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 355.

    I think the problem, like many we face, is caused by our rapidly aging population. As it stands there are more retired, or soon to retire, than those in work. This situation is just not sustainable, certainly not if we want to have well funded services and liveable pensions.

    Sadly the only solution I see is to adopt a part state, part private model like the Japanese. Otherwise we will be bankrupt

  • rate this

    Comment number 354.

    Perhaps if the government stopped wasting taxpayers' money on a certain buttered-up train set and funding for India's space programme, maybe we'd have enough money to sort out this mess.

  • rate this

    Comment number 353.

    John Campbell
    "And English MPs could,if they wanted to,give English people the same benefits that a Scottish Parliament has decreed."

    No, they could not, because we continue to subsidise the Scots to a ludicrous degree while they ither laugh at us or spit at us. Vote "Yes" next year, and starve.

  • rate this

    Comment number 352.

    I find it astonishing the amount who people who are put in charge of these thing have been knighted.......considering "we are all in this together",there are far too many SIRs for my liking

  • rate this

    Comment number 351.

    I see that the moon has come out again to show a complete lack of understanding on the importance of the NHS to this country. Comments like those made @335, 336 and 337 just makes me angry. If we abolished the NHS then what? Private healthcare? That is already starting to happen with the introduction of Health and social care act. Listen to File on 4 and see what happens when profit comes first.

  • rate this

    Comment number 350.

    272 d mcglocklin
    Your taxes are going on the millions and millions who come here for a 'better life' and use all services from the minute they enter,there's hundreds of billions since we stopped having control of our borders and also for the hundreds of billions spent on people who I see every day who won't work because 'why should I for minus wage when I get everything paid by the social!'

  • rate this

    Comment number 349.

    Tell blinkered Cameron to shut the doors before we all go stark raving bonkers trying to cope with the fallout in the NHS , Housing , Schools , Youth unemployment and so on , aaaagggghhhh

  • rate this

    Comment number 348.

    If you compare the cost of private healthcare with the amount that is actually contributed through National Insurance and taxes to the NHS, per head, it's very low - children, the elderly and the unemployed do not contribute on a daily basis! Either we have to pay more or accept a rationalised or reduced service. Neither option appears to be satisfactory!

  • rate this

    Comment number 347.

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

    nor should we design it around the egos and self serving attitudes of GP's who will do anything other than provide the service patients expect. If they'd do their jobs A&E wouldn't be so hard pressed and people might actually get seen. GP = general paralysis where work is concerned!

  • rate this

    Comment number 346.

    "And those unable to get the charity option or had lack of funds suffered and died so being civilised we progressed and the state devloped in our Case the NHS."
    No one was turned away, and to allege so is ignorant.

    How many people die in the NHS from increasingly rationed or denied care, how many times has Stafford Hospital been repeated without us knowing?

  • rate this

    Comment number 345.

    334.Sally the Rothbardian

    0.6 % of 100% is not rare Sally and is statistically not classified as rare. As I said you can't produce a single example of a privately funded universal healthcare system anywhere in the world and therefore in my opinion your view is null and void.

  • rate this

    Comment number 344.

    333 All for All
    I would be wary of putting more politics in to interfere with the NHS, as this is the main reason it is so inefficient! Too many meddling managers and pesky politicians, and not enough front-line staff.

    Even if the NHS were perfectly run, it would still have to be considering options like the one in this article. There just isn't the money to help everyone, sadly.

  • rate this

    Comment number 343.

    188 - NHS figures say 'health tourism' is exagerarted. Cameron can't even provide figures. Why was NHS direct closed down, that was working. the tory 111 crashed, as you'd half expect with private providers trying to do it on the cheap.

  • rate this

    Comment number 342.

    When they float Tier 1 on the stock market, I think the best bet will be to leave the country.

    Get your NHS shares here !!!

  • rate this

    Comment number 341.

    And those unable to get the charity option or had lack of funds suffered and died so being civilised we progressed and the state devloped in our Case the NHS.
    However I can see you long for these good old days, who needs the poor and the elderly eh.

  • rate this

    Comment number 340.

    309 Stuart

    'The NHS in this country is second to none in the world'

    You're right. It's more like 102nd.

  • rate this

    Comment number 339.

    Goodbye NHS,it was good while it lasted.This lousy Coalition has been hell bent on privatising health services since coming to power.I make no distinction between Tory and Lib-Dem,they are equally toxic.Vote them out!!.

  • rate this

    Comment number 338.

    The GPs are the problem full stop.

  • rate this

    Comment number 337.

    We need to start charging people who come here to the UK for the purpose of treatment. They not only put a strain on our resources and infrastructure - they cost us untold millions every year - but more importantly, stretch the available resources whilst their own countries do not provide it!

  • rate this

    Comment number 336.

    What takes time are immigrants who have an interpreter, paid 4 by us, who need at least double an appointment time. Very few will have paid in. The £200 poss fee for immigrants is not enough, holiday insurance is more than that for a 3 wk holiday. To me they should have to take out private medical ins. Now they are to get English lessons, if I want to learn ie French, France would not pay for me


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