By Nick Triggle
Health reporter, BBC News
Out-of-hours care has been radically revised in recent years
Serious concerns have been raised about the state of England's emergency care services by an NHS watchdog.
The Healthcare Commission found 40% of areas were not good enough after looking at A&E, out-of-hours GP, NHS Direct, walk-in and ambulance care.
The report said changes to services had left patients facing delays and confused about where to go for help.
Critics said the report raised fears over the reform of the NHS, but the government said care would improve.
In recent years, ministers have been overseeing a radical reshaping of emergency care.
Hospitals have been encouraged to become centres of excellence by concentrating on the most specialist aspects of care.
Meanwhile, other providers, including walk-in centres and out-of-hours GP services, are expected to work in partnership to deal with the less serious cases.
The Healthcare Commission said this required good management and communication between different parts of the NHS.
But the report found this was lacking with just a third of the 152 primary care trusts, which are responsible for coordinating local services, having active networks in place.
And individually, each part of the urgent and emergency care service had its own problems.
Less than a half of GP services had arrangements in place to divert callers to the out-of-hours provider - most GPs gave up responsibility for night and weekend care as part of a new contract four years ago.
Out-of-hours providers were also struggling, with a third failing to respond to calls quickly enough.
And ambulances were finding it dfficult to get back on the road quickly enough after taking patients to A&E.
Guidelines say this should be done within 15 minutes of arriving at hospital but in some areas this happened in only 10% of cases.
The problems mean that in many areas too many patients are turning up at A&E instead of using other services, with over half of the visits to some units deemed unnecessary.
The watchdog gave its backing to piloting one number for emergency and urgent care calls so that patients could be signposted to the correct service. The 999 number, however, would still be available for life-threatening situations.
Jim Wardrope, president of the College of Emergency Medicine, questioned what he called the "headlong" rush to introduce all the different services.
"Patients seem to understand the function of the A&E service and their GP service.
"They are less clear about the plethora of other urgent services that have been developed."
And shadow health minister Mike Penning said the reforms were failing, adding: "Patient outcomes are being neglected."
But Professor Sir George Alberti, the government's emergency care tsar, claimed most of the care offered was of a "high standard".
He added: "We are not complacent and we recognise the importance of encouraging continuous improvement in local services to ensure the delivery of timely, high quality care to patients."
Overall, the Healthcare Commission judged 33% of PCT areas as best performing, 27% better performing, 22% fair performing and 18% least well performing.
Fair and least well performing mean the trust areas were not hitting targets or standards where ones were in place.