Wheels are in motion

Professor Jonathan Benger, National Clinical Director for Urgent Care for NHS England, updates on the Urgent and Emergency Care Review:

In November last year we received an extremely positive reception to the End of Phase 1 Report on Urgent and Emergency Care in England.

Sir Bruce Keogh outlined proposals for a radical shift in care, with more extensive services outside hospital and a change in the way patients access emergency care.

Since then, a lot of hard work has been going on behind the scenes to put the wheels in motion via the Urgent and Emergency Care Delivery Group made up of senior representatives from more than 20 different clinical, managerial and patient associations.

The group has been meeting regularly to begin Phase 2 of the review – implementing our proposals.

Over the coming weeks and months as we progress through Phase 2 and into the implementation stage, I will be keeping you up-dated in my blog on the ‘behind the scenes’ work.

Firstly, it’s important to recap on the reasons for the Review. Over the last 15 years, patients admitted to hospital as an emergency have increased by almost 50 per cent.

Yet through hard work and innovations survival rates have increased year-on-year and bed days have reduced from 37 million to 32 million. But this is not enough. Our system is under extreme pressure and is unsustainable in its current form.

Over the next three to five years we are going to enact major changes to provide highly responsive, effective and personalised urgent care outside of hospital.

Secondly, we will designate two types of hospital-based emergency facilities: Emergency Centres and Major Emergency Centres.

Emergency Centres will assess and initiate treatment for all patients and safely transfer them when necessary. Major Emergency Centres will be larger units, capable of assessing and starting treatment for all patients as well as providing a range of highly specialist services.

We are planning around 40 to 70 Major Emergency Centres across the country. However, the overall number of Emergency Centres and Major Emergency Centres will be about equal to the number of current A&E departments.

Our main message is clear – no single organisation can deliver these proposals: change is required right across the system. And no more so than in primary and community care which must be developed and enhanced to provide the vast majority of urgent and emergency care outside hospital settings.

So we are working with NHS Improving Quality to identify and prepare demonstrator sites which will trial and refine the new system, and the networks that will underpin the delivery of urgent and emergency care.

We also have many other strands of work going on, and the Programme Board meets every couple of months to review progress and discuss risks and issues.

Currently eight distinct packages of work are under-way: Whole System Planning and Payment, Commissioning and Accountability; Primary Care; Smart Call/111; Data, Information and Care Records; Community Pharmacy; Emergency Departments and Networks; Ambulance Treatment Service; Workforce.

They sit beneath the Review’s five key changes, and will help to support the achievement of these.

Each of these packages have a wide team working beneath them to join up existing pieces of work at grass roots and consider new bespoke work needed. While there are dozens of examples I could give for each of these, I’ve decided to choose just a couple to illustrate the type of work being done.

For example, within the stream of work on the Ambulance Treatment Service we are looking at how Ambulance Services can be developed and commissioned as a treatment as well as a transport service. Increasingly the capabilities of ambulance staff have expanded, so now they can treat many patients at the scene, reducing unnecessary visits to hospital and accessing alternative pathways of care.

We are looking at incentives, standards and targets to underpin the new role as well as exploring how GPs and other clinicians in the control room can provide support on the phone and to crews on the ground to reduce the number of journeys – particularly for frail and elderly patients, those with mental health needs and children.

And in workforce, for example, there is also much we can do. It’s no secret there are many workforce pressures in Emergency Departments, and a shortfall of Emergency Medicine Consultants.

Health Education England has the statutory responsibility in this area and we are working closely with HEE to influence the direction of travel and deliver the workforce we need for the future, developing the knowledge, skills and abilities of a range of healthcare professionals. In this way we are shifting our focus from a purely medical lens and building on plans for a wider workforce including advanced practitioners, paramedics and pharmacists. If their skills are fully utilized it will make a huge contribution to delivering urgent and emergency care in community settings, and preventing avoidable admissions.

We need change, we need it now and we are forging ahead with these critical plans to keep the wheels of our NHS turning.

Jonathan Benger

Professor Jonathan Benger is National Clinical Director for Urgent Care for NHS England.

Jonathan is the Director of the Academic Department of Emergency Care at the University of the West of England, Bristol and a Consultant in Emergency Medicine at University Hospitals Bristol NHS Foundation Trust. He also has extensive experience of pre-hospital care, having previously contributed to the establishment of a pre-hospital critical care team for Great Western Ambulance, and does regular clinical work in both the Emergency Department and ambulance service.

Jonathan has led or collaborated on 28 grant-funded research projects with a total value in excess of £8million, and has authored more than 100 peer-reviewed publications. His main research interests are the evaluation of new technologies and techniques, service configuration and workforce, emergency airway management, resuscitation and pre-hospital care.

Until May 2013, Jonathan chaired the Clinical Effectiveness Committee of the College of Emergency Medicine, and served on the Council and Executive of the College. He has been closely involved with guideline and policy development in the UK, alongside international initiatives to define and improve the quality and safety of emergency care.

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  1. Tom Lake says:

    I am baffled as to where the figures of 40-70 Major A&E Centres came from. Surely the rational planning process starts from an examination of both needs and of the working of institutions of various kinds that can meet some of those needs. A stage of definition of desired categories of institution should follow and a stage of system modelling to determine how different components of need can be met by different distributions of resources, starting from existing institutions.

    If any of this is available – please publish it.

    Instead of a rational planning process, we seem to have target numbers plucked out of the air on the grounds that there are about 40 teaching hospitals but that they are not uniformly spread through the population. Then we get preposterous examples of concentration of emergency stroke care which can work in London or possibly Leeds but would be strongly retrograde in much of the country.

    Can we please get back to rational evidence-based planning?

  2. joyce brand says:

    Personal experience informs me that the group of people most helpful to the patient in a crisis is the ambulance team. The recruitment process for these health service staff must be one in which the qualities of humanity, patience and skill rate high. Sadly It is much rarer to see such qualities either in the general practitioners’ surgery or accident and emergency departments. Please, please do not make destructive changes in their service.

    Joyce Brand

    • Roger says:

      So, Joyce, you’re saying the skill level and patience’s of ambulance staff are higher than those of clinical and medical/nursing staff in A/E departments.
      I don’t know where you work but my extensive experience across pre-hospital (General Practice, Ambulance Service) and acute settings A/E, ED departments puts me at a severe variance to those comments. and in fact find them very offensive.
      You don’t say what your profession is but my occupations has put me in all of these roles both as a practitioner and as an observer and such your sentiments are very misplaced.
      Ambulance staff have a set of skills that are completely different to those of a GP or A/E staff. If injured out of a hospital environment I know whom I would want attending to me, on the other hand, in a clinical environment those placed as such are far better than any other health care professional I would care to speak off.

      • Alan says:

        Each PERSON has their specialist experience – Some GPs, for example, are excellent at an accident scene whislt other have had no experience and can actualy get in the way.
        Nowadays staff work across boundaries and aim to give a better service. Each is good at what they are experienced in.
        I have 10 years experience in an ambulance followed by 10 years working between a minor Injury unit, Out or hours GP, A&E. I would be a little rusty out on the road! At the same time nurses have gain the same advanced qualification as me and now work out on the road with great effect – but they may be a bit rusty ina hospital setting.
        At the end of the day the service to the patient is whats important. We need to develop this and generaly we are finding that expanding the skills of staff and taking experienced staff into different areas is beneficial and improves patient care.
        I think we are on the right track- but we need to upport these staff and the changes to make it work.