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 95.

    I am fed up of getting a second class service in most areas - from health to arts, just because I don't live in city (I live in a large town). I pay the same taxes but it seems I am not entitled to the same access to the services. Something tells me that the hospital near Keogh's house, just like the theatres near Mr Cameron in No 10, will get the top funding. What a coincidence!

  • rate this

    Comment number 94.

    As far as I can tell this measure is partly a practical response to changes in medical practice and technology. With some highly efffective but very complex treatments we will stand a better chance in a centre which sees many such patients than in a local unit that must 'take off the dust covers, bring up the procedures on screen and say - now how did we do this last time?'

  • rate this

    Comment number 93.

    There was a walk in centre next to our local hospital which was well used. It was decided to move it into the A/E Now nobody uses it because you could be waiting hours, instead they now just use the A/E. Which is now packed to the rafters. Great idea!

  • rate this

    Comment number 92.

    My daughter forgot her inhaler and had an asthma attack at school. All she needed was a few puffs on a blue inhaler. The school nurse wouldn't give her one. The ambulance the nurse called wouldn't give her one. It was only when she got into A&E that a doctor was prepared to accept responsibility and actually make a decision.
    Fat chance of the proposed system working in this litigious country!

  • rate this

    Comment number 91.

    As number 86 quotes, reorgs after reorgs!
    However, they never highlight all the NHSs problems and then try to solve them together-they do it piecemeal. Here they go again!
    Do the right job and do it right. Vain hope.

  • rate this

    Comment number 90.

    The bottom line is there are too many people in this country so it is almost impossible to provide an acceptable service for everyone. Successive governments have failed to control the population of this country (both indigenous and through immigration) so the reality is folks expect less and less of a service in the future and eventually it will be privitised - then you'll have a 2 tier service.

  • rate this

    Comment number 89.

    IIRC this was suggested around 5-6 years ago - to have a super trauma centre in each county that deal with extreme emergencies, and reduce the pressures for this treatment on the other EDs. It was binned off then, why is it suddenly a great idea now?
    Perhaps if support services were better, and patients better informed at "Triage/Welcome" stage in the ED then we would have less pressure in the ED

  • rate this

    Comment number 88.


    I would suggest "70% OF all A&E attendees are now over 65" because they cant see their local doctor due to all the benefit tourism...

    To suggest the strain on the NHS is nothing to do with overpopulation is naive at best.

    Do you by any chance have a source for that statistic?

  • rate this

    Comment number 87.

    Let me guess - the two tiers will both be put out to tender?

    Pathetic see-through plotting by the government yet again.

    If you want to improve the service, STOP cutting budgets and jobs. 5000 nurses since Cameron came to power.

  • rate this

    Comment number 86.

    "We trained hard, but it seemed that every time we were beginning to form up into teams we would be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing; & a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency & demoralization."

    Arbiter Gaius Petronius AD27-66.

    We never seem to learn do we?

  • rate this

    Comment number 85.

    43. Mrs Vee
    Get GPs working shifts, 6am-10pm, 7 days a week, and the A&E problem would disappear overnight.
    No it won't. It'll be full of people misdiagnosed by GPs too tired to work properly.You wouldn't get on a plane flown by a pilot who worked those hours but you'll trust a doc to tell flu from meningitis after an 18 hour shift? I wouldn't.

    How about MORE GPs doing 7-3 & 3-10 shifts?

  • rate this

    Comment number 84.

    I suspect that the two tiers that this Government would really like to create in A&E are a top one with express service and expert care for those who can afford to pay top dollar and a bottom tier for everybody else. When it comes to acute care in the NHS, I predict that it will certainly be tiers before the next election.

  • rate this

    Comment number 83.

    For heavens sake, lay off the politics. Labour did this, the Tories did the other thing.

    Normal people don't gear their lives around what might happen if they suddenly feel ill,etc. Neither can they foretell when an accident will happen.

    Powers-that-be, including medics say, "If in doubt see a medical professional."

    Stop blaming ordinary people Get organised Department of Health.

  • rate this

    Comment number 82.

    In principle a reasonable idea. But Government also needs to address issue of getting to see a GP within a reasonable time - this is becoming increasingly difficult. Some people will go to A&E because it is so difficult to get a GP appointment. So increased GP provision/walk in centres could well ease pressures on A&E.

  • rate this

    Comment number 81.

    Unfortunately, it is somewhat the way it has to be, you don't want a small DGH doing neurosurgery or PCI as they will not see enough cases to maintain the skill required to perform these procedures safely. Centralised centres covering large areas are probably the best way to do it and will give best outcomes, but some people may end up losing out. I'm not sure there is an answer to cover everyone.

  • rate this

    Comment number 80.

    'Was this deaths in the trauma centre'

    I took it as a 20% reduction in deaths due to major trauma. So, compared to taking a 'major trauma' to the closest A&E which might see only (say) one case a fortnight they took 'em to a specialist centre further away that was now seeing (say) one a day.

    Seems entirely plausible to me. That's why we have specialist centres for other stuff.

  • rate this

    Comment number 79.

    @59 they should wait to be treated by their GP instead of clogging up A&E....

    Agreed except for many trying to get a GP appointment can be nigh on impossible so the often hard-pressed A&E becomes the fall-back out of sheer desperation.

  • rate this

    Comment number 78.

    Despite all the Right Wing Media and UKIP hysterics over Benefit Tourism and other foreigners the reason why A&E's are busier and busier is the growing elderly population (70% OF all A&E attendees are now over 65) as they are more susceptible to both injury and sudden illness and because once there courtesy of the massive cuts in Social Support there is no where to discharge them to!

  • rate this

    Comment number 77.

    This is like watching paint dry, why don't the Tories just go ahead and privatise the NHS asap?

  • rate this

    Comment number 76.

    My issue with the 'only go to A&E as last port of call' thing is we as non medical people dont always know how serious an injury is

    E.g Ive been to A&E twice in my life,once I had a broken hand so fine to go there and get it plastered etc.The other time id hurt my ankle, that turned out but nothing more than 'bad twist' but tbh I was in more pain with that than my hand so how would I know?


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