Transforming urgent and emergency care

How NICE resources can support local priorities

Meeting the challenge

The NHS Five Year Forward View explains the need to redesign urgent and emergency care services in England for people of all ages with physical and mental health problems. It sets out the new models of care needed to do so. The urgent and emergency care vanguards have been piloting these.

Trusts and clinical commissioning groups (CCGs) are working to meet the government’s mandate to the NHS that:

  • By 30 September 2018, 90% of people attending A&E are admitted, transferred or discharged within 4 hours of arriving.
  • By 31 March 2019, in most trusts, 95% of people attending A&E are admitted, transferred or discharged within 4 hours of arriving.
  • By 31 December 2019, in the NHS overall, 95% of people attending A&E are admitted, transferred or discharged within 4 hours of arriving.

Our guidance and quality standards can support the strands of work in urgent and emergency care needed to achieve these aims.


Finding the right information

We have a guideline and NICE Pathway on emergency and acute medical care in over 16s: service delivery and organisation. There are also recommendations about urgent and emergency care for specific conditions or circumstances in many of our guidelines and Pathways. The following video explains how to use NICE Pathways.

We also have quality standards, which will help you identify areas for quality improvement work in your STP or integrated care system (see how to use quality standards).

Our quick guides support implementation of our guidelines in social care. These will help you with working on the strands of work towards transforming care.

The tables below show which guidelines, NICE Pathways, quality standards and quick guides are relevant to each strand of work.


The strands of work towards transforming care

Front-door clinical streaming

Every hospital must have comprehensive front-door clinical streaming so that A&E departments are free to care for the sickest patients, including older people.

From December 2017, 98.5% type 1 A&Es had front-door clinical streaming in place. A type 1 A&E department is a consultant-led 24 hour service with full resuscitation facilities and designated accommodation for receiving A&E patients.

NHS Tameside and Glossop Integrated Care NHS Foundation Trust has dramatically improved early recognition of sepsis by implementing our guideline on sepsis.

It did this by giving clinical staff a ‘diagnosing sepsis’ card with 3 simple steps to identify ‘this could be sepsis.' They also added stickers to the emergency department triage sheet. Now, all patients (except those with minor injuries) are screened for sepsis as part of triage.

In less than 2 years, the percentage of patients with red flag signs of sepsis receiving antibiotics within an hour increased from 30–40% to 100%.

Enhancing the movement of people

Every hospital and its local health and social care partners must adopt good practice to enable people to move through services appropriately. This includes:

  • better and more timely hand-overs between A&E clinicians and acute physicians
  • ‘discharge to assess’
  • ‘trusted assessor’ arrangements
  • streamlined continuing healthcare processes
  • seven day discharge capabilities.

University Hospitals Birmingham NHS Foundation Trust used recommendations from our guideline on rehabilitation after critical illness in adults to improve rehabilitation for patients in the intensive care unit.

This reduced:

  • average length of stay in hospital from 35.3 to 30.1 days
  • average length of stay in the intensive care unit from 16.9 days to 14.4 days
  • the number of patients who died while in hospital from 39% to 28%
  • the duration of invasive ventilation and the time to first mobilisation.

Reducing delays in community health and social care

Hospitals, primary and community care and local councils should work together to ensure people are not stuck in hospital while waiting for delayed community health and social care.

Mansfield District Council put our guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs into practice to redesign its housing service and help people get out of hospital.

The service works 24 hours a day, 7 days a week to adapt homes, and coordinate health and care services input. Staff also help people get benefits and put them in touch with agencies such as Age UK. The service helps over 600 people a year. The financial return on investment to the Nottinghamshire health and social care system has been estimated at more than 900%.

Improving availability of specialist mental health care in A&Es

The number of 'core 24' hour mental health teams in A&E departments is being expanded. The service will be available in nearly half of acute hospitals by March 2019. In March 2017, it was only available in fewer than 1 in 10 hospitals.

People go to A&E with many mental health conditions, and we've several guidelines that could help. To access our guidance on this topic, visit the mental health and behavioural conditions topic area of our website.

NICE and NHS England have developed guidance on improving access to urgent and emergency mental health care - see part 1 and part 2. Within the 4-hour A&E target, people with mental health needs should:

  • have a biopsychosocial assessment
  • agree an urgent and emergency mental health care plan.

The guidance supports implementing an evidence-based treatment pathway for urgent and emergency liaison mental health services. It covers interventions recommended by NICE, and includes quality standards, best practice examples and models.

Integrated urgent care services and GP access

NHS 111 and GP out-of-hours services have increasingly been combined . Using clinical assessment services helps ensure that patients are directed efficiently and effectively to the right care pathway.

Since April 2017, the proportion of people receiving clinical input to their NHS 111 call has been consistently above 30%, rising to 39.4% in the latest return. By March 2019, 50% of triaged calls will receive clinical assessment, so that only patients who need to attend A&E or use the ambulance service do so. NHS 111 online has been launched and by 2019 NHS 111 will be able to book people into urgent face-to-face appointments.

By March 2019, evening and weekend GP appointments should be rolled out to the whole population

Our guidance can be used to help with developing integrated urgent care services. For example:

  • when developing pathway algorithms for call handling staff to direct people to the right service
  • when developing GP services.

Search for or browse to the clinical topic or aspect of care you're interested in.

Supporting care homes

CCGs and trusts should strengthen support to care homes to ensure they've direct access to clinical advice, including appropriate on-site assessment.

NHS Wigan Borough CCG has employed a team of pharmacists and pharmacy technicians since 2014 to work with GP practices, residential homes and nursing homes. The team carries out structured medication reviews for care home residents in line with our guidance on medicines optimisation. This has led to a reduction in the number of medicines people take and inappropriate polypharmacy, and improved CQC ratings in some care homes.

Standardising urgent treatment centres

Standardised urgent treatment centres (UTCs) will be rolled out.

These are open 12 hours a day, 7 days a week, and integrated with local urgent care services.

They offer treatment by clinicians with access to diagnostic facilities (usually including an X-ray machine) to patients who do not need A&E care.

Once fully operational, UTCs will offer appointments through NHS 111 as well as GP referral.

Ambulance Response Programme

Working closely with the Association of Ambulance Chief Executives and the College of Paramedics, NHS England has implemented the recommendations of the Ambulance Response Programme across the country.

We have NICE Pathways, guidelines and quality standards on many clinical topics relevant to the Ambulance Response Programme. You could start with our trauma and sepsis pages, which list all our guidance and advice on these topics.

Support for quality improvement

We publish a range of tools to help you use our guidance and quality standards to improve quality.

You can find these on the tools and resources tab for each piece of guidance or standard – such as the guideline on managing medicines in care homes.

These include baseline assessments to check practice against our guidance. We endorse tools produced by other organisations that support the guidance. For example:

medicines use in care homes e-learning (course 1)
medicines use in care homes e-learning (course 2)
managing adult malnutrition in the community
falls risk assessment toolkit .

Our shared learning case studies show how organisations have put our guidance into practice. To search for examples or to submit your own work, go to www.nice.org.uk/sharedlearning .

If patients stay in hospital for longer than medically needed, this can affect the movement of people through A&E and A&E capacity. Our resource on improving transfer of care will help you reduce delays.

Other resources

NHS England has worked with urgent and emergency care vanguards, academics and patient groups to develop system-wide outcome measures. These help individual urgent and emergency care systems identify possible issues, plan improvements and work together to smooth the movement of patients, and their information, across the system.

Contact england.urgentcarereview@nhs.net for more information.

Other NHS publications on urgent and emergency care services are: