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A faulty production line

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)

  • Vinci Ho

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

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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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