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Published: 16/01/2003, Volume II3, No. 5838 Page 10 11 12

Shortening A&E waiting times is crucial to New Labour's reform programme.But with 10 weeks to go until the next round of targets bites, the service is struggling.Tash Shifrin reports

Accident and emergency waiting times are showing red on the political agenda.

In the week that a leaked report from the Downing Street delivery unit warned that the NHS reform programme - and attached targets - faced 'immense risks', the Conservative Party was collecting intelligence on delays in A&E.

Meanwhile, the British Medical Association presented supplementary evidence to the Commons public administration committee on the question of 'gaming' the system to meet A&E targets by keeping patients in ambulances.

The government is known to be concerned that lack of progress on A&E would provide one of the most 'visible' signs that the transformation of the NHS is struggling to produce results.A&E is, after all, a key gateway to the acute service.

But while the centre is clearly keeping a close eye on A&E waits, it is attempting to do so quietly.

Guidance to clamp down on gaming by trusts - detailing exactly when to start and stop the clock and how to define an observation ward - was sent out to trusts' situation reports (sit reps) co-ordinators rather than being published.

The next big target milestone looming is at the end of March, when trusts will be expected to ensure that 90 per cent of patients wait no longer than four hours from arrival at A&E to admission, transfer or discharge. But it is striking how little detail has emerged about trusts' performance on the current target.

Unlike inpatient waiting times, A&E waits are not among the key targets on which star-ratings are based - they appear only among the subsidiary 'patient focus' indicators. Interestingly, this means that trusts have been scored from one to five on A&E waits rather than with a tick or cross mark to show whether the target has been met or not.

In his end-of-year report to the NHS, chief executive Nigel Crisp noted that 77 per cent of patients waited less than four hours in A&E, a 2 per cent rise on the figure he gave in April and on the current target. The NHS plan had stipulated that 75 per cent of patients should be dealt with in under four hours by March 2002.

But more detailed Department of Health statistics for July to September 2002 show that onethird of A&E departments were failing to meet the April 2002 75 per cent target.

And British Association of A&E Medicine president Dr John Heyworth says: 'I think that is probably an underestimate.' The data was collected before the new sit-rep guidance was issued and there have been 'many, many examples of creative interpretation', presenting 'a far rosier picture' than the reality of waiting in A&E.

The new guidance will make things 'far clearer', he says. But he adds that the government's targets are 'not going to be met in the timescale [the government] wants', despite 'a lot of activity' in hospitals to try to meet them. The targets are 'quite ambitious given the level of investment and staffing'. Government reluctance to 'badge' money for A&E means that it is going 'to fill trust debts and to other specialties', he warns.

Emergency access 'czar' Professor Sir George Alberti says gaming by trusts was 'obviously a problem in some parts but I do not think it was a very big problem'.

He concedes there was 'woolliness' and that the new guidance is aimed at 'getting absolute crystal clarity about what is waiting and when patients are in observation wards'. But he adds that targets are 'not a question of numbers: It is, 'are you dealing well with patients?'

'There is no point in trying to massage or manipulate that'.

Progress towards the targets has been 'better than I anticipated', says the man who describes himself as 'a gentle pessimist'. But he says the new 90 per cent target will be 'very challenging considering the facilities we have and the staffing. It will take time to get staff numbers up'.

The variation across the country is due to several factors - in some areas 'people haven't got organised well enough - though That is changed rapidly'. In others It is lack of bed capacity or staff shortages.

Malcolm Alexander is the newly appointed director of the Association of Community Health Councils for England and Wales and the founder of the Casualty Watch survey that has been an annual thorn in the side of the government, particularly as Casualty Watch counted waiting time from arrival at A&E rather than a doctor's decision to admit - a system only adopted by the DoH last year.

Mr Alexander says that the Casualty Watch data is still the only information available to the public on what goes on in A&E.

He calls for the sit rep data to be made publicly available.

He believes that patients waiting in ambulances is 'mostly due to the fact A&E is crowded and there is not a bed'. Bed shortages on the wards are also leading to people being 'warehoused in A&E departments', he says. Mr Alexander points out that in some London hospitals 'There is a significant number of people with severe mental health problems waiting in A&E for a very long time'.

If there is a 'fiddle' around A&E waits, it is the transfer of patients from trolleys to beds in A&E 'so trolley waits are concealed', he says.

Dr Matthew Cooke, an A&E consultant and DoH advisor, says: 'The target is a national average and there is a lot of variation in that. There is a group of trusts running at 95-100 per cent and two or three still below 60 per cent. Not every trust will be at 90 per cent by March.'

There is a north-south divide, with more A&E trouble spots in the south, where bed capacity and staff recruitment are more problematic, than in the north, he says.

But he points out the final 2005 target is 100 per cent, 'which doesn't allow for any variation'.

Mr Cooke says Warwick University is launching a websitebased emergency care leads toolkit, as part of the National Electronic Library for Health, to spread best practice. It will be launched in two or three weeks' time and will carry a list of ways to improve A&E .

Key methods include anticipating bed demand rather than 'firefighting' and using more consultants and senior nurses to see patients straight away instead of the traditional triage approach of moving patients up the line from junior to more senior staff.This can cut admissions by as much as 10 per cent, Dr Cooke says.

Birmingham Heartlands and Solihull trust, where 67 per cent of patients were waiting less than four hours between July and September, is putting this sort of system into practice, with consultants and nurse practitioners meeting patients on arrival. And GP admissions now go to a dedicated ward, A&E matron Hilary Clemson says. 'I think our pressures are the same as anyone's.

'We are doing reasonably well and are nearly there. We are pretty confident of meeting the target.'

But some trusts have started from further behind. North Staffordshire Hospital trust leaps out of the July-September figures with a shocking 36 per cent hitting the four-hour target. But a spokesman explains that when the trust looked into this, it found an IT glitch had skewed the figures. The computer system logged patients in, 'but it didn't force you to put in a departure time', he says.

'By default, it put in a time of its own - about 48 hours after. That is one thing We have sorted out.'

He adds that high-level memos are exchanged with the local ambulance trust pretty fast if patients are kept waiting in vehicles, and the matter is taken very seriously. Less easy to deal with are the effects of a split site - 'You can't just wheel somebody down the corridor to a ward.'

The trust says its four-hour wait figure is now 'around 70 per cent, which We are confident is real'. At this stage it is not sure if it will hit the targets, but it is committed, the spokesman says, and is working with partners to tackle 'holdups in the whole system'.

Royal United Hospital Bath trust is another that has had serious problems in A&E - it used to have the fourth worst waits in the country, says chief executive Jan Filochowski. 'We did have a problem [with people staying in ambulances] - but not now, ' he says.

The trust has 'completely reorganised A&E and the pathways through it so It is much more efficient', and has systems 'to separate out patients with different things wrong with them'.

And the improvement comes against an increase in emergency admissions of 12-15 per cent in the past year, Mr Filochowski says.

But with 'pushing towards 80 per cent' of patients now waiting less than four hours, 'We are definitely determined to hit 90 per cent before the end of March'.

With the worst weather for more than a decade hitting much of the country last week, increasing winter pressures, such determination will be needed. But Dr Heyworth adds: 'It is clear staff in A&E are working extremely hard, with high numbers and high complexity [of patient cases]. If the targets are not met, the finger must not be pointed at A&E departments - because they are working their socks off.'