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BMA survey of accident and emergency waiting times

May 2003

During the week ending 31 March 2003 the Department of Health conducted a pre-announced audit of waiting times in A&E departments in England. The target was for 90% of patients to be seen within four hours.

Following concerns that trusts would simply ‘throw unsustainable resources at those seven days and cancel elective work to meet the A&E target' [1], the BMA decided to survey A&E consultants about the audit week. Data were collected from 95 of the 207 A&E departments in England.

• 72% of departments had introduced exceptional arrangements for the audit period. These included the use of agency staff, double or extended shifts and cancellation of operations.
• In the week prior to the audit, 55% of departments met the government's target (90% of patients seen within 4 hours). This figure rose to 85% during the audit week and fell again to 63% the following week.
• A third of departments (31/95) did not believe the published figures for their department were an accurate reflection of the situation in their department.
• 56% of departments believed that efforts to meet government targets distorted clinical priorities

Survey method
A questionnaire was sent to a random sample of 500 A&E consultants. After excluding responses from countries other than England, data were collected from 95 A&E departments, approximately half of the 207 A&E departments in England. A regional breakdown is given below:

Table 1 - Regional distribution of A&E departments included in the survey

	Number	Percent
North	25	26%
Midlands-Anglia	23	24%
South East	16	17%
South West	12	13%
London	13	14%
No response	6	6%
Total	95	100%

Results
Did your department introduce exceptional staffing or other arrangements during the week of the monitoring exercise?
72% of departments (68/95) introduced exceptional arrangements for the audit week. These included use of agency staff (57%) making staff work double or extended shifts (23%) and cancellation of elective operations (16%).

Other arrangements introduced for the week of the audit included employing additional porters and radiographers, employing a GP and locum SHOs, cancelling annual leave, opening of private wards, using management staff to work clinical shifts and having the presence of a senior trust manager.

Has your department introduced a ‘see and treat’ or similar initiative?
78% of departments (74/95) had introduced a ‘see and treat’ or similar initiative. A third had introduced the initiative in the month preceding the audit week. The majority (66/74) planned to continue the initiative although only 58% (38/66) had been provided with additional funds.

The majority (81%) believed that the initiative had improved the performance of their department, although 71% said that it had negative consequences.

The main problem encountered was that low priority patients were being seen at the expense of the seriously ill and traumatised. There were also widespread reports of an increase in patients with chronic or minor conditions attending the A&E department rather than visiting their GP. Some departments had concerns that patients were being ‘rushed through’ and reported instances where patients had been moved before being adequately assessed or stabilised, or sent to the wrong specialty. Others reported that routine work, such as paper work, restocking supplies, training and appraisal, were not being done.

'Improved turnover of lowest priority patients with the result that higher priority wait longer. Also waiting room patients very angry that lower priority are being seen first'.

'Existing staff especially senior doctors and emergency nurse practitioners are exhausted and disillusioned that funding and resources have not been continued, increased stress and bullying of senior medical staff'.

Please indicate what percentage of your patients met the 4 hour target?
During the week of the audit 85% of departments surveyed said they had met the government’s target. The week following audit this figure had dropped to 63% (see graph).

Proportion of departments that met target



Do you believe that the published figures for your hospital accurately reflect the situation in your department?
A third of departments (31/95) did not believe that the published figures for their department accurately reflected the situation in their department. A frequent claim was that the results of their department were combined with well performing Minor Injury Units to boost the returns. Another was that patients threatening to breach the four hour limit were ‘discharged’ to other clinical areas, such as the medical assessment unit, even if they hadn’t been seen.

'Computer records have been altered, so that A&E waiting times have been falsified to avoid patients going over 12 hour trolley wait'.

'I believe that the figures supplied by the Trust are not accurate as patients waiting on ‘beds’ in A&E are counted as inpatients'.

'The week of monitoring was very atypical. It shows targets can be met – but with significant extra resources. And is the target valid anyway? As soon as monitoring week finished minor waits went up to previous levels'.

Have efforts to meet government targets distorted clinical priorities?
56% of departments (53/95) believed that efforts to meet government targets had distorted clinical priorities in their department and 48% believed they distorted priorities in their trust as a whole.

The majority of departments felt that access was prioritised at the expense of clinical quality, staff wellbeing and recruitment and retention. The main clinical concerns were that:

• The seriously ill and traumatised were waiting longer .
• Patients were being rushed through before they had been adequately assessed.
• Patients were being moved to inappropriate areas.

Conclusions
It should be stressed that many departments were proud of the A&E service they provided during the audit week. One department, for example, reported that efforts to meet targets via the Emergency Services Collaborative had provided funds and motivation for the department to reassess and improve their practise. However, there were widespread concerns that the resources provided during audit week were unsustainable.

This survey has shown that in the majority of A&E departments efforts were directed at meeting the government’s target at the expense of clinical quality, staff wellbeing, and broader objectives such as developing long-term improvements in capacity.

'Sometimes staff can get so pre-occupied with meeting the targets they miss the bigger picture regarding what’s best for the patient'.

References:
1. Health Services Journal 03/04/2003, Volume II3, No 5849, p5-6.