NHS blueprint to shake up emergency care provisions, says director

http://www.guardian.co.uk/uk/2013/jan/18/nhs-blueprint-emergency-care-provisions

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A major review of A&E and urgent care services, to establish a blueprint for what is needed to treat emergencies and save lives in the 21st century, is to be undertaken by the NHS's medical director, Sir Bruce Keogh.

The review comes as a number of hospital A&E departments are under threat of closure, provoking demonstrations and marches by the public and local politicians wherever a shutdown is proposed. But, says Keogh, NHS restructuring is essential to ensure patients get the best possible care. In A&E, as in many other specialities, that is likely to result in fewer centres, staffed by the most skilled clinicians.

"At the moment we have some trauma centres around the country functioning very well at international standard and A&E departments that are variable in what they are and are not able to treat," Keogh said.

The system, he said, is "fragmented and complex" and people do not know where they should be going for help or understand where they have ended up. Urgent care centres exist side by side with A&E departments in some hospitals, but patients do not know the difference or appreciate why they would not always be better off heading straight for the nearest A&E.

"We have urgent care centres, walk-in centres – 11 or 14 names for these things. It confuses me, let alone people who want to interact with the NHS," said Keogh.

"Meanwhile medical science has evolved dramatically. The treatment of common conditions has changed. It has become clear to us that some common conditions, such as heart attack or stroke, are better treated in specialist centres with proper expertise and kit."

People in London who suffer a stroke or heart attack are likely to be driven past the nearest hospital A&E and taken to one that has a specialised unit, while paramedics begin treatment of the patient in the ambulance. The evidence shows that this reorganisation is saving lives.

But, said Keogh, people understandably want to know where they can go for immediate help in an emergency, close to home. There is, he said, "a reasonable public expectation that people when they feel unwell, frightened or anxious about their health need to have somewhere to go nearby".

Keogh will lead the review on behalf of the NHS Commissioning Board. His team will work with clinical commissioning groups around the country to develop a national framework for emergency care. The board says that local commissioning is key to the review.

It also plans to look at seven-day working, to ensure that patients get as good care at the weekend as they do in the week. Studies have shown that hospital death rates rise at the weekend, when fewer and more junior staff are available.

The blueprint is likely to endorse a tiered arrangement for emergency care, from walk-in centres staffed by nurses and GPs, who will treat urgent but uncomplicated problems, to urgent care centres in hospitals, where most injuries and illnesses can be treated, to specialised emergency trauma, stroke and heart units in a smaller number of hospitals. The arrangements will be different in different regions, according to the demographics and geography.

The review will look at the transfer arrangements between these different types of emergency care centre. It will also be critical to improve public understanding and awareness of these different centres, so that people are more likely to know where to go for the sort of care they need.

Mike Farrar, the chief executive of the NHS Confederation, which represents all organisations that commission and provide NHS care, said no change is not an option. "Local urgent and emergency care services are seeing demand rising, year on year. There is no getting away from the fact that the current structure of these services needs to change if we are to secure the best quality patient experience, improve clinical outcomes and, ultimately, save lives.

"There is still a vital need for local urgent care services, but the development of a world-class specialist emergency system capable of saving lives also requires having the right expertise, in the right place, at the right time.

"The review by Sir Bruce Keogh will help clarify the best arrangement of services. It is essential that patients, local communities, and their representatives – including local and national politicians – are properly engaged in the debate."