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CCG Series: Towards a joined-up urgent care system

CCG Series: Towards a joined-up urgent care system


Dr Derek Greatorex, clinical chair of Pioneer status South Devon & Torbay clinical commissioning group (CCG) explores the future of urgent care services - what's next?


‘Christmas chaos for A&E’

‘NHS in England misses A&E target’

'A&E staff know patients better than their GPs’

Headlines like this seem to be coming more and more frequently. There is no doubt that urgent care services, be they at primary or secondary care level, are under increasing strain. The debate about why this is has been exercising the minds of health policy makers and the media alike. Many reasons are cited for this including the “botched” (as described by the Daily Mail) 2004 GP contract, the claim that one in four A&E trained junior doctors are heading off to the Antipodes, the reduction in the numbers of hospital beds etc. There is a lot of debate around all of these areas but the significance of each of these and whose ‘fault’ this all is remains very much in the eye of the beholder.

We have seen a number of recent initiatives aimed at directly or indirectly ameliorating the perceived problems such as the additional winter monies, the PM’s Challenge Fund, NHS 111 and the Better Care Fund (formerly the Integration Transformation Fund). Yes, the aims of these can be seen as laudable but in themselves I don’t feel they are more than a patching up process. I believe we need a more radical look at the way in which we organise what I would call ‘First Contact’ services. No, this is not about Close Encounters of the Third Kind although for many, such radical change may feel as though they are entering into an alien world!  

One of the issues which I picked up in a recent series of engagement events we held as a CCG is the confusion that many of the public felt in knowing where to deal with a particular problem. One may have the choice of GP practice, GP out-of-hours, Minor Injury Units, Walk-in centres, as well as conventional A&E departments. These will often be situated in a variety of settings with variable access to patient information - for most, probably no access. Most of the initiatives we have seen are designed to reduce or at least stop the increase in demand. But is this possible? Would it be more appropriate to design a system that can manage the demand? I would not question the need to educate about the self-management of self-limiting conditions. Education by a health professional at the right time may be an effective way of delivering this advice. But despite this, in the words of Jeff Wayne’s War of the Worlds – ‘And still they come’!

So, perhaps we should move away from the concept of A&E departments as the front door of the hospital towards a more joined up first contact urgent care system. There is clearly a need to retain an A&E department capable of dealing with major trauma and illness, but could we move the other ‘minors’ away from their traditional home into what, for want of a better word, we could call urgent care centres.  Of course this has been tried in various guises around the country. However, for this to work as effectively as possible, this would need to consolidate the various MIUs, GP OOHs, WICs as well as the social and community care emergency response teams into an urgent care hub. The aim would be to create a single point of access for these services (and A&E departments would need to have the right to divert to these where appropriate). There would be greater clarity of access and potential for a greater range of services than could be provided by any of these on their own. 

So rather than entering into re-procurement exercises for bits of the services in a piecemeal fashion, I believe we need to think on a grander scale. The devil is in the detail of course, and local circumstances will vary across the country, but I for one would like to start the debate locally.



I like the summary provided but recommend that a high level process review is conducted from patient to GP/A&E and beyond. The full journey seen in the eyes of the patient and in the eyes of the NHS where billions are wasted on non value adding activities. I recently witnessed 80% of hours applied being wasted in an A&E department where critical resource, Doctors, were observed walking around with paperwork looking for things, including patients.

The details:
I am a practicing process analysis expert, so applied my knowledge to measure, over a three hour period, at Wythenshaw A&E dept a number of Doctors activities. I identified that close to 80% of an their time was spent carrying out non value adding activities such as, walking around, looking for patients, looking for equipment, looking for other staff, looking for equipment plus much more. The Doctor is a critical resource so maximising their time with patients is crucial to operational efficiency. The A&E process should be designed around the Doctor i.e. the typical bottleneck in A&E! Doctors should be the focal point, just like a car is on a production line. Imagine a Doctor fixed in position within A&E, where equipment, patients, staff, paperwork plus more are at their finger tips. Based on my analysis patient throughput would triple! For me, it is clear that low cost process analysis and replication of best practice process design will release waste and dramatically improve operational efficiency across the NHS. I can go on but simple solutions exist to common problems! I would be happy to hear thoughts relating to this. Regards

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