people in comparison actually work 'office hours'.

  • rate this

    Comment number 10.

    So to deal with problems in A & E, we'll cut the number of A & E departments. On top of a proposal to cut walk in centres.

    Can anyone else see a problem with this?

    We don't know how many people requiring NHS services live here, or how many will move here in the future, so no-one can plan for future needs of the NHS.

    And, please don't tell me that added journey times will be beneficial.

  • rate this

    Comment number 9.

    Im confused, isnt the other hys about how this already basically exists :?

  • rate this

    Comment number 8.

    the statistics have been showing that concentration of expertise leads to better patient outcomes for years, but that contradicts the gospel of the free market and privatisation so gets ignored.

    still i'm sure they'll find a way to spin this to make millions for some healthcare plc with links to the cabinet

  • rate this

    Comment number 7.

    Yet another review? How much did this one cost? And what did they conclude? Lets rename the bigger hospitals...

    Why dont they actually spend some money IN the hospital instead of on consultants and think tanks. Then we may actually get value for money instead of a nicely named mess

  • rate this

    Comment number 6.

    Two tier A and E to go with two tier education. Guess which sectors of society will come off worse.

  • rate this

    Comment number 5.

    yes a two Tier NHS one for the Upper Class and Minister and one for the Plebs.

    That is the reality.

  • rate this

    Comment number 4.

    Fine, if those further down the line can competently assess the treatment needs.
    But creating such places enevitably means increased travel time for those with the more complicated tier 1 medical conditions & with ambulance services already hugely undermined by cuts, without these cuts being reversed I cannot see how such a system can be any improvement.

  • rate this

    Comment number 3.

    Whatever they do, all normal folk want is if they become ill is to access a local doctor in a timely manner and get the best treatment avalible in order to get better.

    I know its alot to ask but that is what the NHS is for is it not - we must not forget that.

  • rate this

    Comment number 2.

    This will never happen.

    There will be so much local protest about downgrading "our A&E Dept" that the NHS will never push through the changes, not completely anyway.

    Greater coordination between community services is a pipe-dream. Too many egos, too many vested interests, too many "our way is best".

  • rate this

    Comment number 1.

    All these changes to the NHS are deliberate. Jeremy Hunt wants to destabilise our NHS, in order to soften up public opinion ahead of privatisation to his corporate crony chums.


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