Do not take all your patients to hospital, paramedics told Sir Bruce's inquiry has heard evidence that more than 4,000 lives a year could be saved if hospitals were re-organised. Under the plans, some specialist services are likely to be concentrated in larger units, with patients suffering from conditions such as strokes or major trauma taken directly by blue-light ambulance to designated centres, with particular expertise. Senior doctors have said that they fear "the worst winter yet" for the NHS, with figures showing a 44 per cent rise in those waiting more than four hours in casualty units in the past two years. Sir Bruce is expected to call for sweeping changes in the care offered outside hospitals, including faster access to GPs. The report will make the case for improved training and investment in community and ambulance services, so that paramedics provide more help at the scene of an incident, with nurses and care workers dispatched to offer support in the home, so fewer patients are taken to hospital. The review has found wide variations in current practices across England, but is expected to say that the "default" response of automatically sending an ambulance to 999 calls, and taking most patients to hospitals, does not always offer the best care, and places too much pressure on A&E. In the North West, more than three quarters of patients are taken to hospital following a 999 call, while in the South West fewer than half receive such a response. Ambulance trusts have previously introduced controversial bonus schemes, whereby organisations are paid to keep patients out of hospital. Last winter, London Ambulance Service offered staff bonuses of £250 if they dispatched fewer ambulances, with payment received if 30 per cent of 999 calls were referred to other health care services, instead of patients being brought to casualty. A previous scheme saw the service paid £38 for every patient kept out of A&E after a 999 call is made. Research for Sir Bruce's review suggests that of the five million patients admitted to hospital each year, one million might not have needed to be - if the right help was available from GPs, ambulance services, social services and voluntary agencies. The report is also expected to call for more use of telephone advice services, despite difficulties with the non-emergency 111 phoneline as it was extended nationally. The College of Emergency Medicine, which represents A&E doctors, has said that the NHS is facing its worst winter yet, and that, without changes and investment, probably has "just one year left" of safe care before the service buckles. Last week, Sir Bruce said there was "a feeling that this year was worse" in terms of pressure on A&E departments at this point in the calendar. The latest figures show the number of patients waiting more than four hours in A&E between April and October of this year was 513,626 - 44 per cent more than in the same period two years before. The figures also show 87,000 patients waited between four and 12 hours on a trolley - almost twice as many as in the same period two years ago. Jeremy Hunt, the Health Secretary, has blamed the A&E crisis on poor access to GP out-of-hours services - because of a contract introduced by Labour - and difficulties getting an appointment during regular hours, leaving millions of patients turning to A&E because they have nowhere else to go. He has said that any pay rise for NHS staff next year should only be made if doctors and other workers agree to reform the way they work, to improve the way care is delivered at evenings and weekends. However, Labour says the crisis has been made worse by job cuts under this Government - such as the loss of 6,000 nursing posts since the election, and decisions to axe NHS Direct and close walk-in centres. The review follows investigations earlier this year by The Sunday Telegraph highlighting the numbers of patients forced to wait in ambulances parked outside A&E, as well as the failures of some trusts to achieve targets for reaching 999 cases within times set by the Government. In some cases, the delays were linked to the deaths of patients.