Can we keep up with the demand for urgent and emergency care?

The urgent and emergency care system is under severe pressure. Performance on a number of important indicators, including the four-hour wait and ambulance handover targets, is heading in the wrong direction. Demand is growing and calls for work to be shifted out of hospital look oddly out of line with a system that cannot even constrain, let alone reduce, the rate of increase in many places. Our recent study for NHS South of England raises some questions about the management of urgent and emergency care and identifies some important lessons.

The methods for running a hospital in the face of high levels of variable demand are now quite well understood. They are, however, based on an assumption that capacity and demand are in balance – which may not always be the case.  For example, it may be necessary to make major changes to consultants’ job plans to provide 18-24 hour cover, seven days a week. These methods are also hard to implement and need continuous monitoring and maintenance. The key to success is to ensure that patients flow quickly through the hospital and are discharged rapidly. This may have been made more difficult by attempts to improve efficiency and utilisation, and close beds, which have left hospitals running at high levels of occupancy and with reduced ability to respond to fluctuations in demand or to discharge patients.  

If community services and social care were able to respond flexibly and quickly, this would be less of issue. However, it does not often happen in practice. Community services have been commissioned on inflexible block contracts and often measure response time in days rather than the hours required by hospitals. Social care is feeling the impact of very tight finances and often does not respond at the pace required.

There is still much more to do to improve the urgent and emergency care system, including increasing the availability of primary care appointments, ensuring continuity of care for patients, dealing with problems ‘in hours’ where possible, and improving the quality and consistency of ‘out of hours’ services. The big variations in ambulance service practice also need to be addressed – for example, in the percentage of people who are taken to hospital. And we need better metrics that capture more useful information about the experience of patients and the operation of the system – the four-hour target conceals too many differences in practice to be very useful on its own. 

There are also major issues around how commissioners have operated. Some have taken adversarial approaches, whilst others have tried to do a detailed redesign of pathways. In our report we found examples of questionable approaches – for example, exploiting the difference between the community tariff and the hospital tariff. We also found a number of schemes aimed at avoiding admissions and A&E attendance. These were generally very poorly evaluated, often based on hunches rather than evidence, too small to make much impact, hard to manage and prone to creating additional demand. This adds to the very high level of complexity that is already present due to layers of previous projects, national initiatives and uncoordinated service developments.  A directory of services will help with this but, rather surprisingly, the commissioners we spoke to did not have a clear map of the system’s capacity or of the flows between the different parts of it.  

So how can we overcome the problems around increasing demand?  One option is to create extra capacity, although there is the danger that this will lead to increased admissions or other changes in the behaviour of the system as it fills up. The only way to beat this is through a combination of very senior people making clear decisions at the front door and the ability to extend the hospital beyond its traditional walls by using beds in nursing and residential homes, and in the patient’s own home.

Directing patients elsewhere is another option, although treating minor cases in A&E probably costs no more and possibly less than some of the alternatives and in general they do not impact on the four-hour target. General campaigns to persuade people not to go to A&E do not seem to work, but there is scope to target practices and individuals with very high utilisation rates.

To address the problems created by increasing demand on urgent and emergency care we need more strategic approaches that reduce complexity, reshape primary care and chronic disease management, support patients in their own homes, and change the way that nursing and residential care are incorporated into the system. These need to be built around natural communities and involve a new relationship between the different providers. All of this requires leadership across a system rather than attempting to fix each individual component. 

Keep up to date

Subscribe to our email newsletters and follow @TheKingsFund on Twitter to see our latest news and content.


#40369 Harry Longman
Chief Executive
Patient Access Ltd

The research I published linking 20% lower A&E rates with access to GPs, very rapidly at first by phone, is now over two years old. We have more and more case studies, more and more CCGs are interested and playing around with it, but no one has picked it up with any kind of urgency. You complain above about schemes to divert demand which have no evidence behind them. This one does. Just tell me, what more am I supposed to do to get this on the agenda?

#40370 Angus Murray-Brown

100% GP phone triage isn't the way to save ED and Urgent Care resources - anecdotally a lot of practices are now dropping it as it is generally shunting risk to the GP's side via many more patient contacts as well as increasing expectations in healthcare access - which may stoke the fire more in future. Since the time of Erlang, Queue Theory always allows for balking and reneging.

What would I do? Offer a central prize to the Universities/Academics to come up with the most effective mathematical solution to best resource utilisation. Set 3 problem groups 1) ED efficiency etc 2) GP resource allocation etc 3) Overall design of Urgent Care.

Model the entrants solutions into thousands of simulations to select a winner.

I suspect the results could be stellar as well as being very cost effective. But there is no easy solution to this problem.

#40371 Harry Longman
Chief Executive
Patient Access Ltd

Angus, we don't say it's easy, we do say it works. To say "anecdotally a lot of practices are dropping it" will not do. We have around 90% success rate, I wish it were 100%, but it is sustainable because it is putting GPs back in control of their time, who they see, when and for how long. GPs invented it for that reason. To make it work in high demand practices requires fine tuning and perseverance, but look at what some of them are achieving, eg The Elms Liverpool, another case study from inner Salford about to go public.

Sure we should work on ED efficiency, and again start with demand, and with better allocation of GP resources, and with overall design. But I wouldn't look to mathematical modelling. I'd look for real world practice, probably already happening somewhere, which is how I found GPs on the phone. The first ones showed up by having low A&E, unconsciously.

#40372 Dr Daniel Albert
GP; A&E doctor; CCG non-exec

You are right to identify this as one of the most important issues facing the NHS. The current shortage of emergency medicine middle-grade doctors will translate into a consultant shortage that will haunt us for decades -- if we continue with the same model.

Attempts to replace high-tech hospital care with low-tech community care have broadly failed because the diseases did not down-grade to suit. A large proportion of the work that now goes to A+E is too simple to need hospital care, but too complex for general practice. A gap in medium-severity care has developed, that is widening with the increase in patients with long-term conditions, with older patients and particularly with older patients with long-term conditions.

The solution is to develop high-tech medium-severity urgent care facilities close to where people live. Similar to what might be meant by "Urgent Care Center" in the USA, but nothing like what we use (misuse) the term for over here.

I will talk about this at the "Improving Urgent and Emergency Care Conference" in London on 26th June 2013. Please see You would be welcome to attend.

#40373 Andy's Proctor
West Midlands Council Member
College of Paramedics

More can also be done Pre-hospitally with improved training and investment. Paramedics are in an ideal position to reduce patients requiring treatment at A & E and this can be done further with the push for some Paramedics being able to Prescribe drugs.

#40375 Dillo Sykes
Productive Primary Care

A decent article as usual from Nigel. It is an age old problem he addresses one which has seen me in a personal capacity work with General Practice for more years than I care to remember on improving access systems and patient outcomes.
A key success is levelled on increasing primary care access, and for me balanced with increasing patient confidence that on the day they feel un well they can speak with their GP.

We have many successes of this through our Doctor First system (over 50 practices we have worked directly with) which is rightly documented in the Digital First initiative as an option for General Practice to reduce unnecessary face-to-face appointments.

We don't look to get this on any ones agenda the key is to make sure you are there to help those that need it. There are many big system changes happening at the moment in the NHS and success will come working with those that 'have left home' on the journey to improvement. Without them leaving home in the first place we will make little progress. Let's focus on those key people making the journey before telling them what the answer is or how many evidenced based papers are out me and I'm not a doctor!

#40376 David Carson
Primary Care Foundation

There is not a good relationship between A&E attendances and Admission Rates. Many trusts have high attendances and lower admission rates. Much depends on the process within the trust, those with senior early assessment and decision making tending to do better. We have some way to go to have effective acute ambulatory systems in many trusts. General practice can contribute significantly with good solid evidence linking good access and continuity of care to lower acute referral rates and better QOF outcomes. The key issue is continuity which can be delivered in practices in many ways. We should learn from the past that one size fits all (do it this way and all will be ok) changes to general practice processes tend to benefit a few but degrade performance and response in many. Each practice needs to have confidence in its own system. The operational links between community services and GPs need to be improved and re-establish a proper local team. In too many places this link has been broken. Much can be done by the Ambulance Service however moving beyond high profile interventions transporting the elderly at risk of admission who have been seen quickly by GPs in substantially less than 4 hours to hospital if they do need assessment would be life changing for many.

#40377 Ruth Rankine
Director of Strategy & Business Development
NHS Direct

Nigel, I'd be interested to know if your study looks at the impact of 111 on urgent and emergency care - in a good or bad way?

#40378 Phil Sanmuganathan
Consultant Physician
Acute Trust

Telephone triage by GPs with hot-lines for specialist advice and access to specialist clinics will reduce ED access pressures. This will be similar to having specialists seeing first and getting a management plan done on in-patients who stay for 0-3 days done in an OP clinic setting. This needs co-ordination and co-operation, with community support to prop these patients up at home.

#40379 jay banerjee
Health Foundation QIF/Consultant in Emergency Medicine
IHI, Cambridge, MA/UHL NHS Trust, Leicester

Identification of the populations at risk and tailoring services to their needs should be the way to start. Traditionally we have developed services to respond to defective processes. We need to respond through changes in how we learn, deliver and create cross-bridges to address seamlessness in providing and commissioning. This needs to be done with special emphasis on vulnerable groups - especially frail older people.
Quantifiable solutions through scientific analysis would be a boon. Flow and capacity cannot be addressed reliably without mathematical modeling. It is not very appealing, needs capability and should proceed simultaneously with other tests of change.
We in healthcare have the uncanny ability to look at everything through our eyes only. It is time to do this through the eyes of the people in society and engage in honest discussions to address the wellbeing of the individual, contribute towards population wellbeing and at a price that society is willing to pay.
No single solution will solve a whole systems problem. The issues may be more around a lack of will to move towards integrated working rather than a lack of ideas and potential solutions. Competition needs to be on delivering quality through sharing of knowledge and expertise. We need to stop thinking in silos although it is easier said than done. Many of us are still trying to think our way out of silos rather than acting our way out of it. At the same time, we cannot expect anyone to behave differently unless each one of us does so first. Leadership is crucial – but this needs to be everybody’s problem. No single person, service or institution can get us out of this.

#40380 Confidential de...

We recently had the pleasure of the company of our daughter staying with us along with her month-old daughter. She’d come home to be looked after whilst her husband was away with work.

One evening it became apparent that some discomfort she had been experiencing was getting in the way of daily life with a baby. Sleep was being lost. It needed to be sorted.

“I think we should go to A&E,” said Mother.

I, as a dutiful senior healthcare professional said; “No, this is definitely not an emergency. I’ll ring NHS111 to see if we can get you looked at in primary care this evening.”

We would have preferred the operative simply to have told us of a drop-in facility – I had been thinking of the GP out-of-hours centre that had been located at our preferred hospital in times past – but we understood that she was required to collect a lot of detail. She then consulted a colleague and asked us to ring a local practice for an appointment. We were told that it was acceptable to attend the practice with which we were registered as a temporary resident.

Dad then looked in the medicine cabinet to extemporise an analgesic regimen for overnight use. The ladies would make the necessary ‘phone calls in the morning whilst I went off to work.

I was bleeped during that early morning clinical meeting.

“We’ve telephoned the surgery. We’ve been told that it is company policy not to see temporary residents. They’ve told us to go to some place in the city centre. We’re coming to A&E as we should have done in the first place.”

I had completely lost the argument at this point.

I agreed that they should come to the emergency department (see, I know the current term); in the meantime I made full use of privileged access and asked colleagues in the hospital to provide their specialist advice. Emergency department services were not used in the end.

If we had not been a family with some knowledge of healthcare and the NHS, albeit clearly not bang up-to-date with means of access to its systems other than those in which I work, what would we have done? We would either have (a) come direct to the ED, (b) phoned 111 and when an immediate solution was not offered come to the ED or (c) phoned the practice as advised, got what was to us an unsatisfactory response and then come to the ED.

Poorer people use the ED as the part of the NHS where they can compete most readily for resources with sophisticates who know which buttons to push. Tell them: “You should only use a hospital service as a last resort” and the response is: “We are using it as a last resort!” if the out-of-hospital service is perceived to be hard to use. Even sophisticated intellectuals like Matthew Parris cannot see the point of going to the GP when an ED with attached X-ray department provides a one-stop shop.

So this problem can only be solved by having out-of-hospital services which have sufficient spare capacity to be flexible, can be accessed very easily and in which the public have confidence. It is beginning to look as if the numbers 111 symbolise a barrier of three vertical bars.

Or would Andy have preferred that we called 999 and got the advice of a paramedic?

#40381 Michael Crawford
Consultant Medical Oncologist

Looking at the report to which this blog relates it is unfortunate that there is no reference to the development of Acute Oncology services which every hospital with an Emergency Department is required to have. These exist to minimise the effect of patients with cancer on emergency services by bringing oncological expertise to the management if inpatients or by allowing diversion of patients to designated outpatient facilities.

#40382 Jo Bayley

Getting GPs to do more urgent care will make the problem worse, not better. GP time is finite. The more urgent care they do, the less time they have for chronic disease management. It is good chronic disease management and good management of the frail elderly that will ultimately reduce the demand for urgent care by reducing emergency admissions. There is a wealth of evidence that well-managed long-term care reduces emergency admissions but delivering that care is challenging. The last thing policy makers should do is to reduce the amount of GP time available for it by insisting GPs prioritise seeing 22 year olds with a sore throat for 20 minutes (a real example from my own practice - he demanded an emergency appointment).

#40383 Mary E Hoult
community volunteer

Great article Nigel as always,increasing demand and extra capacity are key to the current situation but will not happen in the current NHS Plan.
So what we have left is rationing and at best slowing down access.
Not good if you are a patient.

#40384 Toby Gillman

Changing consultants' patterns of work may be feasible in the short term but Daniel is correct to identify the current shortage of ED middle grades. The most recent competition ratio for ED ST3s was 0.5; that is 50% of middle grade training places were not applied for.

ED has to be made a more attractive career and 24 hour consultant coverage will have to be implemented very carefully if this is to be the case. As Jo pointed out, however, the answer is not GPs doing more urgent care as it will take away from chronic care. It is also worth pointing out that the GP places nationally last year were not filled, and more GPs are working flexibly, so designing a solution centred around GPs doing more urgent care is also likely to be a short term solution.

With the increasing rate of consultations for minor illness, many practices have found employing specially trained nurses does provide some headroom to allow GPs to better concentrate on more complex patients, and potentially reduce admissions. The problem with this is that there are very few training schemes and so practices need to train them themselves, as well as often needing to train practice nurses as there are very few training schemes for them either.

Care is moving more and more into the community but nursing training is still very biased towards specialties and secondary care. If we are to provide a better standard of care from a diminishing pool of doctors we need to look at it from all angles.

#40385 Richard Jenkins
Group Medical Director
One Medicare

This is a highly complex problem and one that won't have a single solution so aiming at one answer will in my view fail. Multi-factorial problems demand multi-factorial solutions in the main.
One thing we have found is that a non-adversary approach with a shared vision is helpful and engaging all stakeholders is necessary. Building the positive relationships with all providers and service users is a fundamental step, often overlooked. Sharing data, being open and transparent and trusting others in the system needs deliberate effort, often doesn’t come naturally and without it as the foundation the rest of this improvement journey looks doubtful.

#40386 P Kerr
ED Cons

Michael Crawford highlights an area of enormous importance. Oncology has increasing numbers of acute patients presenting at all hours with only Emergency Departments and Acute Physicians to treat them in many cases.
This issue, where major services have not developed access (or withdrawn access) to acute and unscheduled care for their patients as services have grown is at the heart of the problems in Emergency and Uscheduled care in the NHS.
It is clear to most of us the flood of acute oncology patients like many other groups of ACUTE problems in ED will not be sorted in the community

#40389 Amir Hannan
GP and CCG Board member leading on Long Term Condiitons, Information Management & Technology and Patient Engagement / Empowerment
Haughton Thornley Medical Centres, and Tameside & Glossop CCG

I welcome the issues raised as well as the subsequent comments above. There are some very hard lessons for us all.
1) Senior clinicians making decisions at the front door
2) Extending hospitals into the community and into their own homes
3) Managing people in A&E rather than elsewhere
4) General awareness campaigns with targetted messages to practices and individuals
4) A new relationship between providers

Do we also need increased understanding between clinicians in primary and secondary care - something seems to have been lost as a result of the traditional lunchtime meeting being discarded in the pursuit of identifying individual learning needs? Perhaps it is time to bring this back?

We also need to have joined up meetings with social care too - not just healthcare talking to each other. It is becoming increasingly apparent that health and social care really do need to work together particularly with an aging population and the rise in incidence of dementia amongst the population at large. Our systems presently do not cater well for this in general.

Finally we really do need to focus on the needs of patients and the public and support them but also learn from them too to see how they are navigating the system and succeeding. You may find this talk by 2 of our patients who have had access to their records for over 7 years interesting entitled "Our Health, Our Lifetime's Work"

#40390 Marion lynch
Associate Dean
NHS England Health Education

Dear Toby The shifts of workload to other colleagues, ED to GP, GP to Practice Nurse requires skills development and career development. Your comments on PracticeNurse development are welcome and we have programmes in place. The challenge is now to support Practices to see themselves as training organisations for whole primary care workforce. Current payment processes do not help. Your involvement and insights will be welcome. Please contact me. Dr Marion Lynch Oxford Deanery

#40391 Matthew Miller
Consultant General and Colorectal Surgeon
East Sussex Healthcare Trust

Systems of care are usually set up by reasonable people trying to do their best with the resources available. These systems persist until either superceded, or evolve driven by external pressures. Often the underlying assumptions on which these systems are based were not explicitly recognised at the time of setting them up. This makes it even harder later to work out if they still hold true, and to either rectify or adapt to the current situation.
Unfortunately there is a tendency when faced with a clinical decision in a pressured A&E dept to want it made as quickly as possible and with the best chance of managing the patient without unnecessary admission to a scarce acute bed. This has led to the call for more and more senior clinicians to be involved, and to be present for more hours in the day. From personal experience the cases that I was managing as a surgical house officer in the early 90's were the same ones I ended up having to manage as a senior specialist registrar in the 2000's. By then the effect of reduced hours of experience,and more importantly reduced expectations, had resulted in the inability of the Foundation year and Core Trainee doctors to manage these cases. The situation now is where we routinely have newly appointed surgical specialty registrars unable to perform an appendicectomy unaided. Whilst that is an issue mainly for the general surgical dept - the general lack of knowledge in younger doctors about routine matters general surgical has now spread beyond the hospital and pervades all disciplines. This includes many younger GPs. The situation is not helped by many medical schools reducing anatomical teaching and trying to make surgery a postgraduate subject.
Combine the above lack of experience with heightened patient expectations and a litigious culture, then it is unsurprising that problems once dealt with by primary care and junior doctors are now routinely being referred and admitted to hospital.
Likewise a patient with for instance three medical problems will be sent to see three different specialists- as opposed to the old style general physician who was happy to manage the entire situation- and had the advantage of a holistic approach.
The "demand" for specialist care has increased above and beyond the simple number of patients- let alone the increased life expectancy with multiple comorbidities.
One of the unrecognised assumptions in this current situation may be that doctors are getting the same clinical experience and training as in the past, and are able to perform to the same workload. And that performing a 4 month attachment to A&E or General Surgery equips them with the same experience as in the past.
I do not believe that this is the case based on my experience of trainees over the last five years as a Consultant, and discussion with colleagues across specialities.
The overall situation is of course multifactorial - and I do not for one moment believe that there is one magic bullet which will solve it- however we either have to factor in the very real lack of general surgical experience for doctors over the last 5 years and its implications- or we have to address the training enviroment and program for them.
I expect much of this to be mirrored in similar ways in general medicine and its subspecialities.
Should we now be training the next generation of doctors as generalists?

#40392 Peter Devlin
GP, Clinical Director, Primary Care Adviser
Brighton & Hove Integrated Care Services Ltd, Brighton & Sussex University Hospitals

A really interesting discussion. In primary care it is a mistake to separate long term condition care from unscheduled care - most acute admissions arise form the unscheduled care needs of the population with ltc. We need to optimise our proactive care of the these patients, and we need to respond to their urgent needs. Our urgent care response needs to be sensitive and proportionate to underlying risk stratification. Fit young men with sore throats do not need a GP.
There has been very little attention paid to unacceptable variation in internal care pathways within hospitals, variation in use of diagnostics, medications, complication rates, waste and duplication - which leads to huge variation in length of stay. There is still a pervading culture of a need to "fix everything while they are here", what some colleagues refer to as the "acute medicine factory" and a general lack of awareness around the risks that accumulate around each additional day spent in a hospital bed.
Two additional short to medium term solutions:-
1. Primary care needs to be incentivised to move towards stretch targets for appropriately adjusted acute admission rates.
2. Hospitals need to performance manage individual consultant teams around length of stay.

#40412 Michael Paul

I started and ran a group of urgent care centre based on the US model such as you describe, for fifteen years in the City of London, and they were highly effective and very popular. Despite having streams of politicians in the early days, and even a sec of state visit once, never managed to interest the NHS, nor been asked for details of how we did it. I am now trying to interest individual trust A&E depts to consider my proposals without any success. Uphill battle.

#40413 stephen black
management consultant
pa consulting

The first thing many people suggest when the A&E departments are busy and slow is that they are being swamped by demand or other external factors. There has been an orgy of such suggestions in the last few weeks as performance plumbs depths not seen since the early days of the 4hr target.

Most of this commentary is based on plausible stories about why things go wrong. These stories appear to be substantially more powerful that the actual evidence and data which directly contradicts most of them.

For example, Jeremy Hunt and many others have alleged that changes in the GP contract leaving them free to not provide out of hours coverage has led to A&Es being swamped by demand. Nice story, but not remotely consistent with the actual statistics (as John Appleby, almost uniquely among commentators, pointed out here ). I added some other stats supporting this on the HSJ twitter discussion on thursday may 2 (look for the #HSJEmergency hashtag).

Nigel's report claims early on that the data don't explain the current situation. This reminded me of a controversial piece of analysis done by the Audit Commission a year or two before the A&E target was introduced and refreshed by the Healthcare Commission in 2005. This concluded that none of the obvious factors explained the differences in A&E performance (and they included analysis of staffing levels and other hard-to-get internal stats).

I said the following in a BMJ article ( at the time:

"...there is no relation at all between staffing levels and performance. Nor does any relation exist between changes in staffing and performance. None of the intuitively “obvious” factors that might be thought to influence performance seem to matter much.

... the way a department is organised has more influence on its performance than even major changes in staffing. In other words, management matters. And just increasing resources is a poor way to fix performance problems."

This incited much incredulity despite being an accurate summary of the regulator's work.

We seem to have arrived at the same point again. We are identifying problems and proposing solutions neither of which are consistent with the evidence while ignoring known practices that work (Nigel's report also points this out).

In seeking external causes and eschewing known solutions because they are related to "management" ideas not resources, we make the quality of care worse and hurt patients.

#40418 dr alice findlay
consultnat emergency medicine
dartford and gravesham trust

Until patients can gain access to see a doctor within 4 hours, then ED attendances will continue to increase. Worried patients need immediate access, and will go to the place that can provide This is currently only the EDs.As each part of the NHS becomes more inaccessible to the patient, the ED is becoming the only place they can seek advice and treatment in a timely way without appointment , especially out of hours.

#40425 Jo Bayley

"Until patients can gain access to see a doctor within 4 hours, then ED attendances will continue to increase. Worried patients need immediate access."

Access to services must be based on actual clinical need, not perceived need. Very few patients actually need to see a doctor within 4 hours (barring emergencies that we would all agree should be seen in an ED).

The ED 4 hour wait target certainly drives patients into the ED and increases strain on the system but the answer is not to replicate those problems elsewhere. Much of what primary care does is invisible to secondary care consultants (I say this as a former emergency medicine SpR myself), particularly preventative medicine and management of long-term conditions. Diverting GP time from that work to see any patient who is "worried" within 4 hours would be an utter disaster. Primary care would immediately fall over and the demand on EDs would be greater than ever.

ED attendances are rising but so are GP attendances - the average patient now sees a GP/practice nurse 5.8 times per year, up from 3 times less than a decade ago. This is a whole-system problem and the answer is not to shift counter-productive targets from the ED to primary care.

#41985 Urgent Care

I am very glad to know about importance of urgent care centers and emergency services.

#445121 mizuno volleyball
mizuno volleyball
mizuno volleyball

<a href=""><strong>canada goose jackets</strong></a>,<a href=""><strong>canada goose outlet</strong></a>,<a href=""><strong>canada goose jacket</strong></a>,<a href=""><strong>canada goose parka</strong></a>,<a href=""><strong>canada goose sale</strong></a>,<a href=""><strong>canada goose outlet sale</strong></a>,<a href=""><strong>canada goose outlet store</strong></a>,<a href=""><strong>cheap canada goose</strong></a>,<a href=""><strong>canada goose jackets sale</strong></a>,<a href=""><strong>canada goose jackets sale</strong></a>,<a href=""><strong>women canada goose jackets</strong></a>,<a href=""><strong>canada goose men jacket</strong></a>,<a href=""><strong>canada goose sale</strong></a>,<a href=""><strong>canada goose jackets sale</strong></a>,<a href=""><strong>canada goose parka sale</strong></a>,<a href=""><strong>canada goose coats</strong></a>,<a href=""><strong>cheap canada goose</strong></a>,<a href=""><strong>canada goose sale</strong></a>,<a href=""><strong>nike free 5</strong></a>,<a href=""><strong>nike free run 5</strong></a>,<a href=""><strong>nike free 5 women</strong></a>,<a href=""><strong>nike free run 5 women</strong></a>,<a href=""><strong>nike free run womens</strong></a>,<a href=""><strong>nike free women</strong></a>,<a href=""><strong>nike free run women</strong></a>,<a href=""><strong>womens nike free run</strong></a>,<a href=""><strong>nike free men</strong></a>,<a href=""><strong>men nike air max</strong></a>,<a href=""><strong>air max women</strong></a>,<a href=""><strong>women air max</strong></a>,<a href=""><strong>nike air max women</strong></a>,<a href=""><strong>women nike air max</strong></a>,<a href=""><strong>nike air max men</strong></a>,<a href=""><strong>nike air max 90 men</strong></a>,<a href=""><strong>air max 90 women</strong></a>,<a href=""><strong>nike air max 90</strong></a>,<a href=""><strong>air max 90</strong></a>,<a href=""><strong>nike air max 90 women</strong></a>,a href=""><strong>snapback hats</strong></a>,<a href=""><strong>cheap snapback hats</strong></a>,<a href=""><strong>snapback</strong></a>,<a href=""><strong>snapback hat</strong></a>,<a href=""><strong>cheap snapbacks</strong></a>,<a href=""><strong>snapbacks</strong></a>,<a href=""><strong>snapbacks</strong></a>,<a href=""><strong>snapback hats</strong></a>,<a href=""><strong>snapback hat</strong></a>,<a href=""><strong>nba snapbacks</strong></a>,<a href=""><strong>mlb snapbacks</strong></a>,<a href=""><strong>nfl snapbacks</strong></a>,<a href=""><strong>chicago bulls hat</strong></a>,<a href=""><strong>nba snapback</strong></a>,<a href=""><strong>bulls snapback</strong></a>,<a href=""><strong>miami heat snapback hats</strong></a>,<a href=""><strong>nfl hats</strong></a>,<a href=""><strong>mlb hats</strong></a>,<a href=""><strong>chicago bulls snapback</strong></a>,<a href=""><strong>bulls snapback</strong></a>,<a href=""><strong>nba snapbacks</strong></a>,<a href=""><strong>miami heat snapback</strong></a>,<a href=""><strong>miami heat hat</strong></a>,<a href=""><strong>chicago bulls snapback</strong></a>,<a href=""><strong>miami heat snapback</strong></a>,<a href=""><strong>nfl snapbacks</strong></a>,<a href=""><strong>mlb snapbacks</strong></a>,<a href=""><strong>hollister women</strong></a>,<a href=""><strong>hollister men</strong></a>,<a href=""><strong>hollister clothing store</strong></a>,<a href=""><strong>hollister shirts</strong></a>,<a href=""><strong>hollister shorts</strong></a>,<a href=""><strong>hollister jeans</strong></a>, <a href=""><strong>ugg shoes</strong></a>,<a href=""><strong>ugg shoes women</strong></a>,<a href=""><strong>uggs shoes</strong></a>,<a href=""><strong>uggs sale</strong></a>,<a href=""><strong>chanel handbags</strong></a>,<a href=""><strong>chanel outlet</strong></a>,<a href=""><strong>chanel bags</strong></a>,<a href=""><strong>nike free run</strong></a>,<a href=""><strong>nike air jordan</strong></a>,<a href=""><strong>nike free</strong></a>,<a href=""><strong>air jordan</strong></a>,<a href=""><strong>calvin klein outlet</strong></a>,<a href=""><strong>calvin klein outlet online</strong></a>,<a href=""><strong>calvin klein underwear</strong></a>,<a href=""><strong>calvin klein underwear outlet</strong></a>,<a href=""><strong>calvin klein underwear sale</strong></a>,<a href=""><strong>calvin klein outlet stores</strong></a>,<a href=""><strong>calvin klein underwear for men</strong></a>,<a href=""><strong>men calvin klein</strong></a>,<a href=""><strong>mens calvin klein underwear</strong></a>,<a href=""><strong>calvin klein underwear men</strong></a>,<a href=""><strong>calvin klein men</strong></a>,<a href=""><strong>calvin klein men underwear</strong></a>,<a href=""><strong>nike air max women</strong></a>,<a href=""><strong>women nike air max</strong></a>,<a href=""><strong>men nike air max</strong></a>,<a href=""><strong>nike air max men</strong></a>,<a href=""><strong>nike air max women</strong></a>,<a href=""><strong>women nike air max</strong></a>,<a href=""><strong>men nike air max</strong></a>,<a href=""><strong>nike air max men</strong></a>,<a href=""><strong>nike free</strong></a>,<a href=""><strong>nike free run</strong></a>,<a href=""><strong>nike free run womens</strong></a>,<a href=""><strong>nike free women</strong></a>,<a href=""><strong>nike free run men</strong></a>,<a href=""><strong>nike free men</strong></a>,<a href=""><strong>nike free 5</strong></a>,<a href=""><strong>nike free run 5</strong></a>,<a href=""><strong>nike free 5 women</strong></a>,<a href=""><strong>nike free run 5 women</strong></a>,<a href=""><strong>nike free 5</strong></a>,<a href=""><strong>nike free run 5</strong></a>,<a href=""><strong>nike free 5 women</strong></a>,<a href=""><strong>nike free</strong></a>,<a href=""><strong>nike air max 2014</strong></a>,<a href=""><strong>cheap nike air max 2014</strong></a>,<a href=""><strong>nike air max 2014 women</strong></a>,<a href=""><strong>nike air max 2014 men</strong></a>,<a href=""><strong>abercrombie fitch</strong></a>,<a href=""><strong>abercrombie outlet</strong></a>,<a href=""><strong>abercrombie fitch outlet</strong></a>,<a href=""><strong>abercrombie fitch clothing</strong></a>,<a href=""><strong>hollister clothing</strong></a>,<a href=""><strong>hollister clothing store</strong></a>,<a href=""><strong>hollister store</strong></a>,<a href=""><strong>hollister jeans</strong></a>,<a href=""><strong>hollister shirts</strong></a>,<a href=""><strong>hollister shorts</strong></a>,<a href=""><strong>hollister clothing</strong></a>,<a href=""><strong>hollister women</strong></a>,<a href=""><strong>hollister men</strong></a>,<a href=""><strong>hollister clothing</strong></a>,<a href=""><strong>hollister clothing store</strong></a>,<a href=""><strong>hollister outlet</strong></a>,<a href=""><strong>north face outlet</strong></a>,<a href=""><strong>north face sale</strong></a>,<a href=""><strong>north face store</strong></a>,<a href=""><strong>cheap north face</strong></a>,<a href=""><strong>north face outlet store</strong></a>,<a href=""><strong>polo ralph lauren</strong></a>,<a href=""><strong>polo ralph</strong></a>,<a href=""><strong>polo ralph lauren outlet</strong></a>,<a href=""><strong>polo outlet</strong></a>,<a href=""><strong>polo shirts</strong></a>,<a href=""><strong>polo ralph lauren</strong></a>,<a href=""><strong>ralph lauren outlet</strong></a>,<a href=""><strong>ralph lauren outlet online</strong></a>,<a href=""><strong>polo ralph lauren outlet</strong></a>,<a href=""><strong>polo outlet</strong></a>,<a href=""><strong>ralph lauren polo</strong></a>,<a href=""><strong>polo ralph lauren outlet</strong></a>,<a href=""><strong>polo outlet</strong></a>,<a href=""><strong>ralph lauren outlet</strong></a>,<a href=""><strong>polo ralph lauren</strong></a>,<a href=""><strong>polo shirts</strong></a>,<a href=""><strong>polo outlet</strong></a>,<a href=""><strong>polo ralph lauren men</strong></a>,<a href=""><strong>polo ralph lauren women</strong></a>,<a href=""><strong>polo shirts men</strong></a>,<a href=""><strong>polo shirts women</strong></a>,<a href=""><strong>canada goose men</strong></a>,<a href=""><strong>canada goose women</strong></a>,<a href=""><strong>canada goose outlet</strong></a>,<a href=""><strong>canada goose jackets</strong></a>,<a href=""><strong>canada goose jackets sale</strong></a>,<a href=""><strong>woolrich outlet</strong></a>,<a href=""><strong>woolrich store</strong></a>,<a href=""><strong>woolrich clothing</strong></a>,<a href=""><strong>woolrich women</strong></a>,<a href=""><strong>woolrich men</strong></a>,<a href=""><strong>woolrich outlet</strong></a>,<a href=""><strong>woolrich outlet store</strong></a>,<a href=""><strong>woolrich clothing</strong></a>,<a href=""><strong>new balance 574</strong></a>,<a href=""><strong>new balance 574 women</strong></a>,<a href=""><strong>new balance women 574</strong></a>,<a href=""><strong>new balance 574 men</strong></a>,<a href=""><strong>new balance running shoes</strong></a>,<a href=""><strong>new balance shoes</strong></a>,<a href=""><strong>new balance shoes sale</strong></a>,<a href=""><strong>new balance outlet</strong></a>,<a href=""><strong>new balance store</strong></a>,<a href=""><strong>canada goose jackets</strong></a>,<a href=""><strong>canada goose jackets sale</strong></a>,<a href=""><strong>canada goose sale</strong></a>,<a href=""><strong>canada goose parka</strong></a>,<a href=""><strong>canada goose parka sale</strong></a>,<a href=""><strong>montblanc</strong></a>,<a href=""><strong>mont blanc</strong></a>,<a href=""><strong>mont blanc pens</strong></a>,<a href=""><strong>montblanc pens</strong></a>,<a href=""><strong>discount mont blanc pens</strong></a>,<a href=""><strong>discount mont blanc pens</strong></a>,<a href=""><strong>montblanc</strong></a>,<a href=""><strong>mont blanc</strong></a>,<a href=""><strong>mont blanc pens</strong></a>,<a href=""><strong>montblanc pens</strong></a>,<a href=""><strong>discount mont blanc pens</strong></a>,<a href=""><strong>montblanc</strong></a... href=""><strong>mont blanc pens</strong></a>,<a href=""><strong>montblanc pens</strong></a>,<a href=""><strong>discount mont blanc pens</strong></a>,<a href=""><strong>montblanc</strong></a>,<a href=""><strong>mont blanc pens</strong></a>,<a href=""><strong>montblanc pens</strong></a>,<a href=""><strong>mizuno running shoes</strong></a>,<a href=""><strong>mizuno shoes</strong></a>,<a href=""><strong>mizuno women running shoes</strong></a>,<a href=""><strong>mizuno men running shoes</strong></a>,<a href=""><strong>mizuno volleyball</strong></a>,<a href=""><strong>mizuno volleyball shoes</strong></a>,<a href=""><strong>volleyball shoes women</strong></a>,<a href=""><strong>tommy hilfiger outlet stores</strong></a>,<a href=""><strong>hilfiger</strong></a>,<a href=""><strong>tommy hilfiger company stores</strong></a>,<a href=""><strong>nike running shoes</strong></a>,<a href=""><strong>nike air max 2014</strong></a>,<a href=""><strong>nike air max 90</strong></a>,<a href=""><strong>nike air max 2013</strong></a>,<a href=""><strong>cheap nike air max</strong></a>,<a href=""><strong>nike air max shoes</strong></a>,<a href=""><strong>2014 nike air max</strong></a>,<a href=""><strong>nike running shoes women</strong></a>,<a href=""><strong>nike running shoes men</strong></a>,<a href=""><strong>women nike running shoes</strong></a>,<a href=""><strong>men nike running shoes</strong></a>,<a href=""><strong>women nike shoes</strong></a>,<a href=""><strong>women nike air max</strong></a>,<a href=""><strong>nike air max women</strong></a>,<a href=""><strong>men nike air max</strong></a>,<a href=""><strong>nike air max men</strong></a>,<a href=""><strong>ugg boots women</strong></a>,<a href=""><strong>ugg boots men</strong></a>,<a href=""><strong>ugg boots</strong></a>,<a href=""><strong>ugg boot</strong></a>,<a href=""><strong>ugg boots for women</strong></a>,<a href=""><strong>aberc... and fitch outlet</strong></a>,<a href=""><strong>aberc... outlet</strong></a>,<a href=""><strong>aberc... fitch outlet</strong></a>,<a href=""><strong>kate spade outlet</strong></a>,<a href=""><strong>kate spade handbags</strong></a>,<a href=""><strong>kate spade handbags outlet</strong></a>,<a href=""><strong>kate spade outlet online</strong></a>,<a href=""><strong>prada handbags</strong></a>,<a href=""><strong>prada outlet</strong></a>,<a href=""><strong>prada bag</strong></a>,<a href=""><strong>gucci handbags</strong></a>,<a href=""><strong>gucci outlet</strong></a>,<a href=""><strong>gucci bag</strong></a>,<a href=""><strong>gucci outlet stores</strong></a>,<a href="">burberry handbags</a>,<a href="">burberry outlet</a>,<a href="">burberry outlet online</a>,<a href="">burberry Outlet</a>,<a href="">burberry handbags</a>,<a href="">burberry Sale</a>,<a href="">burberry handbags</a>,<a href="">burberry Sale</a>,<a href="">burberry Outlet</a>,<a href="">burberry Sale </a>,<a href="">burberry handbags </a>,<a href="">burberry Outlet</a>,<a href="">burberry handbags</a>,<a href="">burberry Sale</a>,<a href="">burberry outlet online</a> online
mizuno volleyball

#507055 NBA All Star Wa...
NBA All Star War Boots (458)

26. Thus.

Add new comment