'Two-tier A&E' reforms announced

“Plan for two-tier A&E as part of radical shake-up,” was today’s BBC News headline, reflecting the sentiment across the UK media.

The headline comes in response to a new report written by NHS medical director Professor Sir Bruce Keogh, entitled “Transforming urgent and emergency care services in England” (PDF, 1.19Mb).

Professor Keogh’s report sets out numerous proposals, including a new service configuration for accident and emergency (A&E) services in the UK. The report describes current A&E services as “under intense, growing and unsustainable pressure” and in urgent need of change.

Among the proposals is the recommendation to form a new “two-tiered emergency service”, which, the report argues, is a better use of resources than the current set-up.

The proposed shift aims to stop existing A&E departments trying to do everything, which the report says has led to inconsistencies in treatment across the country. The report argues that it is better for some hospitals to specialise and concentrate their resources to cater for the most serious cases – such as heart attacks, strokes and major trauma – and for less serious cases to be treated in a different type of hospital.

To some extent this has already happened, so part of the new approach is to make it clearer where the best and concentrated services are and how they can be used more effectively. The report says that this would also dispel the false belief of many patients that all A&E departments provide a similar service and are equally equipped to treat a range of illnesses. They are not – there is much variation across the country according to the report. As BBC News puts it: “The secret is out: not all A&Es are equal.”

Who is calling for the shake-up of A&E?

The calls for the shake-up are being led by the NHS medical director, Professor Sir Bruce Keogh, a former heart surgeon who led the review published today on behalf of NHS England. The review was in response to concerns that, in his own words: "A&E is creaking at the seams. It is not broken, but it is struggling.” He is also quoted by the BBC as saying: “We need to change the way we work. But what we are suggesting here already exists in places, we are just trying to formalise it so it is available for everyone."

Professor Keogh’s review looked into how the NHS organises and provides its urgent and emergency services in England to see what improvements could be made.

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Why have the changes been announced today?

This has hit the headlines because today the first phase of the review was published. The review sets out the initial proposals for changes to accident and emergency services in England. The changes may take years to implement fully, but the report is clear in the direction it recommends the NHS takes in order to more effectively meet current and future demands on its urgent and emergency care services.

What is happening in other NHS services to take pressure off A&E?

Part of the recommendations are about easing the pressure A&E departments face, which centres around ensuring A&E departments are used as intended, to treat patients in urgent need of treatment or those with life-threatening conditions.

Currently, many patients attending A&E do not fall into this category, which the report argues is not an efficient use of resources as A&E services are highly expensive medical departments to run.

The report indicates patients with urgent but non-life threatening needs could treat themselves using self-care techniques, or be treated by their GP. It also highlights the importance of helping people get the suitable information quickly to ensure they are aware of the most appropriate treatment options (which is many cases is not at A&E).

What other recommendations does Sir Bruce make?

The report made five main recommendations:

• That people need better support to look after themselves in a non life-threatening situation, including help to prevent existing conditions deteriorating.
• That people with an urgent health issue need to have good advice at the first time or place they achieve it. The report recommends the NHS 111 service is enhanced – with access to a nurse or doctor if needed and an appointment booking facility.
• Reducing queues in A&E by making access to GP and other primary care services more easily available on the same day. The report also proposes what the media has described as mobile A&E – paramedics with extended training who can deal with more conditions “at the scene”.
• That people with serious or life-threatening emergencies are treated in centres with the right facilities and expertise. The report proposes that two levels of hospital emergency department are introduced once out-of-hospital services are in place. These will be emergency centres – capable of assessing and initiating treatment for all patients – and major emergency centres - larger units capable of treating all patients via a range of highly specialist services. Professor Keogh expects there to be 40-70 major emergency centres across the country, while the total number of emergency centres is expected to be broadly equal to the current number of A&E departments.
• Better connected services with both information and specialist expertise flowing across traditional care boundaries to deliver patient care in the most appropriate and convenient setting.

Does this mean my local A&E will close?

The current proposals are recommendations to improve the configuration of NHS services in England to better cater for the medical needs of patients. These are yet to be implemented and so the exact local impact is tricky to predict and is likely to vary from place to place.

The best configuration of urgent and emergency services will be decided by local and national NHS organisations planned in response to their local communities’ medical needs. This may lead to some services currently in A&E departments shifting to more specialist hospitals, and the reduction of duplicate services in other hospitals. For a patient, this could mean that the best treatment may not be at the nearest hospital.

The estimates of the number of emergency centres and major emergency centres in the report suggests that there will be roughly an equal number to the current number of A&E departments, suggesting the service is correctly described as a reconfiguration, rather than a reduction in services.

What happens next?

The transformation of urgent and emergency care services across the whole health service is described in the report as a major undertaking with many practical challenges. The report estimates that the major changes will take around three to five years to implement, but significant progress towards some of changes is expected to occur within the next six months.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter*. *