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 335.

    I favor abolishing the NHS completely. It's an inefficient unfair system where people that can't be bothered to work and migrants get free services paid for by hard working tax payers.

  • rate this

    Comment number 334.

    Just now
    316.Sally the Rothbardian

    That's only 0.6% of the population.

    So you agree it is not RARE.
    Ah, no. I'd call 0.6% rare. I'm 99.4% certain more people have fender benders than that, and there's no NHS for cars is there.

    And, every country in the world had user pays, or charity, for healthcare before the state did it. There's your example.

  • rate this

    Comment number 333.

    Wendy @313
    "ideal world"

    Within means, but also 'in conscience & democratic priority', dynamic achievement with horizons ever-moving, vitally guided by 'where the shoe pinches', responding to pleas of patients & staff as well as of those with budget-targets (as much political as 'economic').

    We need local hospitals for the 90-99% as well as regional centres for the 1-10% (and REAL democracy)

  • rate this

    Comment number 332.

    Very sad to read anti Scottish & anti English comments.
    There is no real difference between us.We both have Gas,Electricty & Water companies to support.
    And English MPs could,if they wanted to,give English people the same benefits that a Scottish Parliament has decreed.

  • rate this

    Comment number 331.

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

    Would that be with the most profitable going to the highest bidder? Truly appalling

  • rate this

    Comment number 330.

    GPs are the problem. They are too busy providing as many services as possible to maximise funding for the practice that people attend A&E as they can't see a GP.

    Why do GPs still treat minor problems like eye infections, strains, sprains, colds, indigestion, headlice, migraines...much more?

    Stop paying them to do this, let them focus on patients they should be seeing that clog up A&E

  • rate this

    Comment number 329.

    @324 Mr Ozzie is still using PFI's (despite his criticism when in oppostion)
    Private eye has been banging on this for ages.

  • rate this

    Comment number 328.

    316.Sally the Rothbardian

    That's only 0.6% of the population.

    So you agree it is not RARE.

    I didn't say tax is free, I said TAX entitles you to NHS care that is free at the point of service. You can't produce a single example to back up your neo-liberal nonsense because no country on planet earth has a universal healthcare system funded solely from private money.

  • rate this

    Comment number 327.

    Does anyone know how much is raised in NHS contributions and how much money the NHS receives from the government

  • rate this

    Comment number 326.

    And so it begins. After a year of bashing the NHS in the media to soften up the public, they have finally started the 'divide and privatise' agenda.
    This must not be allowed to happen.

  • rate this

    Comment number 325.

    1. People abuse what they consider is free
    2. People think A&E will see them whatever their problem.

    Easy solution - do not see people in A&E if they are not an accident or an emergency.

  • rate this

    Comment number 324.

    And it was Labour who instigated the PFI which is crippling many hospitals for which we won't have finished paying for many years and we'll probably be building new ones before we've paid for them. Ours is only a few years old and it's already inadequate. Fortunately the old 1960s style one is still standing.

  • Comment number 323.

    This comment was removed because the moderators found it broke the house rules. Explain.

  • rate this

    Comment number 322.

    How about bringing back Minor Injury Centres? oh and drunk tanks.

  • rate this

    Comment number 321.

    318.Aitchemm said: "Praise be to be a Scot living in Scotland. Wonder when we will see returners when we are independent of these English posh boys"

    Ah, the land of milk and honey where you are given everything for free at the English tax payers expense. Bring on the turkey voting for Christmas.

  • rate this

    Comment number 320.

    Oh well I suppose if the pro-private get there way we will be able to recycle the pensioners (those that haven't died of cold) into some sort of fertilizer being as a good chunk of them won't be able to afford health care insurance, plus you can add those with "existing conditions" and those that cannot affort the critical health cover.
    Sounds great until you get old and need it.

  • Comment number 319.

    This comment was removed because the moderators found it broke the house rules. Explain.

  • rate this

    Comment number 318.

    Praise be to be a Scot living in Scotland. Wonder when we will see returners when we are independent of these English posh boys who simply don't care

  • rate this

    Comment number 317.

    Ideally, as many A&Es as possible should be classed as "Major Emergency Centres", giving people local access to such facilities.

    That won't happen of course as this is all about money.

  • rate this

    Comment number 316.

    That's only 0.6% of the population.

    NI is a tax. It's not free, I paid NI (tax) in advance. Your argument is like "my pre-booked and paid holiday is free because I paid for it already" is invalid.


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