A recent analysis from Les Mayhew and David Smith at City University's Cass Business School has suggested some theoretical reasons - backed by data - why achievement of the accident and emergency maximum four-hour wait by 98 per cent of hospitals was probably not all it seemed.

A recent analysis from Les Mayhew and David Smith at City University's Cass Business School has suggested some theoretical reasons - backed by data - why achievement of the accident and emergency maximum four-hour wait by 98 per cent of hospitals was probably not all it seemed.

Equally probably, this should not come as shocking news to many hospitals.

Of these results, a Department of Health spokesperson said: 'It's absolute nonsense to suggest that the A&E waiting time standard is not being met', missing the point entirely. On paper the target was met, the question is, was it met in the spirit in which it was set, or by changing the designation of patients, discharging to medical assessment units or into hospital? Was it met to the eventual disadvantage of patients and at significant cost to the NHS?

Mayhew and Smith's research suggests that when the A&E target was increased from 90 per cent of patients to 98 per cent, the marginal increase of 8 per cent implied an unrealistic improvement in the average A&E patient wait if, as official statistics confirm, the new target was met. Their queuing models suggest a halving of the average wait in a couple of years.

Of course, rerouting and reclassifying patients to help reduce A&E waiting times may not necessarily be a bad thing, as the researchers point out. Medical assessment units or a short emergency stay may be best for some patients, although there is no evidence of this.

Another example of redesignation is almost certainly a result of the government's inpatient waiting-time targets, too. According to hospital episode statistics, from 1998-99 to 2005-06 total elective admissions in England rose by 605,000 - around 11 per cent. Good news, one might presume: more patients being taken off waiting lists to be treated and so reducing waiting times. But a closer look at the source of admission shows that patients admitted from waiting lists actually fell by over 748,000. And while booked admissions (which count as part of the waiting list) rose by 567,000 this still leaves a puzzling reduction in numbers being taken off the lists.

However, all the increase in elective work since 1998 is accounted for by a 786,000 rise in planned cases - which do not count as part of the waiting list. Again, as with the possible redesignation of A&E patients, the fact that the entire increase in elective patients from 1998 is planned cases may simply reflect more appropriate care.
John Appleby is chief economist at the King's Fund.