NHS casualty units `need urgent reform' struggling to cope

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Health Editor

A radical overhaul of hospital accident and emergency departments is urgently needed to cope with rising demand for care and continuing shortage of skilled staff, the Audit Commission says today.

In a hard-hitting report which details a developing national crisis in casualty provision, the commission says "high-quality" patient care is under threat. It warns that "the deficiencies described in this report require priority attention if public confidence is to be retained in the ability of the NHS to meet what are seen as basic needs".

The report outlines measures that will bring immediate improvement, including broadening the role of nurses to treat and discharge patients, and appointing a senior manager to deal with patients who end up waiting on trolleys. It warns, however, that a fundamental change in A&E provision is the only long-term solution.

Most A&E departments have too few doctors to cope with new attendances which have risen by about a third since 1980, the report says. This leaves many patients treated by inexperienced and unsupervised doctors, particularly at weekends when many departments are staffed solely by newly qualified juniors. Nationally, more than 40 per cent more "middle- grade" doctors and 25 per cent more juniors are needed at a cost of about pounds 17m.

Waiting times, the root of most patients' complaints, vary markedly; at one hospital 95 per cent of new patients were seen within an hour while at another the figure was 32 per cent. At one hospital, 84 per cent of admitted patients reached a bed within an hour, but at another the figure was only 2 per cent.

The report criticises departments which have the best Patient's Charter rating for prompt initial assessment of patients, claiming they are often the slowest in treating and discharging them. Stephen Dorrell, the Secretary of State for Health, who last week unveiled new measures to improve emergency and intensive care, has promised another charter to deal specifically with this point.

The report also highlights "congestion" caused by the rising number of acutely sick patients referred by their GPs for emergency admission via A&E. "This is stretching A&E staff resources and causing major delays and problems for other patients," the report says.

More worryingly, some hospitals receiving critically ill patients by emergency ambulance say they do not have the necessary services and expertise, such as intensive care and anaesthesia, available on a 24-hour basis.

The commission concludes that, ultimately, a "reconfiguration" of services is needed, starting with a review of all small A&E departments where there is good access to alternative facilities within 10 miles.

t By Accident or Design: Improving A&E Services in England and Wales; HMSO; pounds 15.