Published: 06/01/2005, Volume II5, No. 5937 Page 3

It now appears unarguable that the fourhour waiting-time target for accident and emergency departments has had a significant effect on A&E admissions.

Exclusive research carried out for HSJ shows that while A&E attendances rose by 4 per cent during April-September 2004, admissions increased by 11 per cent (see news, pages 5-6).

This suggests that the biggest pressure on emergency services comes from events taking place inside hospitals, not those affecting patients before they arrive.

Although diagnostic techniques are improving, the rise in admissions has been too fast to suggest that this has been the cause. The scale of the rise must lead to legitimate questions about the appropriateness of some admissions.

The performance of individual trusts also becomes pertinent. In the wake of the financial problems at Bradford Teaching Hospitals trust, which saw a huge difference between admissions and attendances, the divergence at some other foundation trusts could well be significant.

Foundation trusts, of course, operate under payment by results, which means that most admissions via A&E carry a charge. With the state of NHS finances as they are (see above), primary care trusts need another financial shock like a hole in the head.

There is no evidence that any trust is gaming the system, but rumours abound.

The best safeguard is robust dialogue between commissioner and provider.