Waiting times have risen in nearly three-quarters of England's accident and emergency departments, according to a survey by the Audit Commission.

The survey found wide variations in the performance of similarly busy, similarly staffed hospital A&E departments, 'suggesting that there is scope for those with poor performance to learn from the best'.

The study updates the findings of the commission's 1996 report, By Accident or Design, which highlighted excessive waiting times, lack of medical staff, poor deployment and inadequate monitoring.

'Problems remain in all these areas,' the commission says in its new report. A further 'area of concern' is that just 25 per cent of heart attack patients receive blood-clot dissolving drugs within the target time of 30 minutes proposed in The Health of the Nation.

The commission would like to see 100 per cent of treatment within the target time, although its report admits that this would be 'challenging'.

The update found that in three-quarters of A&E departments, the number of patients waiting more than an hour to see a doctor has gone up by 18 per cent and 'very little use was being made' of nurse practitioners.

Just one-third of A&E departments employed nurse practitioners and most see fewer than 10 per cent of patients. In many departments, they still act as triage nurses.

Trusts are still not monitoring their own performance because they lack the necessary information systems or are not making full use of the systems they already have, the report says.

Although 82 per cent of trusts could give the percentage of patients seeing a doctor within an hour, only 55 per cent could say what percentage were admitted within four hours.

The commission will revisit the departments that fared worst. It recommends that poor performers produce an action plan.

In a separate update on day surgery, the commission noted a 'much higher percentage of many procedures' carried out as day cases than identified in its 1990 report A Short Cut to Better Services and its 1992 report All in a Day's Work. It also noted an increase in dedicated day surgery units, with more directed by consultants.

Audit Commission controller Andrew Foster said: 'Significant challenges remain and that there is scope for poorer performing hospitals to learn from similar hospitals with better performance.'

Accident and Emergency Services Follow Up, progress against indicators from By Accident or Design, and Day Surgery Follow Up, progress against indicators from A Short Cut to Better Services. Audit Commission Publications, Bookpoint Ltd, 39 Milton Park, Abingdon, OX14 4TD.£5 each.