News Focus

Blaming managers for the depressing findings of last week's Audit Commission report on A&E waiting times made for cheap headlines. Jennifer Trueland examines Labour's failure to get to grips with this politically crucial area of policy When Tony Blair spoke at the 1996 annual conference of what was then the National Association of Health Authorities and Trusts, in Harrogate, shortly before becoming prime minister, his theme was clear. Labour in government would be tough on trolleys and tough on the causes of trolleys.

That may be paraphrasing slightly - but not unfairly.

Managers were being sold a vision of an NHS which would have no space for five-hour trolley waits in hospital corridors. Back in June 1996, his words - and promise of a taskforce to end the practice - were welcomed.

How times have changed. As revealed in an Audit Commission report published last week, waiting times in accident and emergency departments in England and Wales have worsened since Labour took power.

What is more, the report is critical of those very managers that Mr Blair was trying to woo, saying that poor performance was not only a question of resources, but how they were used.

The report, using data collected last year, follows two others, By Accident or Design, from 1996, and Accident and Emergency Services Follow Up, from 1998. It covers waiting times, staffing, quality and information. It found that the number of patients seen by a doctor within an hour fell from 72 per cent to 53 per cent while the number admitted within four hours dropped from 89 per cent in 1996 to 76 per cent in 2000. More worryingly, the rate of decline rose sharply after 1998.

Audit Commission public sector research manager Bill Alexander is the report's author. He can find no single satisfactory explanation for the deterioration shown in the report. But he says: 'It must be something to do with management and organisation, how you allocate patients, resources and staff.

But the figures we have do not give a definitive answer. There has obviously been an increase in demand, in that departments are seeing more patients. But the figures on patient numbers have been going up quite gently, certainly at a slower rate than the increase in the numbers of staff.

'There is a possibility that junior doctors' hours might be a factor, but We have found that the hours they're actually working haven't changed much. The bed shortage has become more acute, but we haven't measured that directly.

There is no single answer.'

Larger city hospitals come out worst in the review, which shows that while patients in Wales get the best deal, those in London have the longest waits. Mr Alexander does not believe this is explained by case-mix, though he concedes that inner city hospitals will see patients with more social problems and with mental health needs. But he adds:

'That is speculation - It is not something We have measured.'

Stephen Thornton was also on the bill at that NAHAT conference before he became chief executive of its successor organisation, the NHS Confederation. Last week, not surprisingly, he came out fighting in response to the Audit Commission. In a press release published to coincide with the report, Mr Thornton said: 'The decline in performance in A&E departments, though worrying, is hardly surprising, given the relentless pressure that NHS hospitals are under.

'Many of the problems lie outside the A&E department and have been well rehearsed. That 20 per cent of patients need further treatment and suffer some of the worst delays in A&E is an indication of what is happening in the rest of the hospital when working to their full capacity all the time.'

Confederation policy manager Gary Fereday agrees. 'We are concerned that the government appears to be laying the blame on management in what's a very complex issue. As the Audit Commission stated, there are a number of possible causes, and the commission was unable to identify the particular causes of problems in A&E. We must also remember that managers of A&E are often clinicians at the front end and acutely aware of the problems they face.'

That is as may be. But other aspects of the Audit Commission report suggest that changes could, and should, be made - in the realm of information, for example.

Though improvements were found in this area, with 89 per cent of hospitals able to provide information on waiting times compared to 55 per cent in 1998, the situation is far from rosy. Among other things, the report throws up the startling statistic that one in seven departments still have no computer system and that they could only find the necessary information for the Audit Commission by a hand trawl of patients' cards.

Hardly an efficient use of staff time.

Mr Alexander is also scathing about the use made of figures, saying that too often, little attention is paid to what the information means, with a corresponding failure to learn from it. 'Even if trusts only collect the Patient's Charter data of time to triage and trolley waits, you might expect them to monitor it, ' he says.

'All too often, they do not. It is like they collect the information to feed the beast, then, although some do analyse the data considerably, others just do not.'

Mr Alexander suggests that more should be done to stream patients. He says 60 per cent of patients are non-urgent.

But only 5 per cent of departments make a significant use of nurse practitioners, who could deal with such cases.

Though the report is not convinced that the introduction of admission wards has done any good, Mr Alexander does not want to dismiss them. But he makes the point that they can only work as part of a good, hard look at overall beds policy.

He is, however, optimistic that things will improve, not least because the government's eye seems to be firmly on the problem.

Indeed, health secretary Alan Milburn jumped straight in last Thursday with an announcement of a£100m strategy to end 'inappropriate' trolley waits. This comprises£50m to buy more elective operations, including£40m to buy up to 25,000 operations in the private sector, and£40m for more nurses and£10m for local emergency care leaders. The strategy includes streaming patients, round-theclock diagnostic services and separating routine and emergency work.

But why has it taken him so long?

After all, sources suggest that it was Mr Milburn, then a junior member of the opposition health team, who wrote much of Mr Blair's 'tough on trolleys' speech, showing that the situation can hardly be new to him.

That is what Joyce Robins, director of Patient Concern, would like to know. 'The problem is a fragmentation in the NHS with different trusts, hospitals - and even departments - going their own way, without looking at people who are doing things better. I know centralisation is a dirty word, but what we need is someone, centrally, to take a grip on the situation.' l Views from the front line Tim Jones, University Hospital Birmingham trust emergency services divisional general manager, says part of the problem lies with the change to referral patterns, with more patients coming directly to accident and emergency without going through their GP. He agrees that it is partly a management problem, but adds: 'I do not take the criticisms personally, in that I do not think Mr Milburn and others are referring specifically to A&E managers. We have got to look at the whole process. A&E is the portal to acute care, so any problems with the whole system, in the community and in hospitals, will be magnified in A&E.'

Newcastle upon Tyne Hospitals trust chief executive Len Fenwick says his trust performed very well in the Audit Commission review, in part because it had invested significantly in centralising A&E services at the Newcastle General site. There are three levels: a walk-in centre, minor injuries clinic and a trauma or traditional A&E unit. In addition, there is a minor injuries clinic at the Royal Victoria Infirmary in the centre of Newcastle, which is open until 11pm. The area's hospitals can also take heralded admissions without going through A&E.

Bucking the trend for major cities, all patients are seen within an hour and 99.6 per cent admitted within the four-hour target. Mr Fenwick says: 'Our facilities can be crowded and We are not complacent, but we have worked hard on this issue. As to whether It is a question of resources or management - It is a mixture of both.'