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Why in a healthcare system, in the 21st century, a system that is usually respected around the world, do such fundamental shortcomings keep re-occurring? Is it financial pressures that force management to constantly 'take a chance' that things will probably be OK? Or is it that management feel uncomfortable that there may very occasionally be times when A&E departments are not as busy and staff will be paid for not doing too much? In the past when I have observed statistical process control information regarding A&E, demand fluctuation is predictable but there are obviously peaks and troughs in demand that mean staffing cannot be totally "flexed" to fit perfectly with these peaks and troughs, but departments should be staffed sufficiently to meet demand within the acceptable 2 standard deviations from the average demand level. It cannot be a lack of staff available to recruit, as after these visits those Trusts concerned always seem to have a plan which involves recruiting, and existing and new posts are suddenly filled, and establishment is increased to an acceptable level. Why didn't the Trust know what its safe level was and recruit to this level in the first place? I realise I am not in possession of all the facts, but I see this so often I am left totally bemused by the risk patients are put at yet again, not to mention the stress on the staff left in the department who are obviously going to feel the strain. Can the Trust 'risk share' with primary care to proactively manage the 'frequent attenders' and tackling this and staffing the department to appropriate levels would surely help to avoid such findings on inspection?