NHS medical director proposes two tier emergency service.

BMJ | 16 NOVEMBER 2013 | VOLUME 347 1 NHS medical director proposes two tier emergency service Zosia Kmietowicz BMJ The NHS 111 urgent care telephone service increased the use of ambulances in England during its first year of operation—contrary to what it was designed to do—shows an evaluation of pilot sites published in BMJ Open. The Department of Health commissioned the study to evaluate NHS 111, the new 24 hour telephone service to manage all requests for urgent help, including those for GP out of hours services and urgent problems that may need an ambulance. The service is staffed by non-clinicians who use an algorithm based assessment system, NHS Pathways, to triage calls to other services or care at home. The researchers, from the University of Sheffield, analysed data from two years before (2008-10) and one year after (2010-11) NHS 111 was introduced in four pilot sites and compared these with data from three control sites. In their first year of operation the pilot sites took over 400 000 calls, just over 277 000 of which were triaged by NHS Pathways. Just over a quarter (28%) of the triaged calls were referred to a nurse for clinical advice, and over half were judged to need primary care or urgent care services. The number of calls to NHS Direct, the existing 24 hour telephone and internet service, fell by almost 20% during the study period, as was expected. Although there was no change in the overall number of emergency ambulance calls directly from the public, emergency ambulances being dispatched by NHS 111 rose by 2.9% (95% confidence interval 1% to 4.8%) each month— equivalent to an extra 24 incidents per 1000 triaged calls. The authors estimated that this could lead to an extra 14 500 call-outs for an ambulance service attending 500 000 incidents a year. The researchers said that after NHS Direct closes calls to NHS 111 may increase further. They concluded, “It is probably unrealistic to expect any one service, such as NHS 111, to do everything, and real improvements may only be gained when a series of coordinated measures designed to increase efficiency across all services are implemented.” Cite this as: BMJ 2013;347:f6811 Gareth Iacobucci BMJ Hospital emergency departments in England should be remodelled within the next five years to differentiate between smaller emergency centres and larger major trauma centres treating patients with the most serious needs, a major review has recommended. The plan is the first plank of a major review of urgent and emergency care services led by NHS England’s medical director, Bruce Keogh, which was commissioned to help tackle the ongoing pressure on emergency departments and the wider NHS. The first phase of the review, Transforming Urgent and Emergency Care Services in England, proposes introducing the two levels of hospital based emergency care as part of a “system-wide transformation” over the next three to five years. Under the plan, smaller units, provisionally called “emergency centres,” would assess and initiate treatment for all patients arriving there but would then be able to transfer the small number of patients needing specialist treatment to larger “major emergency centres,” which would possess “consistent levels of senior staffing and access to specialist equipment and expertise.” Keogh emphasised that the proposal was not about cutting existing urgent and emergency care services and said that NHS England expected the overall number of emergency centres to be broadly the same as the current number of accident and emergency departments. Major centres are expected to number between 40 and 70. But he said that a formal distinction between the different types of emergency unit was needed to make clearer the vastly different services being offered at departments across the country. He said that the move could emulate the success that occurred from reconfiguring stroke services in London into larger, more specialised units. The report, produced by a working party chaired by Keith Willett, director for acute episodes of care at NHS England, said that the two levels of emergency department would be introduced only once access to urgent care services outside hospitals had been “sufficiently improved and enhanced.” It made a series of recommendations for improving urgent care services outside hospitals, to help reduce pressure on hospital emergency departments. These include enhancing the NHS 111 nonemergency telephone line so that patients would be able to talk directly to a doctor, nurse, or health professional or book an appointment with their GP if needed; and improving access to GPs by freeing up time and resources in primary care. Other recommendations are to provide better support for patients to care for themselves and developing the 999 ambulance service into a “mobile urgent treatment service” that could treat more patients where they were injured or became ill. The review emphasised the importance of simplifying the current plethora of urgent and emergency care services to ensure that the system was better integrated and easier for patients to navigate. To help achieve this, existing major trauma networks would be used as a basis to develop broader emergency care networks. Cite this as: BMJ 2013;347:f6828 NHS 111 led to more ambulance dispatches, finds study of pilot areas