13 Nov 2013

A&E review backs ‘two-tier system’


Accident and emergency units would be no more under plans proposed today by England’s medical director.

Instead they would be divided into emergency centres and major emergency centres – effectively creating a two-tier service.

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The emergency centres would take patients needing assessment and to starting treatment and the more serious cases such as heart attack and stroke patients would go to the major centres.

The aim is to take the pressure off a system which Sir Bruce Keogh said was bursting at the seams.

The report was ordered by the Health Secretary Jeremy Hunt in response to the A&E crisis which saw units under pressure even during the summer months.

Sir Bruce and his team have now come up with what they say are radical plans to transform the urgent and emergency care services in England.

“They are victims of their own success,” Sir Bruce said.

“They function as a safety net for people who are worried, frightened, anxious or in pain.

“When A&Es become very busy it means other parts of the system are creaking as well. They are under stress.”

Read more: NHS ‘reconfiguration’ not as scary as patients think

So what the team behind today’s report wants to see is more people kept out of A&Es or emergency centres if that is what they end up being called.

They suggest stage one should be for the patient to stop and think about whether they can help themselves. The next stage is then to either call 111 or 999.

The proposals include beefing up the 111 service so there are round the clock clinicians or other healthcare professionals available and – once there patient records system is up on line – they will have access to people’s notes.

The suggestion is that they can decided what should happen next and even make an appointment for that patient to be seen by a GP the next day if necessary.

They also suggest increasing paramedic training to enable them to treat more people at home or in the community.

The plethora of walk-in-centres, urgent care centres and minor injury units would also come under the banner of urgent care centres to reduce confusion.

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But inevitably people will need to go to accident and emergency and they suggest the two tier system in which there are fewer, more specialist units for the worst cases.

This has already been trialled successfully in London with most heart attack and stroke patients regularly taken past their local hospital to a more specialist unit.

There is evidence that this has resulted in a reduced death rate.

How an emergency service looks in a rural area, though, will be different from those in larger cities.

Sir Bruce said it would be up to each area how they configured their units.  But he said this did not mean a reduction in A&E units overall.

There are currently 140 type 1 (blue light A&Es units).  These plans suggest 40-70 major emergency centres and 70-100 emergency centres.

The problem facing A&Es is the sheer volume of people passing through their doors.  Every year the NHS deals with 5.2m emergency admissions to England’s hospitals.

Read more: A&E wards face ‘worst winter ever’

But 40 per cent of patients who attend and A&E department are discharged requiring no treatment.

Some of this has recently been blamed on GPs and the change in out of hours care and the difficulty in sometimes booking an appointment.

Dr Tim Ballard, a GP and member of the panel which put the report together, said that while there had been some problems in this area, recent figures showed that 80 per cent of people, for instance, were happy with their GP opening hours.

Yet GPs will be expected to pay a large part in these changes in order to divert people from hospitals when they do not need to be there.

And although the report was generally welcomed across the health service, there remained concern about the immediate future.

The College of Emergency Medicine said the review looked into the future when “the crisis is here with us now”.

And Labour said that the government had to take responsibility for the crisis, including the closure of walk-in centres, staff cuts and patients spending hours on trollies.

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