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Sir Bruce Keogh proposes new blueprint for urgent and emergency care across England
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.
One big change since April 2013 has been the 111 service. In our area the reports from this service indicate that the advice at the end of the consultation is very often ‘dial 999’ for sets of circumstances which would NEVER result in such advice if ( for instance) the patient was talking to the GP service – either in hours to their own GP or out of hours to the ‘base doctor’. In addition conditions such as ‘sore throat with fever’ are advised to ‘contact your GP within 6 hours’!
An example of the 999 advice was a woman of 33 years who had epigastric pain after taking ibuprofen.
It took us a while to work out what was going on- but we came to the conclusion that the service was operated by non-clinicians using computer prompts which involved minimal judgement and operated at 0% risk-not sustainable.
We have found in our own service that GP telephone consults for same-day service reduces attendance at the service by 50% and has a 75% approval rating by patients in our PPG survey. The moral is -the more trained/experienced the clinicians fronting the place where patients self- refer, the less often they are seen. I am uncertain how this would translate into policy , certainly the paramedic service is superbly good and assessments by them at home are invaluable, but the 111 idea, although excellent, needs some work.
Dr Ruth Brown,
Whilst I partially agree that workloads have increased with the introduction of the 111 service, the workload increase has been due to the poor supervision of the NHS pathways tool. NHS Pathways was introduced to triage 999 calls from 2006, by the Northeast ambulance service, then subsequently, the 111 out of hours service, then rolled out across the country. Its problem has been that the call handlers (who are non clinically trained) have inadequate supervision. Whilst ambulance services do audit these staff, their feed back wasn’t given back to the call takers for 2+ weeks after the audited call, therefore allowing potential mistakes to recur. I attempted to address this as a clinical supervisor, and recommended live audits, feedback, and subsequent support from the day of audit (if needed). However, this suggestion fell upon deaf ears with the management. This may, in my opinion, reduce the A&E workload, and get patients to the correct disposition. If more problem solving was placed at the point of call, rather than the end disposition, patients would be steered in the right direction, rather than paramedics doing a full physical skills assessment and then pointing the patient in the correct direction. This is where resources are being soaked up.
I would like to express my opinion regarding Paramedics in the community.
There is at the moment a shortage of people working in primary care in the UK, especially nurse practitioners, did you know however that there are about 1000 paramedics that work in the same area but have to work in a diminished capacity due to outdated laws and yet they are of the exact skill set of a nurse practitioner, the two main obstacles we face is that as a profession we are not VAT exempt, so we become an expensive option for urgent care and walk in centers to appoint.
The second obstacle is that we cannot prescribe but have to use PGD’s for additional medication, both of these reasons need to be addressed for the profession to move forward and also we are a massive untapped resource sitting there being under-utilised.
Your figure1, p18 is key to understanding the problem and finding effective solutions: 78 mil GP attendances (out of 340 mil) and 8 mil A&E attendances (out of 21.mil) can be managed by simple self-help and/or some advice, ie they are inappropriate users of the NHS – time wasters, all with minor ailments and conditions not needing any NHS facilities. Yet the public demand to see a GP or an A&E consultation. There has been a huge increase in demand of the NHS urgent/emergency care (compared to 20 or 30 yrs ago) and disproportionate to the incidence of disease(s). This has been fuelled by the increasing public expectations of the 21st century and 24/7 mentality and the easy accessibility of a ‘free’ service. If the public had to pay for the use of the service (even a small fee) there will be a considerable reduction in the demand. There is substantial evidence for this from Republic of Ireland when it introduced charges (for going to see a GP or A&E) during the last few years as a result of the financial crisis.
My premise is that the NHS will not be able to manage this uncontrollable demand of Urgent/Emergency care unless the public uses the service responsibly. The trends in demand (for GP and A&E consultations) over the last 25-30 years have shown that exortations and ‘education’ of the public do not work. The only way that the public can do so is by imposing some restrictions or financial disincentives. How about a £10 fee for every GP or A&E attendance? This will make the public use the NHS responsibly in my opinion, stop wasting doctors and nurses valuable time and let the professional treat those patients that really need their expertise.
My views are based on my 33 years’ experience in front-line emergency NHS service, 22 of which as an A&E consultant in a Major Emergency Centre.
When will we be able to see the evidence base for this report (Appendix 1)?
Specifically how do you justify the statement that there were over 1 million “avoidable” hospital admissions last year? Do the people that called them avoidable actually have experience of providing hospital care for older people or are we just recycling statements based on ignorance and ageist prejudice? How many of the alternative pathways to hospital admission have been properly evaluated in rcts – or are we heading for more expensive failures like Evercare and other well-intentioned but half-baked schemes?
If you read the whole article, it is a summary of a report which has been published. If you bothered to click the link it would take you to the report and Appendix 1 is entitled … “The Evidence Base from the Urgent and Emergency
They have spent a huge amount of time and effort consulting and writing the report, you may find it valuable to spend a small amount of time reading it.
This is an interesting review and presents a starting position for improvement. Much remains unclear however.
Reference is made throughout to the integral nature of critical care transfers. Is it envisaged that Intensive Care Medicine as a specialty will be centralised in Major Emergency Centres, following the PICU model or will more widespread provision of Level 2 and 3 services be maintained? How big does an ICU have to be to survive?
What will define a ‘remote’ or ‘rural’ hospital?
“Hospitals are a source of valuable expertise, but community healthcare staff and patients with long-term conditions who are under specialist care shouldn’t always have to travel to a hospital to access this expertise. Improved communication between the hospital and community will allow GPs and patients to obtain specialist advice in a more timely way, or directly access a clinic or similar service when required. This approach has been shown to improve health outcomes and patient satisfaction, and should be more widely adopted. By removing the barriers between hospital and community it is possible to build a network of care in which information and expertise flows to where it is needed when it is needed, allowing urgent care to be provided closer to home.”
Or rather, specifically the last sentence. Should this not apply equally to admitted patients, being cared for by regional specialists, could ‘telemedicine’ not offer a safer and cost minimising alternative than transferring a patient for specialist review, when a particular specialist procedure (such as percutaneous coronary intervention) is not the reason for transfer and treatment itself is available locally?
Many thanks for your consideration of the above.
This is a very good report and long over due, but a registered paramedic with 36 years service with the Ambulance service. I have to say please please don’t get the paramedic profession confused with the Ambulance service just because they are currently the largest employer or this report may fail at that point like so many of previous reports. The Ambulance service must realise that employ the paramedic and not continue to suppress their education.
While much of what is proposed cannot be argued with there are issues around implementation. The main issues are firstly, where are we going to get the staff to support these changes. Currently we have problems in recruiting the necessary A & E staff will we be able to recruit the necessary staff. Secondly, nce we recruit them how are we going to ensure that we can retian the staff. Thirdly, how are we going to ensure that the hospitals wiht just an emergency centres remain financially viable especially as we seem to be moving to ore specialist hospitals.
Sir Bruce,I know you are well intended but we already have a system in most acute hospitals which is Triage, patients are selected on the basis of need I see your new solution as extremely worrying for patients going into A&E .I speak from experience as my husband waited 16 hours after the decision to admit was taken.
Thank you to Sir Bruce and his team for the clarity in this report. We serve patients in one of the most socioeconomically deprived wards in Manchester. To support urgent access for our patients we offer a face to face GP triage service which acts also to signpost to other services as well as an opportunity to help patients learn more about how to look after themselves. We also realise that reassurance delivered face to face is superior to that over the phone and hence we offer a Skype consultation service. Just a couple of ways we are supporting the call to action.
A/E is not a “brand” it’s a service that we pay for and we are not commodities to be processed. The best way forwards is to return GP surgeries to 24/7 opening hours not 111 or locus doctors so that they don’t need to go to A/E.
Providing better information for self care doesn’t work, the information will probably make things worse in the oh my god I have cancer scenario. This is why you have experts to care for you.
Talking to some one using a computer to diagnose is not a good move just look at the way ATOS denies valid disability claims using this approach 111 is a joke.
Care in the community failed, so why try to increase it.
Getting to emergency care centres will lead to an increase in deaths in the ambulances, and also tie up ambulances for longer periods leading to more deaths, so that will save the problem of life threatening illness, does the word logistics mean nothing to these people.
The gap between hospital and community services is vast it became wider when the health and social security department was split, and the health and welfare act 2012 removed all accountability from the departments to protect hunt and ids. There are so many different bodies and quangos involved they need all the money to run those so there is none left for patient care.
The local commissioners are not experienced in commissioning and are fatally underfunded this is an area that keogh missed entirely.