The National Medical Director of NHS England today proposes a fundamental shift in provision of urgent care, with more extensive services outside hospital and patients with more serious or life threatening conditions receiving treatment in centres with the best clinical teams, expertise and equipment.

Sir Bruce Keogh is publishing a report on the first stage of his review of urgent and emergency care in England. You can read more about the review as it progresses on NHS Choices.

Developed after an extensive engagement exercise, it proposes a new blueprint for local services across the country that aims to make care more responsive and personal for patients, as well as deliver even better clinical outcomes and enhanced safety.

Sir Bruce says the current system is under “intense, growing and unsustainable pressure”.  This is driven by rising demand from a population that is getting older, a confusing and inconsistent array of services outside hospital, and high public trust in the A&E brand.

He advocates a system-wide transformation over the next three to five years, saying this is “the only way to create a sustainable solution and ensure future generations can have peace of mind that, when the unexpected happens, the NHS will still provide a rapid, high quality and responsive service free at the point of need.”

In a letter to Health Secretary Jeremy Hunt and NHS England Chair Sir Malcolm Grant, Sir Bruce says: “Our vision is simple. Firstly, for those people with urgent but non-life threatening needs we must provide highly responsive, effective and personalised services outside of hospital. These services should deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families. Secondly, for those people with more serious or life threatening emergency needs we should ensure they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery.”

Highlighting opportunities to shift care closer to home, he says 40 per cent of A&E patients are discharged requiring no treatment; up to one million emergency admissions were avoidable last year; and up to 50 per cent of 999 calls could be managed at the scene.

And citing modern treatment of the nation’s two biggest killers – heart attacks and strokes – he points out that survival rates have improved significantly by taking patients to specialist centres that provide the best available hospital treatment.

Sir Bruce says: “Advancing science has directed the way we deliver services to achieve the best results, but it also exposes the illusion that all A&Es are equally able to deal with anything that comes through their doors. We now find ourselves in a place where, unwittingly, patients have gained false assurance that all A&E’s are equally effective. This is simply not the case. A&E departments up and down the country offer very different types and levels of service, yet they all carry the same name. We need to ensure that there is absolute clarity and transparency about what services different facilities offer and direct or convey patients to the service that can best treat their problem.”

The report makes proposals in five key areas:

• Providing better support for people to self-care – The NHS will provide better and more easily accessible information about self-treatment options so that people who prefer to can avoid the need to see a healthcare professional
• Helping people with urgent care needs to get the right advice in the right place, first time – The NHS will enhance the NHS 111 service so that it becomes the smart call to make, creating a 24 hour, personalised priority contact service.  This enhanced service will have knowledge about people’s medical problems, and allow them to speak directly to a nurse, doctor or other healthcare professional if that is the most appropriate way to provide the help and advice they need. It will also be able to directly book a call back from, or an appointment with, a GP or at whichever urgent or emergency care facility can best deal with the problem.
• Providing highly responsive urgent care services outside of hospital so people no longer choose to queue in A&E – This will mean: putting in place faster and consistent same-day, every-day access to general practitioners, primary care and community services such as local mental health teams and community nurses to address urgent care needs; harnessing the skills, experience and accessibility of community pharmacists; developing our 999 ambulance service into a mobile urgent treatment service capable of treating more patients at scene so they don’t need to be conveyed to hospital to initiate care.
• Ensuring that those people with more serious or life threatening emergency needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery. Once it has enhanced urgent care services outside hospital, the NHS will introduce two types of hospital emergency department with the current working titles of Emergency Centres and Major Emergency Centres. Emergency Centres will be capable of assessing and initiating treatment for all patients and safely transferring them when necessary. Major Emergency Centres will be much larger units, capable of not just assessing and initiating treatment for all patients but providing a range of highly specialist services. The NHS envisages around 40-70 Major Emergency Centres across the country. It expects the overall number of Emergency Centres – including Major Emergency Centres – carrying the red and white sign to be broadly equal to the current number of A&E departments.
• Connecting urgent and emergency care services so the overall system becomes more than just the sum of its parts. Building on the success of major trauma networks, the NHS will develop broader emergency care networks. These will dissolve traditional boundaries between hospital and community-based services and support the free flow of information and specialist expertise. They will ensure that no contact between a clinician and a patient takes place in isolation – other specialist expertise will always be at hand.

Sir Bruce adds: “Let me be clear that there is no simple solution. This report sets out some principles. How they are developed locally will, and must, vary to suit local circumstances and wishes. We will need different approaches in metropolitan, rural or remote areas. We know people will want to see change as soon as possible, but we need to ensure that there are no risky, ill considered “big bangs”, and that there is a managed transition.”

Phase two of the review is now under way, overseen by a delivery group comprised of more than 20 different clinical, managerial and patients’ associations.

Sir Bruce says that it will take three to five years to enact the change necessary and that he expects significant progress over the next six months on the following areas:

• Working closely with local commissioners as they develop their five-year strategic and two-year operational plans;
• Identifying and initiating transformational demonstrator sites to trial new models of delivery for urgent and emergency care and seven-day services;
• Developing new payment mechanisms for urgent and emergency care services, in partnership with Monitor;
• Completing new NHS 111 service specification so that the new service – which will go live during 2015/16 – can meet the aspirations  of this review;

Co-producing with clinical commissioning groups the necessary commissioning guidance and specifications over the remainder of 2014/15.