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BMA survey of accident and emergency waiting times

March 2005

Summary
In February 2004 the government introduced a new incentive scheme aimed at reducing waiting times in accident and emergency (A&E). For each of the staged targets met, trusts are paid £100,000 to spend on capital projects. The most recent target was for the period 1 October 2004 to 31 December 2004 and required 97 per cent of patients to be seen, treated or discharged within four hours.

The BMA survey of A&E waiting times was distributed in the first week of January 2005 and received a response from 80 per cent of departments (163/205).

From the results of the survey it was clear that many staff had worked incredibly hard to improve patient care in A&E and that some A&E departments had been able to use money from the scheme to purchase equipment which could bring further benefits to patients.

Nonetheless, the survey revealed a number of areas of concern:

Of the 125 departments that had met one or more of the first three targets, only 65 (53%) said their department had benefited from the money. In many cases the funds had been simply absorbed by the trust deficit.

Of those departments that had met the most recent target (for the period 1 October to 31 December 2004) only 26 per cent (42/163) said the figures submitted were an accurate reflection of the performance of their department. In an effort to meet the target:

• 48 per cent of departments used additional agency staff for the period of measurement
• 26 per cent reported that elective surgery had been cancelled
• 16 per cent reported direct manipulation of data

Forty-eight per cent of departments (78/163) said they did not meet the target for the period ending 31 December 2004. The main reasons for not reaching this target were:

• not enough in-patient beds; 90 per cent said this was a major reason, 10 per cent said this was minor reason
• delayed discharges; 80 per cent said this was a major reason, 20 per cent said this was a minor reason
• delay in accessing specialist opinion; 57 per cent said this was a major reason, 40 per cent said this was a minor reason
• not enough nurses; 49 per cent said this was a major reason, 41 per cent said this was a minor reason
• not enough middle grade doctors; 46 per cent said this was a major reason, 42 per cent said this was a minor reason
• department too small; 36 per cent said this was a major reason, 31 per cent said this was a minor reason
• delay in accessing diagnostic services; 30 per cent said this was a major reason, 59 per cent said this was a minor reason

Eighty-two per cent of departments reported threats to patient safety from pressure to meet the four-hour target. The most common complaints were that:

• care of the seriously ill or injured was being compromised
• patients were being discharged from the A&E department before they were adequately assessed or stabilised
• patients were being moved to inappropriate areas or wards

Improvements in waiting times for patients need to be sustainable. The key to sustainability is support from management for hospital-wide changes. For many respondents it was not the target itself but the way the target was implemented, for example by bullying staff resulting in stress and poor morale. Withholding money from incentive payments from successful A&E departments was a further source of demoralisation for staff.

Ninety-eight per cent of departments reported that workload had increased in the last 12 months. This is likely to be a result of a combination of changes in doctor and patient behaviour. For example, many departments were reporting an increase in referrals from primary care and that patients were reporting to A&E as their first port of call.

The A&E four-hour target will always be limited if its implementation fails to involve first degree care, acute mental health and social services. Rather than focusing on the A&E department, attention needs to be on the whole area of unscheduled care. The aim should be the development of a collaborative strategy from the local health economy, that is, primary, secondary and community care working together to create a more efficient system that is better for patients.