Ten priorities for action to improve the care of acutely ill patients

• rising demand and the changing needs of an ageing population
• lack of comprehensive, effective alternatives to hospital admission across 7 days
• complex discharge issues
• handover and flow
• recruitment into emergency and acute medicine

In spring 2013, the Royal College of Physicians (RCP), NHS Confederation, the Society for Acute Medicine and the College of Emergency Medicine brought together frontline professionals, leaders, policymakers and innovators in health care to consider the future for urgent and emergency care services. The priority areas for action below are a direct output of those discussions:

1. We must develop effective and simplified alternatives to hospital admission across 7 days

We must ensure that patients have access to expert diagnosis and assessment in different settings, and ensure there is clear information on the services available to them. These services should be centred around, and respond to, both the physical and mental health needs of patients.

2. We must adjust the financial incentives across the system so that they support effective management of demand for unscheduled care

We need the resources to invest in primary, community and social care, so they can contribute to providing effective urgent and emergency care services. The marginal tariff provides a mechanism to realise this investment, which should be transparent and driven by local commissioners.

3. We must focus on supporting patients to leave hospital 7 days a week

Hospital teams should ensure early planning for discharge from hospital, involving a range of health care professionals. The use of ‘step down’ care facilities who need supportive care but not a hospital bed, should be extended.

4. We must organise high-quality consultant-led hospital services across 7 days

We must reorganise hospital care so that patients have access to consultant-led care regardless of the day of the week. A consultant physician should always be available ‘on call’ and should be present in the acute medical unit for at least 12 hours per day, seven days per week with no concurrent duties except the delivery of care to acute admissions.

5. We must promote greater collaboration within the hospital and beyond to manage emergency patients

We must promote a collaborative model of care, including senior-decision making in the emergency department and acute medical unit. Multi-specialty teams, with expertise in physical and mental health, should work in a network across the hospital and community to manage patients on an emergency care pathway.

6. We must ensure there is sufficient capacity within the hospital, and the wider system, to meet changing demand

We must ensure that there is adequate bed and staffing capacity to meet the needs of patients admitted as emergencies. Wherever possible each day should start with some unoccupied beds on the AMU. Likewise, community health and social care capacity, with appropriate support from medical teams, should be increased, in order to absorb preventable unscheduled admissions.

7. We must focus on ambulatory (‘day case’) emergency care where appropriate

Those involved in commissioning and planning emergency care services must focus on ambulatory emergency care where they can, setting out which admissions they consider to be avoidable, and what proportion should be more appropriately managed in the community. This should relieve pressure on the AMU, the Emergency Department and more widely within the hospital.

8. We must develop a sustainable workforce, fit for the future

We need to ensure that emergency medicine and acute medicine remain attractive career options. Job planning must take into consideration the intensity of workload as well as the numbers of hours worked to ensure the long-term sustainability of a consultant career in these acute specialties.

9. We must show leadership

We must further enable leadership development and cultural change within the NHS, through promoting evidence-based decision making, new organisational values and behaviours, and public transparency.

10. We must focus on public health and preventive health strategies

We must support early intervention and preventative strategies where extra investment on community and preventive health is required; specifically, the future payment mechanism should be designed to support coordination of these services.

Access the full report, Urgent and emergency care: a prescription for the future

Sir Richard Thompson, president of the RCP, said:

These 10 priorities are the product of two multidisciplinary conferences held earlier this year, and summarise some of the actions that are urgently needed to help primary and secondary care cope with the rapid changes in health care that derive both from the success of medical treatments and the increasing age and changing nature of the population. Unless some of these actions are carried out quickly, the quality of NHS care will fall.

Dr Johnny Marshall, GP and NHS Confederation director of policy, said:

The current situation in urgent and emergency care is unsustainable. But we know that pressures in the emergency department are really an indication of the whole health service being under pressure.

It is essential that we take decisive action - and quickly - to address these pressures, if the NHS is to continue to provide comprehensive high quality healthcare when people need it. It's as simple and serious as that.

As doctors, we know that we need to strive not just for symptom relief but to address the underlying causes. The combined expertise of the two summits, distilled into this report, is our shared prescription to put NHS urgent and emergency care back on its feet.

Dr Chris Roseveare, president of the Society for Acute Medicine, said:

The recent pressures on acute services within the NHS have been unprecedented. Urgent action is required if we are going to prevent a further deterioration in the quality of care for patients admitted to hospital in an emergency. Collaboration by clinicians across traditional boundaries will be a vital part of the solution.

By highlighting ten key priorities for change, this document represents a major step forward. Clinicians must continue to work closely with managers, patient representatives and politicians and ensure that these actions are implemented urgently, before the demands inevitably rise again next winter.

Dr Clifford Mann, president of the College of Emergency Medicine, said: 

These 10 'calls to action' are the product of a wide consensus and I would urge all those engaged in commissioning and providing acute care to use them as a template for their service plans.

NHS England are currentl conducting a Review of Urgent and Emergency Care, led by Professor Keith Willet, National Clinical Director for Acute Episodes of Care.

Commenting on the ten priority areas for action, Professor Willett said:

At its heart the urgent and emergency care review is about bringing together the expertise from across the health and care system to determine how best to organise emergency care in future.

We welcome this important contribution from the Royal College of Physicians, NHS Confederation, Society for Acute Medicine and College of Emergency Medicine as doctors, nurses and healthcare leaders all have a crucial role to play in designing a new system that is sustainable and fit to meet future challenges.

For further information and to arrange interviews, please contact Andrew McCracken on +44 (0)20 3075 1354 / 07990 745 608, or email andrew.mccracken@rcplondon.ac.uk