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Revealed: NHS's plans to bar patients from attending A&E without a referral

Exclusive NHS England is considering pilots to stop walk-in patients attending A&E departments, requiring them to be referred by a GP or NHS 111.

Dr Helen Thomas, national medical advisor for integrated urgent care at NHS England, said NHS England ‘may well pilot’ a 'talk before you walk' scheme that requires all patients - unless they come via ambulance - to be referred or speak with a GP or other clinician before attending A&E.

She suggested that the talks have involved the health secretary at some level, but added that they were at an early stage.

It is an attempt to reduce demand that is threatening to engulf secondary care and emergency care services this winter.

Pulse has already reported that patients are having to wait 13 hours to be seen at A&E, while other hospitals are having to enlist GPs to help them reduce their waiting lists for referrals and others have sent patients out of county for certain specialties.

This latest suggestion, however, would stop patients from attending A&E without a referral from elsewhere.

Dr Thomas said: ‘[Health secretary] Jeremy Hunt has mentioned to some of my colleagues, maybe we should have a "talk before you walk" and we may well pilot that. 

‘I think it’s been done in other countries where they’ve actually said you can’t come into ED until you’ve talked on referral or you have to have that sort of docket that you’re given by having talked on the phone that you do need to come to ED.’

Dr Thomas added that while piloting such a scheme would be a political ‘hot potato’, a pilot in just one area would yield ‘some really interesting information’.

Speaking at the Urgent Health UK conference to out-of-hours providers on the future of urgent care in the wider NHS, she said that out of 100 patients that come to A&E ‘only 20 have called 111’.

She said: ‘So I think that other 80 – there is opportunity there. Some of them will need ED but there’s an awful lot that won’t.’ 

Speaking to Pulse, Dr Thomas said that the discussions of a pilot are in the early stages and admitted that ‘it’s going to be tricky to do it’.

She said at the conference: ‘The difficulty is we have to then have an alternative solution other than A&E within four hours and that might put pressure on out-of-hour provision, that you would have to see this patient within four hours and there is some thought about that within NHS England to ask you to do that.’

Dr Simon Abrams, chair of Urgent Health UK, which represents out-of-hours  said that while the pilot will 'inevitably' put more pressure on out of hours services, he said it is an 'interesting proposal' that has the potential to provide better care for patients.

He said: 'It might reduce the workloads of A&E departments, which on the whole is staffed by very junior doctors and if you can put a slightly more senior doctor over the telephone to that patient, maybe you can provide better care.'

He added: 'So much of what is happening now is about getting the right clinician and the right care for the problem that the patient is presenting.'

But Dr Abrams said the idea 'needs a lot of thinking through', adding that 'whether it will be acceptable either to a political party or to patients, I don't know'.

The Department of Health and NHS England both denied the story. Click here for their full comments.

How secondary care services are already beginning to struggle

Patients in Margate faced waits of up to 13 hours to be seen at the A&E department at Queen Elizabeth The Queen Mother Hospital because of understaffing.

In Cambridgeshire, Addenbrooke's sent a letter to GPs warning its medical decisions unit was 'currently full and there are patients within the emergency department awaiting admission that cannot be placed into inpatient beds due to a lack of bed capacity'.

Meanwhile, NHS England has already launched a scheme to triage patients at the door of A&E, sending some to co-located primary care services.

Pulse has also reported that GPs in Lincolnshire are being asked to consider alternative providers outside of the county for non-urgent ear nose and throat (ENT), cardiology, neurology and dermatology services, while GPs in the north of the county have been asked to review referrals and take on patients to tackle a backlog of 30,000 patients waiting for treatment.

 

Readers' comments (41)

  • Good, Why not close all the A&E, no A&E and budget would be balanced.

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  • so - who they gonna call?...

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  • It happens in other countries I understand but just watch the number of 999 calls increase if arriving in an ambulance will guarantee being seen,

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  • already given up hope NI GP

    seems fair enough as GPs are required to do everything anyway.The more considered approach is to send them away to a more appropriate place for treatment/assessment after triage.Medical care needs to remain free and accessible at the first point of contact

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  • Obviously doesn't understand the GMS contract which does not cover minor injuries. A LES would have to be put in place for local GPs to assess these patients on either a block contract or pay by activity. This is non core work,also fails to recognise primary care at breaking point anyway

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  • Quicker to go to a European Hospital A/E- Brexit & problem sorted.

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  • The day this is implemented is the day I stop doing on calls.

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  • Things I've seen 'walk in' - catastrophic strokes, fracture dislocations, STEMIs, raging sepsis, major facial trauma, stabbings.
    Things I've seen come in ambulances - unilateral conjunctivitis, ingrown toenails, feeling a bit lonely.
    How people pitch up doesn't dictate their seriousness. It'll be less than 24 hours of this being implemented that some poor stoical patient will keel over with a STEMI in a GP practice having been bounced out of A&E.

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  • Dr Helen Thomas said "I think it’s been done in other countries...".
    One might have expected her to be certain and state the countries. May well be true, but I have never heard of such an arrangement.
    Overall, seems like an ill-conceived plan highly likely to have a serious adverse effect on ambulance services once the usual abusers of the service have sussed it out. Also a risk that less assertive ill people may not seek/receive treatment they need. At least it is to be piloted.
    Better plan is to scrap A&E waiting time guarantees (or make it 8 hours) and triage according to need. There would probably be no need for additional seats in the waiting area. Nobody seems to associate shorter waiting times with an increase in inappropriate attendance.

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  • .... Just speak to your GP before you dial 999. + a million other things to ... Just see your GP.

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  • ‘Medical care needs to remain free and accessible at the first point of contact’

    That’s what got us into this mess.

    Communism leads to fears from famine, not capitalism.

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  • I seem to remember Hunt was quite happy to turn up at A and E on a weekend, with one of his children, for a routine condition

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  • Use Hunt's answer: "I can't solve your problems"

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  • Tantalus

    5p for a bag reduced use at supermarkets by 85%.
    £5 to be seen in A&E or GP surgery would likely have a similar result.
    The argument that people would not seek help because of a nominal charge is ridiculous.
    I agree with Big and Small that free at the point of access is the problem.

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  • It will not work. The only way is to charge them.

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  • Vinci Ho

    Somebody needs to clarify whether this is about talking to a GP based in A/E or a GP in community. But based on what Simon(Abrams) said , it was expected to be the latter at least in out of hours.
    Then it is about investing new resources(MMET) , especially expertise(E) in general practice. No new resources, no talk......

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  • if you can solve car parking problem in uk, you will know how to solve demand of nhs. restricting a and e attendance will be met with unbearable demand elsewhere. public will find answer to all restrictions. spend a lot of money in primary care. free service at point of delivery will always be misused no matter what you do.

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  • Vinci Ho

    But one also has to imagine the logistics in reality:a patient turned up the front door of a A/E despite knowing that they need to get a 'permission' . You then had a security guard stopping him/her to go in the building and asked him/her to ring a GP or NHS111????

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  • Utterly beautiful idea as it is insane
    Have they really done the figures on demand, capacity, accessibility, resource and flows....
    At scale....
    I think not
    TimeToWakUp

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  • Vinci Ho

    There is a bare minimum of resources to meet a certain level of demands (yes, argument still on needs versus demands).
    All I know is even patients have to be charged for attending A/E in public hospitals in Hong Kong , they are still running at a subscription of over 100% of the capacity (at worst 120%) last year.

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  • Vinci Ho

    Perhaps there is something we can never change:
    ''It can only be what it is, not what you want it to be.''
    Burnham
    Star Trek Discovery

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  • Yeah, right. BIG pinch of salt reading this one. Someone verbalises an idea, says it too loud, someone else hears it and assumes it's rolling, and before you know it you are diving into a bowl of false news- looks good, sounds good, but no nutritional value.
    Have none of them heard about Queuing Theory- the more barriers put up with segregated queue lines the slower the throughput and less efficient the system becomes!

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  • claptrap-I am not commissioned or contracted to provide urgent care as a GP As others have said arriving in an ambulance is not a compelling marker for severity of illness either-whole system reform as part of STP or ACS might get you where you need to be but we are 15-25% adrift of the sort of funding we need to be able to deliver gold standard care and cant hold onto the workforce

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  • @Catherine Welch
    I prescribe a good dose of The Thick of It.
    This is how this sort of nonsense starts, but given the any number of batshit crazy ideas NHSE come out with, this would only serve to count as just another.
    If Dr Helen Thomas didnt want anyone to know then she should not have told anyone.

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  • PS- seems to have hit the Graun headlines too;
    https://www.theguardian.com/society/2017/oct/13/jeremy-hunt-considers-barring-walk-in-patients-from-ae

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  • I’m sure Hunt declared that all ED departments were to have GP cover by now anyway?? Seems that’s all gone quiet. I am fed up with the inappropriate use of appointments/ED attendance, wanting instant second opinions about trivial things. This consumer society and ‘right’ to have same day access to see your GP will not change unless there is some barrier, filter or payment. The patient who turns up wanting ‘a check over’ as about to go on a cruise with no symptoms may think twice if he/she had to pay....

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  • Just Your Average Joe

    NHS to remain free at point of care.

    Charge £50 pounds to enter A&E care park!

    That might make people think before they go there!

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  • doctordog.

    One of the more stupid, dangerous ideas I have heard for some time.
    Nominal charging seems a good idea , until a seriously ill patient can’t or won’t pay.

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  • Just Your Average Joe

    Not completely joking about charge for A&E car park - though really it should be charge for A&E if you haven't called 111 before you go, they give you a code which validates referral was advised.

    If it proves visit was a genuine accident/emergency needing attendance it will be waived.

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  • Just Your Average Joe

    The real issue is demand and the expectations encouraged by succesive governments.

    There is no capacity in primary care to see more, but the problem is OOH is so poorly funded and staffed it would implode under more strain, which is part of the dilemma.

    Patients have worked out OOH and 111 send them are hours of triage and waiting to A&E so they just skip the middle man and go themselves.

    It is what they are turning up with which is the issue, and for things already seen by GP and OOH, walk in centres for a 2nd/3rd opinion on same self limiting issue.

    My sore throat is so bad - until antibiotics given etc. My child has a cough or fever, but actually urti.

    The elderly need hospital in most cases, it is the younger patients who could be diverted, even the minor fractures to walk ins. most of the kids have been seen, or don't need seeing.

    Charging is the only way to rein in demand - but suicide in the next election, and a law suit waiting, when someone dies because they were worried about the charge.

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  • I love Catherine Welch’s reminder to us about queuing theory

    This all boils done to which street corner you want the queue to be on

    The queue does not go away ... they simply line up somewhere else

    Centrally they can only cope with moving a queue rather than truly understanding WHY the queue exists.

    A child says “I don’t want the queue here... I want it there”
    And adult says “ the queue might be in the wrong place but let’s really understand why first”

    The psychodynamics of why people attend AandE is a highly complex and multifaceted equation and when you deeply look at the cause and effect you see the truth behind AandE activity. Some you will recognise and some will surprise you, some you can tackle and others are utterly unreachable.

    And finally if you imagine the game of chess. You don’t simply move a piece to another square because you can. You wait and explore many many moves ahead - cause and effect.

    TimeToWakeUp oh... and grow up.

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  • I say bring it on as soon as possible, after all what could possibly go wrong?

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  • Wow. Unbelievable. How much do we pay these NHS managers? This will hammer GPs and the ambulance service which is already on its knees. What WILL reduce demands on A&E overnight is getting rid of the four hour target. It’s so simple.

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  • I have personally walked or limped into A and E with a dislocated shoulder, a fractured fibula and severe asthma needing admission (not all at once). Spending time speaking to 111 or a GP before attending with the first two would have been a total waste of time. For the third it would have been life threatening on more than one occasion as I always tend to the “why didn’t you come in earlier” behaviour pattern anyway. Triage once at A and E is a) obviously sensible and b) already happens.

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  • I have also seen people walk in with sepsis, fractured pelvis, tibial plateau fracture, meningitis, peritonitis and so on. Some of them had a clinical pattern likely to be missed on phone triage.

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  • Discouraging people from seeking help is a dangerous game. Every article like this (in a newspaper not pulse) means one more ill person seeking help too late.

    'Time wasters' are not new in the NHS, not unique to this country and not unexpected. Buy any step to reduce time wasters will also put off those really in need of help. We have all seen patients harmed for not attending soon enough and we risk encouraging that by making the decision to seek help harder.

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  • Sounds like nonsense. It increases the number of contacts with the NHS hence increase demand. It may reduce A&E workload but will increase 111, and GP services at a time they are struggling.

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  • Sounds I may need to take a break until the Big Bang and the dust settling down.

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  • Peculiar that Mr Hunt would propose a "talk before you walk" system.

    I thought he had shown by example that one should straight to ED:

    November 2014, "Jeremy Hunt took children to A&E rather than wait for GP", available: http://www.bbc.co.uk/news/health-30207608

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  • This is a very bad idea.

    Destroying the reassurance that we get from knowing that in a crisis, whatever time of day, whatever state of physical or mental health we are in, help can be available just by getting ourselves to the A&E front door, would be political suicide.

    What is required is that emergency departments continue to develop their systems for redirecting patients who turn up but are not in a crisis.

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  • Rogue1

    Ive had 2 people with obstructive jaundice triaged by NHS 111 sent to me (GP)!? Everyone knows its a surgical emergency (obviously not 111). It is a waste of resource, close it and spend the money on core services

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