Sir Bruce Keogh to lead review of urgent and emergency services in England

The NHS Commissioning Board today announces that it is to review the model of urgent and emergency services in England.

The review, led by Medical Director Sir Bruce Keogh, will set out proposals for the best way of organising care to meet the needs of patients.

The review team will work with clinical commissioning groups (CCGs) to develop a national framework offer to help them ensure high-quality, consistent standards of care across the country.

Sir Bruce said: “The NHS is there for all of us and should offer appropriate, effective and rapid care whenever and wherever it is needed.

“Treatments for many common conditions such as heart attacks and strokes have evolved considerably over the last decade and are now best treated in specialist centres.  Yet we know people want their A&E nearby.

“This makes me think we need to review the increasingly complex and fragmented system of urgent and emergency care, so that sick, anxious and often frightened people can get what they need when they need it.”

The NHS Commissioning Board stresses that local commissioning will be at the heart of this review, which follows the Board’s commitment in its recent planning guidance.

It aims to enable CCGs to shape services for the future and put in place arrangements that meet the needs of patients.  It says it will work closely with CCGs to ensure the views of all those with an interest are taken into account.

It plans to publish emerging principles for consultation in the Spring.

In its planning guidance, published late last year, the NHS Commissioning Board said it would review urgent and emergency care as part of plans for more seven-day services.

As well as seven-day working, the review aims to help CCGs find the right balance between providing excellent clinical care in serious complex emergencies and maintaining or improving local access to services for less serious problems.

It will set out the different levels and definitions of emergency care.  These range from top-level trauma centres at major hospitals to local accident and emergency departments and facilities providing access to expert nurses and GPs for the treatment of more routine but urgent health problems.

As well as looking at how emergency care is provided, the review will also assess transfer processes between these levels of emergency care.

The NHS Commissioning Board also says it wants to improve public understanding of the best place to go for care. By helping the public to go to the right place first, both they – and those who have very serious illnesses and injuries – will be seen more quickly by specialist clinical teams with the right qualifications and facilities.

The NHS Commissioning Board adds that the review will take account of the way that emergency care in England works with other areas of the NHS, such as GP surgeries, community care, and the 24-hour NHS 111 advice line.

It stresses that the pattern of urgent and emergency care, including the number and location of services, will continue to be de developed locally to meet the different needs of urban and rural communities. The review aims to provide a national framework so high quality, consistent standards are offered across the country.

In future, planning reconfigurations should take account of the review’s conclusions, the emerging evidence and the national framework.

The review’s terms of reference will be published shortly.

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  1. Andrew West says:

    I hope the review will not be shelved taken seriously. It needs to specifically look at:
    1 Making access to the NHS equally hard or easy as patients are like water. They flow down the path of least resistance which is why they end up in A&E.
    2 Stop GPs sending patients to A&E without FIRST discussing the case with a senior A&E doctor. The patients quite often need to go direct to Acute medicine. The A&E department is not a referral agency for primary care!
    3 Many patients come to A&E or UCC because they cannot get a GP appointment. Address the capacity problems in primary care.
    4 Patient flow is like traffic on a road. The obstruction is at the front but the build up of traffic is at the back. In a hospital the obstruction is getting patients OUT but the build up (overflow) is in A&E where everyone else feels it is the only part of the hospital with elastic walls! What makes this situation so frustrating is that A&E suffers but cannot influence discharge from hospital. The biggest discharge problem is the need for social care when health care is no longer needed. I hope the review looks into social services as they are the key to unlock the traffic jam in hospitals.

  2. John King - Retired Occupational Health Physician and in charge of an A&E 1971 - 73 says:

    The problems of inappropriate attendance at A&E are not new. A thorough review of the “emergency” medical services is welcome. On several occasions in the last nine years I have had long waits for attention in my local A&E – the same one I ran many years ago. The delays all too often were caused by the plethora of alcohol and drug intoxicated patients. Some occasions were crises in my personal health, in others I was there as a carer for even older and frailer members of my family. Perhaps my personal and professional experiences of A&E could be a valuable resource to this review? In all that I have seen so far, there has been no mention of patient representation on the review team although in the recent UPR at SLHT the contribution of patient representation was significant.

    As others above have said, I would like to be part of the team.

  3. Richard Day, Consultant Geriatrician says:

    I strongly support review. We must not forget the need to involve Social Services and other support mechanisms. And ambulance too. A lot of older patients turn up at ED after 7pm, not ill, but perhaps having lost their balance: it is very difficult to discharge people then to an empty house, easy the following day when services available. If ambulance confident to leave that patient at home, knowing there will be support that evening or first thing in the morning, an admission can be prevented. In other words, trust and communication needed.

  4. Chris Croden says:

    This review is much needed as the Ambulance Services and A&E Departments get to breaking point in trying to respond to spikes in demand everytime we get some extreme weather or a National outbreak of flu.
    The general public will always follow the line of least resistance when it comes to accessing Emergency and Urgent care. If, as individuals, we get the runaround from NHS Direct or 111 we go direct to A&E, or for those who cant/wont pay for a taxi, 999 is the number of choice.

    There are good examples of emergency care pathways which really work (Ambulance direct to regional heart attack centres and stroke centres) but these work because they made sure all parties were involved in the design and such pathways were commissioned to work 24/7. Lots of Ambulance services work with different partners to point patients along effective alternative pathways such as Falls/Diabetic/Epilepsy/Vulnerable Adults, but in practice these routes to other care providers do sometimes take the Ambulance Clinicians longer to arrange than simply transporting to the nearest A&E. Further investment is needed in making sure that the Ambulance Service has the resources to respond quickly with staff who can treat, refer and transport to the most appropriate care facility based on the needs of each individual patient.

  5. Dr Melanie Clements says:

    I completely agree that this review is an excellent idea and very much needed.
    My plea is that this review also looks at services from the point of view of children and Young people. Children and Young people account for 25-28% of ED attendances but the training of the staff and environment do not reflect this. Urgent care centres and minor injury units have significant challenges.

    I have been the national clinical lead for the emergency and urgent care programme at the NHS Institute of Innovation and Improvement for over 2 yrs. The programme lead Kath Evans has been working on this agenda for over 3yrs. This programme will end on the 31st March 2013 when the Institute closes. We are keen to ensure the work and materials are not lost.

    We have walked the whole system looking at emergency and urgent care services in many parts of the country and have accrued considerable knowledge of the current system and challenges. We have also facilitated whole system working across the whole patient pathway to enable leaders and professionals to work together to understand and address the rising attendance at ED. We have also listened to children and families about their experiences.

    Some of the innovations include addressing the self -care agenda and working with primary and secondary schools. The primary care lesson planner is to be released in March, other around developing clear traffic light pathways for the high volume conditions e.g. fever and consistent patient information. ( Guide to A Whole system Approach for Children and Young People’s Emergency and Urgent Care)

    We are currently visiting all 17 ED departments in the East of England as a supportive peer review process reviewing against the Inter-collegiate standards for Children and Young People in Emergency care settings.
    A taster of what we have found can be seen here

    Please contact either of us for more information

    Best Wishes and good luck
    Melanie Clements
    Consultant Paediatrician/ National Clinical Lead Emergency and Urgent Programme for Children and Young People, NHS Institute for Innovation and Improvement

  6. Zabeda Ali-Fogarty says:

    I would very much like to be involved in this review and want to know about the process of engagement. I am a registered nurse. I have worked for many years in the acute sector and I am presently working as an agency nurse in private organisations within the community. I am also the Managing Director of ESP IT Consultancy Ltd. Our focus has been on communication and information flow in real-time to enable continuity of care in the health and social care sector. There is a lot of work to be done here and engaging with the different sectors is a very complex matter. We understands the challenges that patients and carer faces during the transition of care, and understands the complexity of care delivery when there is lack of information.

  7. Stephen Watkins says:

    The proposed review sounds very timely. We would hope this could include defining “what good looks like” within its terms of reference. My team at the NHS Benchmarking Network have just published a report on benchmarking urgent care services. Over 60 Trusts took part in the first phase of the project which identified great variation in provision arrangements. The findings from the benchmarking review are striking and highlight excellent performance in some Trusts, and opportunities for improvement in others. Around two thirds of Trusts were able to point to and describe examples of excellent practice within their own services. A learning network has been established to share this good practice and a second phase of benchmarking involving around 100 Trusts will commence in May 2013.

    Stephen Watkins – Director, NHS Benchmarking Network

    • B Gaskell says:

      Stephen – Where can I access the Benchmark report you refer to? Having previously worked with you and your organisation and knowing the quality of the work produced I am very interested in the outcomes of the review.

      Barbara Gaskell
      Senior Performance Improvement Manager
      North West London Commissioning Support Unit

      • Stephen Watkins says:

        Thanks for the e-mail Barbara and apologies for my late response. I’ll send you full details of the benchmarking assessments which have reported at both commissioner and provider levels. One of the clear findings from the review is that the Trust’s with the best staffing ratios and highest presence of senior medical staff achieve the best mortality outcomes.

  8. Hilary Maggs says:

    As the clinical manager of a nurse led Minor Injuries Unit in a community hospital with a largely rural catchment area (16 miles from the nearest acute hospital) I welcome this initiative.I hope it will also review the care given in stand alone Minor Injury Units and Urgent Care Centres.

  9. Mike Paynter says:

    After a decade or so of the DH tinkering around the edges of reforming emergency care hopefully this review will tackle the fundamental issues facing emergency care in the UK. Emergency departments are for emergencies i.e life and limb threats, the remainder (majority) of patients currently managed in EDs could and should be managed in strategically located urgent care centers. Urgent care centers however need to be clearly defined, standardized and appropriately resourced with ready access to diagnostics, to often such centers are poorly defined / staffed and lack true vision as to their function and purpose.

    A national approach is required, acknowledging the urgent care health needs of both urban and rural populations.

    Mike Paynter
    Consultant Nurse

  10. Stuart Barker says:

    I feel this review of services will be really benficial to both emergency and life threatening cases and to more urgent and minor injury cases.

    Please bear in mind the role of physiotherapists working in emergencey and urgent care departments. I currently lead a team of physio’s working in an urgent care centre and I feel the input we can provide with musculoskeletal cases and elderly mobililty cases is vital to a fully functioning department.

    Our presents aids the doctors and nurses by freeing them to see the more medical and serious cases and our prompt and appropriate management of these client groups can directly impact the A&E clinical quality indicators.

    I look forward to reading the review.


  11. John Lydon says:

    A&E foot-fall reflects the lack of timely access to GP’s. No timely access to a GP – call for an ambulance or pop into A&E. There you go review complete.

    Educate the public – that will take a generation, at least (anti-smoking campaign). How about £20.00-£50.00 charge for non-emergency attendance at A&E or calling out an ambulance – that would soon ‘educate’ the public.

    • Ali Grecu says:

      Issuing fines to patients would be (grossly) unfair. Where exactly are patients to go in the hours where GP surgeries are closed (or not available for drop-in appointments) or when the first appointment they can get with a GP is 3 weeks away?
      Patients do their bit through the money that is taken from their wages, no choice about it, in NI contributions and general taxation. They don’t need to do anything else. They’ve got little say over how the system is organised and run so we can’t, in all good conscience, blame the patients for the failings of the system!
      The system and people who run it are the ones that have to do something to improve things, to do their bit in return.
      Yes, sure, more health education always help, especially in the preventing side of things and it will reduce the costs overall (for preventable conditions, chronic conditions, etc) in the long run.
      But it will have little impact on the overcrowding in the ED departments.

      More fluid transfer from ED to other departments, minor Injury units, better access to GP services and better care in the community, on the other hand, will go a long way. Patients are neither stupid, nor mean, they just need care at certain points in time when the Emergency Departments are the only ones providing it AND the only ones to which the patients have access.

      This review cannot come sooner.

  12. David Hill says:

    I very much welcome this review as a new clinical commissioner in Surrey and would very much like to be involved at an early stage.

  13. Dr Ankolekar, ST5 Rehabilitation Medicine says:

    Dear Sir,

    The review of urgent and emergency services in England has been overdue. We should be proud, that we are one of the few nations that provide urgent and emergency care free to anyone.

    I am concerned with the way transfer of care takes place. We need a more robust system. We need IT systems which talk to each other. Its surprising that, in todays day and age we cannot access Radiology and Biochemistry results from referring hospital.

    Urgent and Emergency care does not stop in the Emergency Department. We also need to address the needs of patients who are inpatients. Its is suprising to see how many times inpatients are transfered to the emergency department.

    A review will help.



  14. Mr R Horton, Paramedic says:

    Everyone I know welcomes this review. We have to work harder at education of health. It must start in school, every child should leave school knowing basic life support and when to call for an ambulance. A single point of access has to be correct, providing the health community is educated and united in its delivery of services and we must put support to the infrastructure to sustain the education or we’ll be back here again in a decade.

  15. Peter Adams says:

    So much to look at here if the review is to be truly comprehensive. Dimensions considered should cover technology, including diagnostic testing; competencies needed at the various key points in the system; how the “A” part of “A&E” is best evolved as well as the “E” part; medical and clinical career development including new urgent care hybrid roles; critical mass for local and more centralised facilities, public education & communication; tariff or other payment systems to support/encourage the main patient pathways – and lots more…

    Peter Adams, Urgent Care Consultant

  16. John Gooderham says:

    The review is to be welcomed, as there are indications that ambulance services and EDs are being overwhelmed. Patient education is not the only answer: the system has to be better at redirecting those making the ‘wrong’ decision to attend ED. The review team must include representatives of patients and the public, ie from LINks or local Healthwatch.

  17. Ruth Rankine says:

    Who are the review team members?

    • Simon@NHS CB says:

      Hi Ruth
      Thank you for your question. This is yet to be decided, the terms of reference for the group will be published shortly.

      Kind regards

      Digital Communications Officer
      NHS Commissioning Board

      • Dr Daniel Albert says:

        I have a particular interest in the organisation of Urgent Care services and ideas for new types of services that will address the trend for increasing amounts of activity to end up in hospital emergency departments and acute medical units.
        I am a GP but currently work in A&E, acute medicine and CCG commissioning.
        I would like to be considered as a member of the review team.

  18. Mr R Bailey, ED Consultant Chesterfield says:

    I welcome the review. It is essential that there is representation from the College of Emergency Medicine and “jobbing” DGH Emergency Physicians as well as the CCG’s and Primary Care. All too often these reviews lack input from the people on the front line who know all about the issues and are also “Londoncentric” – please don’t waste this opportunity by making the same mistakes.

  19. AB Rodger says:

    Perhaps a last chance to save our emergency medical service from total collapse? The review is most welcome and MUST deliver without delay.

  20. Michael Vidal says:

    For this review to command the respect and confidence of the public it must have amongst the review team members representatives of patients and the public. A good model is the one used by NHS London for the Cardiac Services which had a patients panel working with the expert panel. The problem is that when reviews are done and the public are consulted after it on the result you have a lack of engagement caused by people believing that it is just a box ticking and their views will be ignored. This was actually said to me when I was consulting on a service change.

    • J Holding says:

      I completely agree with Michael’s comment. So much time and money is wasted in the NHS developing services which work well on paper, but lack input from Patients, and those responsible for delivery; front line staff. These groups can share valuable insight.
      Early and meaningful engagement leads to practical, cost effective and sustainable change, it smoothes the way to successful implementation, and it builds public trust in the local NHS

  21. Jean O'Keefe says:

    This review is long overdue and I totally agree that heart attack and stroke patients should be treated in specialist units, not in standard A & E.
    My husband suffered a stroke caused by a brain haemorrhage in April 2011. We live 10 minutes away from our local hospital to where he was taken. He spent 7 hours in A & E before being placed in a holding ward for a further 5 hours before finally being transferred to what was supposed to be a specialist stroke unit in the same hospital. I was with him all the time and I couldn’t believe how little attention he was given in comparison to those with minor injuries and, incredibly, to two drunken girls who only needed to sleep it off but had the attention of all the staff. My husband died 6 days later.

  22. Adrian Clements says:

    A long overdue review. Successive strategies have concentrated on trying to prevent patients from accessing care where they believe that they receive the care they require and has led to a fragmented poorly understood system which the public soon navigate themselves through, usually ending up at an A&E department, through the failure of other parts of the service to successfully deliver the outcome required. Through investment in these alternative models of care this has starved appropriate investment in Emergency departments to the levels required to enable them to deliver high quality patient care even at times of increased demand.
    I hope the review will identify the need to resource this essential part of our Emergency care system to the levels required to make working in Emergency departments a good career choice and for us to provide the quality of care the public expect and to which we strive.

  23. Keith Walters says:

    About time there was a review. Public education is vital. We must develop a system where emergency doctors concentrate on true emergencies – most of my work these days is dealing with patients who are NOT real emergencies. I belief that anyone who can wait in an A&E trolley bay for more than two hours without needing any intervention is not an emergency. They may be an urgency. If I end up dealing with too many urgent cases rather than emergency patients I end up de-skilled. Patients must go to the correct place for their needs. I am not a GP or an urgent care physician. Please let me do the job I was trained to do.

    With thanks

    Keith Walters Emergency Medicine Consultant Norwich

    • Joy Hale says:

      Keith, as a member of EEAST’s comms team, I’m really interested in your comment, assuming you’re referring to Norfolk’s use of NHS? We always try and seek the views of stakeholders when it comes to public ed so anything you and your colleagues can feedback to us that we can use with internal or external messages would would be really helpful.

      Generally speaking, I hope this review could kickstart a bit of a reality check about getting people to understand how skilled people actually use their skills. Some crews have often said that what they’re trained for (or even just what they went into the ambulance service to do in the first place) is so often different to what happens on the job.