This site is intended for health professionals only

At the heart of general practice since 1960

pul jul aug2020 cover 80x101px
Read the latest issue online

Independents' Day

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 (43)

  • 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.

    Unsuitable or offensive? Report this comment

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

    Unsuitable or offensive? Report this comment

  • 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.

    Unsuitable or offensive? Report this comment

  • 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.

    Unsuitable or offensive? Report this comment

  • 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.

    Unsuitable or offensive? Report this comment

  • 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.

    Unsuitable or offensive? Report this comment

  • 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.

    Unsuitable or offensive? Report this comment

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

    Unsuitable or offensive? Report this comment

  • 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:

    Unsuitable or offensive? Report this comment

  • 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.

    Unsuitable or offensive? Report this comment

View results 10 results per page20 results per page50 results per page

Have your say