Professor Keith Willett, Director of Acute Care for NHS England, sets out the proposals arising from the Urgent and Emergency Care Review. This presentation was given at the Nuffield Trust's annual Health Policy Summit in March 2014.

1. Cracks? - I think its already broken
NHS England’s Review of Urgent
and Emergency Care
Professor Keith Willett
Director of Acute Care
NHS England

2. 97-98 99-00 01-02 03-04 05-06 07-08 09-10 11-12
0
1000000
2000000
3000000
4000000
5000000
6000000
Since 1990s, EMERGENCY ADMISSIONS have grown
while attendances at major A&Es have stayed broadly
constant
Source: King’s Fund
Attendances at type 1 A&E units have remained
broadly constant
Type 1 A&Es account
for 98% of emergency
admissions from A&E
Emergency admissions trends vary
significantly over three periods in the last
15 years
7.8% annual growth
-1.2% annual
growth
-0.1% annual growth2+ day
2.2% annual
growth
2.0% annual
growth
4.0% annual
growth
1.0%
annual
growth
Total
Type 1 A&E units are consultant-led 24-hour services
Type 2 A&E units are single specialty
Type 3 A&E units include minor injuries units and walk-in centres
1.4% annual
growth
0.5%
annual
growth
0-1 day

3. Current provision of urgent and emergency care services
3
>100 million calls or visits to urgent and emergency services annually:
• 438 million health-related visits to pharmacies (2008/09)
Self-care and self
management
• 24 million calls to NHS
• urgent and emergency care telephone services
Telephone care
• 300 million consultations in general practice (20010/11)Face to face care
• 7 million emergency ambulance journeys999 services
• 14.9 million attendances at major / specialty A&E
departments (2012/13)
• 6.9 million attendances at Minor Injury Units, Walk in Centres etc (2013/13)
A&E departments
• 5.3 million emergency admissions to England’s hospitals (2012/13)Emergency admissions

4. BACKGROUND
• In Jan 2013 NHS England announced the Urgent and
Emergency Care Review.
• A steering group was established to develop an evidence
base and principles for a new system. An engagement
exercise took place from June to August 2013
• Using the information gained from this exercise we
developed proposals to transform the delivery of urgent
and emergency care, and published a report in November
2013.
• The Review is now moving into delivery phase

5. Evidence Base for Change
• 90+ pages
• 300+ references
supporting the Clinical
Evidence Base
• End to End review of the
clinical pathways
• Test and improve through
engagement

6. THE REVIEW’S VISION …..
For those people with urgent but non-life threatening needs:
• We must provide highly responsive, effective and personalised
services outside of hospital, and
• Deliver care in or as close to people’s homes as possible,
minimising disruption and inconvenience for patients and their
families
For those people with more serious or life threatening emergency
needs:
• We should ensure they are treated in centres with the very best
expertise and facilities in order to maximise their chances of survival
and a good recovery

7. Solution: shift care closer to
home
7

8. Helping people help themselves
Self care:
• Much better and easily accessible information about self-treatment options needs to be made
available – patient and specialist groups, NHS Choices, pharmacies
• Accelerated development of advance care planning
• Right advice or treatment first time - enhanced NHS 111 - the
“smart call” to make:
• Improve patient information available to call handlers
• Directory of Services
• Improve levels of clinical input (mental health, dental heath, pharmacy)
• Booking systems for GP call back, booking into UCC or A&E, dentist, pharmacy
8

9. Highly responsive urgent care service
close to home, outside of hospital
9
• Faster, convenient, enhanced service:
• Same day, every day access to general practitioners, primary care and
community services
• Harness the skills and accessibility of community pharmacy
• Develop 999 ambulances so they become mobile urgent community treatment
services, not just urgent transport services
• Support the co-location of community-based urgent care services in coordinated
Urgent Care Centres.

10. Serious and life threatening conditions –
expertise and facilities
10
• Two levels of hospital based emergency centres
• Emergency Centres* - capable of assessing and initiating treatment for all
patients
• Major Emergency Centres* - larger units, capable of assessing and initiating
treatment for all patients and providing a range of specialist services.
• Emergency Care Networks
* names are illustrative

11. The new
system
11

12. THE DELIVERY GROUP
NHS
Engla
nd
Tools & Levers
Professionals
and
Workforce
System
Partners
Users
Commissioners
and Providers
Challenge

13. Approach to Phase 2
• Continue to “build in public”
• 8 Work Programmes:
– WHOLE SYSTEM PLANNING AND PAYMENT, COMMISSIONING
AND ACCOUNTABILITY
– PRIMARY CARE ACCESS
– 111 (CONTACT FIRST)
– DATA, INFORMATION AND CARE PLANNING
– COMMUNITY PHARMACIES
– EMERGENCY DEPARTMENTS and EMERGENCY CARE
NETWORKS
– AMBULANCE TREATMENT SERVICE
– WORKFORCE
I
T
E
R
A
T
I
V
E

14. Questions

15. DELIVERY PLAN – big ticket items
Better
support
for self
care
Promote effective self-care 1. Develop self-care resources
2. Guidance produced on marketing campaigns
(so that messages are same across the country
so far as is practicable)
3. Signposting/linkage to LTC third sector
partners, etc, for advice and support
Introduction and roll-out of
advanced care planning
1. Development of national care plan template
and tools to support delivery of 15m care plans
by 2015
Right
advice
right
place
first
time
Integrate pharmacy into the
UEC system
2. Changes to national pharmacy contract to
introduce minor ailments service etc.
Improve clinical input to NHS
111 and ambulance services -
more ‘hear and treat’
1. Development of new national specification
for NHS 111 to include recommended clinical
input, and extended range of services for
booking, including guidance on reprocurement
2. Development of guidance on ambulance
models to include support required in control
room
Integrate system by improving
referral rights through UEC
system
NHS 111 and NHS ambulance services,
pharmacy, etc
1. Ensure national 111 specification and
procurement strategy enable local referral
rights
2. Development of guidance on improving
referral rights across UEC system
Enhance the DOS to be real 1. DOS development work: Health and Social

16. DELIVERY PLAN – big ticket items
3. Highly
responsive
out of
hospital
services
Develop the ambulance
service model to offer
more treatment on the
scene
1. Development of Guidance on models for treatment on
scene by ambulance service
2. HEE work on paramedic Development and training
3. Enable GPs to offer support to ambulance and A&E (in
enhanced service to go live from April 14)
Develop community
pharmacy facilities to
wider range of services
1. Principles for extended pharmacy offer, backed up by
contractual changes
Successful models of care
for improved primary care
access
- in and out of hours
1. Principles for improved primary care access 24/7,
accompanied by necessary national contractual incentives
2. Headline specification for local urgent care facilities
Successful models of care
for improved community
services
- in and out of hours
1. Principles for improved community services (in and out
of hours) accompanied by necessary national contractual
incentives
2. Headline specification for local urgent care facilities
7/7 access to hospital
specialist advice to PC and
key OOH services
1. Hospital specialists: who should be available,
appropriate response times – academy/colleges/specialist
(NHSE)
4. Specialist
centres to
maximise
Designation of major
emergency centre and
1. Develop national specifications in conjunction with
clinical stakeholders
2. Determine process for accreditation and designation of

17. DELIVERY PLAN – big ticket items
Connecting
services so
the system
is more
than the
sum of its
parts
New improved system of
commissioning, finance,
and payment
1. Guidance on recommended footprint of the
commissioning unit
2. Guidance on what is meant by joint (?)/
collaborative commissioning arrangements – Inc.
health and Local Authorities)
3. Development of new tariff and incentives
structure to drive dissolution of barriers across
organisations
Timely access to relevant
patient clinical data
across the system
1. Full implementation of the SCR
2. Enhancements to improve SCR
Establishment of
effective emergency
networks
1. Development of guidance on constitution of
emergency care network in conjunction with
national clinical and operational stakeholders.
4. Unified quality
measurement system
1. Development of metrics to measure whole
system performance.
5. Identifying what good
looks like in terms of
dissolving boundary
between heath and
community care
1. Identify sites for exemplars and best practice

18. Questions