'Staff shortages threaten emergency services'

More than half of NHS trusts do not have enough A&E staff to provide a proper round-the-clock service, a report suggested today.

More than half of NHS trusts do not have enough A&E staff to provide a proper round-the-clock service, a report suggested today.

The National Audit Office (NAO) found that while waiting times in casualty departments had fallen significantly in recent years, many hospitals faced difficulties recruiting the necessary staff, even when funding was in place.

Changes to the provision of GP out-of-hours services and reductions in junior doctors' working hours also posed risks to A&E services, the report said.

Edward Leigh, chairman of the Public Accounts Committee, expressed concern over staff shortages and the long waiting times still experienced by some of the most vulnerable patients.

Today's report - Improving Emergency Care in England - said there had been "significant progress" made towards meeting the maximum four-hour wait in A&E set in the NHS Plan.

In 2002, 23% of patients waited more than four hours in emergency units, but in the three months April-June 2004, only 5.3% waited that long.

But the NAO said there was a risk that undue focus on the target "could mean less attention being paid to the timely completion of treatment for patients who could in fact be safely managed in far less than four hours, or those who had already exceeded that threshold".

Despite large drops in lengthy waits, the report said that many patients with complex needs, such as older people and the mentally ill, were likely to stay longer than four hours.

This might be due to having to wait for a psychiatrist or other specialist.

The report also said that nearly a quarter (23%) of patients in A&E who needed to be admitted to hospital waited more than four hours.

Many bottlenecks, such as the management of beds and the availability of specialists, are outside the control of A&E and need to be tackled together to improve services, the NAO said.

The NAO's survey of 126 trusts in England found that shortages in A&E clinical staff were common.

They found that 84% of trusts reported a shortage of nurses compared with funded posts, 43% said there was a shortage of permanent consultants and 55% reported a lack of other medical staff.

Since April, GPs have been able to opt out of providing out-of-hours care for patients, which instead is handled by primary care trusts, private sector contractors or ambulance trusts, for example.

The NAO report said that the full effect of the changes to out-of-hours care on the rest of the emergency care system had yet to be felt and there were risks.

"From our visits and surveys we found concerns that failure to integrate the new services adequately could result in increased pressure on A&E departments," it said.

The Government plans that by December 2006 the NHS Direct helpline will act as a single point of access for out-of-hours services, A&E, walk-in centres and minor injury units, referring patients where most appropriate.

England's 81 walk-in centres have proved popular with patients, with 1.6 million visits in 2003-04.

In some areas they are located near A&E departments to help manage demand there.

"However, the Department (of Health) consider that the initiative is in many places satisfying a demand that was previously unmet, and the impact in terms of reducing attendance at A&E nationally is minimal," the report said.

NAO head Sir John Bourn welcomed drops in delays faced by A&E patients.

"This is against a background of a continuing high demand for A&E services.

"There is scope, however, in those trusts which are behind the best, for further reductions in the time patients spend in A&E," he said.

Mr Leigh acknowledged that in a period of heavy demand, with A&E visits last year topping 12 million, waiting times in general had been "substantially reduced".

But, he said, less pleasing was the fact that more than half of trusts felt they did not have enough medical staff.

"There are particular shortages of those staff with the specialist skills needed to deal with children, vulnerable older patients and patients with mental health problems - the kinds of patients who tend to wait the longest," Mr Leigh said.

He added it was unacceptable that so many patients needing to be admitted were waiting more than four hours.

"I am alarmed also by the finding that A&E patients are being delayed by bottlenecks in the wider hospital system.

"A&E patients who need to be admitted to wards are often being unnecessarily held up because staff on the wards are not efficiently managing the admission and discharge of their non-emergency patients."

Mr Leigh said A&E was working increasingly with other providers, such as ambulance trusts, to provide emergency care, but truly integrated working was "proving hard to achieve".

"The Department's promise in 2001 that it would link all these services through a single point, NHS Direct, is starting to look a little empty, given that we are now being told it will not happen until December 2006," he added.

NHS chief executive Sir Nigel Crisp said: "I welcome the fact that the NAO has recognised that there has been significant progress as 19 out of 20 people are seen, diagnosed and treated within four hours in A&E.

"Thanks to extra investment, the number of doctors and nurses is increasing as more of them are relishing the opportunity to have more specialised roles in A&E."