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 255.

    Just think, if you start insisting on GPs working all hours, you need to at least DOUBLE the number of GPs and also the nurses working in the GP sector because doctors don't do dressings and many people going to A&E require dressings. Small practices would become big practices. Big practices cost big money. You STILL need A&E for the cases the GP can't handle or when not at home.

  • rate this

    Comment number 254.

    @ 246. jgm2
    QE = £375B rising.

    The £500b bailout includes purchases and capital injection for liquidity. But we bought the shares ABOVE market so not a deal at ALL.

    Even if we do recoup £400b as u suggest:

    thats £10,000 for every adult!!

  • rate this

    Comment number 253.

    The NHS should be abolished.

  • rate this

    Comment number 252.

    @239 I'm inclined to agree with you. When I was young you went to the doctor when you needed to, were given a plastic numbered token and waited 'til your number was called. Mind you, Doctors also did home visits and worked weekends in those days.

  • rate this

    Comment number 251.

    Has the NHS ever heard of the customer ? Perhaps people go to A & E because it meets the customer needs, out of hours GP services are a complete waste of time. The NHS needs to adapt to meet the needs of the customer - expand A & E and close down out of hours GP services and stop paying GPs so much.

  • rate this

    Comment number 250.

    Maybe they should reform GP surgery's and change them into walk in centre's that also have nurses and are open 24/7 and just have A&E for emergency's only. And allow the walk in centre's to charge foreign and EU visitors for all treatment received.

  • rate this

    Comment number 249.

    The NHS is too big, too complex and far too political to manage effectively. Demand for health services will always outstrip supply as more can always be done. Overlay that with empowered and increasingly litigious patients, disillusioned staff and no appetite for change and you have a ticking time bomb. No amount of cash can or will fix the problems.

  • rate this

    Comment number 248.

    Oh for direct investment to the front line services of the NHS rather than having yet another review! It may pay the management consultants well, but does little for the morale staff or even the well-being of the patients.

  • rate this

    Comment number 247.

    The "fly in the ointment" is the GP service, it's an out of date anachronism which is past it's sell by date. In my experience chemists provide 95% of what GPs do. The proposed "emergency centres" should be extended to cover the bulk of the GP service which should be phased out.

  • rate this

    Comment number 246.

    222 economaster

    'QE + Bailout = £875Billion+ and rising'

    Not true. The 'bailout' amounted to about 80bn quid which was not given as a handout but used to buy distressed assets (bank shares) at what may turn out to be bargain prices.

    The 875bn figure was manufactured by Labour in 2010 to get a figure close to the (then) national debt and so kid on that the national debt was all the banks' fault

  • rate this

    Comment number 245.

    233 and others : read the review. the two tiers are of familiarity and skill not rationing. Treating a complex critcal case of stroke with latest techniques is many times more costly than seeing a average drunk or smoker or foreigner or muppet in A&E. The reform should get that a bit better. A person consumes about 90% of their lifetime healthcare costs in the last year of life (IIRC - ???)

  • rate this

    Comment number 244.

    Mr Straw's and Mr Blunkett's comments today and yesterday give some indication as to why the NHS and A&E are struggling. but that is a no go area as far as any discussion goes.

  • rate this

    Comment number 243.

    @231 Diddlypete.

    Most broken bones, especially ankles are from missadventure, carelessness or general fault of the owner.

    An ulcer, very often caused by bad luck due to helico bacti pylori, and a very common cause of stomach pain. If acute could be life threatening.

    I'd say the second option deserves my tax more than the first. You should have been given a crutch and sent home..

  • rate this

    Comment number 242.

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

    You want to "decongest" A&Es? Stop closing down walk in centres, probably the single most effective way to take pressure off A&Es and GPs.

  • rate this

    Comment number 241.

    With plans to create 40 - 70 major A&E centres, together with 70 - 100 A&E centres, the UK system will rely heavily on the triage of patients at the first point of contact with primary care. It is questionable that the 111 telephone advice line is directly linked to this, as it is not for emergency calls. A new computer system for telephone triage will streamline the system & improve patient care.

  • rate this

    Comment number 240.

    I think he forgot to say that Major Centres are to be retained within the NHS and the less serious centres will be put out to tender because as always, the private sector gets the easy stuff (the cream) - money, money money and the NHS does the really serious stuff and sorts out the mistakes of the private sector.

  • rate this

    Comment number 239.

    Surely the expansion of walk-in centres is the answer. Perhaps we should dispense with the GP altogether and just have walk-in centres. I can never get an appointment to see mine so what's the point in having them?

  • rate this

    Comment number 238.

    Am I right to assume that patients with "less serious conditions" would have to wait for longer hours under the new proposal?

  • rate this

    Comment number 237.


    '..minor injuries and illness should be refused treatment via emergency care routes to allow these services to effectively deal with real medical emergencies.'

    I agree with your other points but it's called ACCIDENT and Emergency. A broken arm isn't an emergency in the same way as a stroke but it still needs treatment now to prevent worse injury.

  • rate this

    Comment number 236.

    Great,so you have a heart attack etc and it takes 20 mins longer to reach the shiny bigger hospital...
    Do you want some chance,or no chance?
    I can already hear estate agents adding it to their list's of sales patter,"school catchment area and any serious life threatening illness you've got 50% more chance of survival if you buy in this area"!!


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