A message from Sir Bruce Keogh on the Urgent and Emergency Care Review

A message from Sir Bruce Keogh on the Urgent and Emergency Care Review

I want to bring you up to speed with progress on the Urgent and Emergency Care Review that I launched with NHS England earlier this year. Over the coming months people involved with the Review will continue to blog here and keep you up-to-date about the work we are doing. Perhaps more importantly, I want to encourage you to comment on what we are doing.

There were a number of reasons why I believed that a review of the current emergency and urgent care system was necessary.

Many patients and clinicians have voiced real concerns that the current system is under pressure and will struggle to cope long-term with the growing demands. Looking back, the performance of the system during the cold winter of 2012 proved that those worries were valid.

Therefore, my hope was that this Review would be a stimulus for thought about how we could better organise and offer care between our hospitals, primary and community care, and social services to deal with these pressures.

We are in the second decade of the 21st century. The way we deliver care now is very different from 10 or 20 years ago. Advances in medical science have meant that treatments have improved and acceptable standards have continuously evolved.

So I also hoped that this Review would allow us all to consider whether the system of care we currently know, use, and work in has kept pace with these advances and, if not, what changes need to be made.

I was also conscious of the ongoing debate across the health and social care sectors about whether we currently deliver care in a way that is truly in tune with the needs of the patients, really listening to the people that rely on these services.

We are living longer, our health needs are becoming more complex, and I wanted to see whether the current system was geared up to meet these types of challenges.

Above all, I wanted to move the debate into the public domain, using the best evidence available to us, and with no issues considered “untouchable” or off the table.

The first phase of this review is now complete. It was all about generating an evidence base and principles for change which we believed would tackle some of the current problems and deliver a better, more sustainable, urgent and emergency care system.

Over the summer we tested our ideas and asked the public to feedback on them, including suggestions for improvements. I am pleased to say that you responded to our invitation in substantial numbers.

Today we published our report on the first phase of this Review, outlining our findings so far and our plans for the future.

I would encourage you to continue to help us with our work. You can read what we have concluded so far on NHS Choices: nhs.uk/NHSEngland/keogh-rev...

Let us know your thoughts.

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62 Replies

  • We have had my husband down there a couple of times last year. My complaint is they sent him home without knowing what was wrong with him.He had some sort of attack and after he came out of it they just said we don't know what was wrong with him. It took him to collapse at another hospital to finally find out what was wrong with him.

  • This is very frequently experienced by patients and is a big problem in my opinion. My clients are frequently discharged without any progress towards treatment, and this has happened to family members and friends too. The staff appear to be less concerned for wellbeing than they need to be to deliver effective care.

  • I think that people should be more aware of what A&E is there for. Keep walk in centres for minor or referral purposes. Anyone incapable because of alcohol or drugs but not life threatening should be deposited in drunk tanks with supervision and charged fixed fee rates as this is totally self inflicted. Specialist teams at easy reach hospitals.

    The 4 hour limit should be scrapped and a rated time limit set.

    Life Threatening 1 ASAP

    Severe trauma 1 ASAP

    Observation because of possible complications 2 ASAP

    Cut or break 3 Triage stall bleeding send to xray

    Non life threatening 4 No Time limit

    Drink or Drugs (Non life threatening) 5 Drunk tank charges made to those able to pay

  • I agree with the drink and drugs issue. I went to A&E with a friend and was horrified with the resources taken up by one patient who had to sober up before he could be treated. However, whilst sobering up a police officer had to stay with him and staff had to keep monitoring him.

    I realise there may be many reasons for starting to drink, but it is still (in my opinion a choice that an individual has made ie self induced).

  • This comment shows a level of ignorance about the causes of alcohol and drug problems and how to treat them and is unnecessarily harsh and unhelpful, especially to those whose alcohol and drug use is connected to mental health problems and underlying trauma. What is needed is not drunk tanks. Putting drunks together just creates more problems, especially for those whose drinking or other dug use is related to experiences of abuse by carers subject to similar problems. What we need are better targeted, more responsive services that tackle alcohol related problems at an earlier stage. The worst thing about the comment is that it ignores what really works which is motivational interventions and IBA to prevent worsening of the problems for those not yet dependent and improved mental health services to address the underlying issues instead of handing them off

  • I am not going to get into a great argument over people that have a drug/drink addiction, they I agree need support to combat this problem. However those that just go out to get wasted are taking away the time the A&E Departments have so little of.

  • I agree A&E is the wrong place but we need the right place to be created so that these clients can be diverted there from A&E, hopefully after an accurate triage assessment of all their needs resulting in a coherent treatment plan

  • See my post later it explains what I saw in a tv programme a place in Wales has already installed.

  • ..I certainly agree that Drunks and Drug addicts who consume both, by their own choice, should be charged a Fee for, not only taking up valuable space and time in Ambulances , but also for their Treatment. These so called " Conditions " are SELF INFLICTED, and whilst it might sound harsh, I think even the Police should leave these people where they found them, then perhaps these so called " Patients" will learn the stupidity of their actions ...this would not only help the finances of the NHS, but make available more time to those who have a genuine accident and illness = SOLVED !

  • I had to visit A&E this summer as I fell and broke my arm. It was very busy, and even at only 7.00 on a Monday evening there were several "lost souls" who were either drunk, or drugged or completely confused.

    Some of these were very vocal and aggressive and the whole atmosphere was very intimidating.

    I really do think that there should be minor illness/injury units in the community, especially in areas with large populations. Many transient people, students, visitors, travellers, and so on aren't actually registered with GPs so they do need somewhere to go for general health problems.

    The A&E staff are amazingly patient and tolerant, and should be paid extra for the stress!!

  • No other country treats all & & sundry for free the way the UK NHS does. A professional concentrated effort must be made to ensure people from countries not entitled to free health treatment have medical insurance or cash to use the service. In my Job I was regularly asked where the DSS office was & the next question was where nearest hospital was. If those in high places don,t believe we are the a Health tourism capital of the world they are sadly deluded.

  • My local hospital Whipps Cross is under threat of closure and often heavily criticized. However on every occasion that a family member has had to attend either A & E, or as an in patient, Maternity we have had nothing but superb service. In the past year we have attended for varied reasons, Endocrinology, eye clinic, maternity, Ambulatory - my husband had DVT, and A & E as I broke my ankle. We genuinely couldn't have asked for better service, attention, kindness and thorough good treatment. When in A & E 2 people came in due to gnat bites......another had a cut finger that didn't need stitching even, just a plaster...yet the treatment and response from staff was admirable, polite (unsure if I could keep up that level of service?) I think that more walk in centres would be an answer - I've seen them work extremely well in NZ for instance - perhaps on High Streets? These could be for lesser concerns, but when we know we need some sort of medical care/attention? I believe we have taken too much for granted in our hospitals, possible A & E departments more so than any other. lets take a step back, look at the rest of the world and realise just how lucky we are...So we have to wait a few hours...never if you are really ill.....So be it, someone who is really needy is being seen to first, for free, our turn will be soon. We are such a lucky nation, but so good at putting ourselves down, to the point we believe it...lets stop and just be grateful.

  • Thats a good idea about the high street chemists take the pressure by having walk in places.

  • For a start make GP's more accountable too many people sent to A & E for attention that could be dealt with in a GP surgery. Secondly ensure the triage method is used correctly drunks and cut fingers do not require attention from Doctors there are very capable Practitioner Nurses who can take care of these people and finally start to pay A & E staff properly it must be galling to know that box tickers get as much if not more than they do.

  • My GP surgery sent me a letter a year and a half ago after I had been admitted to A&E asking why I hadn't gone to the surgery first as I was admitted in surgery hours. I had been picked up by ambulance after I woke my kids screaming the house down at 2am and then lay on a trolley outside A&E until 8.30am when they finally had a bed. I had to be given gas and air just to be able to walk down my own staircase so even if it had been surgery hours I'm not sure what my surgery could have done, but for some reason they still wrote to me, presumably because some politician here in Wales has made them accountable if one of their patients goes to A&E. It's completely the wrong thing to do. They are wasting paper and ink on a survey I was too apoplectic to fill in. They money should have gone towards an extra nurse instead.

  • Thankfully I have only been to A&E once which was in 2010 when I and had to ring the out of hours service, I was kept in for two days while they investigated the problem, so I was quite happy with the service. I think though that all these problems with A&E have come about because of people not being able to see their Doctor out of hours, people are not ill to order you cannot run a surgery like an office 9-5, they should go back to opening later and weekends this would put less pressure on A&E

  • It seams a shame that we have a hospital in our town,the wards are closed,it is only used for clinics and a minor injuries unit. (Nurse led.)A&E is fourteen miles away. This hospital should be fully reopened, be able to deal with more accidents and this would help with reducing bed blocking at the main hospital.

  • My 98-year-old mother died last year, and on several occasions whilst in a residential care home, she either fell or needed greater medical attention than could be given from the home's staff. So when the GP was not available (ie any time outside scheduled visits) the staff had to call an ambulance. The A&E units at Queen Mary's Sidcup, and again at PRUH Farnborough Kent were both plagued with the problem of not having enough cubicles. Consequently there was a queue of ambulance staff and their patients waiting for a cubicle to become available for my mother to be seen properly by a doctor. So the number of cubicles available is a crucial element for saving valuable ambulance staff time.

    I know of a couple of neighbours / friends who have recently had heart attacks / problems who have been taken a good distance away to Kings College hospital and had immediate surgery. So although this is quite a distance, I do think the expert assessment and surgery by more specialist staff is a good things, and wish it had been available 30 years ago when my own father died from a heart attack. So I am supportive of the proposals.

  • An interesting proposal Sir Bruce, and I think it is certainly a review worth having.

    I represent a national charity, OCD-UK, a charity completely service-user led, and I did want to ask where you see mental illness, but specifically severe anxiety illnesses like OCD and Panic fitting within a new A+E.

    We know from experience that people with mental health issues will often end up at A+E when they feel they have nowhere else to turn.

    I welcome your thoughts.

    Kind regards.

    Ashley Fulwood

    on behalf of OCD-UK

  • A&E's should not be closed. To take off the pressure from A&E promote and keep open Walk In medical centres, 8am to 8pm 7 days a week. Ensure both A&E and Walk in Centres are adequately manned.

    First and forecast should be patient care and treatment. Medical aid that does and can save life as its needed. Diagnosis of a condition should not be down to Nurses, but with the specialising consultant or GP.

    Diagnosed Lung patients should all have access to a pulmonary rehabilitation course as this educates the patient in how to help manage their condition and help prevent the rapid deterioration in health. This helps preserve the patients health and means a reduced likelihood in the demand on NHS resources ie additional medications and hospitalisation.

    Early detection in lung health could have a greater cost savings on medicines and greater preservation in patients health..

    With the increase in population there needs to be an increase in medical professionals. Something has got to give, Patient care or Patient Death.

  • For almost 10 years I have lived in Crete. My medical experiences have been exceptional - from diagnosis of a thyroid problem at 59 which was overlooked in the UK and surgery on the TFL ( Tensor Fascia Latta ) and a benign tumour. UK diagnosis - told to walk more ! However I also experienced excellent care back in the 70's early 80's in Bristol and Birmingham. Great doctors and nursing staff in the days of Matron !

    Now A&E - after an unpleasant dog-bite I was seen at the local 24 hour Clinic in our village and had excellent care within half an hour of the event. When they were not so happy with the wound at a later date I was given a letter to take to the local hospital in Chania. It was here that I learnt that everyone paid 5 euro on checking in at Reception. Now surely that has to be an excellent idea for a cash strapped NHS - and may possibly make people who take things for granted think more carefully about attending with a gnat bite or a grazed knee ! I know this goes against the principles of the NHS from its early days of 1947 - but as you say - times and things have changed - and it all costs money. I do think that if people had to pay something then there would be more respect and the value of what they are actually receiving understood. People must not expect something for nothing.

    We also have walk in clinics in the next village for blood testing and ultrasound and clinics in Chania just for diagnosing - of course some of it is private but oh so affordable. A similar service in the UK would take the pressure away from main hospitals. Greece itself is strapped for cash - but the clinics are state of the arte and thriving. We also keep our own records - now there's another saving. We are actually trusted to keep our blood test results/scans. After a scan we are given the pictures and the report - so no additional costs in sending to the GP where yet another appointment has to be made. and yes they do get lost ! Leaving space for a needier appointment.

    It was a sad day when cottage hospitals closed - as they too could fulfil the role of A&E and also act as interim care for people that were well enough to leave hospital but not quite well enough to return home. Could be a cause of long waiting lists as beds are taken by people who are unable to return home and it takes time to arrange alternative care.

    I have rambled I know - but hopefully have given you food for thought - a Greek Salad maybe ?

  • I love the idea of being charged a nominal fee for attending A&E. Not sure how plausible it would be to administer, but it might make people think twice. I know of a few younger people who simply didnt go to the GP because they couldnt get an appointment so went to A&E as they could be treated. I also know of people who cant get appointments at the doctors that dont impinge on work so wrongly use A&E - if there was a charge maybe it would make people think twice and thus reduce the non-urgent attendance at A&E

  • My experience as an occasional user of A&E, Drop In Centres and my local and someone who cared for a son with cancer is that the two tier approach is the right way to go. Drop In Centres can work well and take the pressure off local A&E but if/when GP Services are available 8am-8pm 6 days per week this will also make a massive difference.

    If the reality is that we have a national shortage of senior A&E staff then it makes sense to concentrate expertise in specialist centres. I have also heard that having other hospital specialists - haematologists - available to see Emergency Admissions has helped to reduce hospital stays and save money.

  • After reading this report am generally in agreement with "Sir Bruce Keogh on the Urgent and Emergency Care Review". Patients need a simpler system. Having just a NHS111 service or 999 in an emergency make sense with specialist services for some of the more complicated services.

    But there are a few points which concerns me.

    It seems that the "NHS brand" for large urban populations where choice & services are more readily available can be accessed more quickly than for rural districts.

    An elderly population, when retiring tends to "Move to the country" where the pace of life tend to be less. As we get older so the increase risk of stroke & cardiac problems occurs. With geographic layouts putting pressure on the already stretched emergency services extended journeys will decrease the survival rates.

    Certainly in such rural areas novel approaches to seek specialist help & treatment needs to be considered for those on the front line when dealing with patients, and I hope you take this in your financial support & guidance in allowing new technology, telecommunications & equipment needed for this.

    From my experience, it is not how quickly someone is treated in emergency situations that increase survivability, but it is the joined up work & thinking of the service to allow a citizen to gain their independence back, and support not only of the care episode in hospital but the services that are needed long term afterwards.

    I have at times been very frustrated in the lack of communication & action between departments within the hospital & more so with the connection between Hospitals & social/community services especially between Friday afternoon through to Monday lunchtime.

    Illness are NOT a Monday to Friday 9-5 & neither is the care needed to rehabilitate if you are to achieve the best possible outcome for any citizen.

    I hope you consider addressing this point for all citizens

    My last point is regarding urgent, & in some respect routine care within rural communities. We do have a high proportion of citizens which are "Digitally Excluded" with some health services & advice due to lack of technology infrastructure. The old, vulnerable, those requiring mental health services tend not to have computers, internet connections, or smart phones to be able to interact.

    May I suggest that a pilot research study is set up to try new ways of bring Healthcare technology to those citizens.

    I would suggest there could be 2 ways to approach this.

    1/ If an elderly person phones the NHS111 service & it is felt that an "Over the Phone" consultation cannot achieve a positive outcome, that a mobile community healthcare person could be sent to the persons address. The healthcare person would carry a laptop, communication systems & be able to video link into specialists & GP's as required. The Healthcare community person would work the equipment for the patient.

    In this way a Doctor could talk to the patient & to be able to see too. The Healthcare person could do any hands on checks if the doctor requires such as blood pressure, pulse, saturation, and carry out non invasive checks if necessary.

    2/ The other approach is similar, but this time using local facilities such as a shop, pharmacy, or local community, or even a room in a private dwelling. Teleconferencing facilities would be set up so anyone from the community could come in & use the facilities.

    There would however need to be someone present who knew how to work the equipment to help those patients through the services. But it would be difficult to man this 24/7.

    I hope you make available extra finances to explore how technology could be used in rural settings.

  • I agree that the service provision needs review but often a review means more work and bureaucracy for the staff to contend with. The 4 hour target was a start at ensuring patients don't have wait for treatment but in my experience triage works well and if you are in need you get seen and sorted, sometimes 4 hours is simply not long enough to perform all the diagnostics and get results. Why be forced to admit when another hour could result in a discharge, we need to talk to staff and not keep sending out more and more targets. Why is it that every time something goes wrong we have a knee jerk reaction and introduce another target, another audit form and another survey and then berate the NHS staff for not spending enough time with patients. GPs should work longer hours but that should not mean that all junior doctors get sucked into general practice, hospitals are full to bust with sick people and are an excellent training ground for acute and primary care. The govt keeps talking of care at home and not in hospital but in my experience the community cannot provide the kind of care I received in hospital and are never likely to nor would I want it provided in the community. The out of hours service took 7 hours to come out to me and I am very aware that by that time many people would have dialled 999, I stuck it out and was very ill as a result. I think the NHS is great and my local ED was great when I needed it but they were very very busy. I feel they need a voice of reason - I hope that you are it

  • I have viisited various A & E from Basildon through to The Royal London (Whitechapel) on numerous occaisions during the last couple of years due to family health issues.

    On the whole I have been disgusted at the service provided rude reception staff, having to wait to go through Triage before being booked in and have sat there over 2 hours before triaged some werte there longer (Queens Romford) all to do with targets, childs A & E closed or not open at night when A & E full of drunks and blood really helpful my grandaughter had nightmares over a Saturday night visit. Staff who will not listen to the mother of a severely disabled child as to what is wrong and what must happen as instructed by specialists from another hospital (Basildon)

    But more than anything else it was the filth, old dressings and other items on the floor dirty walls etc. Empty gel containers and some staff did not seem to be very clean. Lack of Dr's , Nurses etc. In Queens on a Saturday night I spoke to the porters there were only 4 on duty for the whole hospital no wonder people had to wait to be moved to xray etc.

    On the other end of the scale The Royal London was fantastic friendly helpful staff clean and booked on immediately and seen really quickly.

    Then you hear that more A & E to close when those there cannot deal with the number of patients out there.

  • I have been 3 times in the past 12 months, myself was a very good experience considering the shortage of staff, the poor staff were working were run off their feet.

    I took my 17 year old son to our local A&E Southport and they were over run and the wait was about 5/6 hours due to the amount of others waiting mostly made up of drunks, we left and unfortunately we first went through the trauma of the out of hours Doctors and that was dire as it took about 9 phone calls to be given an answer the doctor will call you back within 6 hours, well that was much to long to wait so we traveled about 25 miles to the nearest walk in centre and the treatment was over in app 45 minutes.

    My 2 year old daughter had to go to our nearest A&E for children which is about 8 miles further away than out local A&E as the children's treatment centre was closed a few years ago, fortunately we have a car, I worry about those who don't have transport and have a poorly child.

    We really do need more staff and you can give the fat cats less money and put it to employing more staff.

  • I had to visit my local A & E recently with my son who has Autism with suspected Pericarditis. My doctor had telephoned the hospital before hand & they were expecting him for a heart monitor & scan & blood tests. As my son has a very high pain threshhold & was in obvious agony I was extremely worried. Unfortunately we arrived when the nurses & doctors were changing shifts & my son was kept waiting over 4 hours before he saw a doctor. They were obviously very short staffed & owing to the damp weather, there were quite a few younger children who were a priority over my son with chest infections & other ailments. We need more staff & the answer is not to close A & E centres, but to adequately man more walk in medical centres as well, to take the pressure off our A & E hospitals. My son was in obvious distress & we were just left alone for much of the time with various nurses saying the Doctor will be here soon - but he was not.

  • I have a rare auto-immune disorder and am immuno-surpressed.

    Twice, recently, I have been sent to hosp [blues & two's] by my gp who has informed the hosp by fax of the condition, his concerns & the reason for admittance plus list of med's.

    A&E might have 4 hour targets - gp admission units don't.

    Each time it was over 5 HOURS before I was seen.

    When I took myself to A&E the next time I was seen in the same hospital within 75 minutes.

  • I have used my local A & E this year and was satisfied.I would keep things as they are with possibly more investment. I am worried about back door privatization.

  • I represent CMT United Kingdom, a support group for people with a rare neurological condition, resulting in mobility and dexterity issues, amongst other things. Many people with Charcot-Marie-Tooth disease end up in A&E at some point due to falls, burns (due to lack of sensation) and other minor injuries. I've been fortunate in that I haven't recently - although, the last time I did, I was in A&E for over 12 hours.

    Like many others have said here, minor injury units, open perhaps 24/7 if possible in town centres, or 24 hour supermarkets, seem to be the way to go - and if the larger ones were able to include X-Ray facilities, they would reduce the burden on hospitals considerably. I don't believe so much time and effort should be wasted on treating drunks and drug-users (unless they are at death's door), and a drunk tank, as someone else suggested, is a good idea. I also think that people who turn up with gnat bites, colds or minor cuts should be politely turned away, or referred directly back to the nearest pharmacy or MIU and those who ring 999 for the time of the next bus or some other ridiculous reason ought to be sent an immediate £50 fine. The calls are all traced and logged, so finding an address for that caller would not be an issue.

    Doctors surgeries should be open longer hours, and should also ALL contain a minor injury facility, staffed by nurses (not necessarily doctors). There is always the option of moving people from the surgery to the hospital if the need arises - mind you, on the one occasion when I took my father, who'd been having a severe asthma attack from the GP surgery, where they'd been trying to stabilise him, to A&E, it was well over an hour before he was seen or triaged. He'd been sent there because he couldn't breath and was deteriorating, but was not seen as any kind of priority by A&E - lack of communication, perhaps, between the surgery and the staff at the hospital? I don't know.

    I appreciate the comments that some have said about rural communities, distances to travel to hospitals and lack of technology available to the older generation - all these issues need to be considered and addressed. I believe simple things could be addressed too - our local hospital, the Royal Bournemouth does not have paediatric facilities - all children must go to Poole Hospital, which from where I live is another 12 miles away. Why are there no paediatric facilities as such a large hospital? It doesn't make sense, and adds to the burden of families, potentially with no transport and a sick child.

    Hope this all makes sense, and I look forward to hearing more about this in due course. My one main concern is that implementing these schemes (if they are) should not warrant the employment of large numbers of administrative/management staff, taking essential funds from front line staff. There are enough pen-pushers in the NHS, make 'em work for their money for a change, and leave the front line staff to do the job they were trained for.

    Karen Butcher

    Chief Operating Officer

    CMT United Kingdom


  • I represent the National Rheumatoid Arthritis Society and we would like to welcome the Urgent and Emergency Care Report - End of Phase 1 Report.

    We recognise what the Government is saying about the proliferation of long term conditions and the level of demand on existing services. Moreover, we agree about the need to ensure that the NHS supports self-care and provides readily accessible, reliable advice to help people take responsibility for their own health (where appropriate).

    We welcome the following proposals set out in the Phase 1 Report and believe these will benefit patients with long term conditions:

    Ensuring clinicians in the new NHS 111 service have access to relevant aspects of a patient's medical and care information (if consented to by the patient).

    Improving communication between the hospital and community to allow GPs and patients to obtain specialist advice in a more timely way, or directly access a clinic or similar service when required.

    We are also keen to see more information about proposals to allow GPs to lead integrated multi-disciplinary teams to manage whole pathways of care including the exacerbations of those patients with long term conditions.

  • We are a very active organisation called APP - Action on Postpartum Psychosis and we also host the UK's MMHA - Maternal Mental Health Alliance . Both are dedicated to campaigning for better services for women with serious postnatal illness . We are part of a team from the universities of Cardiff and Birmingham who continue to press for improved resources , especially in the provision of MBU 's ( Mother & Baby Units) and better education of all front line staff dealing with PP..

    We continue to be alarmed at the ignorance of many of such staff - from GP's to those in A&E , in general psychiatric wards , the police , and also the general public . A not - untypical scenario is for busy clinicians when faced with the anxious family of a woman who is becoming postnatally ill is to assume , a priority , that she has postnatal depression. They may delay admission to hospital or will send to A & E with a PND diagnosis . Manic symptoms can often be missed or underestimated or treated with incorrect drugs. We are pushing hard for any evidence of postnatal manic symptoms to be treated as a potential psychiatric emergency .

    In the UK suicide is still a leading , if not the leading , cause of maternal death . ( See Dr Margaret Oates' successive " Confidential Enquiries into Maternal Deaths" ) . We at APP are addressing this and continue to advocate for all services involved to do likewise.

    PP (Postpartum Psychosis) rapidly escalates . We have 6 women on our Board of Trustees who can eloquently attest to this and APP now has a membership of nearly 700 women who have experienced PP. They know - unequivocally - that PP MUST be included in any consideration of two - tier or Super Emergency A&E 's.. Women's postnatal mental health can no longer remain on the back burner of clinical practice.

  • Thank you for your post Sir Bruce.

    Before replying CLLSA would like to explore together your report to gain insight into how this may affect those living with the many varied challenges a cancer of the immune system may throw up along their disease pathway. As a cardiac patient myself and a CLL patient A&E is almost a second home, however I am based in Wales so cannot respond immediately with personal experience of the English system.

    This is an important issue for us as visits to A&E may become a part of CLL life for many due to disease progression, immune and treatment complications that require an urgent and focused response. The average age of diagnosis of a CLL patient is 72 our members also experience the challenges faced by the older generation too in gaining appropriate care,,

    We have posted your appeal for feedback to our members to our own community healthunlocked.com/cllsuppo... asking for our members feedback and I have copied /directed my charity colleagues to your questions too. I hope soon to be able to forward or post here the collective thoughts of the CLL Support Association.

    From a colleague at the CLLSA:

    "I hope that Sir Bruce Keogh's review of A&E provision in the NHS ensures that patients with chronic conditions such as CLL are treated appropriately and effectively in what ever provision is made available in a reviewed structure. My personal experience as a CLL patient has taught me that the current provision i.e. GP visit and/or referral to A&E is dependent on the level of understanding of the individual doctors or nurses of a specific chronic condition. On two occasions, the seriousness of my developing infections have been underestimated by GPs and doctors in A&E to the extent that I have become seriously ill, requiring stays of 7 days or more in hospital.

    I think it is vitally important to ensure that the individual professionals involved in triage arrangements in any emergency provision are aware of 'exceptional' conditions which should immediately prioritise patients for attention. There are many conditions that would require such additional attention but my concern is for the CLL community who are immuno-compromised with all of the problems and issues that this involves. CLL patients need to be treated urgently and aggressively if they are to avoid life threatening complications. However because CLL has traditionally been regarded as an old person's condition and as one of the 'good' blood cancers, it's seriousness can be underestimated."


    Trustee – Chronic Lymphocytic Leukaemia Support Association

  • I agree with an Urgent and Emergency Care Review. I recently went to A&E on the recommentation of 111 but I would have preferred to go to an out of hours GP for urgent assessment but the local "out of hours" service seems to put you through on the phone to 111. I waited in A&E for 12 hours and saw what I consider at least 90% of poeple who should not be there at all, but ought to be going to a phamacist or GP instead and of course there were the "regulars" with thick medical files to their names also waiting. The A&E should be kept for REAL accidents and LIFE THREATENING illnesses with a TRIAGE system as they have working at the Birmingham Eye Hospital where patients are graded as a genuine emergency or given an appointment to return at a later date for attention. In the "olden days" the A&E would not deal with someone they thought should have gone to their GPs instead. The GPs should have a medically trained person dealing with appointment requests to asertain their urgency for appointments. Of course we would not have the high degree of problems at A&E if the GPs returned to working out of hours or we have more "walk in" centres. I think it's turned out to be a cushy and lucrative number to be a GP as regards their working hours!

    Also on my visit to A&E I was kept in hospital for 3 days being assessed, with no resultant diagnosis of my problem (I was having heart attack symptoms). The tests I consider should have taken only 1 day but with staff only working in the daytime e.g. the radiologist who makes a diagnosis from a scan (9:00 - 5:00-er) this dragged out to 3 days. Surely, the speed of diagnosis and treatment should be 24/7 not 9:00 - 5:00 of awaiting the appearance of a consultant at specific times of the day which also straches out the hospital stay. Beds are being taken up by the SLOWNESS

  • Thank you very much for this update.

    Here at The IBS Network, the national charity for irritable bowel syndrome, we recognise the individuality of IBS patients and the complexity of their health issues. Affecting around a third of the population, irritable bowel syndrome is a complicated and incurable syndrome with no single universal treatment. For patients with IBS, it is often a long term illness which requires an in-depth understanding of the patient in order to manage the symptoms appropriately.

    We are in agreement with the self care ethos needed to be encouraged by the NHS and have recently developed the Self Care Plan, an authoritative resource for individuals with IBS. Through the adoption of this resource, IBS patients are able to inform themselves of the influencing factors that affect their symptoms as well as the various means of treatment available to them. By encouraging self management of their symptoms from a reliable resource, patients are not only able to lead a better quality of life but also help to reduce unnecessary GP visits.

    There are many voluntary organisations and charities, such as ourselves, that already provide essential services to patients as well as possess resources with great potential to support the NHS in treating patients with complex or long term conditions. Therefore we are interested in the role of charities during this period of change.

    Looking forward to future updates.

    Yours sincerely,

    Amelia Rippon

    Office Manager

  • Mainly I found that there is no clear understanding of the scope of the A&E. In my experience the A&E teams tend to diagnose what the patient hasn't got, rather than what that patient has. Many tests are done to eliminate obvious causes but if none of those are found to apply, the patient is sent home with paracetamol or codeine and told to speak to the GP, despite the pain or discomfort that brought that patient to the A&E in the first place still being present after 4-5 hours waiting and being seen. If that patient has a better understanding of what it is that A&E should do as a standard and the methodology/way of working of the A&E facility, then I suspect that that patient's expectations will be more easily met and would act as a preventative step when the patient decides whether to go to A&E in the first place.

    Secondly, the categorisation Major and Minor is misleading to the public. For a healthy person, anything that occurs with his/her health that deviates from the normal has the tendency to be of great importance to that person. The categorisation should be public-facing not medical specialist-facing - i.e. what the public understands as minor or major. I would say that the use of 'urgent' and 'non-urgent' would give a patient a better feel for whether to turn up to A&E in the first place and if he/she does, whether he/she will be treated urgently or not so urgently.

    I would also suggest an increase in the visibility of A&E's methodology and procedures, the tests likely to be done for a particular set of symptoms, the category in which the symptoms are more likely to be assigned and the likely timelines for as many indicative sets of symptoms as the A&E usually encounters on a daily basis. If these are published on the A&E's website, the GP's waiting rooms and website, the A&E waiting rooms, etc, then the patient can look up his/her symptoms, understand which category is likely to apply and assess whether a trip to the A&E is really necessary in the first place and if it is, the likely timeline and testing that would need to be done.

    Many of the responses above mentioned walk-in centres - I have also experienced these and I agree that they are critical in reducing the number of 'non-urgent' matters usually dealt with by A&E at present.

    Lastly - availability of testing machines outside 9am-5pm. I'm fortunate that I live between two good hospitals, both with A&E facility. However, one A&E facility has its own dedicated CT scanner, ultrasound machines, Xray capability on a 24X7 basis, whilst the other doesn't. What happens with those people that do not have the benefit of an alternative facility as I do? Occupy the beds until the next day, I suspect, or being sent home with the risk associated.

    These are my thoughts based on my experience. I haven't yet read the document you have attached but I will do so and comment accordingly.

    Thank you.

  • I have a few medical problems so are quite regular at southend on sea hospital. I have to say the service is amazing I have all ways been so well looked after .had a trip to a and e recently and I noticed there where afew people just sitting around to keep warm .didn't seem like there where lots of none urgent cases waiting to be seen , its hard to say whats urgent and whats not . to busy worrying about myself . perhaps non urgent shoud be sent to a health care center .

  • Dear sirs, the NHS and A&E departments are creeking under the volume which indicates there is not sufficient provision within the community to cover the basics.

    Example: If a person lives alone and has a fall there is no choice if that person is deemed at risk but to be admitted to hospital via A&E. If there was an emergency sitting service that could be called upon this could prevent that admission.

    Alcohol related minor injuries and just sobering up should be out in the community.

    Supermarkets are open 24 hours and yet basic health provision is not. Could a small amount of GP surgeries be open on a drop in basis in each Town.

    If we get things right in the community there will be less impact on the Hospitals Services.

    At present in order to free up hospital beds people are being released too quickly often result in re admissions.

    the finance and emphasis must be placed in the Community other wise you are shutting the stable door after the horse has bolted.

    One other area that desperately needs to be improved is information gathering and the national use of that information.

    If you ask the question as too why hospital admissions have increased so dramatically in the last 18 months no one can give you an evidence based answer.

  • I had two visits to A&E with my last round of chemotherapy.

    My first visit was due to a pain in my chest. I rang the chemo ward and was told to go to my doctor or A&E as there was no doctor available on the chemo ward to see me. The concern of the nurse was I may have a blood clot. I rang my doctor who said there was nothing he would be able to do as I would need an xray to check for clot and I should go straight to A&E.

    I had a few tests in A&E and was told I did not have bllod clot it was not explained to me why they did not think I had a blood clot and I was quite upset as did not understand how they could be sure. Saw another doctor who explained better. I felt that A&E was not the best place to deal with this and the ward should have been able to do if they had a doctor.

    My second time was due to low platelets. I had a blood test at my doctors as I noticed the signs, unfortunately doctor did not pick up and when I questioned the results it was late in the day and too late to get blood test to see if they were improving. The only way I could get an emergency blood test after 5.00 was in A&E. I spent 3 hours waiting for test, A DOCTOR HAD TO TAKE MY BLOOD. once I got results I left as I knew it was raising so was ok but the staff left me waiting for a doctor to come and see me, when I questioned how long it would be they insinuated that it was A&E department not blood testing service. I agree with them but unfortunately the NHS has no other facility for an emergency blood test. I therefore think a two tier system would improve this and stop peolpe requirinG a simple blood test wasting doctors time although it was in no way my fault.

  • The most important thing to rememeber is the NHS is a SERVICE not a BUSINESS as the Government are running it as. You cannot run the NHS as a business, people are not commodities and no 2 people are the same. A total shakedown and audit is needed, certainly the many Mangers are not require and their wages would best spent on frontline , nurses, improvements etc.

    This proposed 2-tiered system is a joke. The Health service has a 2 tirered system already, the Private system and the NHS system. Those who can afford the Private System should be encouraged to use it. Isit unreasonable to ask the Wealthier populace to use the Private system andfree up the NHS for those unable to afford to go private. But more than that the Private system should not use the NHS resources. I have lost count with the amount of sharing a ward with Private patients, who pay to see the same Dr I have on the NHS system. If a Patient seeks Private treatments then that Private Clinic should have the facilities to deal with it. Certainly not take up the space a NHS paitent could use and have thier own operation stopped for a Private person.

    The 111, 999 is too confusing. Many of the Elderly round by me have no idea what to use. Minors and Majors, whom decides? The telephone operator, the patient? What if the patient doesnt say a certain thing that indicates the problem to be major or if the operator fails to realise the patient is a major not a minor. Too much can go wrong with the telephone system.

    Far more important to have the facility to assess the need and then process the patient to the correct level required.Triage can work but the facility should be close to a main hosptial so the process is swift and not intaling lengthy travelling.

    Why not use the out patients Departments that are empty during the evening out of hours, so patients can go and see Drs there and if needed be admitted if necessary or given medication if that is required with follow ups by own GP etc. The bonus of using the out paitents Dept within the main hosptials is the instant access to everything, beds, blood testing, xray operating theatres etc. Far better system than putting a Drs clinic in the 24hr supermarkets. Making clear the A 7 E is for the emergency life threatening events, RTA, heart attacks, strokes, poisionings etc. The Out Paitents clinics for the assessment of the rest.

    STOP the targets for the A & E Dept. You cannot set a target with the whole NHS being mismanaged and run as a business. People dont clock in with broken legs, minor injuries, RTA emergency. What comes in the door should be dealt with as is, not flung out the door if the patients goes overs an allotted 2 minutes. It should be in, assess, treat, admitt or discharge when solved.

    As A & E is a 24/7 service then blood, testing, pharmacy,xrays etc should be available there and then. Not on a limited time. You cannot book to have a broken leg, heart attack to fit in with what A & E has available. If the nurses can work in shifts, then so can all the staff to operate the facilities too.

    Maybe a look towards support form other outside the NHS to help ease the burden. Such as flu jab, open to all people of all ages. Such a small price to compare to vaccinate the populace and save the admission of those who may be more prone to the flu. Also looking to the Council to Grit everywhere and save the Winter flood of people, especially the Elderly who fall during the icy/snow season. That alone would save the NHS considerable time and money and stave off the wards been filled with the elderly who require longer time to heal than those of the younger population.

    Playing ping pong with the wards, to admit A & E patients is WRONG. I have been moved off a ward many times so the space could be used by one coming up from A & E. When just along the corridoor is a ward ready but kept empty. Being kicked off a ward at 2am in the morning is no laughing matter. I was even thrown off a post op ward, despite coming up to the ward straight from recovery from having major abdominal surgery. The ward I was put on was ill equipped to deal with post operative patients. In fact all it was, was a minor clinic open during the day. I had no antibiotics, no obs checked, no medication, no pain management, or oxygen, no drip changes and no Dr visits as nobody passed on I was stuck down on a Hell ward. Hell ward it was, the nurses were horrendous. I was verbally abused, told I was taking up valuable space of somebody who actually needed the bed, than a mild stomach ache waste I was. One particular nurse shouted at me as my urine bag overflowed from the catheter I had in. Did she empty it, yes then dropped it over me and left me wet. She even refused to help another woman who came down, who was being violenting sick, saying she had to dish out the breakfasts first and she did. I complained and nothing the PALS were a waste of time. They ignored complaints, decided what to do and what not to do, which was address the complaint. Then turned around saying time was up. I have nightmares about that ward and I freak out everytime a ward move is being implemented. I panic if I go anywhere near that ward or it is mentioned. No suprise I got infection by that ward move and took over 21 months to heal.

    Handovers should be restructed and retrained so the actual patient notes are handed over not some rushed scribble. Again I have had a just up from surgery needing obs put down as to be released in the morning. Then get told off by the Drs as my obs werent done. Not the patients fault the wincorrect information is being relayed. Whoah betide any mere patient speak and say, no thats nots right. You get punished for that.

    This not talking/liasing with other dept within the NHS has got to stop. I fall under at least 2 NHS clinics, Gynae and Bowel. Both spend more time pushing me back and forth between themselves than actual treating me. Both blames the other. As a Patient that is not acceptable, and this policy should be removed from the NHS asap.

    The biggest shakeup is attitudes need re-adressing within the staff of the NHS. Far too many nurses are not just rude they are beyond rude and agressive. As for the Drs many need to remember the patient is actually there and not a screen to talk at or over. It maybe a standing joke that Drs lose their bedside manner when they've left Med school, is not so funny when its the patient receiving the ATTITUDE! The sstaff all need to work together, far too often you will get a good team shift followed by chaos and then your suffer as the next shift either doesnt do anything or is playing catchup.

    Nurses, sex life should be kept out of the hosptial and well away from patients as should many of their life. Listening to loud nurses telling warts and all while you try to sleep, or are waiing for a bag change which wont happen until the gossips finished isnt on. Neither is listening to a nurse having sex outside the open window, while you are waiting on her to admit you, same nurse who is having her break according to another member of staff.

    Re- classification of Thyroid disease. My Endo, whom I fired, said a Diabeitic has to keep tight control of their levels or they would die. A thyroid is a minor hiccup and is never life threatening. That was his exact words. Thyroid is life threatening and is no laughing matter when you are suffering with thyroid disease.

    Certainly attitudes to be stopped towards thyroid patients. With them being treated with proper care and attention, not fobbed off. The Guidelines too need to be reminded that they are just that and a patient presenting with multi problems should be actively investigated. Certainly no more of, its normal and its YOUR AGE etc that we get. Take a good look through this site and see the problems, us thyroid patients are suffering and being mismanaged.

  • I see you have had similar problems to me at one of my local A + E - I sympathise When the NHS get it right it is great but when they dont the experience is horrendous. Lots of nurses and doctors are great - but when they are not it can make you feel like you are rubbish - one doctor told me once in front of an entire ward and medical staff to get a wash as I stunk (I had been confined to bed in severe pain and no one had offered to help me to get to a bathroom to wash) I just lay there and cried. I know what you mean about staff shouting out about their love life up an ddown the corridors when you and others are calling for help because they are sick or in pain - not really professional is it

  • Having had experience of A&E, paramedics, walk-in centres, helpline and out of hours GP, I would like to say the following:

    It's too complicated! In an emergency or accident situation you don't have time to consider what is the best/correct option.

    Paramedics are fantastic and should be able to direct a patient to the correct place, not just A&E.

    Walk-in centres are fantastic but should all be able to take x-rays, as we have used one before and then needed to go to A&E for the x-Ray. Great local care for minor injuries or when you're not sure if an illness is serious or not. Much better to be local as in the country an A&E department can be 30 miles away. They need to be open 24 hours a day. However, on one occasion my son couldn't have an X-ray until he'd been referred by a dr, thereby wasting time and money.

    When my father phoned NHS direct in the night to say that he thought my mother was dead they insisted on asking loads of questions about her age etc. when really he needed to be sent help straight away!

    My experience of out of hours GP cover is that it doesn't work and people to do feel it works do they use A&E. The dr don't know the patient.

    It is very difficult to get an appointment with the GP - you have to plan to be I'll in my surgery or call at 8.30 in the morning with everyone else calling and wait until you get through, not ideal. We are all under pressure not to take time off work or keep our children off school, so longer opening times really helps.

    A&E waiting areas are grim - uncomfortable with no water and waiting times are far too long. The triage system means you often have to go over details several times, trotting backwards and forwards for each next stage.

    Why not have a triage nurse to greet you on arrival, take quick details and direct you straight to , for example, either a nurse, an x-Ray, a GP, elderly care, or emergency areas?

    With the new on-line summary records developing, then patients complex medical background can be seen more easily. Why not give the patient a copy to keep and show to medical staff in any situation?

    Thanks for reading.


  • I think A & E is superb for emergencies - my husband has end stage 5 renal failure and an aortic aneurism and whenever he has had an emergency admission by ambulance his medical care has always been excellent, staff have been knowledgeable and friendly and always had an empathic manner however busy the department. I have also attended A & E for minor injuries such as a fracture and the medical care then has also been really good. We have always found paramedics to be the most caring and helpful people who have enabled us to feel empowered and supported, also staff trained to remain on the line while waiting for an ambulance in a real emergency have been superb.

    Minor gripes - it would be preferable for the accompanying relative to be allowed into the triage cubicle straight away as that would make the experience less stressful for patient and relative, also the relative is often the one in a position to explain what happened - particularly in my husband's case as he is hard of hearing but would not tell anyone. It would be helpful if there was a coffee/snacks machine in the A&E department and notices in cubicles to say where it is - last time we waited six and a half hours without water as it was late evening and the shop was closed - dehydration is not good for anyone. It would be useful if there was an educative notice in the cubicle explaining what in some detail what kinds of problems an A & E department is there to deal with and the procedure for assessing patients, also a notice stating the cost of parking as in an emergency no one stops to read that - several times I have left the department on my own in the dark only to have to walk back into the department to try to get change and as a female pensioner that was a stressful experience, even a porter to accompany me in such situations. But these are minor complaints. Everyone complains about the waiting times, especially for blood results or to be seen by the medic in order to be discharged, but demands on services make that an inevitable result of the cuts in services and staffing and we are still lucky to have the NHS.

    At our local A & E department there is also a lack of seating for relatives near enough to triage so rather than go to the waiting room along the corridor relatives prefer to wait by the triage door along with patients on trolleys brought in by ambulance who are seen in order of priority. It does work but must be stressful for patients - last time we went there were 9 trolleys with patients in nightdresses and similar, all unwell but with a whole lot of people waiting outside the triage room, some as long as an hour. As a patient waiting on a trolley I would find that difficult if I was feeling unwell enough to have been brought in by ambulance and if I was not feeling unwell I wonder why I am an emergency. There does not seem enough differentiation between people who need a medical assessment because of symptoms for which they called an ambulance, the walking wounded who have had an accident or injury or are just feeling otherwise unwell, and more serious emergencies.

    Our local walk in centre is excellent, there is parking nearby and staff are friendly and efficient - several times I found that I have finally got the correct diagnosis of an infection after having previously seen my GP, the specialist triage nurses seem better at assessing ears for infection than many GPs. The walk in centre triage system is excellent and takes only minutes for an initial brief assessment which sorts out the serious from non-serious.

    The main problem in A & E departments appears to be the number of people who go to the department for things that are really not serious emergencies though they may feel significant to the patient. I wonder whether it would be a good idea to have a 24 hour minor injuries clinic attached to A & E and patients to be sent there first unless they are clearly a serious emergency ie breathing problems or chest pains, or have previously been assessed by paramedics. A quick triage assessment in the minor injuries section could determine whether they wait for staff there or are sent through to A & E thus keeping the more serious triage service for serious accidents and emergencies. The term accident does imply that any accident can take a patient to A & E so differentiating between serious and minor accidents and injuries initially would make sense and reduce waiting times for A & E triage whilst allowing people to choose to wait in the minor injuries section or see their GP the following day.

  • Thanks to all those who have taken the time to read our Report and respond so far. The comments are incredibly helpful, and the points you are raising are really relevant to the discussions taking place within the Review team as we move in to the delivery phase of the Review.

    Please keep commenting: we are considering all of the feedback received.

    Urgent and Emergency Care Review Team

  • Thanks for giving us this opportunity to contribute. I visited the A&E dept at Southend Hospital last summer, with a sliced-off top of my finger that refused to stop bleeding, I was seen within a reasonable time and was treated with courtesy and care. I have used 111 on behalf of my husband and was able to ask for a prescription ( we knew what he needed) to be left at my local pharmacy. In both cases I was treated like a sensible patient who could negotiate the system. I also have experience, second-hand, with my elderly mother, of the walk in minor injuries clinic at Ely Hospital in Cambs. This facility is wonderful for filtering out the non-critical, more than GP concerns! or for use in out-of-hours cases. There needs to be tiers of treatment which include GPs, these local centres, and maybe more specialised A&E depts in hospitals where they are geared up to del with crises of a more serious nature.

    I agree about charging people who are health tourists, or those who have mis-used drink and drugs., however, without a NHS contributor, or an identity card, I don't know how this could be achieved.

    I am a cancer survivor and truly value the NHS. In spite of the problems in some areas, it does a wonderful job

    Thanks for the openness of the consultation


  • I have read about this rethink Idea.

    I live in Scotland, I have Asthma. Bronchiectasis and scarring of the lungs and I am under The Royal Infirmary of Edinburgh`s lung unit`s care.

    We must have a different setup, than that of down south as I have never had the kind of problems I have read about on these blogs, My last "fish out of water experience" was initially dealt by with NHS 24 who sent a crew to the house administered treatment and once I was reasonably stabilised then called an ambulance who took me to A&E for further treatment and admission.

    This works very well, BUT , my concern would be if the paramedic first response unit were overwhelmed with calls and were not able to get to me as quickly ( 3 minuets) from end of call, I may not have had such a good outcome.

    I agree that abuse of A&E is of major concern to people who have life threatening conditions but, is that not why NHS 24 or YOUR emergency 111 line are set up to deal with??.

    If used properly the Doctors out of hours, NHS 24 Emergency 111 and Paramedics are more than capable of handling run of the mill illness BUT Emergency treatment for people with life threatening illnesses must have a rush through treatment at A&E EVEN as a walk in patient.

    So I agree that education of minor ( non life threatening conditions ) have to be impressed on people (like colds) and other minor conditions are treatable AT HOME and do not require an A&E professionals intervention who`s time is valuable and being wasted on people with probably non emergency conditions so should be treated at home if required followed by a doctors surgery appointment the next day.

  • Thankyou for this opportunity to respond.

    Others have commented on the need to expand the hours of GP services when considering A&E services overall. I find it incredible that my London GP has such limited hours in particular why are they closed at lunchtime and half day one day a week. Surely there is a way to organise rosters so a patient focused rather than health professional focused service is available to meet the needs of people in the 21st century. The current system (to me) seems out of date with the times.

  • I have lived in a town with a minor injuries unit and, from what I saw, it didn't work. This particular town is right on the edge of three different counties and isn't properly covered by any of them so patients can be sent to several different hospitals away from their town during their illness. A familiar tale, I'm sure, but what makes this town different in my eyes is that it is the town closest to London's third airport. If you are unfortunate enough to fall ill while travelling through Stansted you are most often taken to Addenbrookes in Cambridge 18 miles away as it has the best road links. If the motorway is a problem in that direction you might be taken to Harlow which is a short distance (probably about 14 miles) but usually with greater traffic issues as the hospital is nowhere near the motorway. If both A&Es are full, bad luck, you're off to Broomfield in Chelmsford. Again, over 15 miles away, I think. My main problem with A&E is just that there isn't one! Stansted Airport has plenty of land surrounding it and more than enough demand in the surrounding area, in the airport employees alone. If there was ever a major incident at Stansted most of the casualties would probably die in ambulances on route. I've no idea why the airport was allowed to become so huge (and even become London's designated terrorist incident airport!) with such remote access to emergency treatment. Oh, but if you trip over your luggage you can get sewn up at minor injuries two miles away. So I guess that's ok, then. NOT! The growing airport has caused a population shift the NHS has not reacted to. Thousands of people live and work, some of them in a hazardous environment, in an area well over 10 miles from A&E. How bigger incident will it take and how many would have to die for someone to do something about it? BAA should be forced to give land over to building a new hospital. Millions have been spent on the airport's road links. They have inadvertently created the perfect site.

  • Having just come to this post I have not taken the full time to completely read all response and the attachment, apologies if I have repeated anything already written. From what has been raised in the original post I would recommend the following in dealing with A & E:

    Continue with separate areas at A&E for children and adults, keep the waiting time limit.

    Provide separate accommodation for drink related patients to be dealt with, this was highlighted on a programme not that long ago based in Wales, which was excellent in the way the managed it along with doctors, nurses, police and ambulances, but charge each person who attends but the money has to be paid before they leave. Starting price £25 - £100 depending on the time they spent there. They will soon learn to curb their drink activities.

    Walk-in Centres make sure the public are fully aware of these centres but state that on occasions you may have to have an appointment, (this happens in my area).

    GP's are the first people to complain about the cost of their patients trip to A&E, so make them use their reception televisions advising patients what the correct procedure is for wanting treatment. Where the location and telephone numbers of walk-in centre, minor injury's, out of hours GP service, drink centre, finally the local A&E.

    Lastly produce a leaflet with all the correct procedures that the public should follow and get it distributed to all households. Thus putting the onus back on the public.

  • Thanks Georje. A useful model regarding diverting drinkers, but one which does not distinguish between widely different needs. For those clients who have begun to drink hazardously or harmfully and who have resources, a brief intervention and a sobering invoice might produce an immediate positive change. But for clients with more profound problems and deeper dependence and who do not have the resources I feel we need something else, because the suggested regime would have no impact and they will present again and again unless a deeper solution is found. The distinction might be made through triage and then clients with more profound needs referred appropriately with some support to help them engage

  • Dear Sirs/Madams

    I would like to see a better change for not just the accident and emergencies but for the NHS as a whole. It is my belief, and has probably been discussed before in the political debates but I do believe that by putting annexes on GP practicing surgeries and using them for a small department of the NHS A&E, being manned by Doctors and nurses as well as other specialist medical staff, I believe will help take the strain off main stream hospitals, make more jobs and even help save somebody's life. GP's are stretched to the limit and hospitals are turning people away because of a lack of doctors or those trained in the medical field that the patient has been admitted into. The NHS does need a radical modern way of dealing with A&E and I do believe by building the Doctors surgeries larger or adding these annexes would help alleviate a lot of the stress.

  • We recently spent all night in Musgrove Park Hospital, Taunton, A&E when my wife was taken ill and collapsed with severe upper leg pains which paramedics who came to the house thought might be symptoms of a life threatening condition.

    Although it was not a particularly busy night, I was struck by the absence of security staff and the atmosphere of vulnerability and fear that I sensed among the very few medical staff that seemed to be available to deal with the walking wounded and others like us waiting for diagnosis. It reminded me of my own experience as a police officer on night duty when there was never enough cover.

    Whatever they do to change A&E working practice they should at least ensure there is enough medical staff and security to reassure patients and staff that whatever happens they're able to deal with it safely and quickly. That is the whole point of A&E. The hospital management have a duty to override the social considerations of staff and place them where and when they're most needed. Of course they need to be paid accordingly.

    It would also help if GP's did their own share of night duty as they once did. They get paid enough

  • I am fortunate to live in Norfolk where our NNU A & E department is vast. Having also worked at the hospital waved its flag constantly until last year when my elderly father had a fall and was taken to A & E late that night. This then became a nightmare, myself and my husband stayed with my father all night. He had remained in an ambulance outside for 2 hours in constant pain. I went into A&E informing them of the situation, and was told that as he had not been admitted into A & E was under the care of the ambulance crew, who were not trained to give pain relief. I then went in search to find someone who could. If I had not wiitnessed this I wouldn't have believed it. Once my father was admitted to A&E it was another 2 hours before being seen. I remember saying to the sister on duty at that time, my father did not get to 91yrs to come into A&E to die, unfortunately the following day he did. His care that night was very questionable, had we not spent the night with him I dread to think what would have happened. Having witnessed staff working flat out in A&E, the abuse they have to deal with, security staff having to deal with patients, this is not a hospital but a war zone at times, this should not in any way shape or form be allowed to continue. We are all living longer and the situation has to be dealt with now, we dont want promises but action. Good Luck.

  • I went to A + E earlier this year. I find that with emergencies I can end up in one of two local hospitals as I am equidistant between them. The one I went to this year was in Haverfordwest and the treatment I got was very good, I had to wait for a short while in the ambulance but not for very long and couldnt grumble. I went to the same one a year ago with a broken wrist - the treatment was on the whole reasonable then but my wrist wasnt properly set with the result that it is slightly wonky now and nothing can be done about it short of breaking it again (no thank you). A couple of years ago I went to the other one in Carmarthen and my experience there was horrendous - I was told to go home till the morning (could not do that as I had no transport and my knee was so swollen and fixed I could not get in a car) - agreed to let me stay on a trolley overnight in a cubicle - only pain relief was some tablet which they refused to tell me what it was (I can not take codeine), left me with no means to call for help - no water or food for over 12 hours - no access to toilet - nurses etc screaming up and down the corridors about their love life and ignoring patients calling for help. When I complained I was ignored I had to crawl off the trolley to ask for help to get to the toilet and was then left in a corridor in tears. So I would say that A + E are variable on the place, and the day, and the time. There needs to be consistentcy of care and care needs to be monitored and overseen by independent bodies.

  • Rather than a very specific problem with A&E departments where most problems are illuminated by the media rather than proper analysis by those qualified to do so, I have just made a general note about a problem that must be common throughout the world of work.

    I used to work in the software industry and I can't imagine the NHS is any different regarding my point which follows.

    It seems quite a regular thing that a new manager wanting to stamp his mark on his new department will do so by sweeping away systems or procedures of work that are seen to be problematic. After new systems and procedures have been composed and implemented there then follows a period of even greater problems. All that has been achieved is to swap on old set of problems for a new set that none of the staff know how to deal with.

    Everyone in the department gets disgruntled because at least with the old system everybody knew what to do in order to circumvent existing problems. The new manager gets a job somewhere else leaving chaos in his wake for others to tidy up. Job done!

  • Think I'm too late for this debate, but the biggest improvement isn't needed in A and E. Its the wards. Not enough staff for safe, quick, efficient care and subsequently discharges. The other change - ban nursing and other care staff from using the word "target". I want to be addressed as a "patient" not "target".

  • This is not a 'back to the drawing board' discussion, it is solely down to funding. The country is in economic crisis. There have been and still are numerous cut backs in all walks of life. Try teaching the doctors and nurses how to run on a shoestring, they are not just over stretched, it has gone on for so long now all the elasticity has gone. For the pittance the hospitals run they do a fantastic job. I am fortunate enough to teach in a private school where funding is not an issue, our results show the difference to what a well funded organisation can do.

  • People are using A+E services because they can't get appts. with their GP. There is one particular doctor I see at my surgery but I normally have to wait a month to see her. Lets start at the GP level and work our way up. Also I would gladly pay a nominal amount for services offered

  • I had a knee replacement last week , I came home 3 days later , by the weekend I was feeling rough with a temperature and a general feeling of unwell , I phoned the ward where I had been and explained how I was feeling only to find that I was to go through a&e , I did this only because of how I was feeling , this must be wrong and time wasting when I could have returned to the ward or seen the out of hours service , I felt this was wrong but followed instuctions

  • These modern A&E departments have become factory conveyor belt systems. since many of the smaller ones have been closed down at local hospitals, of course they will will be over whelmed with patients.

    Perhaps now, Patients are not getting the help many could possibly need.

    Sometimes life threatening conditions being over looked because of pressures involved.

    Also the big problem is many that would have gone to a local casualty department now turn up at a major A&E centre with very minor trauma, filling up the Halls.

    One possible Solution is drunkards are charged full rate for self inflicted sickness by over indulging.

    but this has to be made in Law.

  • I have been taken by Ambulance to the A@E seven times, both at Southend University Hospital and the Royal Free in London , in the past two years, and have been very satisfied with the treatment received, ( five occasions have been Admitted with Exacerbations of my COPD, I appreciate they are extremely busy, and even allowing for this , they have treated me well. Thanks to both Hospitals.