Keogh review puts GPs at heart of urgent care reform

GPs should work with other NHS services to deliver fast, consistent advice and urgent care outside hospitals around the clock, an NHS England review has said.

Sir Bruce Keogh: urgent care reform plan

The bureaucratic burden on GP practices must be cut to boost access to primary care and reduce pressure on A&E, the review by NHS England medical director Sir Bruce Keogh argues.

RCGP chairwoman Professor Clare Gerada welcomed the report for highlighting GPs' vital role in urgent care without blaming the profession for existing problems.

Transforming urgent and emergency care services in England calls for a dramatic rise in the proportion of urgent care delivered closer to home.

But it warns that ‘many people are struggling to navigate and access a confusing and inconsistent array of urgent care services provided outside of hospital, so they default to A&E’.

Sir Bruce says A&E is a ‘trusted brand’, with an average wait of just 50 minutes for treatment and most patients treated within four hours.

But in a letter to health secretary Jeremy Hunt and NHS England chairman Sir Malcolm Grant, he warns: ‘The opportunities for bringing about a shift from hospital to home are enormous.

‘We know that 40% of patients attending A&E are discharged requiring no treatment at all; there were over 1m avoidable hospital admissions last year; and up to 50% of 999 calls requiring an ambulance to be dispatched could be managed at the scene.’

Sir Bruce argues that ‘starting from scratch, nobody would design the current array of alternatives and their configuration’, warning that the complicated NHS system itself is driving up demand by ‘sending people around various services, confused about who to call and where to go’.

The review calls for a series of changes to improve urgent and emergency care including:

  • A ‘significantly enhanced’ NHS 111 with access to patient records, offering advice from a range of clinicians, appointment booking or call back by GPs and others, or a transfer to 999 services if necessary.
  • Faster and consistent same day, every day access to primary care and community services for people with urgent care needs.
  • Improved 999 services to handle more cases ‘at scene’, with support from GP advice.
  • Two levels of hospital-based emergency centre, with standard centres and a tier of ‘major emergency centres’ with consistent levels of senior clinical staffing and more specialist capability.
  • The ‘array’ of confusing terms for services should be reduced by co-locating community-based urgent care services in facilities uniformly referred to as ‘urgent care centres’.

Professor Gerada said: 'We are pleased that this report recognises the vital role of general practice and other community primary care services in providing care to patients with urgent needs. It is encouraging to see a report that sets out landmark changes in the way NHS emergency and urgent care will look in the future but that doesn't blame GPs.

'It explicitly recognises the sustained pressure and multiple demands on general practice in recent years, and the need to "create headroom" to transform the way we work so that we can continue to provide safe care for our patients. For the recommendations in this report to become a reality, that "headroom" has to include greater government funding and resources, including more GPs.'

GPC deputy chairman Dr Richard Vautrey said: ‘We would agree that the current system is too complicated and fragmented.'

Proposals to overhaul NHS 111 show the GPC is 'being listened to’, he added. ‘There is a need for more clinicians involved in dealing with calls so that patients are not only directed to the right service, but are given appropriate advice and if possible treatment through that one contact,’ he said. ‘The NHS 111 call service needs to be integrated with the see and treat elements of the urgent care service.’

Dr Vautrey said GPs already provide 24/7 services through daytime work and out-of-hours care. But he warned: ‘Both services are running hot in terms of coping with high demand and workload pressures.

‘We need a commitment from NHS England to reverse the fall in the proportion of funding spent on general practice so that both practices and out-of-hours organisations can start to take on additional staff to meet these growing demands. Expecting the current number of GPs to work harder and longer will simply lead to more GP burnout.’

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