We need the public to play a key role in the development of urgent and emergency care

Sir Bruce Keogh, NHS England’s medical director, explains the next steps in his plans to revamp A&E services across the country:

A&E is creaking at the seams. It is not broken but it is struggling.

In my view our A&E service has become a victim of its own success. It functions because people are seriously ill, frightened or in pain. It is the exemplary frontline of the NHS.

There is a feeling this winter will be a bit difficult – even harder than last year. We plan for winter every year but what we have done differently this year is to start planning for it in May. We have given out the winter monies a lot earlier to give hospitals and communities time to plan. We have also put in place A&E working groups to bring together all those interested groups – hospitals, clinicians, providers.

And we have also had a bigger and more successful response to the flu vaccination. So what we are seeing are new thoughts and innovations coming together.

None of these, however, provide a long term solution to the pressures on A&E, so it is clear my review of urgent and emergency services is needed. The last time we had a systematic review of emergency care was in the 1970s – 40 years ago. Since then medical sciences have changed and advanced. We also have a change in population with people living longer and that brings with it more pressures on A&E. The public want and need change to the services we provide on the front line.

The truth is that not all A&Es are of the quality they were in the 1970s. And in the face of increased demand we have added a whole raft of bolt-on services that go under a host of different names – minor injuries and walk-in centres among them. We have also established specialist centres to deal with critical conditions such as heart attacks and strokes. All this change has just created confusion.

It is time for transparency, honesty and improvement. These are the essential prerequisite for a debate on urgent services and what we are unveiling today is just the beginning with more work to do. We want the public to have a say on what they want for the medium and long term.

We already know people want and need facilities close to their home. These facilities need to be safe to care for whatever situations arise. But there are also some critical conditions that need specialist care – and those patients should get that specialist treatment as quickly as possible.

These proposals have not been developed by bureaucrats but by people who are closely involved with urgent care on a daily basis.

I’m worried a story has emerged that we are going to create mega-centres and other smaller A&E units will be allowed to wither on the vine. This is categorically not true.

There will be between 40 and 70 Major Emergency Centres but they will be connected as part of a network to smaller emergency centres who will still be receiving the majority of ambulances. By passing patients with acute conditions onto the specialist centres, we can decongest smaller A&E units so they have more capacity.

We are proposing that we formalise things so there are smaller A&E units that can link in and network with larger specialised centres. These proposals are about improving services for the few with critical conditions that need specialised care, and for the many that still need an A&E close-by.

Among our key recommendations from this first phase of the review is one that we listen to patients and the public generally who have been adamant in telling us they don’t always want to trouble an NHS professional all the time, but they want help in managing their own care.

We also know that an enhanced 111 service can be at the hub of all we do: able to put patients in contact with a GP, a nurse, a pharmacist or the mental health team, for example, to get the proper, first-hand advice they need rather than just sending them to A&E. This service will also ensure they get a prompt appointment to see the person who is best placed to help them. It means people can book to see their GP the next day, or get in to A&E without a four hour wait. Of course, as part of this enhanced response service, people who need a 999 ambulance, will get just that.

We also know the most trusted people within the health service are our paramedics. We will be giving them more training so they can effectively become mobile treatment services – another way of giving people the excellent treatment they need at home without necessarily being admitted to hospital.

We want to continue to build this with phase 2 of the review where we will be looking at workforce issues and what the costs are. We need to do this with the Royal Colleges and the other specialist associations.

Our timescale for all this is three to five years, but much of it has started already and we envisage a lot more things happening a lot faster than this.

Most important of all is that people who live and breathe this every day, and their patients, tell us what needs to happen and what we should do.

My pledge is that the public build to ensure we get this right will continue and I want you, our patients, to continue to send us your views, your ideas and your suggestions.

Bruce Keogh

Professor Sir Bruce Keogh is NHS England’s Medical Director and professional lead for NHS doctors. He is responsible for promoting clinical leadership, quality and innovation.

Formerly, Sir Bruce had a distinguished career in surgery. He was Director of Surgery at the Heart Hospital and Professor of Cardiac Surgery at UCL. He has been President of the Society for Cardiothoracic Surgery in Great Britain and Ireland, Secretary-General of the European Association for Cardio-Thoracic Surgery, International Director of the US Society of Thoracic Surgeons, and President of the Cardiothoracic Section of the Royal Society of Medicine. He has served as a Commissioner on the Commission for Health Improvement (CHI) and the Healthcare Commission. He was knighted for services to medicine in 2003.

Follow Bruce on Twitter @drbrucekeogh


  1. Mrs Norma Huxter says:

    Where on earth does Bruce think we are going to get enough people to fulfil this dream of his? We can’t find enough people now and with cutbacks, where does he think the funding is coming from? I am 65 years old and in all my lifetime I believe I have only ever been to A&E twice, and that was as a child when I scalded myself and burned my fingers. I think charging time wasters and drunks at A&E will be one way forward. I don’t think NHS staff should refuse to discover whether foreigners are entitled to care by asking them for proof that they are, afterall, we are asked to provide proof of insurance for our treatment, whether we are in EU or the rest of the world. It hardly takes any time to do this and it would show we are not an International service but a National one.

  2. Julie says:

    If 3 A&E departments in our area hadn’t been closed then the remaining one would not be under the strain that it is. It stands to reason that the patients will need to go somewhere….

  3. Mervyn C Jermy says:

    Why don’t every Hospital with an A & E Dept. have a walk in Centre next door so that people just turning up at hospital would have to report there first, this could be staffed by nurse practitioners, then the only way to A & E would either be by ambulance or referral from the walk in centre next door thus protecting the valuable doctors time and relieving a lot of their load, and people with minor ailments would be treated and sent on their way.

    • Ken Edwards says:

      As a strategic assessment of A&E future, I accept the general line of argument and conclusions.

      Against this, some practical concerns from a member of the public.

      1. The existing geographic pattern of A&E units may not easily be split in the manner proposed
      2. Migration will have to be closely co-ordinated into CCG plans which will dictate some timings.
      3.There is also a transport issue as some patients will need to go further to the right destination.
      4. I note the comments about 111 and despite the evidence, personal and anecdotal comment by others to me do not echo this. I accept there may be a historical effect. Also, reading what is said I think I have found a great new way to avoid holding on the telephone trying to get a GP appointment – I just phone 111 and let them hold on for me ….. This sounds like an unintended consequence.

      5. The move to a smaller number of specialist acute units clearly has clinical evidence based on outcomes. What is less clear to me is that thought is given to the scale at which it becomes better to have two units rather than one e.g. why do we not just have one centre for each specialism which might not even need to be in the UK – absurd perhaps, but when does the balance change. Why 40-70 Major centres, why not 10 or 5 and how does the ‘perfect footprint’ match what we have now – see 1 above.

      6. Also I am not sufficiently expert to know if A&E location would be divorced from other hospital specialisms e.g. does having a main centre A&E need certain ‘back office’ wards and expertise.

      All these might be considered operational detail perhaps, but on such detail grand plans can falter.

      So, in isolation this sounds a good direction of travel but for my part as a member of the public I would want to have some degree of assurance that issues such as the the above are understood and have been considered.

  4. A Mcpherson says:

    Could A and E`s update either their Hospitals` web site or create a national site which has a simple `Traffic Light` style warning system letting patients know before they attend A and E the likely waiting times for non-urgent treatment.
    It may have an effect of patients choosing to attend a hospital a little further away or delaying attending for some minor ailments.
    It could help?

  5. Mary E Hoult says:

    Sir Bruce, I have great experience in the A&E situation and would be happy to contribute to your debate. I have already e/mailed several key contacts who are interested in this subject and the issues your are promoting.