Sir Bruce Keogh: the future of urgent and emergency care services in England

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  • Posted:Tuesday 06 January 2015

Sir Bruce Keogh, National Medical Director of NHS England, discusses the state of the urgent and emergency care system at our conference in December 2014.

With A&E waiting times regularly hitting the headlines, Sir Bruce says we must strive to provide responsive services close to home and that people with serious, life-threatening conditions must be treated in places with appropriate expertise. He says there are a number of things which must be done to get there, pointing out that the system must be intuitive and easy for people to use, something which is not currently the case.


Fewer things stimulate emotions and debate, campaigners, activists and local politicians more than A&E, and that is because there has been a steady and relentless growth in demand for our accident & emergency services for the winter of 2012/13. We established what were called Accident & Emergency Tripartite Groups, which in the new structures of the NHS brought together the Trust Development Authority, Monitor and NHS England to try and identify and solve local problems.

By 2013/14 it had become clear to us that we needed to engage more people than just those in the debate, and we established what were called urgent care working groups, which were subsequently to go on to become System Resilience Groups, that would bring together commissioners, providers and anybody else who have an interest in urgent and emergency care.

So this year we’ve started to address winter much sooner, so in January and March we held a number of workshops. In April we published our flu plan. In June we published our operation planning capacity guidance. At the same time the Secretary of State announced £400 million to be put into the system. In October a further £300 million was put into the system with a view to addressing issues of staffing and bed capacity, not just in acute hospitals, but also in community services.

But meantime other things have been going on. We’re caught, in the NHS, in the quadruple pincer of increasing demand, escalating costs, rising patient, public and professional expectations in a tightened fiscal environment. And that’s coupled with some pretty dramatic demographic changes. So we now have more older people than younger people in this country, and older people suffer from the ailments of longevity. Younger people, on the other hand, are brought up in a slightly different world of immediacy of information, immediacy of knowledge, and an expectation of immediacy of service, if you like, so it’s against some of those changing societal and demographic changes and demands on A&E that I was asked by the Secretary of State to undertake a review of the urgent and emergency care system in January 2013, and the vision at that time was really quite simple.

The first thing is, is that it is clear that we need to provide for our citizens responsive services close to home. The second thing we need to do is to ensure that those people with serious life-threatening conditions are treated in places which have the appropriate expertise to deal with those.  

There are several steps for getting there. The first is that we need to improve the support that we offer people for self-care. In other bits of their lives people do an awful lot of self-care in the form of online banking, online travel bookings, and in health we have in many respects fallen behind that kind of expectation which exists in other parts of society.

The second thing we need to do is ensure that people get the right advice at the right time. Now much of that has been focussed on improving 111 services, which you all know got off to a bit of rocky start but it is now much better than it was, and is working pretty well in most areas. It is also important that we offer services outside hospital which are much easier to access and which make it easier for people to attend those services rather than queue in A&E. The next step is that we need to ensure that people with very serious conditions are treated and are seen in centres of expertise and, of course, the really important thing for achieving all of this is that we need to connect all parts of our urgent and emergency care system together in networks.

Now the strongest drivers for making this work are to ensure that whatever new system we put in place is quite simply intuitive and easy for people to use. At the moment we don’t present the public with a system that is easy and intuitive. So, for example, providing responsive services outside hospital to try and discourage people from wanting to queue in A&E means that we need to offer consistent same-day services seven days a week to the general practitioners, to primary care, to community services, to local mental health trusts and organisations. We need to harness the skills of community pharmacists in a way that we haven’t done before, and we need to turn our ambulance services into more like mobile treatment facilities. We published our progress update on NHS choices in August 2014 which covers a bit more detail than I’ve given today.

So I think, Chris, I’ll stop my remarks at that point and wish you luck in your deliberations today, because we’re really interested in what comes out of here. Thanks very much.



Member of the public,
Comment date
08 January 2015
I agree Sir Bruce but we are tired of hearing what should be done, tired of hearing repetitive excuses as to why not and very tired of having few that seemingly can do little about it. We need someone who can take it by the scruff of the neck and bang a few heads together as the problem is not all the lack of money.
Enough of the soft, defensive approach and more towards giving very strong leadership and management decisions that matter and count - warts and all.
Of course it will not be easy but that is what leaders and managers are paid to do, that is the role and responsibility that they entered when getting their jobs and that is what the public and patients pay them to do and deserve not infinite statements, meetings and reviews. Of course it will not be easy but then nor is it for the countless patients that are suffering.

Anjan Bose

clinical lead CCG,
NHS Thurrock CCG
Comment date
08 January 2015
we agree with Sir Bruce
the biggest problem with NHS is this publicity that we have pumped in £700 million ponds and what it has done-nothing//its not that there are just more people attending A&E but once there the exit back to home is grossly lacking and the reason is drastic cuts in social services funding
unless we improve the repatriation of patients back to community we will not solve the issue
in our area we have GP in A&E yet the achievement of target is 92.5% and that is only because of lack of funding in social care/services
i hope the government realises this and address the issue through HAWBB

Ivan Benett

GP & clinical director,
Central Manchester CCG
Comment date
09 January 2015
Having A GP or anyone else in A&E won't stop the demand increase of sick people. We need to stop them getting so I'll in the first place. This means a more proactive and responsive Primary Care. It means making it easier to see a GP early on in illness, especially with Long Term Conditions. I can expand if called upon 4


Historian of Medicine,
Comment date
12 January 2015

One of the issues not addressed by Sir Bruce is the number of the frail elderly with pneumonia arriving at A&E. In such circumstances is a referral to a Hospice for support through the process of dying from pneumonia a possibility open to the A & E staff? Do Hospices see helping the extremely elderly die as part of their mission? If not, then should there be special palliative care wards for the dying elderly. These would be only for those times when letting pneumonia end a life is the humane thing to do for a person whose quality of life is so poor that appropriate care cannot be arranged by over-stretched social services. Research has shown that families trying to cope with those dying at home get inadequate support and little help with pain relief or sedation (this is especially a problem for the opiate niaf). With an aging population the fact that some of the pressure on A&E is from the under-resourced dying needs to be addressed. This is an observation based on family experience.

john kapp

Comment date
14 January 2015
The Better Care Fund task force are rightly calling for Community Care Centres to which GPs can refer patients. I have one at 3, Boundary Rd Hove BN3 4EH, which runs NICE recommended Mindfulness Based Cognitive Therapy (MBCT) courses which teach self care. See my papers on section 9 of www, We have applied for funding under the BCF extension of 50%

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