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 75.

    60.Harry Lime
    'We must not forget that our loving, caring Government has cut the money to run the NHS by 20 per cent'

    20% - strangely enough thats the same figure of people treated per day at a NHS clinic in Manchester who are not entiltled to free healthcare but get it anyway (BBC programme last month)

    Wonder if there's any correlation?

  • rate this

    Comment number 74.

    Like all "public services" you should be able to opt out and buy your own provision elsewhere, well away from the grasping Socialists desperate to take your money and waste it on vanity projects, massive pay rises for their vote bribe targets and the general inefficiency of the bloated "public sector".

  • rate this

    Comment number 73.

    So, the truth is out, two tier NHS = those who can pay V those who can't.

  • rate this

    Comment number 72.

    Make any service totally free for everyone even those who could afford to make a contribution and it will without doubt be abused. I see patients standing outside my local hospital in dressing gowns attached to drips having a fag, do they really deserve treatment?
    A&E should be 3 tier the third comprise large rooms where they can throw the drunks to wallow in their own and other peoples vomit.

  • rate this

    Comment number 71.


    No, no. They charge your private medical insurance. Which is a legal requirement if you're not covered on the NHS.

    It's a fairly simple, and more importantly, fair concept. I do it every time I go on holiday.

  • rate this

    Comment number 70.

    My recent experience of the NHS has been excellent from the phone call to 111 to the medic who came to see me and ordered an ambulance to take me to hospital. The A & E dept swiftly had my arm x-rayed, offered me a cup of tea and found a bed in a ward. The nurses were polite and pleasant and the food good. The NHS will aways be a government football because they don't want to pay for it!

  • rate this

    Comment number 69.

    If the A&E in our town closed, heart attack and stroke patients simply wouldn't make it to the 'regional centre'. In the rush hour (which is most of the time these days) it can take over an hour to travel half a mile let alone 10.

  • rate this

    Comment number 68.

    "we'll only sew that leg back on sir, when you find your credit card"

  • rate this

    Comment number 67.

    There is an easy, nil cost solution to overcrowded A&E departments. All drunkards admitted should be placed in a secure room to recover from their drunkenness - and left there until they are sober. There should be no other intervention. They are responsible for their state of being - no one else - why should genuine A&E patients be put at risk whilst resources are wasted pandering to these idiots

  • rate this

    Comment number 66.

    How about National Health meaning just that. National not international

  • rate this

    Comment number 65.

    @62 Was this deaths in the trauma centre, or an overall reduction of 20% when taking into account the other hospitals etc in the area?

  • rate this

    Comment number 64.

    My GP is great for anything that can wait a week or more.
    Walk in centres are needed and work if open till at least 8pm (ours don't).
    I tried 111, but would rather pin my hopes on a Google search in future.
    A&E should be the last port of call but for many it's the only port of call.

  • rate this

    Comment number 63.

    A two tier A&E?

    Presumably 2nd and 3rd class if politicians have anything to do with it.

  • rate this

    Comment number 62.

    Radio 5 reported that trials of concentrating 'major trauma' into fewer, specialist centres had resulted in a 20% reduction in deaths. We might like the idea of a 'specialist centre' in our own town or city but they only become 'specialist' through repeated practise. No point having an A&E that only sees one major trauma a fortnight. Better that sees one twice a day. They'll be better ready.

  • rate this

    Comment number 61.

    54. Global Yawning

    "How about a "You can't use it, until you've paid into it" shake up of the NHS...that’ll save a few quid!"

    So, the paramedics have just scraped you up off the road. Now, do they rush you to the nearest A&E? Or do they ask you to prove you've paid into the NHS...?

  • rate this

    Comment number 60.

    We must not forget that our loving, caring Government has cut the money to run the NHS by 20 per cent. I don't think that anyone needs to say any more here.

  • rate this

    Comment number 59.


    "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.


    You're missing the point.
    By definition, the 40% are NOT Accidents or Emergencies.
    Therefore, they should wait to be treated by their GP instead of clogging up A&E....a service they might one day genuinely need.

  • rate this

    Comment number 58.

    It's time we go past the belief that GP's are at the core of the NHS. This may have been true in the 40's and 50's but now it seems obvious that the GP service has become a huge, overpaid, and self-satisfied bottle-neck to NHS services.

    Patients want access to basic NHS services 24/7. Since the GPs can't/won't provide this then let's replace them with a system that can/will.

  • rate this

    Comment number 57.

    Everything Labour touched turned to er, manure. This is why the NHS is in such a mess - they paid doctors a fortune to work less.

  • rate this

    Comment number 56.

    Re - 50.
    6 Minutes ago

    Why are you voting for 3????

    Because this Island is poplulated with people free to decide what to think and do for themselves, not a communist state that tells people what to do and think, like you are suggesting.


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