Urgent need to review access to A&E services

http://www.guardian.co.uk/society/2013/jan/24/urgent-access-accident-and-emergency

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The NHS is internationally renowned for its excellence but is under increasing pressure. There is a growing consensus that it must change to meet the needs of an ageing population, make the most of healthcare technology, reduce the UK's childhood mortality rate and allow the NHS to live within its means. A big part of the problem is that too many services are in the wrong place. This often means that care is not as effective as it could be, and it is increasingly unaffordable.

Firstly, we need far more investment in good care closer to people's homes, helping to keep patients out of hospital and in the community where it is in their best interests. This means co-ordinating care across primary, community, secondary and social care, and making better use of technology, to meet people's needs and take the pressure off acute services. Secondly, some hospital services need to be centralised so that, for example, people requiring urgent stroke care get access to the best doctors and nurses 24 hours a day. Sometimes it makes sense to travel further to be treated by high-quality specialists rather than be treated locally by staff who do not see enough patients with a particular problem to become adequately skilled.

Changes of this kind are often highly controversial locally, with the result that they can be stalled or ducked, sometimes for years. In the current climate, such fudging will make matters worse. It will risk increasing numbers of NHS organisations becoming unsustainable, while quality suffers.

We cannot ignore the changes coming down the tracks. If we fail to address this issue now we risk an increasing number of NHS organisations becoming unsustainable – this will mean change within more narrow limits later. The NHS must organise changes in a much better way than it has in the past. Medical Royal Colleges, the Academy, the NHS Confederation and National Voices are working together to ensure that this happens.

To make these changes successful we need to see: services developed around patients, not the interests of organisations or staff; patients, communities and local political representatives being fully included in the decision-making process from the outset; changes justified by quality improvements and backed by clinical evidence, not solely driven by finances; and people's concerns about safety and access to services, including transport issues, properly resolved.

Debates on this are happening all around the country. Local communities have to decide the best way forward, but no change is not an option. We must grasp this nettle – the NHS will not have a sustainable future unless we do. Mike Farrar Chief executive, NHS Confederation, Professor Terence Stephenson Chairman, Academy of Royal Medical Colleges, Jeremy Taylor Chief executive, National Voices, Dr Hilary Cass President, Royal College of Paediatrics and Child Health, Dr Clare Gerada Chair, Royal College of General Practitioners, Professor Norman Williams President, Royal College of Surgeons

• I welcome Bruce Keogh's urgent care review (Specialist centres not A&E are way forward for NHS, 18 January). At last there is recognition that we need a tiered structure for emergency care.During the Kidderminster hospital campaign in 1997-98 we discovered that the Northern Ireland health department had sensibly defined four tiers of hospital emergency department: the major trauma unit; the standard A&E unit; the minor injuries unit; and between the last two a halfway house which for England could be the urgent care centre if it is closely defined for each area. To improve local services for people who lose their cherished A&E department for genuine clinical reasons, the replacing urgent care centre should be staffed by doctors and nurses and backed up with inpatient beds for those not requiring the expertise of the larger A&E unit.

Now, as heart attack and stroke patients all must go to an appropriate centre, they would not be seen in every district general hospital as they were in 1998, but other medical admissions could be assessed and treated by the urgent care centre with adequate back-up facilities. The less serious surgical emergencies could be assessed there also and only transferred if necessary. This would avoid many of the unnecessary journeys to an A&E that overload remaining A&E departments and cause great difficulties for local people for the relatively minor cases that still need hospital assessment.

Andy Black, writing in the British Medical Journal of 24 January 2004 after what he described as "the Kidderminster debacle", described the likely problems accurately: "If the price of moving the complex emergency to an appropriate centre of expertise is that this patient is accompanied by another nine or 10 patients who are not complex acute cases another set of problems is launched." In Kidderminster, with only a nurse-led minor injuries unit, we have seen this repeatedly. At the moment there are umpteen descriptions of urgent care centres and I fail to understand why this confusion has not been addressed already. If local people, about to lose their A&E, understand that the replacement will cope with the emergency admissions that do not need the centre of expertise, the changes could be more acceptable. However, satisfactory alternative arrangements must be in place before any closure or downgrading takes place. The reasons for change must be clinical and not only financial. Richard Taylor Independent MP for Wyre Forest 2001-10

• The major review by Bruce Keogh is another go by the NHS to transfer care away from hard-pressed A&E departments to "appropriate" and "best possible care" centres. Sadly in most cases it has been totally unsuccessful. This is mainly because we have had strategic thinkers who have wished for the public to behave in a certain way rather than behave as they do. And there is that constant unremitting need for reform in the NHS as "no change is not an option", or so we are told. Although it would be worth knowing where we are, or where we have got to before yet more restructuring is contemplated? Vast amounts of NHS managerial time could be saved and focused on improving patient care if the service was not constantly in some sort of managerial or structural Maoist revolution.

Where the diversion of patients from A&E departments has succeeded has been with the establishment of stroke and trauma centres where patients are taken by paramedics who assess the patient and transport that individual to the appropriate centre.

Suggestions to reduce demand further is usually via a jumble of establishments such as walk-in centres, urgent care centres and the ubiquitous helpline, otherwise known as "wait until Monday" or "go to A&E". What exactly is a minor injury? How would the public know? At what point if concerned and worried does one upgrade oneself from a minor injury to urgent care? When is someone to know they are no urgent but an emergency? Why not go to the A&E department when in many cases you get transferred there anyway as your initial assessment of your illness has been, not surprisingly, incorrect.

There is no doubt seven-days-a-week primary care would assist. But it is not a panacea. Many problems about so-called A&E abuse (a term I loathe) is that certain groups are late presenters of symptoms, others have no access to GP services, and many are so mobile that they have great difficulty accessing a GP due to lifestyle and work issues. Urgent care centres could allow for easy access and divert people away from A&E.

There are numerous examples of 24/7 urgent care centres acting as gatekeepers for the walking wounded who attend A&E. This reduces demand on the department and locates a service in a place the public know about and in most cases trust. This would not solve every problem, but it would help. David James Kidlington, Oxfordshire