A FUNDAMENTAL shift is needed in the provision of "urgent care" services in the NHS to reduce the strain on A&E centres, according to a first phase review published this month by the National Medical Director of NHS England.
Sir Bruce Keogh says the current system is under "intense, growing and unsustainable pressure" driven by rising demand from a population that is getting older and faced with a confusing and inconsistent array of services outside hospital. He advocates a system-wide transformation over the next three to five years.
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."
The report highlights that 40 per cent of A&E patients are discharged requiring no treatment and that 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. In the treatment of the UK’s two biggest killers – heart attacks and strokes – it has been demonstrated that survival rates are improved significantly by taking patients to specialist centres that provide the best available hospital care.
The report makes proposals in five key areas. These include providing better support for people to self-care thus avoiding the need to see a doctor, and also helping people with urgent care needs to get the right advice and ongoing support via the NHS 111 service.
The report also calls for “highly responsive urgent care services outside of hospital so people no longer choose to queue in A&E”. This would mean “consistent same-day, every-day access” to primary care and community services and developing the 999 ambulance service into a mobile urgent treatment service capable of treating more patients at the scene to avoid the need for hospital.
In dealing with patients with serious or life-threatening emergencies it calls for the development of two types of hospital emergency departments: 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.
The report also advocates connecting urgent and emergency care services "so the overall system becomes more than just the sum of its parts". This would involve developing broader emergency care networks that dissolve traditional boundaries between hospital and community-based services and support the free flow of information and specialist expertise to ensure that no contact between a clinician and a patient takes place in isolation – other specialist expertise will always be at hand.
Responding to the review, Dr Clare Gerada, Chair of the RCGP, said: "We are pleased that this report recognises the vital role of general practice and other community primary care services in providing care to patients with urgent needs.
"This report proposes a substantial overhaul of the way patients will access urgent care services and GPs are keen to play their part and clear up the confusion that many patients face about where to go when they need urgent care. But we must make sure that general practice does not get ignored or left behind in the debate. The massive under-investment that general practice has seen in recent years must be redressed as a matter of urgency, for the sake of patients and the rest of the NHS."
The Royal College of Emergency Medicine welcomed the review but pointed out that it is very much future focussed saying "the crisis is here with us now".
“Over the past decade many efforts have been made to find solutions to try and provide alternative services to help patients whose conditions could be treated outside of the Emergency Department. Our experience is that most of these have been unsuccessful. Almost all were implemented without effective testing or piloting.
"Last week the College published its recommendations for resolving the ED crisis. These are pragmatic solutions, deliverable in a short time scale. Action to address these priorities would restore stability, efficiency and safety to the emergency care system. Without such action the recommendations of the Keogh review cannot be implemented.”