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Review backs 'two-tier' A&E plan

A two-tier A&E should be created to ease pressure on an "emergency service at its limit", according to a major review.

NHS medical director Professor Sir Bruce Keogh said the current system is under "intense, growing and unsustainable pressure" caused by increasing numbers of people turning to A&E, an ageing population and "confusion" over existing services.

His report calls for an overhaul of the system in England to treat more people in their own homes and keep them out of A&E.

For those who do need to go to hospital for emergency treatment, he said two types of A&E should be created - emergency centres for assessing patients and starting treatment, and major emergency centres providing specialist care, such as for strokes or heart attacks.

Prof Keogh insisted the changes were not about closing local A&E departments, but about creating a safe service that could cope with increasing demand.

Under the plans, the 111 non-emergency service - which has been beset by problems since it launched earlier this year - would be enhanced to provide people with a "one stop" service over the phone.

Staff would have medical records to hand so they could give the right advice to patients on their illnesses, and a wider range of medical staff - such as doctors, paramedics, pharmacists, dental experts and mental health nurses - would be available to speak to patients.

Workers at 111 would be able to book appointments for patients at their local A&E or urgent care centre, and doctors and pharmacists could provide prescriptions ready for patients to collect. If a problem was more serious, staff could still call an ambulance.

The review also said ambulances responding to 999 calls should become "mobile urgent treatment services, not just urgent transport services" and provide more care at the scene. Paramedics would receive extra training and closer links would be established with GPs and community health teams.

Today's report also proposes bringing together the current range of walk-in centres, urgent care centres and minor injury units under one banner name - urgent care centres. This is to avoid the confusion over where to go for help, which leaves substantial numbers of patients heading to A&E.

The plans would see between 70 and 100 emergency centres developed in hospitals, alongside 40 to 70 major emergency care centres.

The emergency centres would assess and start treatment for patients, arranging transfer to more specialist centres if needed.

Major emergency centres would be larger units, capable of assessing and starting treatment for all patients, but also providing specialist care, such as for heart attacks, strokes, paediatrics or major trauma.

The health service as a whole, including A&E departments, must also move towards seven-day working, the report adds.

" Prof Keogh said "doing nothing is not an option".

He said: "We are here really because A&E is creaking at the seams. It's not broken but it is struggling.

"In many senses, our A&Es have become victims of their own success because they function as a safety net for people who are worried, frightened, anxious or in pain and therefore have problems that concern them.

"When A&Es become very busy it means other parts of the system are creaking as well, they are under stress.

"It's against that background that there's a feeling this winter will be difficult."

Prof Keogh said the "whole heap of bolt-on services" such as walk-in centres and minor injury units had created a "whole heap of confusion".

But he insisted the review was not about letting local A&E departments "wither on the vine".

In fact, the new emergency centres and major emergency centres would be "broadly" similar in number to existing A&E departments.

The review sets out plans to reorganise care over the next three to five years and said out-of-hours services must become more effective.

The College of Emergency Medicine said the review looked to the future when "the crisis is here with us now".

Earlier this week, Downing Street confirmed that Prime Minister David Cameron is getting personally involved in overseeing the NHS's response to winter pressure on A&E.

In 2012/13, more than a quarter of all patients attending major A&E departments were admitted to hospital, up from 19% in 2003/04.

Figures released last month showed the number of A&E units failing to meet the Government four-hour target has almost trebled in a year. Some 39 departments failed to meet the target of seeing 95% of patients within four hours during the period July to September, compared with 14 units during the same period in 2012.

Shadow health secretary Andy Burnham said: " This is an issue affecting every man, woman and child in England and, on the brink of a dangerous winter, it's just not good enough to have a Government acting as a spectator on the sidelines blaming everyone else.

"Ministers said this report would have lessons for the immediate winter as well as the longer term.

"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."

Health Secretary Jeremy Hunt told the Commons on Tuesday that the review would not shy away from taking "difficult decisions".

He later welcomed the report, adding: "We all know that the NHS needs to change to meet the needs of an ageing population.

"We've already taken action to help the NHS cope, investing £500 million to help with winter pressures and agreeing a £3.8 billion integration fund to look at joining up health and care services - exactly the sort of networks Sir Bruce describes.

"We know that change will not happen overnight and we'll work with NHS England to ensure the NHS offers world-class standards of patient care."

Prof Keogh said the proposals were about "improving outcomes" for patients.

"It is about improving the outcomes for patients with very serious conditions - let me be absolutely clear, that two tier system already exists," he told BBC Breakfast.

"By serious conditions what I mean are trauma, heart attack, stroke, to name three of them.

"Ambulances already when they pick up somebody with major injuries take them to designated trauma centres, they already take people with heart attacks to specific designated heart attack centres and similarly for strokes.

"We have shown that when you do that, that despite initial concerns that the additional travel time would create problems, that the outcomes for patients are significantly better."


Prof Keogh told BBC Radio 4's Today programme: "A couple of years ago, we designated 25 trauma centres across the country and we said ambulances will only take serious trauma cases there because many A&Es were only dealing with one trauma case every two weeks.

"The naysayers said well, of course, there will be problems with travel times, we'll put patients' lives at risk.

"In the first year of operations, we've seen a 20% increase in survival for equivalent injuries."

Prof Keogh said that a similar pattern emerged in London when the number of stroke centres was reduced from 32 to eight. He said "we have seen vastly increased survival, more patients returning to independent living and actually savings to the NHS".

He said that around four in 10 people (40%) visiting A&E leave without treatment, with most simply requiring assurance. He said the answer was to put clinicians at the other end of the non-emergency helpline service 111, an idea that he acknowledged was "controversial".

"One of the things we're going to do - which I know some people find controversial - we're going to beef up or we're proposing beefing up the 111 system. So what patients have told us about the 111 phone number is they want two additional things: first of all, they want to be able to talk to a clinician if they are worried, rather than a qualified call handler - and by clinician I mean a nurse, a doctor, a dentist, a pharmacist - to give them good advice.

"But those clinicians also need access to people's medical records so we need to put the informatics in place for that.

"The second thing that they want is if there is any concern, then whoever is dealing with their problem can either call an ambulance or in many cases, fix up an appointment for someone to see their GP, see their specialist, see a mental health nurse and so on and so forth, so that would go a long way in bringing care to people's homes."

Another proposal would see paramedics receive additional training and used more for their medical expertise, rather than just a mode of transport.

Prof Keogh said: "We already know that 50% of 999 calls could be dealt with at home particularly if the paramedics had direct access to GPs or specialists."

He insisted these measures were the best way of taking pressure off A&E.

Dr Dan Poulter, a Government health minister and qualified medical doctor, said of the report: "There are many things in it we need to take note of and Sir Bruce would be well-placed to give better comment.

"I work as a doctor still and I don't recognise there is a crisis in A&E.

"What I do recognise, though, is there's a lot of people living longer and living longer with multiple medical conditions, as the Keogh report sets out.

"We need to make sure we find better ways of looking after people, keeping them well in their own community and providing that community support."

He was speaking to reporters during the Royal College of Midwives (RCM) annual conference in Telford, Shropshire.

Also at the conference was Labour's Andy Burnham, who said the comments showed the Government's "utter complacency" about issues affecting A&E departments.

He said: "To have a minister come along and say 'Crisis? What crisis?' is very worrying and shows utter complacency.

"There urgently needs to be a change, and the Government needs to snap out of that complacency."


From Belfast Telegraph