NHS organisations need to commit to making Keogh's A&E plan happen

NHS organisations need to commit to making Keogh's A&E plan happen

At last NHS England has the beginnings of a solution to one of the major crises facing the health service. Its long-term plan to address the A&E problems, unveiled on Wednesday, is clinically led, evidence-based, and provides a route to public acceptance. But it will be extraordinarily difficult to implement.


Such is the public's attachment to A&E that it probably took a crisis to stand any chance of convincing them of the need for change. Now we have one, most of the media has fallen in line, with even the Daily Mail giving the plan a fair hearing.


The proposed timescale of three to five years for transforming urgent and emergency care services in England is ambitious, but it offers the chance to build momentum before the arguments are forgotten. If it is allowed to drag on, early successes might have the perverse effect of taking enough pressure out of the system to undermine further reforms. And keeping it clear until the 2020 general elections would be good.


The broad approach to implementation taken by medical director Prof Sir Bruce Keogh and Prof Keith Willett, NHS England's national director for acute episodes of care, implicitly recognises the absence of trust between the public and the NHS leadership. The plan is built around trialling and then implementing community-based services as the precursor to changing A&E departments themselves, not shutting services and then opening new ones later.


This is in line with the approach to reconfiguration that then health minister Lord Darzi advocated under the Labour government. But now commissioners have to achieve this with flat cash.


The clinical and political sensitivity apparent in the plan is such that they have committed specifically to testing the proposals work for children, the elderly and frail, as well as those with mental health needs. Keogh and Willett appear to be doing everything possible to minimise the risk of a backlash from patients.


The crucial second phase of the report – how to make it happen – will follow in the spring. This will unpick how NHS England and clinical commissioners should commission the services, how the workforce will be retrained, and how best to help trusts and their A&E departments implement the changes.


One of the toughest jobs will be to restore public and NHS confidence in the 111 urgent care service, the botched reform of which has seriously damaged the credibility of NHS England in its critical first few months. GPs in particular, who warned NHS England the service would come apart, will take a lot of convincing.


The 111 changes look to be the part of the package that is most likely, in time, to need its own emergency treatment. The plan is certainly ambitious – for 111 clinicians to have access to at least some of your medical notes, to have doctors, nurses, paramedics, pharmacists and mental health support that you can talk to and who can then book you an appointment with your GP and a range of other services, such as a home visit from a psychiatric nurse.


The promise is that these services will in turn provide fast and consistent same day care.


So to make this plan work there needs to be, within five years, expanded and coordinated primary and community care services, freely sharing information and meeting patient needs round-the-clock. And presumably doing all this with no new money.


Set against this, developing 999 ambulances into mobile urgent treatment services looks relatively easy to implement.


The waves created by these reforms will reach every part of the NHS. Something, somewhere will have to be decommissioned to create the capacity in the system for the changes that happen. That will be the right thing to do, but it will create its own strains in the service and provide plenty of scope for political opportunism.


This review has been marked by prodigious consultation, reflected in the broad support offered by bodies such as the BMA and the College of Emergency Medicine. Organisations across the NHS need to commit to making this plan happen, and stick with it when it gets tough.

By Richard Vize

The Guardian, 14th November 2013

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