Sir Bruce Keogh’s anticipated review into accident and emergency has been published today to a chorus of praise and boos. The Mail describes it as a ‘sticking plaster’. The Independent is cautious. The Guardian is critical. And the Telegraph and the Sun are more positive.
Sir Bruce Keogh gave a masterly performance on the Today programme, which may go some way to calming fears in the press. He said that the current system, which was designed in the 70s for the 70s, is unsustainable. At the root of his analysis is the belief that the present system is inefficient because patients have to go to the NHS to receive attention, rather than the NHS reaching out to patients. So, in short, emergency care has to become more flexible and mobile.
Some of Keogh’s figures are striking. 40 per cent of patients who rock up at A&E need reassurance rather than attention, he said. To tackle this, Keogh recommends ‘beefing up’ the controversial NHS 111 line by giving it the resources and personnel to provide better clinical advice, while at the same allowing staff to fix appointments and call ambulances when necessary – both of those proposals were suggested by disgruntled users of 111. Keogh also says that 50% of 999 calls for ambulances could be dealt with by paramedics at the scene or by local clinicians (GPs and pharmacists); so Keogh will encourage paramedics to make those judgments.
As for A&E departments, Keogh has drawn a distinction between ‘major emergency centres’ and standard casualty centres; but he categorically denies that he is proposing to introduce a ‘two-tier system’ because this distinction already exists in most metropolitan centres. Serious conditions, such as strokes and heart attacks, are treated in a few designated centres; Keogh says that this has improved survival rates and the quality of care by ensuring that emergency cases receive swift attention. Keogh’s plan is to extend that system, leaving those suffering from less serious conditions, such as broken arms, to rely on around 100 local casualty centres. Keogh is adamant that these local centres will operate on current lines; this is not a downgrade, he says.
Keogh’s plan is comprehensive, even if it is obviously best suited to urban and well-connected areas rather than rural Britain. But, can its basic message be communicated to patients? The present system is under such strain because patients call 999 or go to A&E because they don’t what else to do. Keogh has designed proposals to tackle that problem from the clinical side; but perhaps the greater challenge is to direct patients to the correct service in the first place. For instance, public confidence in the 111 service is so low that there are concerns that patients won’t use it. Part of that challenge is to ensure that local services are open and functioning 24 hours a day, 7 days a week. That will require the GP contract to be negotiated and for a wider role for pharmacists, physiotherapists and the like to be developed. Keogh has, then, posed a problem for Jeremy Hunt.