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 515.

    My suspicion is that, with the Tories in charge of the NHS, it will all end in tiers. And you can be in whatever tier you want - provided you can afford to pay for it!

  • rate this

    Comment number 514.

    The real problem here is public ignorance regarding appropriate use of services. Another is general lack of education as displayed by some of the naive comments regarding solving the crisis by further overloading an already overloaded GP service. Gp's do not earn millions- if any of us did we would retire tomorrow to escape from the manythankless individuals who have posted on this topic

  • rate this

    Comment number 513.

    "It is likely to take three to five years before the overhaul is completed." by which time, whichever party is in power, they will have spent more money coming up with another idea.

    Why is this so difficult? Sick people want access to Dr's when they are sick and not necessarily A and E

  • rate this

    Comment number 512.


    The thing is that it is the native UK baby boomers of 45/6 that are currently getting older that will create increasing pressure on the NHS as a large chunk of them get Alzheimers. That is not to do with Migration

  • rate this

    Comment number 511.


    111 Operatives are not doctors but they have Doctors in their call centres so calls that need their input get it. The system is risk averse so more people probably end up in A and E. OOH GP services may not meet patient need as well as they used to, but as GP's have had the chance to work a (fairly) normal day/week, there's a slim to zero chance of rewinding that

  • rate this

    Comment number 510.

    509. LBHF Resident
    And if we had a smaller population as would have happened if the idiot politicians had not ushered in massed immigration since 1946

    Once the baby boomers had died , the status quo would come back and if you need people to work in a country - They can be freelancers on contracts you know , you dont have to give any one a passport and a right to stay in UK.


  • rate this

    Comment number 509.


    Neanderthals were the original inhabitants of northern Europe and better adapted to cold winters that cause Cro Mangons to put pressure on health services during winter. Point taken about Logan's Run. There is continued debate about expensive treatments/where NHS resources go. Also welfare reforms will lead to some expiring early. Lastly some of that migration staffed the NHS.

  • rate this

    Comment number 508.

    505. Random Advice
    WHy should i pay the price

    The point is once of the baby boomers had gone , there would not have been crisis of old vrs young , Immigration is short termism that ends up in a vicious of cycle of more and more and more young people to match more and more older people

    immigration since 1946 has been disaster - positive GDP/head has been miniscule from immigration.

  • rate this

    Comment number 507.

    A&E's are so full because people go in with minor ailments because they know they'll be seen quickly. What is needed is GP surgeries to be open longer with more appointments available, People will just go to A&E's if their doctor says they can't see them within 2 weeks. But also people need to stop going to the doctor for a cold, just rest and sleep well at home and you'll be better in a few days.

  • rate this

    Comment number 506.

    The problem is that NHS 111 operatives ain't doctors. If they have the slightest doubt as to the person's symptoms, they send them to A&E. With the old OOH GP system, a patient could get to speak to a) a doctor b) a doctor that knew them and could effectively triage. Unfortunately the government decided it was paying too much, brought in a shiny new computer system and it's cost them a fortune.

  • rate this

    Comment number 505.

    As long as they maintain the "free at the point of service" principle I don't really care whether it is public, private or a mixture of the two as long as it is "fit for purpose".

    Too many people making ideological arguments are missing the point of what a national health service is about.

  • rate this

    Comment number 504.

    503. LBHF Resident
    It was politicians who allowed massed immigration since 1946 when we had a benefit system and NHS system and not the mode of transport .

  • rate this

    Comment number 503.

    'when the NHS was created it was not set up for massive immigration' True enough it was set up as a national health service. Cunard and White Star Lines, they were created for mass transit in both directions. Population growth in the UK is not largely caused by immigration and the problem the NHS faces is an ageing population and not enough money.

  • rate this

    Comment number 502.

    of course there is another approach ......

    P.A. System: Last day. Capricorn 15's. Year of the city - 2274. Carousel begins.

  • rate this

    Comment number 501.


    So does this practice have a patient participation group and if so have the GP's explained the issues so that they can put pressure on Local Healthwatch to put pressure on Healthwatch England and on the Local Health and Wellbeing Board so NHS England do something about it whilst local commissioners work out ways to take the pressure off GP services? That's the way the NHS is meant to work

  • rate this

    Comment number 500.

    This is a farce , when the NHS was created , IT WAS NOT SET UP FOR MASSIVE IMMIGRATION .

    IF WE HAD A SMALLER POPULATION we dont need more hospitals and in fact we are siphoning from parts of the world which actually needs them more

    SO WELL DONE POLITICIANS SINCE 1946 for messing up this country and flooding it with immigrants and destroying England. You just helped the left wing do it !

  • rate this

    Comment number 499.

    Just come in from a 12 hour working day in general practice, all appointments fully booked plus extras seen.

    Really don't feel that we can do any more with current resources, patients who attend are coming more complex as our population ages.

    We are currently FLAT OUT!

    The only way we can be open for longer is to recruit more clinicians, although I am not sure where we will find them!

  • rate this

    Comment number 498.

    The inefficiencies and laziness in the NHS is so great, it is child's play improving services through better use of resources, even when making a surplus too.

    The 'left' simply sabotage to maintain the status quo that suits them so well by perpetuating gold plated pensions, jobs for life irrespective of performance and annual unassessed pay rises (...called increments).

    Carry on Jeremy please

  • rate this

    Comment number 497.

    There must be some charging introduced to deter time wasters and raise funds. What about £100 for anyone turning up drunk in a hospital? And £5 for a GP appointment with exemptions for the poor (provided they came for a genuine reason). Why not pay a contribution to the cost of hospital food (it may improve!). Larger GP centres should treat the walking wounded up to, say, 10pm every weekday.

  • rate this

    Comment number 496.

    Now it's to be a atwo tier service, so presumably it will take longer for those who are seriously ill to get treatment. How long before what has happened in the utilities happens in other areas? I mean by that the government creating small private monopolies and cartels who exploit their lack of competitors to ramp up prices and cut services? There has to be another way.


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